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Herniation Disc

• The discs are pads that serve as “cushions” between the vertebral bodies, which minimize the impact of movement on the spinal column.
• Each disc is designed like a jelly donut with a central softer component (nucleus pulposus).
• Abnormal rupture of the central portion of the disc is referred to as a disc herniation.
• The most common location for a herniated disc to occur is in the disc at the level between the fourth and fifth lumbar vertebrae in the low back.
• If the disc herniation is large enough, the disc tissue can press on the adjacent spinal nerves that exit the spine at the disc herniation level.
• The physical examination, imaging tests, and electrical tests can aid in diagnosing a herniated disc.
• Depending on the severity of symptoms, treatments for a herniated disc include physical therapy, muscle-relaxant medications, pain medication, anti-inflammation medications, local injection of cortisone (epidural injections), and surgical operations.

The vertebrae are the bony building blocks of the spine. Between each of the largest parts (bodies) of the vertebrae are the discs. Ligaments are situated around the spine and discs. The spine has seven vertebrae in the neck (cervical vertebrae), 12 vertebrae in the mid-back (thoracic vertebrae), and five vertebrae in the low back (lumbar vertebrae). Also, beneath the fifth lumbar vertebra in the mid-buttock is the sacrum, followed by the tailbone (coccyx).

The bony spine is designed so that vertebrae “stacked” together can provide a movable support structure while also protecting the spinal cord (nervous tissue that extends down the spinal column from the brain) from injury. Each vertebra has a spinous process, a bony prominence behind the spinal cord that shields the cord’s nerve tissue. The vertebrae also have a strong bony “body” in front of the spinal cord to provide a platform suitable for weight-bearing.

The discs are pads that serve as “cushions” between the vertebral bodies that help minimize the impact of movement on the spinal column. Each disc is designed like a jelly donut with a central softer component (nucleus pulposus). Ligaments are strong fibrous soft tissues that firmly attach bones to bones. Ligaments attach each of the vertebrae and surround each of the discs. When ligaments are injured as the disc degenerates, localized pain in the area affected can result.

Causes of Herniated Disc

As described above, each disc of the spine is designed much like a jelly donut. As the disc degenerates from age or injury, the softer central portion can rupture (herniate) through the surrounding outer ring (annulus fibrosus). This abnormal rupture of the central part of the disc is referred to as a disc herniation. This is commonly referred to as a “slipped disc.”

The most common location for a herniated disc to occur is in the disc at the level between the fourth and fifth lumbar vertebrae in the low back. This area is continually absorbing the impact of bearing the weight of the upper body. This is especially important when we are standing or sitting. The lower back is also critically involved in our body’s movements throughout the day, as we twist the torso in rotating side to side and as we hinge the back in flexion and extension while bending or lifting.

Risk Factors of Herniated Disc

Risk factors for a herniated disc include degeneration of the spine and heavy lifting or bending of the spine.

Symptoms of Herniated Disc

A herniated disc’s symptoms depend on the exact level of the spine where the disc herniation occurs and whether or not nerve tissue is being irritated. A disc herniation may not cause any symptoms. However, disc herniation can cause local pain at the level of the spine affected.

If the disc herniation is large enough, the disc tissue can press on the adjacent spinal nerves that exit the spine at the disc herniation level. This can cause shooting pain in the distribution of that nerve and usually occurs on one side of the body and is referred to as sciatica. For example, a disc herniation at the level between the fourth and fifth lumbar vertebrae of the low back can cause shooting pain down the buttock into the back of the thigh and down the leg. Sometimes this is associated with numbness, weakness, and tingling in the leg. The pain often is worsened upon standing and decreases with lying down. This is often referred to as a “pinched nerve.”

If the disc herniation occurs in the cervical spine, the pain may shoot down one arm and cause a stiff neck or muscle spasm in the neck.
If the disc herniation is vast, it can press on spinal nerves on both sides of the body. This can result in severe pain down one or both lower extremities. There can be marked muscle weakness of the lower extremities and even incontinence of bowel and bladder. This complication is medically referred to as cauda equina syndrome.

Diagnosing Herniated Disc

The doctor will suspect a herniated disc when symptoms described above are present. The neurologic examination can reveal abnormal reflexes. Often pain can be elicited when the straight leg is raised when lying or sitting. This is referred to as a “positive straight leg raising test.” There can be an abnormal sensation in the foot or leg.
A variety of blood tests are frequently done to determine if there are signs of inflammation or infection.

Plain film X-rays can indicate “wear and tear” (degeneration) of the spine. They do not, however, demonstrate the status of discs. To determine whether a disc is herniated, an MRI scan or CT scan is performed for diagnosis. Sometimes a CT myelogram is used to define further the structures affected by a herniated disc. A CT myelogram is a CT that is performed after contrast dye is injected into the spinal canal. This allows for better visualization of the discs in some instances. An electromyogram (EMG) can be used to document precisely which nerves are being irritated by a disc herniation.

Herniated Disc Treatment

A majority of patients with sciatica from disc herniation resolve their pain with various conservative measures, including anti-inflammatory and muscle-relaxant medications, exercises, physical therapy, and time. However, some 10%-15% of affected patients require surgical procedures to relieve the pain.

Occasionally, disc herniation is incidentally detected when a test such as an MRI is performed for other reasons. If no symptoms are present, no particular treatment is necessary.

Depending on the severity of symptoms, treatments for a herniated disc include physical therapy, muscle-relaxant medications, pain medications, anti-inflammation medications, local injection of cortisone (epidural injections), and surgical operations. In any case, all people with a disc herniation should rest and avoid reinjuring the disc. Sometimes, even people with relatively severe pain early on can respond to conservative measures, including physical therapy with an exercise regimen, epidural cortisone injection, and or oral cortisone medication (such as methylprednisolone or prednisone), without the need for surgical intervention.

There are now a variety of surgical approaches to treat disc herniation. Each type of operation is customized to the individual situation and depends a great deal on the spine’s condition around the disc affected. Surgical options include microdiscectomy using small surgical instruments and open surgical repair (either from a posterior or anterior approach). The urgent operation can be necessary when cauda equina syndrome is present.

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