In order to understand herniations, ruptures, and bulges, you must first understand the purpose of a disc.
What are discs?
Intervertebral discs are soft, spongy pads found between the hard bones
(vertebrae) that make up your spinal column. These discs act as “cushions”
between the vertebrae and keep them in place. They also allow your back
to flex and bend – think of them your back’s shock absorbers!
Each disc is composed of two parts – a thick outer ring of cartilage (the
annulus), which resembles a radial tire, and an inner substance (the
nucleus), which has a gel-like consistency.
Your discs are subjected to lots of force when you move – flexing, bending
or twisting – which you’re doing almost all the time. In addition, there are
large forces of compression when you’re not really moving at all (when
you sit, stand or lay down). This means that there are constant stresses and
strains across your discs.
What is a disc herniation?
Lumbar disc herniation is one of the most common health complaints, but it is also the most common reason people of working age opted to undergo spinal surgery. This leads to several important questions that will be answered below. From looking at what it is and what symptoms are often associated with it to exploring potential causes and treatment options, here is everything you need to know about disc herniation.
Simply speaking, disc herniation is a medical term that refers to a problem with one of the discs (rubber-like cushions with a high fluid content) situated between the individual bones (vertebrae) that make up your spine. The discs, which have a tough outer layer and jelly-like inner layer, serve as pads to minimize the impact of your movements on the spinal cord.
Ligaments, a strong, fibrous tissue, surround each disc and firmly attach it to the vertebrae. If one or more of the disc located between the vertebrae shifts out of position and puts unnecessary pressure on any adjacent spinal nerves, it is known as a Disc Herniation. Though disc herniation can occur anywhere along the spinal cord, it most often affects the neck and lower back region.
The term “disc herniation” is often used interchangeably with bulging disc, ruptured disc, slipped disc, prolapsed disc, and even pinched nerves.
What Causes Disc Herniation?
Unfortunately for us, general wear and tear are the top reason for a herniated disc. As we age, the discs in our back are constantly absorbing shock from any movement we make, including walking, running, bending, and twisting. Over time, the discs lose fluid, leading them to become dry, brittle, and cracked and lose their elasticity. This is referred to as disc degeneration. As elasticity decreases, tissue within the disc can begin to leak out resulting in a bulge that shifts the disc from its fixed position.
Depending on your overall health and what types of activities you frequently engage in, a bulging or herniated disc can occur as early as your 20s, though it is more common when you reach your 30s and 40s. Certain activities can cause greater wear and tear on your discs and increase your risk of herniation at an early age. This includes participating in contact sports, using improper lifting techniques when picking up heavy items, and working in a field that requires repetitive bending, standing, and lifting.
There are other potential causes of a herniated disc, though they are much less common become herniation tends to be a gradual process. Other possible causes of disc herniation include:
- Suffering a sudden, jarring injury to the spinal column, such as that may be experienced in a car accident or when participating in contact sports.
- A combination of disc degeneration and damage, such as having a violent sneezing attack when your discs are already weakened. Though a sneeze hardly seems like a traumatic injury, it does cause enough force to herniate a disc.
Risk Factor for Disc Herniation
A variety of risk factors, both controllable and uncontrollable, can make you more susceptible to disc herniation. They include:
- Working in a field that requires extensive physical exertion and pulling and lifting heavy objects.
- Being exposed to a constant vibration, such as when driving.
- Obesity can add extra strain on the back.
- Smoking, which can keep your body from absorbing nutrients needed to maintain disc health.
- Having a recent spinal injury.
- Being over the age of 30.
- Being male (Disc herniation is twice as common in men as it is in women.)
- Family history (Research indicates that some families may have a predisposition for
- herniated discs.)
Common Symptoms of Disc Herniation
It’s important to understand that the most common symptoms associated with disc herniation can vary depending on where the herniation is located on the spinal column and whether it is pressing on an adjacent nerve. Some people with a herniated disc may have no symptoms at all. However, this is rarely the case. The most frequent symptom associated with a bulging or herniated disc is the pain.
