Herniated Discs How are the spine and its discs designed?

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). In addition, in the mid-buttock, beneath the fifth lumbar vertebra, 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, which is a bony prominence behind the spinal cord that shields the cords 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 serve to 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. What is a herniated disc? What causes it? 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 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 lumber vertebrae in the low back. This area is constantly 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 bodys 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. A herniated disk can irritate nearby nerves and result in pain, numbness or weakness in an arm or leg. On the other hand, many people experience no symptoms from a herniated disk. Most people who have a herniated disk dont need surgery to correct the problem. Symptoms You can have a herniated disk without knowing it herniated disks sometimes show up on spinal images of people who have no symptoms of a disk problem. But some herniated disks can be painful. The location of your symptoms may vary, depending on where the herniated disk is located along your spine. Most herniated disks occur in your lower back (lumbar spine), although they can also occur in your neck (cervical spine). The symptoms of a herniated disc 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 level of the disc herniation. This can cause shooting pain in the distribution of that nerve and usually occurs on one side of the body. For example, a disc herniation at the level between the fourth and fifth lumbar vertebrae of the low

back can cause a shooting pain down the buttock into the back of the thigh and down the leg. Sometimes this is associated with numbness and tingling in the leg. The pain often is worsened upon standing and decreases with lying down. If the disc herniation is extremely large, it can press on spinal nerves on both sides of the body. This can result in severe pain down both lower extremities. There can be marked weakness of the lower extremities and even incontinence of bowel and bladder. This is medically referred to as cauda equina syndrome. The most common signs and symptoms of a herniated disk are: y Arm or leg pain. If your herniated disk is in your lower back, youll typically feel the most intense pain in your buttocks, thigh and leg below the knee. It may also involve part of the foot. If your herniated disk is in your neck, the pain will typically be most intense in the shoulder and arm. This pain may shoot into your arm or leg when you cough, sneeze or move your spine into certain positions. Numbness or tingling. People who have a herniated disk often experience numbness or tingling in the body part served by the affected nerves. Weakness. Muscles served by the affected nerves tend to weaken. This may cause you to stumble, or impair your ability to lift or hold items.

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When to see a doctor Seek medical attention if your neck or back pain travels down your arm or leg, or if its accompanied by numbness, tingling or weakness. Causes Disk herniation is most often the result of a gradual, aging-related wear and tear called disk degeneration. As you age, your spinal disks lose some of their water content. That makes them less flexible and more prone to tearing or rupturing with even a minor strain or twist. Most people cant pinpoint the exact cause of their herniated disk. Sometimes, using your back muscles instead of your leg and thigh muscles to lift large, heavy objects can lead to a herniated disk, as can twisting and turning while lifting. Rarely, a traumatic event such as a fall or a blow to the back can cause a herniated disk. Risk factors Factors that increase your risk of a herniated disk may include: y y y Age. Herniated disks are most common in middle age, especially between 35 and 45, due to aging-related degeneration of the disks. Weight. Excess body weight causes extra stress on the disks in your lower back. Occupation. People with physically demanding jobs have a greater risk of back problems. Repetitive lifting, pulling, pushing, bending sideways and twisting also may increase your risk of a herniated disk.

Complications Your spinal cord doesnt extend into the lower portion of your spinal canal. Just below your waist, the spinal cord separates into a group of long nerve roots (cauda equina) that resemble a horses tail. Rarely, disk herniation can compress the entire cauda equina. Emergency surgery may be required to avoid permanent weakness or paralysis. Seek emergency medical attention if you have:

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Worsening symptoms. Pain, numbness or weakness may increase to the point that you cant perform your usual daily activities. Bladder or bowel dysfunction. People who have the cauda equina syndrome may become incontinent or have difficulty urinating even with a full bladder. Saddle anesthesia. This progressive loss of sensation affects the areas that would touch a saddle the inner thighs, back of legs and the area around the rectum.

