2. • A spinal disc herniation (prolapsus disci intervertebralis) is a
medical condition affecting the spine due to trauma, lifting
injuries, or idiopathic (unknown) causes, in which a tear in the
outer, fibrous ring (annulus fibrosus) of an intervertebral disc (discus
intervertebralis) allows the soft, central portion (nucleus pulposus)
to bulge out beyond the damaged outer rings. Tears are almost
always postero-lateral in nature owing to the presence of the
posterior longitudinal ligament in the spinal canal. This tear in the
disc ring may result in the release of inflammatory chemical
mediators which may directly cause severe pain, even in the
absence of nerve root compression.
• Disc herniations are normally a further development of a
previously existing disc "protrusion", a condition in which the
outermost layers of the annulus fibrosus are still intact, but can
bulge when the disc is under pressure. In contrast to a herniation,
none of the nucleus pulposus escapes beyond the outer layers.
• Most minor herniations heal within several weeks. Anti-
inflammatory treatments for pain associated with disc herniation,
protrusion, bulge, or disc tear are generally effective. Severe
herniations may not heal of their own accord and may require
surgical intervention.
• The condition is widely referred to as a slipped disc, but this term is
not medically accurate as the spinal discs are fixed in position
between the vertebrae and cannot "slip".
3. • Terminology
• Normal situation and spinal disc herniation in cervical vertebrae.
• Some of the terms commonly used to describe the condition include
herniated disc, prolapsed disc, ruptured disc and slipped disc. Other
phenomena that are closely related include disc protrusion, pinched
nerves, sciatica, disc disease, disc degeneration, degenerative disc
disease, and black disc.
• The popular term slipped disc is a misnomer, as the intervertebral
discs are tightly sandwiched between two vertebrae to which they
are attached, and cannot actually "slip", or even get out of place.
• The disc is actually grown together with the adjacent vertebrae and
can be squeezed, stretched and twisted, all in small degrees. It can
also be torn, ripped, herniated, and degenerated, but it cannot "slip".
Some authors consider that the term "slipped disc" is harmful, as it
leads to an incorrect idea of what has occurred and thus of the likely
outcome.
4. • However, during growth, one vertebral body can slip relative to
an adjacent vertebral body. This congenital deformity is called
spondylolisthesis.
• Signs and symptoms
Symptoms of a herniated disc can vary depending on the
location of the herniation and the types of soft tissue that
become involved. They can range from little or no pain if the disc
is the only tissue injured, to severe and unrelenting neck or low
back pain that will radiate into the regions served by affected
nerve roots that are irritated or impinged by the herniated
material. Often, herniated discs are not diagnosed immediately,
as the patients come with undefined pains in the thighs, knees, or
feet.
Other symptoms may include sensory changes such as numbness,
tingling, muscular weakness, paralysis, paresthesia, and affection
of reflexes. If the herniated disc is in the lumbar region the patient
may also experience sciatica due to irritation of one of the nerve
roots of the sciatic nerve. Patients with L3 or L5 herniated disc
(usually affecting the knee and leg) also have a high chance of
experiencing decreased sexual performance ( erectile
dysfunction ) due to the tissue involved with the penile muscle
tissue.
5. • If the extruded nucleus pulposus material doesn't press on the p
tissues or muscles, patients may not experience any reduced
sexual function symptoms. Unlike a pulsating pain or pain that
comes and goes, which can be caused by muscle spasm, pain
from a herniated disc is usually continuous or at least is
continuous in a specific position of the body.
It is possible to have a herniated disc without any pain or
noticeable symptoms, depending on its location. If the
extruded nucleus pulposus material doesn't press on soft tissues
or nerves, it may not cause any symptoms. A small-sample
study examining the cervical spine in symptom-free volunteers
has found focal disc protrusions in 50% of participants, which
suggests that a considerable part of the population can have
focal herniated discs in their cervical region that do not cause
noticeable symptoms.
Typically, symptoms are experienced only on one side of the
body. If the prolapse is very large and presses on the spinal
cord or the cauda equina in the lumbar region, both sides of
the body may be affected, often with serious consequences.
Compression of the cauda equina can cause permanent
nerve damage or paralysis. The nerve damage can result in loss
of bowel and bladder control as well as sexual dysfunction. This
disorder is called cauda equina syndrome.
6. • Herniation of the contents of the disc into the spinal canal often
occurs when the anterior side (stomach side) of the disc is
compressed while sitting or bending forward, and the contents
(nucleus pulposus) get pressed against the tightly stretched
and thinned membrane (annulus fibrosis) on the posterior side
(back side) of the disc. The combination of membrane thinning
from stretching and increased internal pressure (200 to 300 psi)
results in the rupture of the confining membrane. The jelly-like
contents of the disc then move into the spinal canal, pressing
against the spinal nerves, thus producing intense and usually
disabling pain and other symptoms.[citation needed]
• There is also a strong genetic component. Mutation in genes
coding for proteins involved in the regulation of the
extracellular matrix, such as MMP2 and THBS2, has been
demonstrated to contribute to lumbar disc herniation.
