A
spinal disc herniation (prolapsus disci intervertebralis), informally and misleadingly called a "
slipped disc", is a medical condition affecting the
spineIn human anatomy, the vertebral column is a column usually consisting of 33 vertebrae, the sacrum, intervertebral discs, and the coccyx situated in the dorsal aspect of the torso, separated by spinal discs...
, in which a tear in the outer, fibrous ring (
annulus fibrosusEach intervertebral fibrocartilage is composed, at its circumference, of laminæ of fibrous tissue and fibrocartilage, forming the annulus fibrosus.-Spelling notes:...
) of an
intervertebral discIntervertebral discs lie between adjacent vertebrae in the spine. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae, and acts as a ligament to hold the vertebrae together.-Structure:...
(discus intervertebralis) allows the soft, central portion (
nucleus pulposusNucleus pulposus is the jelly-like substance in the middle of the spinal disc. It is the remnant of the notochord. It functions to distribute hydraulic pressure in all directions within each disc under compressive loads. The nucleus pulposus consists of chondrocytes, collagen fibrils, and...
) to
bulge outA hernia is protrusion of an organ or the muscular wall of an organ through the cavity that normally contains it. A hiatal hernia occurs when the stomach protrudes upwards into the mediastinum through the esophageal opening in the diaphragm.-Pathophysiology:...
. Tears are almost always posterior-ipsilateral in nature due to the presence of the
posterior longitudinal ligamentThe posterior longitudinal ligament is situated within the vertebral canal, and extends along the posterior surfaces of the bodies of the vertebræ, from the body of the axis, where it is continuous with the membrana tectoria, to the sacrum....
in the spinal canal. This tear in the disc ring may result in the release of inflammatory chemical mediators which may directly cause severe pain, even in the absence of nerve root compression (see "chemical radiculitis" below). This is the rationale for the use of anti-inflammatory treatments for pain associated with disc herniation, protrusion, bulge, or disc tear.
It is normally a further development of a previously existing disc protrusion, a condition in which the outermost layers of the
annulus fibrosus are still intact, but can bulge when the disc is under pressure.
Terminology
Some of the terms commonly used to describe the condition include herniated disc, prolapsed disc, ruptured disc and the misleading expression "slipped disc". Other terms that are closely related include disc protrusion, bulging disc, pinched nerve,
sciaticaSciatica is a set of symptoms including pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve, or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of...
, disc disease, disc degeneration,
degenerative disc diseaseDegeneration of the intervertebral disc, often called "degenerative disc disease" of the spine, is a condition that can be painful and can greatly affect the quality of one's life...
, and black disc.
The popular term "slipped disc" is misleading, as an intervertebral disc, being tightly sandwiched between two vertebrae to which the disc is attached, cannot actually "slip", "slide", or even get "out of place". The disc is actually grown together with the adjacent vertebrae and can be squeezed, stretched and twisted, all in small degrees. It can also be torn, ripped, herniated, and degenerated, but it cannot "slip". "The term 'slipped disc' may be harmful as it leads to a false idea of what is happening and therefore of the likely outcome." However, one vertebral body can slip relative to an adjacent vertebral body. This is called
spondylolisthesisSpondylolisthesis describes the anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. It was first described in 1782 by Belgian obstetrician, Dr. Herbinaux. He reported a bony prominence anterior to the sacrum that obstructed the vagina of a small number of...
and can damage the disc between the two vertebrae.
The spelling "disc" is based on the
LatinLatin is an Italic language originally spoken in Latium and Ancient Rome. Through the Roman conquest, Latin spread throughout the Mediterranean and a large part of Europe...
root
discus. Most English language publications use the spelling
"disc" more often than "disk".
Nomina AnatomicaIn the late nineteenth century some 50,000 terms for various body parts were in use. The same structures were described by different names, depending on the anatomist’s school and national tradition. Vernacular translations of Latin and Greek, as well as various eponymous terms, were barriers to...
designates the structures as
"disci intervertebrales" [plural form] and
Terminologia AnatomicaTerminologia Anatomica is the international standard on human anatomic terminology. It was developed by the Federative Committee on Anatomical Terminology and the International Federation of Associations of Anatomists and was released in 1998. It supersedes the previous standard, Nomina...
as
"discus intervertebralis/intervertebral discIntervertebral discs lie between adjacent vertebrae in the spine. Each disc forms a cartilaginous joint to allow slight movement of the vertebrae, and acts as a ligament to hold the vertebrae together.-Structure:...