Pain may either be intermittent or constant, and in severe cases, it may be excruciating and make it tough to take care of everyday responsibilities and activities. You should be aware that pain in the lower back and leg that lasts for just a few days before going away is often the first sign of a herniated disc.
Be aware that 90% of herniated discs occur between the discs known as L4-L5 and L5-S1. This tends to result in pain that travels down the sciatic nerve, which is one of the longest nerves in the body as far as diameter and extends from the lowest point of the spinal cord and down the back of the thigh.
If the herniated disc is in the back, an “electric shock-like or sharp” pain often occurs in the lower back and may extend down the leg into the foot if the sciatic nerve is affected. Pain may be felt in the buttocks, front and back of the thigh, calf, foot, and toes. The pain can be more severe when sitting, standing, and walking. It is not unusual for the pain in the leg, referred to as radiculopathy or sciatica, to hurt worse than the pain in the back.
When the herniated disc is in the neck, a constant sharp or dull pain is often felt in the neck and may extend through the shoulder blades. In some cases, pain or a feeling of numbness and tingling may radiate down the arm into the hands and fingers. The pain may be worse when moving the neck up and down or back and forth, as well as when sneezing or laughing.
A less common symptom of disc herniation is a neurological condition known as foot drop. Foot drop makes it tough for you to lift your foot when standing or walking on the ball of the foot. Also, you may experience weakness and tingling in your leg, foot, and toes, along with abnormal reflexes and muscle spasms. Although rare, cauda equina syndrome, which causes you to lose control of your bladder/bowels, is also a symptom of a severe disc herniation in the lower back.
How is a Herniated Disc Diagnosed?
Before doing anything, your physician should perform a physical exam to assess your range of motion, reflexes, overall strength in your neck and back, and neurological function. Then, to accurately diagnose a herniated disc, your physician will likely schedule a CT scan or MRI scan that allows him or her to study 3D images of the spinal column. He or she may also perform blood tests to rule out any other potential causes of your physical symptoms.
Disc Herniation Nonsurgical Treatment Options
Just as the symptoms of a herniated disc vary significantly, so do the possible treatment options. Before looking at the specific options, you should be aware that there are multiple things to consider when deciding on your course of treatment. They include:
- How long you have been experiencing any symptoms?
- The severity of your symptoms?
- Your age and your overall health status?
Typically, doctors prefer to start with conservative treatment options, although this may not be the case if your herniation is especially severe. As a general rule, patients are instructed to undergo 6 to 12 weeks of nonsurgical treatment before exploring more invasive procedures.
Nonsurgical treatment may include:
- Medications: The use of over-the- counter non-steroidal anti-inflammatory medications (NSAIDS), such as Ibuprofen and Aleve, are often encouraged to relieve pain and any inflammation. For a patient with severe pain, your doctor may prescribe a prescription narcotic pain medication, along with an oral steroid to reduce inflammation or a muscle relaxer to relieve muscle spasms and pain.
- Epidural injections: Injections provide long-lasting temporary pain relief which may last anywhere from a couple of days to a year. They are often given to facilitate physical therapy and rehabilitative stretching.
- Passive physical therapy treatments: Performed to relax your body and facilitate the healing process, passive physical therapy includes deep tissue massage, hydrotherapy, hot and cold therapy, and electrical stimulation, known as TENS.
- Active physical therapy treatment: Once your body begins to heal, your physical therapist will begin active treatments that are intended to prevent further symptoms and strengthen your muscles. You will be asked to perform exercises and stretches that focus on stabilizing your core back muscles and improving your flexibility.
- Chiropractic manipulation: Based on the location of your disc herniation, a chiropractor may perform different spinal manipulation techniques on you. For example, flexion-distraction is a method that requires the use of a particular table with a thumping rhythm to gently stretch the spine, allowing the chiropractor to isolate the affected disc. This tends to be especially beneficial for anyone whose nerves are being impinged on by the disc. Exercises designed for muscle stimulation, as well as physical therapy and nutritional recommendations may also be incorporated into yourtreatment plan.
