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Herniated Disk (Slipped, Ruptured Disks)
Disk herniation is a rupture of fibrocartilaginous material (annulus fibrosus) that surrounds the intervertebral disk. This rupture involves the release of the disk’s center portion containing a gelatinous substance called the nucleus pulposus. Pressure from the vertebrae above and below may cause the nucleus pulposus to be forced outward, placing pressure on a spinal nerve and causing considerable pain and damage to the nerve. This condition most frequently occurs in the lumbar region and is also commonly called herniated nucleus pulposus, prolapsed disk, ruptured intervertebral disk, or slipped disk
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Description of a herniated Disk (Ruptured, Slipped Disk)
The spinal column is made up of 26 vertebrae that are joined together and permit forward and backward bending, side bending, and rotation of the spine. Five distinct regions comprise the spinal column, including the cervical (neck) region, thoracic (chest) region, lumbar (low back) region, sacral and coccygeal (tailbone) region. The cervical region consists of seven vertebrae, the thoracic region includes 12 vertebrae, and the lumbar region contains five vertebrae. The sacrum is composed of five fused vertebrae, which are connected to four fused vertebrae forming the coccyx. Intervertebral disks lie between each adjacent vertebra.
Each disk is composed of a gelatinous material in the center, called the nucleus pulposus, surrounded by rings of a fiberous tissue (annulus fibrosus). In disk herniation, an intervertebral disk’s central portion herniates or slips through the surrounding annulus fibrosus into the spinal canal, putting pressure on a nerve root. Disk herniation most commonly affects the lumbar region between the fifth lumbar vertebra and the first sacral vertebra. However, disk herniation can also occur in the cervical spine. The incidence of cervical disk herniation is most common between the fifth and sixth cervical vertebrae. The second most common area for cervical disk herniation occurs between the sixth and seventh cervical vertebrae. Disk herniation is less common in the thoracic region.
Predisposing factors associated with disk herniation include age, gender, and work environment. The peak age for occurrence of disk herniation is between 20-45 years of age. Studies have shown that males are more commonly affected than females in lumbar disk herniation by a 3:2 ratio. Prolonged exposure to a bent-forward work posture is correlated with an increased incidence of disk herniation.
There are four classifications of disk pathology:
- A protrusion may occur where a disk bulges without rupturing the annulus fibrosis.
- The disk may prolapse where the nucleus pulposus migrates to the outermost fibers of the annulus fibrosis.
- There may be a disk extrusion, which is the case if the annulus fibrosis perforates and material of the nucleus moves into the epidural space.
- The sequestrated disk may occur as fragments from the annulus fibrosis and nucleus pulposus are outside the disk proper.
Any direct, forceful, and vertical pressure on the lumbar disks can cause the disk to push its fluid contents into the vertebral body. Herniated nucleus pulposus may occur suddenly from lifting, twisting, or direct injury, or it can occur gradually from degenerative changes with episodes of intensifying symptoms. The annulus may also become weakened over time, allowing stretching or tearing and leading to a disk herniation. Depending on the location of the herniation, the herniated material can also press directly on nerve roots or on the spinal cord, causing a shock-like pain (sciatica) down the legs, weakness, numbness, or problems with bowels, bladder, or sexual function.
Diagnosis of a herniated disk (Ruptured, Slipped Disk)
Several radiographic tests are useful for confirming a diagnosis of disk herniation and locating the source of pain. These tests also help the surgeon indicate the extent of the surgery needed to fully decompress the nerve. X rays show structural changes of the lumbar spine. Myelography is a special x ray of the spine in which a dye or air is injected into the patient’s spinal canal. The patient lies strapped to a table as the table tilts in various directions and spot x rays are taken. X rays showing a narrowed dye column in the intervertebral disk area indicate possible disk herniation.
Computed tomography scan (CT or CAT scans) exhibit the details of pathology necessary to obtain consistently good surgical results. Magnetic resonance imaging (MRI) analysis of the disks can accurately detect the early stages of disk aging and degeneration. Electromyograms (EMGs) measure the electrical activity of the muscle contractions and possibly show evidence of nerve damage. An EMG is a powerful tool for assessing muscle fatigue associated with muscle impairment with low back pain.