", [singular form].
Frequency
Disc herniation can occur in any disc in the spine, but the two most common forms are lumbar disc herniation and cervical disc herniation. The former is the most common, causing lower back pain (lumbago) and often leg pain as well, in which case it is commonly referred to as
sciaticaSciatica is a set of symptoms including pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve, or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of...
.
Lumbar disc herniation occurs 15 times more often than cervical (neck) disc herniation, and it is one of the most common causes of lower back pain. The cervical discs are affected 8% of the time and the upper-to-mid-back (thoracic) discs only 1 - 2% of the time.
The following locations have no discs and are therefore exempt from the risk of disc herniation: the upper two cervical intervertebral spaces, the
sacrumThe sacrum is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones. Its upper part connects with the last lumbar vertebra, and bottom part with the coccyx...
, and the
coccyxThe coccyx , commonly referred to as the tailbone, is the final segment of the human vertebral column. Comprising three to five separate or fused vertebrae below the sacrum, it is attached to the sacrum by a fibrocartilaginous joint, the sacrococcygeal symphysis, which permits limited movement...
.
Most disc herniations occur when a person is in their thirties or forties when the nucleus pulposus is still a gelatin-like substance. With age the nucleus pulposus changes ("dries out") and the risk of herniation is greatly reduced. After age 50 or 60,
osteoarthriticOsteoarthritis , is a group of diseases and mechanical abnormalities involving degradation of joints, including articular cartilage and the subchondral bone next to it...
degeneration (spondylosis) or
spinal stenosisSpinal stenosis is a medical condition in which the spinal canal narrows and compresses the spinal cord and nerves. This is usually due to the common occurrence of spinal degeneration that occurs with aging. It can also sometimes be caused by spinal disc herniation, osteoporosis or a tumor...
are more likely causes of
low back painLow back pain is a common symptom of musculoskeletal disorders or of disorders involving the lumbar vertebrae and related soft tissue structures such as muscles, ligaments, nerves and intervertebral discs. It can be either acute, subacute or chronic in its clinical presentation...
or leg pain.
Cervical disc herniation
Cervical disc herniations occur in the neck, most often between the fith & sixth (C5/6) and the sixth and seventh (C6/7) cervical vertebral bodies. Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula, shoulder, arm, and hand. The nerves of the
cervical plexusThe cervical plexus is a plexus of the ventral rami of the first four cervical spinal nerves which are located from C1 to C4 cervical segment in the neck. They are located laterally to the transverse processes between prevertebral muscles from the medial side and vertebral from lateral side...
and
brachial plexusThe brachial plexus is an arrangement of nerve fibers, running from the spine, formed by the ventral rami of the lower cervical and upper thoracic nerve root, specifically from below the fifth cervical vertebra to above the first thoracic vertebra...
can be affected.
Thoracic disc herniation
Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the uppermost thoracic discs can mimic cervical disc herniations, while herniation of the other discs can mimic lumbar herniations.
Lumbar disc herniation
LumbarIn anatomy, lumbar is an adjective that means of or pertaining to the abdominal segment of the torso, between the diaphragm and the sacrum . The lumbar region is sometimes referred to as the lower spine...
disc herniations occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the
sacrumThe sacrum is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity, where it is inserted like a wedge between the two hip bones. Its upper part connects with the last lumbar vertebra, and bottom part with the coccyx...
. Symptoms can affect the lower back,
buttocksThe buttocks are rounded portions of the anatomy located on the posterior of the pelvic region of apes and humans, including many other bipeds or quadrupeds.-Anatomy:...
,
thighIn humans the thigh is the area between the pelvis and the knee. Anatomically, it is part of the lower limb.The single bone in the thigh is called the femur...
, and may radiate into the
footThe foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion...
and/or
toeToes are the digits of the foot of an animal. Animal species such as cats that walk on their toes are described as being digitigrade. Humans, and other animals that walk on the soles of their feet, are described as being plantigrade; unguligrade animals are those that walk on hooves at the tips of...
. The
sciatic nerveThe sciatic nerve is a large nerve in humans and other animals. It begins in the lower back and runs through the buttock and down the lower limb. It is the longest and widest single nerve in the human body....
is the most commonly affected nerve, causing symptoms of
sciaticaSciatica is a set of symptoms including pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve, or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of...
