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| Patient Education -- Herniated
Disk |
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Herniated Disk
A herniated disc is a fragment of the disc nucleus which
is pushed out of the outer disc margin, into the spinal
canal through a tear or "rupture." In the herniated disc's
new position, it presses on spinal nerves, producing pain
down the accompanying leg. This produces a sharp, severe
pain down the entire leg and into the foot. The spinal
canal has limited space which is inadequate for the spinal
nerve and the displaced herniated disc fragment.
The compression and subsequent inflammation is directly
responsible for the pain one feels down the leg, termed
"sciatica." The direct compression of the nerve may produce
weakness in the leg or foot in a specific patter, depending
upon which spinal nerve is compressed.
A herniated disc is a definite displaced fragment of nucleus
pushed out through a tear in the outer layer of the disc
(annulus). For a disc to become herniated, it typically
is in an early stage of degeneration.
Typical Pain and Findings
Typically, a herniated disc is preceded by an episode
of low back pain or a long history of intermittent episodes
of low back pain. However, when the nucleus actually herniates
out through the annulus and compresses the spinal nerve,
then the pain typically changes from back pain to sciatica.
Sciatica is sharp pain which radiates from the low back
area down through the leg, into the foot in a characteristic
pattern, depending upon the spinal nerve affected. This
pain often is described as sharp, electric shock-like,
sever with standing, walking or sitting. The pain is frequently
relieved by lying down or utilizing a lumbar support chair
or insert.
There also may be resulting leg muscle weakness from a
compromise of the spinal nerve affected. Most commonly,
the back pain has resolved by the time sciatica develops,
or there is minimal back pain compared to the severe leg
pain. The location of the leg pain is usually so specific
that the doctor can indentify the disc level which is
herniated. In addition to leg muscle weakness, there may
also be knee or ankle reflex loss.
What Diagnostic Tests are Used for Evaluations
X-rays of the low back area are obtained to search for
unusual causes of leg pain, i.e. tumors, infections, fractures,
etc. An MRI of the lumbar spine area is obtained, as this
will demonstrate the degree of disc degeneration at the
herniated level, in addition to the condition of other
lumbar discs in the low back.
A quality MRI will accurately demonstrate the size of
the spinal canal and most other medically significant
factors. A nerve test may be indicated to demonstrate
whether there is ongoing nerve damage, or if the nerves
are in a state of healing a past insult, or whether there
is another site of nerve compression.
Treatment
The initial treatment for a herniated disc is usually
conservative, i.e. nonoperative. One usually begins with
resting the low back area, maintaining a comfortable posture
and painless activity level for a few days to several
weeks. This in in order to allow the spinal nerve inflammation
to quiet down and resolve.
A herniated disc is frequently aided by non-steroidal
anti-inflammatory medication such as Motrin, Voltaren,
Naprosyn, Lodine, Feldene, Clinoril, Tolectin, Dolobid,
Advil or Nuprin. 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.
Physical therapy may be beneficial, under the direction
of a physical therapist. The therapist will perform an
in-depth evaluation; this information, combined with a
physician's diagnosis, will dictate a treatment based
on successful physical therapy treatment modalities which
have proven beneficial for herniated disc patients. These
may include traction, ultrasound, electrical muscle stimulation,
etc., to relax the muscles which are in spasm and secondarily
inflamed from the compressed spinal nerve. Pain medication
and muscle relaxing medications may also be beneficial
to help physical therapy or other conservative, non-operative
treatment to relieve the pain while the spinal nerve root
inflammation resolves and the body heals itself. If these
conservative treatments are not successful and the pain
is still severe or muscle weakness is increasing, then
surgery is necessary. Surgery may be in the form of a
percutaneous discectomy if the disc herniation is small
and not a completely extruded disc fragment.
If the herniation is large, or is a "free fragment" as
described above, then a microlaminotomy with disc excision
is necessary. A micro-laminotomy requires one to two days
of hospitalization after the surgery for the wound to
heal and postoperative physical therapy to begin. The
sciatic pain down the leg should be resolved immediately
after the surgery. However, there will be some discomfort
in the low back area where the operation is performed,
lasting several days to a couple of weeks. This is controlled
with pain medication.
Prognosis
A person who has sustained one disc herniation is statistically
at increased risk for experiencing another. There is an
approximate 5% rate of recurrent disc herniation at the
same level, and a lesser incidence of new disc herniation
at another level. Factors involved may be weight related
level of physical conditioning, work or behavioral habits.
Since these factors are typically the same after surgery,
there is an increased risk of herniated disc in this group,
over the general population.
However, the good news is that the majority of disc herniations
(90%) do not require surgery, and will resolve with conservative,
nonoperative treatment, without significant long-term
sequelae. Unfortunately, approximately 5% of patients
with herniated, degenerated discs will go on to experience
symptomatic or severe and incapacitating low back pain
which significantly affects their life activities and
work. This unfortunate result is not always specifically
the result of surgery. The causes of this unremitting
pain are not always clear or agreed on, and my be from
several sources. When this occurs, the prognosis is poor
for returning to normal life activities regardless of
age.
After a successful laminotomy and discectomy, 80-85% of
patients do extremely well and are able to return to their
normal job in approximately six weeks time. There may
be small permanent patches of numbness in the involved
leg which, fortunately, are not disabling. Flare-ups or
exacerbations of less severe and less significant sciatic
type pain may develop in the future (usually on an infrequent
basis).
Recommendations
Our advice to those who have herniated disc disease is
to become knowledgeable in back school lifting techniques
and activity modifications from your physical therapist.
Making your back strong through exercises performed for
approximately 30 minutes daily will restore normal flexibility
in the lumbar spine region, as well as strengthen muscles
which can resist strain and repeat injury. Always avoid
heavy lifting, especially in association with twisting
of the lumbar spine. Protect your back for at least nine
months to a year after sustaining the herniated disc.
Feel free to consult your physical therapist for more
specific recommendations regarding postoperative or post-herniated
disc lumbar spine reconditioning and maintaining a well-conditioned
spine.
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