Herniated Discs
with Miguel Jimenez, M.D.
Herniated discs are a common source of lower back pain. They occur when the disc, the cushion between the vertebrea in the spinal column, herniates or ruptures and puts pressure on the spinal nerves. The term many sufferers use for this is a "slipped disc."
Miguel Jimenez, M.D. - Orthopaedics, Fellowship Trained, Spine Surgery, who is with Advanced Healthcare, noted that along with pain, a person with a herniated disc might notice sensory changes, such as numbness, tingling or weakness in their legs. This will occur in the limb whose nerves are being compressed by the slipped disc.
Who is at risk?
Most herniated discs occur in males 30 to 50 years of age who work in a profession that requires heavy lifting, twisting or asymmetrical postures. It also seems to occur most frequently in those with stressful occupations, though researchers are not sure why. Cigarette smoking also increases the risk.
Another group that can suffer from disc problems are those with osteoarthritis affecting the spine, particularly if spinal stenosis is present. Osteoarthritis of the spine tends to narrow the space available for the nerves in the spine. This narrowing is called stenosis and may result in earlier, more severe symptoms of nerve compression.
The Anatomy of the problem
Sitting between the vertebrae in the spine, the discs act as cushions or shock absorbers. Each disc is composed of a jelly substance in its center (the nucleus polpusos) and a fibrous band around it (the annulus) that holds the cushioning jelly in place.
There are different types of herniations. These include:
• A disc bulge, in which the annulus bulges on the outside. It usually causes no symptoms.
• A disc herniation is when you get a protrusion; the herniated disc material puts pressure on the nerves.
• An extrusion is when the herniated material is almost completely detached from the parent disc and puts more pressure on the nerves.
According to Dr. Jimenez, a disc bulge is not a true herniation. "If you get an MRI on people without any symptoms, as many as a third have some sort of disc abnormality but no symptoms. Just because you see something abnormal on an MRI doesn't mean that this is the cause of their problem," he said.
Miguel Jimenez, M.D. - Orthopaedics, Fellowship Trained, Spine Surgery
Advanced Healthcare
Herniated discs are a common source of lower back pain. They occur when the disc, the cushion between the vertebrea in the spinal column, herniates or ruptures and puts pressure on the spinal nerves. The term many sufferers use for this is a "slipped disc."
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The problem of the lower spine
About 90% of herniated discs occur in the lower lumbar region of the spine, the doctor said. This is because the area is one of the main weight-bearing parts of the spine. The lumbar spine is also flexible but at either end the spine is stiffer. This puts extra stress on the lumbar vertebrae.
"Patients with herniated discs can have sciatica which starts in the back and can progress below the knee. You can determine the location of the problem by looking at where the pain is. Patients with higher herniations can have symptoms in the thigh, for example," the doctor said.
Sciatica is often aggravated by sitting down and relieved by lying down or standing. "The thinking is that when you sit, you tend to lean forward more than you would when you are standing up. By leaning forward, it's believed you increase pressure within the disc space. Medical research has also documented increased disc pressure in the sitting position," Dr. Jimenez said.
Disc degeneration
As people age, their disc dehydrate, then fragment. Some may develop annular tears that let the jelly (nucleus herniate) out. "The inner portion has few nerves, people are usually asymptomatic at this stage. Only when the fibrous band tears completely do people develop symptoms they can feel," the doctor said.
The leaking jelly sets in motion other problems. There is increased pressure, inflammation, and decreased blood to the nerves. "Also, extruded nucleus pulposus is believed to release chemicals that increase inflammation and induce a pain response in the nerve," the doctor added.
The problem develops over many years. However, symptoms may occur earlier if the patient also suffers from lumbar spinal stenosis.
Diagnosing and treating the problem
The diagnosis of a herniated disc can be made on clinical exam.
Non-surgical treatment is usually tried for six to eight weeks first. At this time an MRI (Magentic Resonance Imaging) or CAT (Computerized Axial Tomography) Myelogram (CAT imaging enhanced with radio-opaque dye) to locate the problem, are performed. However, surgery is considered immediately in people with a large disc herniation in the upper part of the lumbar spine because this can result in Cauda Equina syndrome.
"Cauda Equina syndrome can create difficulties with bowel and bladder control, saddle anesthesia (numbness in the groin area) and sensory changes and weakness in the legs. Best results occur when we operate within 48 hours," Dr. Jimenez said.
Non-surgical treatment may include a short period of bed rest (usually two to three days but no longer) and non-steroidal anti-inflammatory medications. Oral steroid or cortisone injections may also be used to decrease inflammation and may provide some relief. A patient is usually treated with physical therapy. Many patients respond well to these treatments.
Continued non-operative treatment, however, can result in scarring around the nerve in patients with prolonged symptoms and this may compromise the final outcome. There is a window of opportunity in which patients who have a herniated disc and require surgery will benefit the most from surgery, Dr. Jimenez said.
An overview of surgery
After disc surgery, the patient usually goes home the next morning. The patient is usually up walking four hours after surgery.
The surgery is done under a general anesthetic. It is usually performed with a microscope or magnifying glasses through a small 1 to 1.5 inch incision. With the pressure on the nerve relieved, the majority of patients will feel better after surgery. "The larger and more symptomatic the herniation, the better the outcome from sugery if it is not delayed. When someone with a small disc bulge on the MRI is operated on, their outcome may not be as good," Dr. Jimenez said.
Post-op physical therapy starts with back strengthening and range-of-motion exercises about six weeks after surgery. Most people can return to work as early as four to eight weeks after surgery.