- Therapeutic ultrasound: Frequently done in conjunction with physical therapy or chiropractic manipulation, this procedure uses the sonic waves passed from the ultrasound machine’s wand to vibrate the soft tissues around your herniated disc. The vibrations heat the tissue, which reduces pain, relaxes tight muscles, and improves the tissues’ ability to stretch. There is some evidence that therapeutic ultrasounds can enhance the body’s ability to produce the collagen that makes up your tendons and ligaments.
Keep in mind that doctors almost always utilize a combination of non-surgical interventions to relieve pain and increase the likelihood of successfully treating your herniated disc. In fact, even without any intervention anywhere from 80% to 90% of herniated discs will heal entirely on their own within two years of the initial herniation. Of course, most people cannot live with the symptoms for that long.
Disc Removal Surgery (Discectomy) Options
Let’s assume you have a diagnosis of a disc herniation. If you are experiencing persistent pain in your buttocks and legs or shoulders and arms for at least 6 to 12 weeks without a significant improvement, you might consider surgery for your disc herniation. If you are experiencing weakness of an arm, leg or foot, you probably want to do something sooner. Loss of bowel or bladder (cauda equina) is a surgical emergency.
The goal of surgery is to relieve pressure on the nerve going to your arm or leg by removing the disc herniation (discectomy) with as little damage to the surrounding tissues. Removal of the herniation provides a better healing environment for the disc too.
There are three things that influence the surgery and size of the incision to perform a discectomy:
- The size of the instruments (The smaller the better)
- The location of the herniation (Central or foraminal)
- The direction of the approach to the disc herniation (Transforaminal or Interlaminar)
When you are referred for a discectomy, there is rarely much discussion, especially if you hear the words “minimally invasive”. But there are some things worth knowing.
The main reasons that endoscopic instruments can be so small is for two main reasons. One, the light source is located at the tip of the endoscope instead of somewhere in the operating room. Two, there is a 2 mm channel in the center of the endoscope that is used to pass instruments through to perform the surgery. (Watch a video about the endoscope here)
An interesting feature of the endoscope is that surgery is performed in a completely enclosed environment with continuous water irrigation (no air). As a matter of fact, the water under pressure actually acts like a “retractor” of sorts as it pushes tissue out of the operative field.
Most discectomies are now performed through a tube that acts as the retractor of soft tissues. The tube holds the tissues out of the way like typical blade retractors used to do. The main difference between tubes is the diameter. The endoscopic tube is about 7mm or a little larger than a ¼ inch. This is small when considering the diameter of the smallest tube for a microdiscectomy is usually 16 – 22 mm (½-1”).
Location of Disc Herniation – Foraminal
In the lumbar spine, a disc may herniate into the central or foraminal canal. The foraminal canal is pretty small and is best accessed using an endoscope from the side. This is the transforaminal approach. Larger tubes will not fit in the foraminal canal. As a matter of fact, a foraminal disc herniation is the ideal indication for an endoscopic transforaminal approach. This is a great approach that minimizes soft tissue injury to get access to the disc and requires no bone removal.
Location of Disc Herniation – Central of Paracentral
In the lumbar spine the disc may herniate into the central or paracentral part of the central canal. If a microdiscectomy is performed, the approach is from the behind and between the lamina (Interlaminar). Since the tube is pretty good sized, a portion of the lamina must usually be removed. The lamina removal (laminotomy) is necessary to get the tube close enough to the disc.
The endoscopic approach can utilize the interlaminar approach from the back without usually removing any bone since the tube is so small. Central discs that are contained can also be approached using the transforaminal approach. (Video on the interlaminar approach here)
- Micro-discetomy: While you are under general anesthesia, your surgeon will make a small (less than an 1 ½”) incision along the affected area. A retractor or tubular retractor is then used to move the soft tissues to the side so that the surgeon can remove the membrane covering the nerves. It’s very typical to have to remove a part of the bony arch of the spinal column (laminotomy) to get visualization. A tiny microscope allows your surgeon to visualize the nerve and remove any disc fragments that are pushing on it. After closing the incision, sterile strips are applied. Most surgeons perform this on an outpatient basis and will send you home with specific aftercare instructions.
If you suspect that you may have an issue related to your discs, please do not hesitate to contact me for a free one-on-one MRI consultation.