Herniated Disc (Lumbar)

Herniated Disc (Lumbar)

Herniated Disc

Herniated discs are ruptured or "slipped discs." Only a small area may be affected, or the entire disc may not be ruptured or slipped. The tough outer layer of cartilage cracks allowing inner (soft) cartilage to protrude out of the disc.

Bulging discs occur when the inner portion of the disc pushes against the outer cartilage and causes the perimeter (at least a quarter to half) to bulge. Bulging discs are a degenerative and often age-related condition.

Signs and Symptoms

• Pain
• Muscle weakness or spasms
• Overactive reflexes
• Sensation of "pins and needles"
• Uncomfortable tingling and burning
• Numbness in the foot, hand, or leg
• Stiff neck

Lumbar Herniated Disc

Herniated discs occur when the cushioning discs between your vertebrae slip out of place or rupture. These discs are meant to act as shock absorbers, but when they press on nearby nerves, they can cause significant pain, numbness, or weakness. This condition often results from age-related degeneration, repetitive strain, or sudden injury. Treatment options range from physical therapy and pain management to, in severe cases, surgery.

Lower back problems can occur for many different reasons. The terms ruptured disc and slipped disc seem to be used more commonly in the last few decades. People often assume that everyone who has back pain has a ruptured disc. However, a true herniated nucleus pulposus (the official medical name for this problem) is not very common. Most problems that cause pain in the back are not due to a herniated disc.

To better understand how a herniated disc occurs, it is helpful to know some anatomy of the spine and more specifically, the parts of the spine involved.  The intervertebral discs are the cushions that act as shock absorbers between each of the vertebra in your spine. There is one disc between each vertebra. Each disc has a strong outer ring of fibers called the annulus, and a soft, jelly-like center called the nucleus pulposus.

The annulus is the disc's outer layer and the strongest area of the disc. The annulus is a strong ligament that connects each vertebra together. The mushy nucleus of the disc serves as the main shock absorber.

A herniated disc occurs when the intervertebral disc's outer fibers (the annulus) are damaged and the soft inner material of the nucleus pulposus ruptures out of its normal space. If the annulus tears near the spinal canal, the nucleus pulposus material can push into the spinal canal.

Causes

A true herniated nucleus pulposus is also common among young and middle-aged adults.  It is less likely in children and elderly adults.  The degenerative changes that occur in the spine with aging make it less likely for them to develop a true herniated disc.

Discs can rupture suddenly because of too much pressure all at once on a disc. For example, falling and landing in a sitting position can cause a great amount of force across the spine. A vertebra can fracture or break, or a disc can rupture if the force is strong enough. Bending over places a great amount of force on the discs between each vertebra and bending while lifting a heavy object can force a disc to rupture.  

Discs can also rupture from a small amount of force - usually due to weakening of the annulus fibers of the disc from repeated injuries that add up over time. If the annulus has weakened lifting something or bending in such a way causes too much pressure across the disc can cause it to rupture.  

A herniated disc causes problems in two ways. First, the material that has ruptured into the spinal canal from the nucleus pulposus can cause pressure on the nerves in the spinal canal.  The nucleus pulposus material may also cause chemical irritation of the nerve roots. Both the pressure on the nerve root and the chemical irritation can lead to disruption of how the nerve root works. This combination can cause pain, weakness, and/or numbness in area of the body that the nerve usually affects.

Symptoms

The symptoms of a herniated disc come from pressure on, and irritation of the nerves usually include:

• Pain that travels into one or both legs
• Numbness or tingling in areas of one or both legs
• Muscle weakness in certain muscles of one or both legs
• Loss of the reflexes in one or both legs

Where these symptoms occur depends on which nerve(s) has been affected in the lumbar spine. Therefore, the location of the symptoms helps determine the diagnosis.  Where the pain is perceived may help identify which disc has probably ruptured.  However, many people have back pain because they have other problems in their back when the disc ruptures.  Also, the symptoms of a true herniated disc may not include any back pain.

Diagnosis

Making the diagnosis of a herniated nucleus pulposus begins with a complete history of the problem and a physical examination. The physician will ask about injury, pain, numbness or weakness and where it occurs.  Also, whether this is a first-time occurrence or a new problem.  If there is pressure from the herniated disc on the nerves that go to the bowel or bladder there will be problems with urination and bowel movements and this is an emergency that may require immediate surgery.

Lower back X-rays will not show a herniated disc, but they will provide an idea of how much wear and tear is present in the spine and may show other causes of the problem.

The most common test done today to diagnose a herniated disc is the MRI scan. This test is painless and very accurate.  It is the best test to do (after X-rays) if a herniated disc is suspected.

Conservative Treatment

Treatment of a herniated disc depends on the symptoms and the progression of the symptoms (whether they are getting better or worse). If the symptoms are getting steadily worse, surgery may be required. If the symptoms are getting better, surgery may be delayed since many symptoms completely resolve over several weeks or months.

Conservative treatment includes observation (watching to see if the problem gets better or worse and progression of weakness, pain and numbness); Rest and decrease in activity.  Pain medications may be used to help control pain depending on severity.  The physician may recommend over the counter pain medicines or stronger prescription pain pills.  Epidural Steroid Injections may be recommended if surgery is warranted to try to reduce pain further. 

Surgical Treatment

Laminotomy or Discectomy

The term laminotomy means "make an opening in the lamina", and the term discectomy means "remove the disc".  This is a traditional way of treating a herniated disc.

This procedure is performed through an incision down the center of the back over the area of the herniated disc. Once the incision is made through the skin, the muscles are moved to the side so that the surgeon can see the back of the vertebrae. X-rays during surgery may be required to make sure that the correct vertebra is chosen. A small opening is made between the two vertebrae where the disc is ruptured. This allows the surgeon to see into the spinal canal. The term laminotomy (make an opening in the lamina) comes from the fact that usually a small amount of the bone of the lamina must be removed. This is to make room to see into the spinal canal and to allow room to work.

Once this is done, the surgeon moves the nerve roots out of the way to see the intervertebral disc. The surgeon locates the disc material that has ruptured into the spinal canal and removes it. This removes any pressure and irritation on the nerves of the spine. Using small instruments that fit inside the disc itself, he also removes as much of the nucleus pulposus material still inside the disc as possible.

After the procedure is complete, the muscles of the back are returned to their normal position around the spine. The skin incision is repaired with sutures or metal staples.

Rehabilitation

Physical therapy may be recommended.   Exercise is vital to recovery and to maintaining a healthy spine.  Regular exercise is the most basic way to combat back problems. However, it must be safe and appropriate for each injury.  Scientific studies have shown that people who exercise regularly have far fewer problems with their back. It strengthens the abdomen, arms, and legs, and reduces back strain.   Exercise also helps strengthen the muscles in the back and can reduce the risk of falls and other injuries.  Stretching reduces risk of muscle spasms. Weight bearing exercises can reduce the risk of compression fractures and help prevent loss of bone mass due to osteoporosis.  Aerobic exercise has been shown to be good for pain relief because endorphins (the natural chemicals of the body that combat pain) are released during exercise.