Physical therapists are skilled in treating acute back pain caused by the disk herniation. The physical therapist can provide noninvasive therapies, such as ultrasound or diathermy to project heat deep into the tissues of the back or administer manual therapy, if mobility of the spine is impaired. They may help improve posture and develop an exercise program for recovery and long-term protection. Appropriate exercise can help take pressure off inflamed nerve structures, while improving overall posture and flexibility. Traction can be used to try to decrease pressure on the disk. A lumbar support can be helpful for a herniated disk at this level as a temporary measure to reduce pain and improve posture.
Symptoms of a herniated disk (Ruptured, Slipped Disks)
- Pain-severity and location of the pain depend upon which discs herniated and how large the herniation is;
- Pain may spread over the buttocks, down the back of one thing and into the calf
- Pain may be in one or both (more rare) legs
- Numbness, tingling, or weakness in the legs or feet
- Bowel or bladder changes
- In severe cases inability to find comfort even lying down
- Sudden aching or twisted neck that cannot be straightened without severe pain
- Numbness tingling or weakness in one or both arms
Diagnosis of a herniated disk (Ruptured, Slipped Disks)
The doctor will ask about your symptoms and medical history, and perform a physical exam. The doctor will ask specific questions about the pain and examine the spine. The doctor will also test the movement, strength, and reflexes of the arms and legs.
Test may include:
- X-ray- a test that uses radiation to take a picture of structures inside the body, especially bones.
- CT Scan- a type of x-ray that uses a computer to make pictures of structures inside the body
- MRI- a test that uses magnetic waves to make pictures of structures inside the body and allows both the bones and the disk to be seen
- Diskography- a test that involves injecting a dye into the center of the disk and then taking an x-ray, which may show the dye leaking out.
- Electromyography- a test that measures the electrical activity of muscle by placing needle electrodes into the muscle. This can indicate whether the nerve signal to the muscle is firing normally.
- Myelography- a type of x-ray that uses dye injected in the space around the spinal cord to more clearly outline the space containing the spinal cord, the nerves, and show any disk herniation.
Treatment of a herniated disk (Rupture, Slipped Disks)
Treatments may include:
- Non steroidal anti-inflammatory medications (NSAIDS) such as ibuprofen or naproxen, may be prescribed to reduce pain.
- Muscle Relaxants
- Muscle relaxants may be prescribed to reduce muscle spasms.
- Steroid Injections
- If medicine doesn’t help, steroids may be injected into the area around the nerve and disk herniation backbone to reduce pain and inflammation.
- Bed Rest
- Bed rest for one or two days is often suggested for severe pain. You should lie on a firm mattress with your knees and hips partially bent. Your lower legs may be elevated on pillows or a wedge.
Back or Neck Massage and Physical Therapy
Back or neck massage and physical therapy can help:
- Relax the neck and back muscles
- Decrease pain
- Increase strength and mobility
- After the acute phase there are certain back and abdominal exercises that can help the recovery phase and prevent recurrences
- Hot or Cold Packs
- Hot or cold packs help reduce pain and muscle spasms.
- Stretching the Spine
- A doctor or chiropractor can sometimes help reduce pain by stretching your spine. Any spinal manipulation for a chronic disk problem must be done very carefully and only by an experienced, licensed practitioner.
Weights and pulleys may be used to relieve pressure on the disks and the patients from moving around; this is more common for disks in the neck area.
- Neck Collar or Brace For a herniated disk in the neck, a neck collar or brace may be used to relieve muscle spasms. Surgery is often appropriate for conditions that do not improve with the usual treatment. In this event, a strong, flexible spine is important for a quick recovery after surgery. There are several surgical approaches to treating a herniated disk, including the classic discectomy, microdiscectomy, or percutanteous discectomy. The basic differences among these procedures are the size of the incision, how the disk is reached surgically, and how much of the disk is removed. Discectomy is the surgical removal of the portion of the disk that is putting pressure on a nerve causing the back pain. In the classic disectomy, the surgeon first enters through the skin and then removes a bony portion of the vertebra called the lamina, hence the term laminectomy. The surgeon removes the disk material that is pressing on a nerve. Rarely is the entire lamina or disk entirely removed. Often, only one side is removed and the surgical procedure is termed hemi-laminectomy.