Tests and diagnosis In most cases of herniated disk, a physical exam and a medical history are all thats needed to make a diagnosis. If your doctor suspects another condition or needs to see which nerves are affected, he or she may order one or more of the following tests. Imaging tests y y X-rays. Plain X-rays dont detect herniated disks, but they may be performed to rule out other causes of back pain, such as an infection, tumor, spinal alignment issues or a broken bone. Computerized tomography (CT scan). A CT scanner takes a series of X-rays from many different directions and then combines them to create cross-sectional images of your spinal column and the structures around it. Magnetic resonance imaging (MRI). Radio waves and a strong magnetic field are used to create images of your bodys internal structures. This test can be used to confirm the location of the herniated disk and to see which nerves are affected. Myelogram. A dye is injected into the spinal fluid, and then X-rays are taken. This test can show pressure on your spinal cord or nerves due to multiple herniated disks or other conditions.

Nerve tests Electromyograms and nerve conduction studies measure how well electrical impulses are moving along nerve tissue. This can help pinpoint the location of the nerve damage. Treatments and drugs Conservative treatment mainly avoiding painful positions and following a planned exercise and pain-medication regimen relieves symptoms in nine out of 10 people with a herniated disk. Many people get better in a month or two with conservative treatment. Imaging studies show that the protruding or displaced portion of the disk shrinks over time, corresponding to the improvement in symptoms. Medications y Over-the-counter pain medications. If your pain is mild to moderate, your doctor may tell you to take an over-the-counter pain medication, such as ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or naproxen (Aleve, others). Many of these drugs carry a risk of gastrointestinal bleeding, and large doses of acetaminophen may damage the liver. Narcotics. If your pain doesnt improve with over-the-counter medications, your doctor may prescribe narcotics, such as codeine or a hydrocodone-acetaminophen combination (Vicodin, Lortab, others), for a short time. Sedation, nausea, confusion and constipation are possible side effects from these drugs. Decrease or eliminate your Tylenol use if these combination medications are prescribed. Nerve pain medications. Drugs such as gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), tramadol (Ultram, Ryzolt) and amitriptyline often help relieve nerve-damage pain. Because these drugs have a milder set of side effects than do narcotic medications, theyre increasingly being used as first-line prescription medications for people who have herniated disks.

Muscle relaxers. Muscle relaxants such as diazepam (Valium) or cyclobenzaprine (Flexeril, Amrix) also may be prescribed if you have back or limb spasms. Sedation and dizziness are common side effects of these medications. Cortisone injections. Inflammation-suppressing corticosteroids may be given by injection directly into the area around the spinal nerves, using spinal imaging to more safely guide the needle.

Therapy Physical therapists can show you positions and exercises designed to minimize the pain of a herniated disk. As the pain improves, physical therapy can advance you to a rehabilitation program of core strength and stability to maximize your back health and help protect against future injury. A physical therapist may also recommend: y y y y y Heat or ice Traction Ultrasound Electrical stimulation Short-term bracing for the neck or lower back

Surgery A very small number of people with herniated disks eventually need surgery. Your doctor may suggest surgery if: y y y Conservative treatment fails to improve your symptoms after six weeks A disk fragment lodges in your spinal canal, pressing on a nerve and resulting in progressive weakness Youre having significant trouble performing basic activities such as standing or walking

In many cases, surgeons can remove just the protruding portion of the disk. Rarely, however, the entire disk must be removed. In these cases, the vertebrae may need to be fused together with metal hardware to provide spinal stability. Or your surgeon may suggest the implantation of an artificial disk. Home style y Take pain relievers. Over-the-counter medications such as ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or naproxen (Aleve, others) may help reduce the pain associated with a herniated disk. Use heat or cold. Initially, cold packs can be used to relieve pain and inflammation. After a few days, you may switch to gentle heat to give relief and comfort. Avoid too much bedrest. Too much bedrest can lead to stiff joints and weak muscles which can complicate your recovery. Instead, rest in a position of comfort for 30 minutes, and then go for a short walk or do some work. Try to avoid activities that worsen your pain during the healing process.

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