• Location
The majority of spinal disc herniation cases occur in lumbar
region (95% in L4-L5 or L5-S1). The second most common site is
the cervical region (C5-C6, C6-C7). The thoracic region
accounts for only 0.15% to 4.0% of cases.
7. • Herniations usually occur posterolaterally, where the annulus
fibrosis is relatively thin and is not reinforced by the posterior or
anterior longitudinal ligament in the cervical spinal cord, a
symptomatic posterolateral herniation between two vertebrae
will impinge on the nerve which exits the spinal canal between
those two vertebrae on that side. So for example, a right
posterolateral herniation of the disc between vertebrae C5
and C6 will impinge on the right C6 spinal nerve. The rest of the
spinal cord, however, is oriented differently, so a symptomatic
posterolateral herniation between two vertebrae will actually
impinge on the nerve exiting at the next intervertebral foramen
down. So for example, a herniation of the disc between the L5
and S1 vertebrae will impinge on the S1 spinal nerve, which
exits between the S1 and S2 vertebrae.
• Cervical
Cervical disc herniations occur in the neck, most often
between the fifth & sixth (C5/6) and the sixth and seventh
(C6/7) cervical vertebral bodies. Symptoms can affect the
back of the skull, the neck, shoulder girdle, scapula, shoulder,
arm, and hand. The nerves of the cervical plexus and brachial
plexus can be affected.
8. • Lumbar
Lumbar disc herniations occur in the lower back, most often
between the fourth and fifth lumbar vertebral bodies or
between the fifth and the sacrum. Symptoms can affect the
lower back, buttocks, thigh, anal/genital region (via the Perineal
nerve), and may radiate into the foot and/or toe. The sciatic
nerve is the most commonly affected nerve, causing symptoms
of sciatica. The femoral nerve can also be affected and cause
the patient to experience a numb, tingling feeling throughout
one or both legs and even feet or even a burning feeling in the
hips and legs.
Pathophysiology
• There is now recognition of the importance of “chemical
radiculitis” in the generation of back pain. A primary focus of
surgery is to remove “pressure” or reduce mechanical
compression on a neural element: either the spinal cord, or a
nerve root. But it is increasingly recognized that back pain,
rather than being solely due to compression, may also be due
to chemical inflammation. There is evidence that points to a
specific inflammatory mediator of this pain. This inflammatory
molecule, called tumor necrosis factor-alpha (TNF), is released
not only by the herniated disc, but also in cases of disc tear
(annular tear), by facet joints,
9. • and in spinal stenosis In addition to causing pain and
inflammation, TNF may also contribute to disc degeneration.
Diagnosis
Diagnosis is made by a practitioner based on the history,
symptoms, and physical examination. At some point in the
evaluation, tests may be performed to confirm or rule out other
causes of symptoms such as spondylolisthesis, degeneration,
tumors, metastases and space-occupying lesions, as well as to
evaluate the efficacy of potential treatment options.
Physical examination
Main article: Straight leg raise
The Straight leg raise may be positive, as this finding has low
specificity; however, it has high sensitivity. Thus the finding of a
negative SLR sign is important in helping to "rule out" the
possibility of a lower lumbar disc herniation. A variation is to lift
the leg while the patient is sitting. However, this reduces the
sensitivity of the test.
10. • Treatment
In the majority of cases, spinal disc herniation doesn't require
surgery, and a study on sciatica, which can be caused by
spinal disc herniation, found that "after 12 weeks, 73% of
patients showed reasonable to major improvement without
surgery." The study, however, did not determine the number of
individuals in the group that had sciatica caused by disc
herniation.
Initial treatment usually consists of non-steroidal anti-
inflammatory pain medication (NSAIDs), but the long-term use
of NSAIDs for patients with persistent back pain is complicated
by their possible cardiovascular and gastrointestinal toxicity. An
alternative often employed is the injection of cortisone into the
spine adjacent to the suspected pain generator, a technique
known as “epidural steroid injection”. Epidural steroid injections
"may result in some improvement in radicular lumbosacral pain
when assessed between 2 and 6 weeks following the injection,
compared to control treatments. Complications resulting from
poor technique are rare.
11. Ancillary approaches, such as rehabilitation, physical therapy,
anti-depressants, and, in particular, graduated exercise
programs, may all be useful adjuncts to anti-inflammatory
approaches.
Lumbar
Non-surgical methods of treatment are usually attempted first,
leaving surgery as a last resort. Pain medications are often
prescribed as the first attempt to alleviate the acute pain and
allow the patient to begin exercising and stretching. There are
a variety of other non-surgical methods used in attempts to
relieve the condition after it has occurred, often in combination
with pain killers. They are either considered indicated,
contraindicated, relatively contraindicated, or inconclusive
based on the safety profile of their risk-benefit ratio and on
whether they may or may not help:
Surgical options
• Chemonucleolysis - dissolves the protruding disc
• IDET (a minimally invasive surgery for disc pain)
• Discectomy/Microdiscectomy - to relieve nerve compression
• Tessys method - a transforaminal endoscopic method to
remove herniated discs
12. • Laminectomy - to relieve spinal stenosis or nerve compression
• Hemilaminectomy - to relieve spinal stenosis or nerve
compression
• Lumbar fusion (lumbar fusion is only indicated for recurrent
lumbar disc herniations, not primary herniations)
• Anterior cervical discectomy and fusion (for cervical disc
herniation)
• Disc arthroplasty (experimental for cases of cervical disc
herniation)
• Dynamic stabilization
• Artificial disc replacement, a relatively new form of surgery in
the U.S. but has been in use in Europe for decades, primarily
used to treat low back pain from a degenerated disc.
