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Lumbar Disc Herniations

What is a Disc Herniation?

Disc herniations are also called “slipped discs” or “ruptured discs”. When a patient has a disc herniation, the outer ring of the disc (annulus fibrosus) ruptures and allows some of the softer inner core material (nucleus pulposus) to escape. An analogy would be a tube of toothpaste which was stepped on where the cap comes off and some of the toothpaste leaks out.

What is the difference between a Lumbar Disc Herniation, a Disc Protrusion and a Disc Bulge?

It is often thought that any change in the disc beyond a normal and health appearance is a disc herniation. This is not the case. There are several different changes in the shape of the disc which can occur:

  1. Disc Bulge:                                                                                 

A “disc bulge” is a change in the shape of the disc where the outer layer (annulus fibrosus) is weakened and allows a change in the shape to happen. The outer layer is only weakened to the point where it allows the pressure from the inner core to change its shape, but will not allow material to actually push all the way through and herniate. To qualify as a “bulged disc”, the change in the disc or bulging has to consist of more than 50% of the circumference of the disc when looking at it from the top down (cross-section). An analogy would be a hamburger which is too big for its bun and bulges out. Disc bulges are often part of the normal aging process of the spine and may not be part of a spine disease.

      2. Disc Protrusion

A “disc protrusion” is a change in the shape of the disc where the outer layer is weak in a smaller area. This weakness is more profound than in a “disc bulge” and allows that part of the disc to push out significantly more but in a smaller area. In a “disc protrusion”, some of the core material (nucleus) will push very hard against the weakened area and its material will be part of the protrusion, but not leak out through the outer ring (annulus) of the disc.

      3. Disc Herniation

A “disc herniation” goes beyond what happens in a disc bulge or a disc protrusion. To qualify as a true herniation, core material (nucleus pulposus) of the disc must have escaped from the main part of the core. Sometimes, a small amount of annulus still remains, coating this material, while at other times the core material is completely outside the outer ring (annulus fibrosus) and becomes a disc fragment.

Who is most likely to get a Lumbar Disc Herniation?

A true disc herniation is most common in younger adults aged 35-45, but can occur at any age. The rarest cases occur in children.

Studies have found that disc herniations are present in 5% of the population under the age of 40 who have no symptoms. Over the age of 40 this number doubles to 10%. Very few of these people actually have symptoms.

The most common spinal levels for discs to herniate are at the lower Lumbar, L4/5, and L5/S1 disc segment.

Which part of the Lumbar Disc is most likely to herniate?

The most common area for a herniation is on the sides of the back of the disc (posterior-lateral), where the outer ring (annulus fibrosus) is thinnest. Next to this part of the disc we have a spinal nerve on each side. When a disc herniates in this location, a spinal nerve can be affected. Depending on how much disc material herniates, a spinal nerve can either be irritated and inflamed or actually compressed

How common are Lumbar Disc Herniations?

Lumbar disc herniations account for only 5% of all low back problems, however they are the most common reason for Sciatica (Nerve Root Pain). They are also the most common reason for surgery of the spine.

Why do Lumbar Disc Herniations happen?

Disc herniations happen for a variety of reasons. In some patients it is the final result of many small injuries. For instance, patients who work in manual labor and are exposed to frequent heavy lifting may have lifting injuries from time to time. In this case, the outer ring of the disc (annulus fibrosus) may become inflamed and eventually gets weaker. When it reaches the limits of its ability to keep the inner core (nucleus) in its place, it may take only a small event such as coughing or sneezing to completely rupture the outer ring (annulus fibrosus). These patients are often surprised that they could have herniated a disc from a cough or sneeze. The reality is that the disc herniation was the result of many different events which happened over time and not just the cough or sneeze.

Other patients have a relatively normal disc, but suddenly overload it through a significant unusual weight loading which suddenly increases the pressure inside the core of the disc. The outer ring (annulus fibrosus) which normally could resist the force of incremental changes cannot compensate for the sudden, dramatic pressure against it and ruptures. This can happen in patients who lift a weight which is much heavier than what they are used to, or lift it with poor posture (legs straight, rather than bent). An example would be someone who is normally relatively sedentary and then has to move a refrigerator.

Disc herniations can also have a genetic component, i.e. can run in families. Sometimes one of the genes in charge of making a certain disc protein can be defective, leaving the disc weakened from birth.

