Herniated Disc

Herniated nucleus pulposus (HNP), or herniated disc, is a common cause of neck and back pain in 20-50 year olds. The intervertebral discs are the primary shock absorbers of the spine, resting between each vertebral body. Each disc is comprised of an outer annulus, a leather like surrounding shell, and an inner nucleus, essentially a gel comprised mostly of water. Each disc is named for the vertebra above and below it. For example, the disc between the 4th and 5th lumbar vertebra is called the L4-5 disc. Healthy discs, associated with paired facet joints at each disc level, provide mobility of the spine as well as cushioning. The discs undergo slow aging changes throughout life, eventually drying out, cushioning less and less effectively. Even in young people, a sudden increase in load through the spine such as a twist, bend, fall or unbalanced lift can result in rupture of the disc, spilling the inner contents backward into the spinal canal where the spinal cord and exiting nerve roots are housed. This can lead to neck or upper back pain if a cervical disc is involved, mid back pain if a thoracic disc is involved, or low back pain if a lumbar disc is involved. If the herniated material makes contact with a nerve, radiating pain down the path of the exiting nerve may result. In the most severe cases, compression of the spinal cord or cauda equina may result in profound weakness, numbness, and loss of bowel and bladder control.

Cervical Disc Herniation


HNP within the cervical spine can lead to neck stiffness, muscle spasm, headaches, shoulder and upper back pain, and may also cause radiating pain into the arms, or between the shoulder blades. The pattern of pain or numbness will help your doctor determine the disc level, and therefore the nerve root involved. At each disc level within the spine, a pair of nerves peels off of the spinal cord to exit the spine, and travel down each arm in a specific distribution. Most commonly the disc between the 5th and 6th cervical vertebra (the C5-6 disc), or the disc between the 6th and the 7th cervical vertebra (the C6-7 disc) is involved, affecting the 6th and 7th nerve roots, respectively. This can result in pain, tingling, numbness of the outer upper arms, outer forearms, thumb, and middle three fingers. The next most commonly herniated cervical disc is C4-5, resulting in shoulder pain, tingling numbness and/or weakness.

 

Thoracic Disc Herniation

HNP within the thoracic spine is relatively uncommon because the rib cage protects this area of the spine, reducing the motion and forces transmitted to and through the discs here. Never-the-less, discs can herniate in this area, and may cause significant mid-back pain, radiating chest pain, subtle bladder problems including difficulty in completely emptying the bladder, urinary urgency, urinary frequency, progressive weakness to the legs, and even loss of bowel or bladder control.

Lumbar Disc Herniation

HNP within the low back is very common, especially at the bottom two levels, L4-5 and L5-S1. Symptoms commonly evolve over several days to weeks, beginning with back pain or spasm, and ultimately leading to leg pain, tingling, numbness or weakness. After the onset, a couple of days of rest, and then slow, steady return to more normal activities, combined with mild analgesics will allow reduction of pain for most people.

Resolution of Neck and Back Pain

Most people who develop neck or back pain will have resolution of that pain within 6 to 12 weeks. For milder pain that doesn’t resolve within that period of time, more severe pain, or if other symptoms such as constant tingling, numbness, weakness, or bowel/bladder symptoms develop, further treatment by an orthopedic spine specialist is appropriate. Diagnostic work-up and treatment are dictated by the presenting symptoms. Neck or back pain, mild numbness, mild radiating radiating arm or leg pain can be treated with analgesics such as naproxen (Aleve), ibuprofen (Advil), or acetaminophen (Tylenol), heat, ice, and gentle stretching. Physical therapy is appropriate, as may be a short course of chiropractic. If symptoms persist despite these measures, further imaging studies such as X-Ray or MRI scanning may be appropriate. Mild narcotics, mild anti-spasm medicines, and even a short course of oral steroids occasionally improve symptoms. If not, typically the next step in the treatment of HNP is consideration of epidural steroid injections. These injections are used to target inflamed tissue with potent anti-inflamatory medication. This may result in reduction in swelling of nerves, that may lead to improvement in neck, back, arm or leg pain. Corticosteroids are different from anabolic steroids frequently discussed in the news to improve athletic performance. Serious side effects to steroid injections are rare, but it is important to understand that only about 50% of injections provide relief of pain. It is reasonable to have 3 or 4 injections a year for persistent pain, but continued use of injections only makes sense if prolonged relief of pain is achieved with each shot.

Cervical Disc Surgery

Surgery may be a reasonable option for those few patients who have not responded to time, medications, therapy, chiropractic, and injections. For patients with primarily arm symptoms, decompressing of the nerve can be affected either through the front of the neck or through the back of the neck. The procedure from the front involves complete removal of the offending disc, re expansion of the collapsed disc space, and placement of a total disc arthroplasty or bone graft to allow fusion of the adjacent vertebra. There are advantages and disadvantages to each that will be discussed elsewhere on this web site. For most patients, typically a one or two day hospitalization is required. Fusion patients are required to wear a brace for 4-8 weeks. No brace is necessary for disc arthroplasty patients. Surgery on the back of the neck is called laminoforaminotomy. This minimally invasive procedure involves widening the holes (neuroforamen) out which the paired nerves exit toward the arms. No brace is necessary after this procedure. Surgery is highly effective at resolving arm pain, less effective at resolving numbness, and unpredictable in relieving weakness and neck pain. Patients can return to walking the day after surgery, and most can easily care for themselves within a day or two after surgery.

Thoracic Surgery

Because this area is more difficult to access surgically, symptoms in general should be severe and prolonged prior to consideration of surgery. Surgery can be done through the chest wall (thoracotomy), through a minimally invasive thoracoscopic procedure, or through the back. All options are major surgeries, resulting in at least 2-3 days in hospital, and a few weeks to recover.


Lumbar Discectomy

Surgery for lumbar HNP is highly effective at relieving leg pain and back pain, and less reliable at reducing numbness and resolving weakness. This surgery is typically done through a minimally invasive approach, with the use of an endoscope or microscope, with the incision being placed on the low back. Most surgery is done in the outpatient setting, with patients walking within a couple of hours of completion of surgery. 90% of patients will have significant improvement of leg and back pain. However, up to 10% of patients will suffer a re-herniation at the same level sometime between a month to several years after surgery. The major goal of surgery is rapid resolution of debilitating pain. Several excellent studies have shown that surgery allows return to work and normal activities faster than simple observation for patients who have waited at least 6-12 weeks after the onset of symptoms. However, these studies clearly show that patients with ongoing symptoms who choose not to have surgery for 12-18 months will achieve similar results. In other words, surgery will resolve the pain more quickly than waiting will. For patients with progressive weakness, severe, unrelenting pain, and those who have difficulty controlling bowel or bladder (cauda equina symdrome), most spine specialists recommend surgery sooner rather than later.

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