Overview

 

Herniated disc, commonly known as slipped or ruptured disc, is a condition in which the central part of the intervertebral disc protrudes into the spinal canal. This typically occurs due to a tear in the tough fibrous annular ring that surrounds the soft inner core of the disc. This results in herniation of the softer material (the nucleus pulposus) into the spinal canal. Aging and trauma can predispose to disc herniations.

Most commonly disc herniations occur in the lowermost part of the spine, especially between the 4th and 5th lumbar vertebral bodies, and between the 5th lumbar vertebral body and the sacrum. This protrusion usually occurs to one side of the spinal canal, compressing one of the nerve roots. Impingement on the nerve causes pain, numbness, and weakness in the part of the skin and muscle that are supplied by that particular nerve root.

Causes

Why do I have this problem?

Herniation occurs when the nucleus in the center of the disc pushes out of its normal space. The nucleus presses against the annulus, causing the disc to bulge outward. Sometimes the nucleus herniates completely through the annulus and squeezes out of the disc.

Although daily activities may cause the nucleus to press against the annulus, the body is normally able to withstand this pressure. However, as the annulus ages, it tends to crack and tear. It is repaired with scar tissue. This process is known as degeneration. Over time, the annulus weakens, and the nucleus may begin to herniate (squeeze) through the damaged annulus. At first, the pressure bulges the annulus outward. Eventually, the nucleus may herniate completely through the outer ring of the disc.

Symptoms/Signs

The pain syndrome associate with the herniated disc is dependent upon the intervertebral level at which the herniation occurs.

Lumbar disc herniation typically causes "sciatic" type pain that extends from the back into the buttocks, thighs and legs, usually on one side. The following table describes the location of motor weakness, reflex change, and sensory deficit commonly seen with different disc herniation levels

Disc Level	Motor deficit	Reflex change	Sensory deficit
L3-4	Hip flexion and knee extension	Knee reflex	Anterior thigh, media calf
L4-5	Foot and toe dorsiflexion	None	Dorsal foot
L5-S1	Foot plantar flexion	Ankle reflex	Lateral foot and sole

Diagnosis

Spine examination may reveal a loss of normal spinal curvature and decreased range of motion due to muscle spasm. A Lasegue test, also known as straight-leg raise test, is performed. Raising the leg stretches the nerve roots, which may aggravate sciatic pain in the presence of a disc herniation.

Individual muscle groups are tested for strength to determine any signs of weakness. Reflexes are tested at the knees and ankles. Sensation to pin is tested in both legs.

A Lasegue test, also known as straight-leg raise test, is performed to examine if any lumbar nerve roots are involved. The patient lies down, the knee is extended, and the hip is flexed. If pain is aggravated or produced, it is an indication the lower lumbosacral nerve roots are inflamed.

Treatment

The initial treatment for a herniated disc is usually conservative and involves non-steroidal anti-inflammatory medication and rest. Approximately 80% of herniated discs can be managed conservatively. An epidural steroid injection may be performed utilizing a spinal needle under x-ray guidance to direct the medication to the exact level of the disc herniation. This is performed either by the neurosurgeon or a pain specialist.

Nonsurgical Treatment

Unless your condition is causing significant problems or is rapidly getting worse, most doctors will begin with nonsurgical treatment.

At first, your doctor may want your low back immobilized. Keeping the back still for a short time can calm inflammation and pain. This might include one or two days of bed rest. Lying on your back can take pressure off sore discs and nerves. However, most doctors advise against strict bed rest and prefer their patients to do ordinary activities using pain to gauge how much is too much. In rare cases in which bed rest is prescribed, it is usually used for a maximum of two days.

A back support belt is sometimes used for patients with lumbar disc herniation. The belt can help lower pressure inside the problem disc. Patients are encouraged to gradually discontinue wearing the support belt over a period of two to four days. Otherwise, their trunk muscles begin to rely on the belt and start to atrophy (shrink).

Doctors prescribe certain types of medication for patients with lumbar disc herniation. At first, you may be prescribed anti-inflammatory medications such as aspirin or ibuprofen. Severe symptoms that don't go away may be treated with narcotic drugs, such as codeine or morphine. But narcotics should only be used for the first few days or weeks because they are addictive when used too much or improperly. Muscle relaxants may be prescribed if the low back muscles are in spasm. Pain that spreads down the leg is sometimes relieved with oral steroids taken in tapering dosages.

You may work with a physical therapist. Therapy treatments focus on relieving pain, improving back movement, and fostering healthy posture. A therapist can design a program to help you prevent future problems.

Some patients who continue to have symptoms are given an epidural steroid injection (ESI). Steroids are powerful anti-inflammatories. In an ESI, medication is injected into the space around the lumbar spinal nerves where they branch off of the spinal cord. This area is called the epidural space. Some doctors inject only a steroid. Most doctors, however, combine a steroid with a long-lasting numbing medication. Generally, an ESI is given only when other treatments aren't working. But ESIs are not always successful in relieving pain. If they do work, they often provide only temporary relief.

Most people with a herniated lumbar disc get better without surgery. As a result, doctors usually have their patients try nonoperative treatments for at least six weeks before considering surgery. But when patients simply aren't getting better, or if the problem is becoming more severe, surgery may be suggested.

Surgery

If the symptoms you feel are mild and there is no danger they'll get worse, surgery is not usually recommended. However, if signs appear that pressure is building on the spinal nerves, surgery may be required, sometimes right away. The signs doctors watch for when reaching this decision include weakening in the leg muscles, pain that won't ease up, and problems with the bowels or bladder.

Surgical treatment for lumbar disc herniation includes :


laminotomy and discectomy

microdiscectomy

posterior lumbar fusion

Laminotomy And Discectomy

The lamina forms a roof-like structure over the back of the spinal canal. In this procedure, a thumbnail-sized piece of the lamina is removed (laminotomy) so the surgeon can more easily take out the problem disc (discectomy). This procedure is mainly used when the herniated disc is putting pressure on a nerve and causing pain to spread down one leg.

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