What symptoms do patients with Lumbar Disc Herniations have?

Pain from a lumbar disc herniation can be felt in different ways, depending on where the disc herniated and how much material herniated.

Pain can be felt from the low-back to the legs. Sometimes patients feel numbness or tingling in the legs as well.

In other patients, the herniation does not affect the nerve itself, but inflames the outer ring of the disc or some of the structures next to it. This may result in low-back pain which is often sharp, deep pain which can radiate up and down the spine

Spasms of the mid-back muscles are very common in this situation. In severe cases, the spine can literally be twisted or bent to one side as a result of severe spasms. Some patients can literally not straighten their spine.

Unlike other pain syndromes where the pain may vary during the day, pain from disc herniation is often very steady and annoying.

Here again are some of the common symptoms of lumbar disc herniations:

  1. Low-back pain
  2. Low-back pain radiating to the leg
  3. Low-back stiffness
  4. Pain with movement of the low-back
  5. Spasms of the low-back muscles
  6. Leg pain only without low back pain

How do spine specialists make the diagnosis of a Lumbar Disc Herniation?

Spine specialists use information from the patient history, the physical examination and special spine tests to make the diagnosis.

  1. History

The patient history often points to a disc herniation. A patient’s description of coughing, sneezing or lifting a weight prior to having low-back pain or leg pain is very common. Some patients have a history of prior disc herniations and can pinpoint that the current problem is “just like when I herniated it before”.

Often questions are asked about sensation and strength in the legs.

The spine specialists may also ask specific questions about your bowel and bladder function. The reason for that is the fact that very large disc herniations can affect the spinal cord or cauda equina. When these structures are compressed, we often lose the ability to urinate and cannot control our bowels. This is rarely the case, but if it is may require emergency surgery.

      2. Examination

On the examination, patients often walk with a limp and have limited mobility of their back. Here are some common examination techniques done for disc herniations:

  1. Palpation (touching and pushing on the spine)
  2. Reflex Testing of the legs
  3. Sensation Testing of the legs
  4. Straight Leg Raising Test
  5. Muscle Strength Testing (motor testing) of the legs
  6. Valsalva Test
  7. Ankle Clonus Test
  8. Babinsky Test

      3. Imaging

The following images are often used to diagnose a disc herniation:

a. X-Rays

A basic X-Ray of the spine cannot show the disc itself, but it shows the space between the vertebrae where the disc is located. The height of each disc can be seen. However this may not point towards a disc herniation.

b. MRI Scans

MRI technology is the most advanced tool to actually see a disc herniation and is the study of choice. The images created by the MRI will show the discs, the spinal nerves and the spinal cord in detail. When a re-herniation following a disc surgery is suspected, intravenous dye is often given to be able to know what might be scar tissue as opposed to a new disc herniation.

c. CT Myelogram

This study is sometimes used if other imaging studies cannot show a disc herniation, yet the spine specialist is suspecting one. For instance when a patient has had metal inserted in the spine at the time of a previous surgery, the MRI images may be less than optimal in that area. A myelogram may help in this situation.

d. Lumbar Discogram

A discogram is a study where a spine specialist injects medication into a disc to help make a diagnosis. A disc may look suspicious for degeneration on an MRI study, however that may not be enough proof to recommend surgery. A discogram can get more information from the disc, such as whether a particular disc is painful.

What treatment do spine specialists offer for Lumbar Disc Herniations?

Most disc herniations will heal with time and do not require surgery. In fact, only 5% of all disc herniation will require an operation. Over 90% of patients with a disc herniation will improve in the first 6 weeks. However, patients often have significant pain during this time and can benefit from non-surgical care.

  1. Non-surgical Care

A. Rest

Taking time off from activities which stress the spine is important. If work exposes a patient to lifting, work restrictions may have to be placed. Staying in bed for longer periods of time has not been shown to help disc herniations. Typically it is recommended to do activities as tolerated except for lifting, running, excessive bending and twisting of the back, as well as high-impact activites.

B. Alternative Health Care

Alternative Health care options can often complement conventional medical care. Massage Therapy, Acupuncture, Meditation exercises and Herbal Remedies can all help with the pain from this condition. Massage Therapy can help with the muscle components of a lumbar disc herniation.