In microdiscectomy, through the use of an operating microscope, the surgeon removes the offending bone or disk tissue until the nerve is free from compression or stretch. This procedure is possible using local anesthesia. Microsurgery techniques vary and have several advantages over the standard discectomy, such as a smaller incision, less trauma to the musculature and nerves, and easier identification of structures by viewing into the disk space through microscope magnification.
Percutaneous disk excision is performed on an outpatient basis, is less expensive than other surgical procedures, and does not require a general anesthesia. The purpose of percutaneous disk excision is to reduce the volume of the affected disk indirectly by partial removal of the nucleus pulposus, leaving all the structures important to stability practically unaffected. In this procedure, large incisions are avoided by inserting devices that have cutting and suction capability. Suction is applied and the disk is sliced and aspirated.
Arthroscopic microdiscectomy is similar to percutaneous discectomy, however it incorporates modified arthroscopic instruments, including scopes and suction devices. A suction irrigation of saline solution is established through two entry sites. A video discoscope is introduced from one site and the deflecting instruments from the opposite side. In this way, the surgeon is able to search and extract the nuclear fragments under direct visualization.
Laser disk decompression is performed using similar means as percutaneous excision and arthroscopic microdiscectomy, however laser energy is used to remove the disk tissue. Here, laser energy is percutanteously introduced through a needle to vaporize a small volume of nucleus pulposus, thereby dropping the pressure of the disk and decompressing the involved neural tissues. One disadvantage of this procedure is the high initial cost of the laser equipment. It is important to realize that only a very small percentage of people with herniated lumbar disks go on to require surgery. Further, surgery should be followed by appropriate rehabilitation to decrease the chance of reinjury.
Chemonucleolysis is an alternative to surgical excision. Chymopapain, a purified enzyme derived from the papaya plant, is injected percutaneously into the disk space to reduce the size of the herniated disks. It hydrolyses proteins, thereby decreasing water-binding capacity, when injected into the nucleus pulposus inner disk material. The reduction in size of the disk relieves pressure on the nerve root.
Spinal fusion is the process by which bone grafts harvested from the iliac crest (thick border of the ilium located on the pelvis) are placed between the intervertebral bodies after the disk material is removed. This approach is used when there is a need to reestablish the normal bony relationship between the vertebrae. A total discectomy may be needed in some cases because lumbar spinal fusion can help prevent recurrent lumbar disk herniation at a particular level.
Alternative Treatment for herniated disks (Ruptured, Slipped Disks)
Acupuncture involves the use of fine needles inserted along the pathway of the pain to move energy locally and relieve the pain. An acupuncturist determines the location of the nerves affected by the herniated disk and positions the needles appropriately. Massage therapists may also provide short-term relief from a herniated disk. Following manual examination and x-ray diagnosis, chiropractic treatment usually includes manipulation to correct muscle and joint malfunctions, while care is taken not to place an additional strain on the injured disk. If a full trial of conservative therapy fails, or if neurologic problems (weakness, bowel or bladder problems, and sensory loss) develop, the next step is usually evaluation by an orthopedic surgeon.
Prognosis for herniated disks (Ruptured, Slipped Disks)
Only 5-10% of patients with unrelenting sciatica and neurological involvement, leading to chronic pain of the lumbar spine, need to have a surgical procedure performed. This strongly suggests that many patients with herniated disks at the lumbar level respond well to conservative treatment. For those patients who do require surgery for lumbar disk herniation, the reviewed procedures of nerve root decompression caused by disk herniation is favorable. Results of studies varied from 60-90% success rates. Disk surgery has progressively evolved in the direction of decreasing invasiveness. Each surgical procedure is not without possible complications, which can lead to chronic low back pain and restricted lifestyle.
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