Spine Disorders

Herniated Disc

Definition

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.

This view looking down the spinal canal shows how a herniated or bulging disc can irritate the nerve.

In this situation there is a portion of the annulus that has isolated itself from the rest of the disc and all or part of its displaced will out into the canal. This situation is the one that responds best surgery. It may not respond to conservative therapy, including manipulation and even chemonucleolysis.

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 (as the picture below illustrates), 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 identify the disc level which is herniated. In addition to leg muscle weakness, there may also be knee or ankle reflex loss.

These types of symptoms can also occur in the cervical region. The most common levels for disc problems are in descending order C6-C7 (C refers to cervical and the number refers to the number of the vertebral body counting from the top), C5-C6, C7-T1 (here the T refers to the thoracic spine, the part that the ribs attach to), C4-C5 and very rarely C3-C4. Pressure on a nerve root is referred to as cervical radiculopathy. Cervical disc herniations can press on the spinal cord and cause a problem called cervical myelopathy. This group of symptoms differs from the symptoms caused by pressure on the nerve roots. In general, cervical myelopathy is a more urgent problem than cervical radiculopathy (radiculitis).

The most common symptom of a cervical disc herniation is neck pain that radiates (spreads) down to the arm in various locations. The specific location of the arm pain depends on which disc is involved. There can also be associated paresthesias (pins and needles) and in some cases weakness of some of the arm muscles. Patients find that turning their head away from the painful side helps. Extending the head makes the pain worse so that looking up is avoided. Bending the head down usually gives some relief. Most of the symptoms of a disc herniation are related to pressure on a specific nerve root. Rarely, large disc herniations can cause pressure on the spinal cord. Pressure on the spinal cord can result in a problem called cervical myelopathy. It can cause among other things spasticity which can present as problems walking.

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, cervical or thoacic 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.

Spinal Stenosis

Back aches and pains are a health concern for millions of people. Nearly 28 million Americans saw their doctors because of back and low back pain in 2001. There may be many reasons for backaches and pains. One cause could be spinal stenosis.

Stenosis means narrowing. In spinal stenosis, the spinal canal, which contains and protects the spinal cord and nerve roots, narrows and pinches the spinal cord and nerves. The result is low back pain as well as pain in the legs. Stenosis may pinch the nerves that control muscle power and sensation in the legs.

Causes of Spinal Stenosis

There are many potential causes for spinal stenosis, including:

  • Aging. As you get older, the ligaments (tough connective tissues between the bones in the spine) can thicken. Spurs (small growths) may develop on the bones and into the spinal canal. The cushioning disks between the vertebrae may begin to deteriorate. The facet joints (flat surfaces on each vertebra that form the spinal column) also may begin to break down.
  • Heredity. If the spinal canal is too small at birth, symptoms may show up in a relatively young person.
  • Changes in blood flow to the lumbar spine.
Symptoms of Spinal Stenosis

  • Pain and difficulty when walking, aggravated by activity.
  • Numbness, tingling, hot or cold feelings, weakness or a heavy and tired feeling in the legs.
  • Clumsiness, frequent falling, or a foot-slapping gait.
Diagnosing Spinal Stenosis

These symptoms also can be caused by many other conditions, which makes spinal stenosis difficult to diagnose. There is usually no history of back problems or any recent injury. Often, unusual leg symptoms are a clue to the presence of spinal stenosis.

If simple treatments, such as postural changes or nonsteroidal anti-inflammatory drugs, do not relieve the problem, your orthopaedic surgeon may request special imaging studies to determine the cause of the problem. An MRI (magnetic resonance image) or CAT (computed tomography) scan may be requested. A myelogram (an X-ray taken after a special fluid is injected into the spine) may be arranged. These and other imaging studies provide details about the bones and tissues and assist the orthopaedic evaluation.

Treatment

  • Changes in posture. People with spinal stenosis may find that flexing the spine by leaning forward while walking relieves their symptoms. Lying with the knees drawn up to the chest also can offer some relief. These positions enlarge the space available to the nerves and may make it easier for stenosis sufferers to walk longer distances.
  • Medications. Sometimes the pressure on the nerves is caused by inflammatory swelling. Nonsteroidal anti-inflammatory medication such as aspirin or ibuprofen may help relieve symptoms.
  • Rest, followed by a gradual resumption of activity, also can help. Aerobic activity such as bicycling is often recommended.
  • Losing weight can also relieve some of the load on the spine.

When stenosis causes severe nerve root compression, these treatments may not be enough. Back and leg pain may return again and again. Because many stenosis sufferers are unable to walk even short distances, they often confine their activities to the home.

Surgical Treatment

If conservative treatment does not relieve the pain, your orthopaedic surgeon may recommend surgery to relieve the pressure on affected nerves. In properly selected cases, the results are quite satisfactory, and patients are able to resume a normal lifestyle.