. The
femoral nerveThe femoral nerve, the largest branch of the lumbar plexus, arises from the ventral divisions of the second, third, and fourth lumbar nerves. It descends through the fibers of the Psoas major, emerging from the muscle at the lower part of its lateral border, and passes down between it and the...
can also be affected. Can cause the patient to experience a numb, tingling feeling throughout one or both legs and even feet or even a burning feeling in the hips and legs.
Causes
Disc herniations can occur from general wear and tear, such as jobs that require constant sitting, but especially jobs that require lifting. Traumatic (quick) injury to lumbar discs commonly occurs from lifting while bent at the waist, rather than lifting while using the legs with a straightened back. Minor back pain and chronic back tiredness is an indicator of general wear and tear that makes one susceptible to herniation on the occurrence of a traumatic event from bending to pick up a pencil or a traumatic injury from a fall. When the spine is straight, such as standing or lying down, internal pressure is equalized on all parts of the discs. While sitting or bending to lift, internal pressure on a disc can move from 17 psi (lying down) to over 300 psi (lifting with a rounded back).
Smoking is a major risk factor as the chemicals within smoke cause diminished nutrition and oxygenation of the discs leading to dehydration & degeneration which can then proceed to herniation.
Herniation of the contents of the disc into the spinal canal often occurs when the front side (stomach side) of the disc is compressed while sitting or bending forward, and the contents (nucleus pulposus) get pressed against the tightly stretched and thinned membrane (annulus fibrosis) on the rear (back side) of the disc. The combination of membrane thinning from stretching and increased internal pressure (200 to 300 psi) results in the rupture of the confining membrane. The jelly-like contents of the disc then move into the spinal canal, pressing against the spinal nerves, thus producing intense and usually disabling pain and other symptoms.
There is also a strong genetic component. Mutation in genes coding for proteins involved in the regulation of the extracellular matrix, such as
MMP272 kDa type IV collagenase is an enzyme that in humans is encoded by the MMP2 gene.Proteins of the matrix metalloproteinase family are involved in the breakdown of extracellular matrix in normal physiological processes, such as embryonic development, reproduction, and tissue remodeling, as well as...
and
THBS2Thrombospondin-2 is a protein that in humans is encoded by the THBS2 gene.-Further reading:...
, has been demonstrated to contribute to lumbar disc herniation.
Symptoms
Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue that become involved. They can range from little or no pain if the disc is the only tissue injured, to severe and unrelenting neck or
low back painLow back pain is a common symptom of musculoskeletal disorders or of disorders involving the lumbar vertebrae and related soft tissue structures such as muscles, ligaments, nerves and intervertebral discs. It can be either acute, subacute or chronic in its clinical presentation...
that will radiate into the regions served by affected nerve roots that are irritated or impinged by the herniated material. Often, herniated discs are not diagnosed immediately, as the patients come with undefined pains in the thighs, knees or feet. Other symptoms may include sensory changes such as numbness, tingling, muscular weakness, paralysis,
paresthesiaParesthesia is a sensation of tingling, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...
, and affection of reflexes. If the herniated disc is in the lumbar region the patient may also experience
sciaticaSciatica is a set of symptoms including pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve, or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of...
due to irritation of one of the nerve roots of the
sciatic nerveThe sciatic nerve is a large nerve in humans and other animals. It begins in the lower back and runs through the buttock and down the lower limb. It is the longest and widest single nerve in the human body....
. Unlike a pulsating pain or pain that comes and goes, which can be caused by muscle spasm, pain from a herniated disc is usually continuous or at least is continuous in a specific position of the body.
It is possible to have a herniated disc without any pain or noticeable symptoms, depending on its location. If the extruded nucleus pulposus material doesn't press on soft tissues or nerves, it may not cause any symptoms. A small-sample study examining the cervical spine in symptom-free volunteers has found focal disc protrusions in 50% of participants, which shows that a considerable part of the population can have focal herniated discs in their cervical region that do not cause noticeable symptoms.
Typically, symptoms are experienced only on one side of the body. If the prolapse is very large and presses on the spinal cord or the
cauda equinaThe cauda equina is a structure within the lower end of the spinal column of most vertebrates, that consists of nerve roots and rootlets from above...
in the lumbar region, affection of both sides of the body may occur, often with serious consequences.
There is now recognition of the importance of “chemical radiculitis” in the generation of
back painBack pain is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine....
. A primary focus of surgery is to remove “pressure” or reduce mechanical compression on a neural element: either the
spinal cordThe spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain. The brain and spinal cord together make up the central nervous system. It is around 45 cm long in men and around 43 cm long in women. The length of the spinal cord is much shorter than...