• Nucleoplasty
Surgical goals include relief of nerve compression, allowing the
nerve to recover, as well as the relief of associated back pain
and restoration of normal function.
13. Rehabilitation
Rehabilitation of a herniated disc varies greatly upon a
patient’s condition. Major factors taken into consideration are
the patient’s pain threshold and severity of injury. [Degree of
injury] ranges from some minor discomfort to immense pain that
causes movement restrictions *. Possible sciatica symptoms are
also taken into account when discussing a patient’s discomfort.
Electrostimulation
A module of rehabilitation is electrostimulation * which is
commonly used in the physical therapy field. Electrostimulation
therapy includes placement of electrode pads proximal to the
strained or weakened erector spinae surrounding the herniated
disc.
• Laser Light Therapy
[Laser light therapy] is a light utilizing module with an instrument
that emits the therapeutic light directly onto the injured area.
• Ultrasound Therapy
Ultrasound* is similar to laser therapy in its direct application to
damaged tissues but utilizes vibrations in a crystal-containing
handheld unit.
14. • Hot/Cold Therapy
A general form of therapy is the use of ice packs and heat
packs which are usually wrapped in a towel and applied
directly.
• Weightlifting
Weightlifting has been used in conjunction with the
aforementioned therapeutic modalities. Gasiorowski’s research
proves that patients who qualify for surgical procedures can
alternatively select weightlifting to avoid risks of surgery.
Weightlifting involves the use of multigym machines, free-
weights, and barbells. As a part of this type of therapy,
plyometric exercises were implemented to help correct any
imbalances in the patient’s gait that resulted from disc
herniation *.
• Epidemiology
15. Stages of Spinal Disc Herniation
Disc herniation can occur in any disc in the spine, but the two
most common forms are lumbar disc herniation and cervical
disc herniation. The former is the most common, causing lower
back pain (lumbago) and often leg pain as well, in which case
it is commonly referred to as sciatica.
Lumbar disc herniation occurs 15 times more often than
cervical (neck) disc herniation, and it is one of the most
common causes of lower back pain. The cervical discs are
affected 8% of the time and the upper-to-mid-back (thoracic)
discs only 1 - 2% of the time.
The following locations have no discs and are therefore exempt
from the risk of disc herniation: the upper two cervical
intervertebral spaces, the sacrum, and the coccyx.
Most disc herniations occur when a person is in their thirties or
forties when the nucleus pulposus is still a gelatin-like substance.
With age the nucleus pulposus changes ("dries out") and the
risk of herniation is greatly reduced. After age 50 or 60,
osteoarthritic degeneration (spondylosis) or spinal stenosis are
more likely causes of low back pain or leg pain.
16. • 4.8% males and 2.5% females older than 35 experience sciatica
during their lifetime.
• Of all individuals, 60% to 80% experience back pain during their
lifetime.
• In 14%, pain lasts more than 2 weeks.
• Generally, males have a slightly higher incidence than females.
Prevention
Because there are various causes for back injuries, prevention
must be comprehensive . Back injuries are predominant in
manual labor so the majority low back pain prevention
methods have been applied primarily toward biomechanics
Prevention must come from multiple sources such as
education, proper body mechanics, and physical fitness.
Education
Education should emphasize not lifting beyond ones
capabilities and giving the body a rest after strenuous effort.
Over time, poor posture can cause the IVD to tear or become
damaged. Striving to maintain proper posture and alignment
will aid in preventing disc degradation
17. • Exercise
• Exercises that are used to enhance back strength may also be
used to prevent back injuries. Back exercises include the prone
press-ups, transverse abdominus bracing, and floor bridges.
Abdominal bracing protects against joint and disc injury. If pain
is present in the back, the stabilization muscles of the back are
weak and a person needs to train the trunk musculature.
Another preventative measure is to not work ourselves past
fatigue. Signs of fatigue include shaking, poor
coordination,muscle burning and loss of the transverse
abdominal brace.Individuals who engage in power lifting
place their bodies under heavy stress Barbells are common
tools used in strength training.The usage of lumbarsacral
support belts may restrict movement at the spine and support
the back during lifting
POSTED BY ATTORNEY RENE G. GARCIA:
For more information:- Some of our clients have suffered this kind of
injuries due to a serious accident. The Garcia Law Firm, P.C. was able to
successfully handle these types of cases. For a free consultation please
call us at 1-866- SCAFFOLD or 212-725-1313.
http://en.wikipedia.org/wiki/Herniated_disc