Low back pain

The combination of pain-killers and modest amounts of a muscle relaxant are usually prescribed for the first-time low back pain patient. At the initial examination, the physician will also note if the patient is overweight or works under conditions (such as driving a truck or sitting at a desk for long hours) that offer little opportunity for exercise. Some authorities believe that low back pain is particularly prevalent in Western society because of the combination of overweight, bad posture (made worse if there is added weight up front), and infrequent exercise.

Although bed rest may be necessary for severe back problems, exercise is now considered to be an important addition to treatment and can help speed recovery for many patients with low back pain. Exercise helps reduce stress on the lower back by increasing flexibility and strength. To avoid injury, however, carefully follow the exercise routine prescribed by your doctor. In some cases, a full neurological examination may be necessary, including tests to determine if there may be a ruptured disc or other source of pressure on the cord or nerve roots.

Sometimes x-rays will show a disc problem that can be helped by surgery. Milder analgesics (aspirin, acetaminophen, or stronger nonnarcotic medications) and electrical stimulation -- using TENS or implanted brain electrodes -- can be very effective for low back pain. What is not effective is long-term use of muscle-relaxant tranquilizers. Many specialists are convinced that chronic use of these drugs is detrimental to the back pain patient, adding to depression and increasing pain. Massage and manipulative therapy are used by some clinicians but, except for individual patient reports, their usefulness is still undocumented.

Neck Pain

Neck pain is a problem for most people at some point during their lives. Neck pain may feel like a "kink," stiffness, or severe pain. Pain may spread to the shoulders, upper back, or arms, or it may cause a headache. Neck movement may be limited, usually more to one side than the other.

Neck pain refers to pain anywhere from the area at the base of the skull into the shoulders. The neck includes:

  • The bones of the spine (vertebrae).
  • The joints that guide the direction of the movement of the spine.
  • The discs that separate the vertebrae and absorb shock as you move.
  • The muscles and ligaments that hold the spine together.

Neck pain is often caused by a strain or spasm of the neck muscles or inflammation of the neck joints. Examples of common activities that may cause this type of minor injury include:

  • Holding your head in a forward posture or odd position while working, watching TV, or reading.
  • Sleeping on a pillow that is too high, too flat, or doesn't support your head, or sleeping on your stomach with your neck twisted or bent.
  • Spending long periods of time resting your forehead on your upright fist or arm ("thinker's pose").
  • Stress. Tension may develop in the muscles that run from the back of the head across the back of the shoulder (trapezius muscle). These muscles may feel tight and painful.
  • Working or exercising using the upper body and arms.
  • Neck pain also may be caused by a sudden (acute) injury.

Whiplash occurs when the head is forced forward then snaps backward (or vice versa). This may cause stretching or tears (sprains) of the neck ligaments.

Severe neck injuries are those that are likely to cause significant damage. Examples of severe neck injuries include:

  • High-energy injuries, such as serious motor vehicle accidents, falls from significant heights, and major sports-related injuries.
  • Direct blows to the head or neck.
  • Blows that transmit significant force to the neck, such as being struck forcefully on top of the head.
  • Penetrating neck injuries, such as stab wounds and gunshot wounds.
  • External pressure applied to the neck, such as strangulation.
  • A neck injury may cause damage to the spinal cord, requiring emergency care. Symptoms include loss of movement, numbness, tingling, loss of feeling, difficulty controlling the muscles of the arms or legs, or loss of bowel or bladder control.

Neck pain may be caused by a health condition rather than an injury.

Arthritis or damage to the discs of the neck can cause a pinched nerve. Neck pain caused by a pinched nerve generally affects one side of the neck and the arm on that side. Other symptoms may develop, such as numbness, tingling, or weakness in the arm or hand.

Meningitis is a serious viral or bacterial illness that causes inflammation around the tissues of the brain and spinal cord. Symptoms come on quickly and include severe headache, stiff neck, fever, and sometimes vomiting. The neck stiffness makes it hard or impossible to touch the chin to the chest.

Influenza (flu), which usually is not serious, can cause symptoms similar to meningitis. When neck pain is caused by flu, the neck and the rest of the body tend to ache all over, but severe neck stiffness is absent.

Neck pain that occurs with chest pain may be caused by a serious problem with the heart, such as a heart attack or an inflammation of the muscle of the heart.

Torticollis is caused by severe muscle contraction on one side of the neck, causing the head to be tilted to one side. The chin is usually rotated toward the opposite side of the neck. Torticollis is usually a symptom of another medical problem. It may be present at birth (congenital) or caused by injury or disease.

Treatment for neck pain depends on the cause and severity of symptoms as well as your age and other health conditions. Treatment includes first aid measures, medication, physical therapy, manipulative therapy (such as chiropractic or osteopathic), or surgery. Home treatment can help relieve pain, speed healing, and reduce the chance of further neck problems.