, or a
nerve rootA nerve root is the initial segment of a nerve leaving the central nervous system. Types include:* A cranial nerve root, the beginning of one of the twelve pairs leaving the central nervous system from the brain stem or the highest levels of the spinal cord;...
. But it is increasingly recognized that back pain, rather than being solely due to compression, may also be due to chemical inflammation. There is evidence that points to a specific inflammatory mediator of this pain. This inflammatory molecule, called tumor necrosis factor-alpha (TNF), is released not only by the herniated disc, but also in cases of disc tear (annular tear), by facet joints, and in
spinal stenosisSpinal stenosis is a medical condition in which the spinal canal narrows and compresses the spinal cord and nerves. This is usually due to the common occurrence of spinal degeneration that occurs with aging. It can also sometimes be caused by spinal disc herniation, osteoporosis or a tumor...
. In addition to causing pain and inflammation, TNF may also contribute to disc degeneration.
Diagnosis
Diagnosis is made by a practitioner based on the history, symptoms, and
physical examinationPhysical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
. At some point in the evaluation, tests may be performed to confirm or rule out other causes of symptoms such as
spondylolisthesisSpondylolisthesis describes the anterior displacement of a vertebra or the vertebral column in relation to the vertebrae below. It was first described in 1782 by Belgian obstetrician, Dr. Herbinaux. He reported a bony prominence anterior to the sacrum that obstructed the vagina of a small number of...
, degeneration,
tumorA tumor or tumour is the name for a swelling or lesion formed by an abnormal growth of cells . Tumor is not synonymous with cancer. A tumor can be benign, pre-malignant or malignant, whereas cancer is by definition malignant....
s, metastases and space-occupying lesions as well as evaluate the efficacy of potential treatment options.
Straight leg raise
The
Straight leg raiseThe Straight leg raise also, called Lasègue's sign or Lasègue test, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk, mostly located at L5 , S1 or S2 .-Technique:With the patient lying down on his/her back on an...
may be positive; this finding has low specificity, however it has high sensitivity. Thus the finding of a negative SLR sign is an important in helping to "rule out" the possibility of a lower lumbar disc herniation. A variation is to lift the leg while the patient is sitting. However, this reduces the sensitivity of the test.
Imaging
- X-ray
X-radiation is a form of electromagnetic radiation. X-rays have a wavelength in the range of 10 to 0.01 nanometers, corresponding to frequencies in the range 30 petahertz to 30 exahertz and energies in the range 120 eV to 120 keV. They are shorter in wavelength than UV rays...
: Although traditional plain X-rays are limited in their ability to image soft tissues such as discs, muscles, and nerves, they are still used to confirm or exclude other possibilities such as tumors, infections, fractures, etc.. In spite of these limitations, X-ray can still play a relatively inexpensive role in confirming the suspicion of the presence of a herniated disc. If a suspicion is thus strengthened, other methods may be used to provide final confirmation.
- Computed tomography
Computed tomography is a medical imaging method employing tomography created by computer processing. Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two-dimensional X-ray images taken around a single axis of rotation.CT...
scan (CT or CAT scan): A diagnostic image created after a computer reads x-rays. It can show the shape and size of the spinal canal, its contents, and the structures around it, including soft tissues.
- Magnetic resonance imaging
Magnetic Resonance Imaging , or nuclear magnetic resonance imaging , is primarily a medical imaging technique most commonly used in radiology to visualize the internal structure and function of the body...
(MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. It can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows soft tissues even better than CAT scans.
- Myelogram
Myelography is a type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors...
: An x-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces. By revealing displacement of the contrast material, it can show the presence of structures that can cause pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurOsteophytes, also known as bone spurs, are bony projections that usually form along joints.-Pathophysiology:Bone spurs form due to the increase in a damaged joint's surface area. This is most commonly from the onset of arthritis. Bone spurs usually limit joint movement and typically cause pain...
s. Because it involves the injection of foreign substances, MRI scans are now preferred in most patients. Myelograms still provide excellent outlines of space-occupying lesions, especially when combined with CT scanning (CT myelography).
- Electromyogram
Electromyography is a technique for evaluating and recording the activation signal of muscles. EMG is performed using an instrument called an electromyograph, to produce a record called an electromyogram. An electromyograph detects the electrical potential generated by muscle cells when these...
and Nerve conduction studies (EMG/NCS): These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether there is another site of nerve compression.