C. Nutrition and Weight Loss

Proper nutrition and weight loss can have a positive impact on many spine conditions. Excess weight on the spine often contributes to the symptoms of pain and spasms (Spine and Obesity).

D. Tabaco Cessation

Smoking reduces the amount of oxygen available to tissues. In the presence of a disc herniation, oxygen is needed to assist in healing from the inflammation resulting from the herniation. Nicotine may also interfere with the disc’s nutrition. In addition, nicotine appears to cause some sensitivity to pain.

E. Chiropractic Care

Chiropractic care including manipulation and adjustments of the spine can help with the pain and spasms from this condition. One limitation of spine manipulation is the presence of a spinal cord or nerve compression problem. This is called a “neurological” problem and often results in weakness in the legs. In this situation, spinal manipulation should be minimal if at all, for fear of pushing out more disc material making the neurological problems worse.

In absence of this, manipulation can be helpful in relieving some or all of the symptoms of nerve compression.

F. Spine Exercises

Spine exercises can help with the muscle pain and tightness from this condition. Exercise also increases the amount of oxygen delivered to the spine which can help with healing. Pilates, Yoga and T’ai Chi can help maintain the spine’s flexibility.

G. Physical Therapy (PT)

PT has many modalities to offer for this condition. They can range from Manual Therapy and Exercises to Traction and Ultrasound Treatments. PT can help disc herniations through a variety of means. This includes exercises, change in spine posture, and conditioning of certain muscles at risk for atrophy (loss of muscle bulk due to nerve damage). Physical therapists can also explain in detail what activities to avoid and which are best for a disc herniation. They can use modalities such as ultrasound and muscle stimulation to help with back spasms.

H. Self Help Tools

Self Help Tools are items which can be purchased to help with back pain. They range from Back Braces to Back Mattresses and Ergonomic Devices such as chairs and computer accessories. There are also a variety of Non-Surgical Decompression devices on the market which may offer some benefit.

I. Spine Medications

Below are the most commonly used groups of the medications for disc herniations. They can be used alone or in combinations depending on the severity of the symptoms and the doctor’s advice.

1. Non-steroid Anti-inflammatory Drugs (NSAIDS)

This group of medications which includes Ibuprofen and Naproxen Sodium amongst many others can have some benefit for disc herniations. However, higher doses are typically needed which may be difficult to tolerate.

2. Steroids

Steroid type anti-inflammatories can be very helpful especially for nerve pain in the arm. They are usually just used for the short term due their side effects.

3. Muscle Relaxants

Muscle relaxants are helpful when neck or back spasms are present. They may be able to interrupt the cycle of spasticity.

4. Pain Killers

Narcotic pain medications are usually reserved for severe pain or pain not relieved by the medications above. They should be used for the short term to avoid addiction.

5. Nerve Pain Medications

These medications can be very helpful for nerve pain from a compressed spinal nerve.

6. Antidepressants

These medications can help with nerve pain and the depression some patients suffer from pain.

J. Injections

  1. Trigger Point Injections/Muscle Blocks

Sometimes a muscle which is in severe spasm can be injection with medications such as steroids or local anesthetics for relief.

      2. Lumbar Epidural Injections

Epidural injections can deliver medication such as steroids and local anesthetics directly to the disc and a spinal nerve. This can help significantly in reducing the inflammation and pain from a disc herniation.

      3. Lumbar Interlaminar ESI

      4. Lumbar Transforaminal ESI

      5. Lumbar Nerve Root Block)

      6. Caudal Epidural Steroid Injection

 

K. Minimally Invasive Procedures

1. Percutaneous Lumbar Discectomy

2. Lumbar IDET

3. Endoscopic Lumbar Discectomy Surgeries

 

      2.Surgical Care

Surgical care for lumbar disc herniations is usually reserved for patients who do not get better after non-surgical care for 6-12 weeks and have significant symptoms. Only 5% of patients with disc herniations undergo surgery. Exceptions are patients who have signs of severe spinal cord or spinal nerve compression, who may need urgent surgery to avoid permanent nerve damage.

Here are some of the spine surgeries commonly performed for Lumbar Disc Herniations:

1.Endoscopic Lumbar Spine Surgery

2.Lumbar Micro Discectomy

3. Lumbar Discectomy

4. Lumbar Fusion

5. Lumbar Artificial Disc Replacement