Treatment
The majority of herniated discs will heal themselves in about six weeks and do not require surgery. One study found that "After 12 weeks, 73% of patients showed reasonable to major improvement without surgery."
If pain due to disc herniation, protrusion, bulge, or disc tear is due to chemical radiculitis pain, then prior to surgery it may make sense to try an anti-inflammatory approach. Often this is first attempted with non-steroidal anti-inflammatory medications, but the long-term use of NSAIDS for patients with persistent back pain is complicated by their possible cardiovascular and gastrointestinal toxicity; and NSAIDs have limited value to intervene in tumor necrosis factor-alpha (TNF)-mediated processes. An alternative often employed is the injection of cortisone into the spine adjacent to the suspected pain generator, a technique known as “epidural steroid injection”. Although this technique began more than a decade ago for pain due to disc herniation, the efficacy of epidural steroid injections is now generally thought to be limited to short term pain relief in selected patients only. In addition, epidural steroid injections, in certain settings, may result in serious complications. Fortunately there are now emerging new methods that directly target TNF. These TNF-targeted methods represent a highly promising new approach for patients with chronic severe spinal pain, such as those with failed back surgery syndrome. Ancillary approaches, such as rehabilitation,
physical therapyPhysical therapy is a health care profession which provides services to individuals in order to develop, maintain and restore maximum movement and functional ability throughout life...
, anti-depressants, and, in particular, graduated exercise programs, may all be useful adjuncts to anti-inflammatory approaches.
Conservative treatment
Pain medications are often prescribed to alleviate the acute pain and allow the patient to begin exercising and stretching.
There are a variety of non-surgical alternatives to treat the condition, including:
- Bed rest and lumbo-sacral support belt.
- Physical therapy
Physical therapy is a health care profession which provides services to individuals in order to develop, maintain and restore maximum movement and functional ability throughout life...
- Massage therapy
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Oral steroids (e.g. prednisone
Prednisone is a synthetic corticosteroid drug that is particularly effective as an immunosuppressant, and affects virtually all of the immune system. It is used to treat certain inflammatory diseases and cancers, but has significant adverse effects. It is usually taken orally but can be delivered...
or methylprednisoloneMethylprednisolone is a synthetic glucocorticoid drug. It is sold in the USA and Canada under the brand names Phocenta, Medrol, Solu-Medrol and Cadista. It is also available as a generic drug....
)
- Epidural
The term epidural is often short for epidural anesthesia, a form of regional anesthesia involving injection of drugs through a catheter placed into the epidural space...
(cortisoneCortisone is a steroid hormone. Chemically, it is a corticosteroid closely related to corticosterone.-History:...
) injection
- Intravenous sedation, analgesia-assisted traction therapy (IVSAAT)
- Weight control
- Chiropractic
Surgery
Surgery should only be considered as a last resort after all conservative treatments (non-surgical therapy) have been tried, that did not alleviate the pain and heal the disc herniation.
Surgery is indicated if a patient has a significant neurological deficit. The presence of
cauda equina syndromeCauda equina syndrome ' is a serious neurologic condition in which there is acute loss of function of the neurologic elements of the spinal canal below the termination of the spinal cord.-Causes:...
(in which there is incontinence, weakness and genital numbness) is considered a medical emergency requiring immediate attention and possibly surgical decompression.
Regarding the role of surgery for failed medical therapy in patients without a significant neurological deficit, a
meta-analysisIn statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses. This is normally done by identification of a common measure of effect size, which is modelled using a form of meta-regression...
of randomized controlled trials by the
Cochrane CollaborationThe Cochrane Collaboration is a group of over 10,000 volunteers in more than 90 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
concluded that "limited evidence is now available to support some aspects of surgical practice". More recent randomized controlled trials refine indications for surgery
- The Spine Patient Outcomes Research Trial (SPORT)
- Patients studied. "intervertebral disk herniation and persistent symptoms despite some nonoperative treatment for at least 6 weeks...radicular pain (below the knee for lower lumbar herniations, into the anterior thigh for upper lumbar herniations) and evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise–positive between 30° and 70° or positive femoral tension sign) or a corresponding neurologic deficit (asymmetrical depressed reflex, decreased sensation in a dermatomal distribution, or weakness in a myotomal distribution)
- Conclusions. "Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis"
- The Hague Spine Intervention Prognostic Study Group
- Patients studied. "had a radiologically confirmed disk herniation...incapacitating lumbosacral radicular syndrome that had lasted for 6 to 12 weeks...Patients presenting with cauda equina syndrome, muscle paralysis, or insufficient strength to move against gravity were excluded."
- Conclusions. "The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. "
Surgical options include:
- Microdiscectomy
- IDET (a minimally invasive surgery for disc pain)
- Laminectomy
Laminectomy is a spine operation to remove the portion of the vertebral bone called the lamina. There are many variations of laminectomy, in the most minimal form small skin incisions are made, back muscles are pushed aside rather than cut, and the parts of the vertebra adjacent to the lamina are...
- to relieve spinal stenosis or nerve compression
- Hemilaminectomy - to relieve spinal stenosis or nerve compression
- Lumbar fusion (lumbar fusion is only indicated for recurrent lumbar disc herniations, not primary herniations)
- Anterior cervical discectomy and fusion (for cervical disc herniation)
- Disc arthroplasty (experimental for cases of cervical disc herniation)
- Dynamic stabilization
- Artificial disc replacement, a relatively new form of surgery in the U.S. but has been in use in Europe for decades, primarily used to treat low back pain from a degenerated disc
Degeneration of the intervertebral disc, often called "degenerative disc disease" of the spine, is a condition that can be painful and can greatly affect the quality of one's life...
.
- Nucleoplasty
Surgical goals include relief of nerve compression, allowing the nerve to recover, as well as the relief of associated back pain and restoration of normal function.
Emerging treatment options
The identification of tumor necrosis factor-alpha (TNF) as a central cause of inflammatory spinal pain now suggests the possibility of an entirely new approach to selected patients with severe pain due to disc herniation, protrusion, bulge, or disc tear. Specific and potent inhibitors of TNF became available in the U.S. in 1998, and were demonstrated to be potentially effective for treating
sciaticaSciatica is a set of symptoms including pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve, or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of...
in experimental models beginning in 2001. Targeted anatomic administration of one of these anti-TNF agents,
etanerceptEtanercept is a drug that treats autoimmune diseases by interfering with the TNF receptor by acting as a TNF inhibitor.Etanercept is a fusion protein produced through expression of recombinant DNA...
, a patented treatment method, has been suggested in published pilot studies to be effective for treating selected patients with severe pain due to disc herniation, protrusion, bulge, or disc tear. The scientific basis for pain relief in these patients is supported by the most current review articles. In the future new imaging methods may allow non-invasive identification of sites of neuronal inflammation, thereby enabling more accurate localization of the "pain generators" responsible for symptom production.
Investigational treatments
Future treatments may include stem cell therapy. Doctors Victor Y. L. Leung, Danny Chan and Kenneth M. C. Cheung have reported in the European Spine Journal that "substantial progress has been made in the field of stem cell regeneration of the intervertebral disc. Autogenic mesenchymal stem cells in animal models can arrest intervertebral disc degeneration or even partially regenerate it and the effect is suggested to be dependent on the severity of the degeneration."
See also
- Back pain
Back pain is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine....
- Degenerative disc disease
Degeneration of the intervertebral disc, often called "degenerative disc disease" of the spine, is a condition that can be painful and can greatly affect the quality of one's life...
- Low back pain
Low back pain is a common symptom of musculoskeletal disorders or of disorders involving the lumbar vertebrae and related soft tissue structures such as muscles, ligaments, nerves and intervertebral discs. It can be either acute, subacute or chronic in its clinical presentation...
- Sciatica
Sciatica is a set of symptoms including pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the sciatic nerve, or by compression or irritation of the sciatic nerve itself. The pain is felt in the lower back, buttock, and/or various parts of...
- Vertebral column
In human anatomy, the vertebral column is a column usually consisting of 33 vertebrae, the sacrum, intervertebral discs, and the coccyx situated in the dorsal aspect of the torso, separated by spinal discs...
- Spinal stenosis
Spinal stenosis is a medical condition in which the spinal canal narrows and compresses the spinal cord and nerves. This is usually due to the common occurrence of spinal degeneration that occurs with aging. It can also sometimes be caused by spinal disc herniation, osteoporosis or a tumor...
- Failed back syndrome
Failed back syndrome or post-laminectomy syndrome is a condition characterized by persistent pain following back surgeries.Failed back syndrome , also called "failed back surgery syndrome" , refers to chronic back and/or leg pain that occurs after back surgery. It is characterized as a chronic...