Everything You Need To Know About Herniated Disc (Slipped) Disc, Causes, Symptoms and Signs, Diagnosis, and Treatment - Page 2 of 8

Humans are the only mammals walking on two limbs all the time, and for this function, a special structure must exist. Our backbone (the vertebral column) is that structure. Its curves and the sizes of its individual vertebrae, as well as the intervertebral discs, are essential for it to keep its function. A herniated disc is one of the commonest and most bothersome conditions of the backbone. It can be very disabling for a patient and can turn him from a healthy individual into a bedridden one within days. In this article we will see why our vertebral column is fascinating, what causes a herniated disc, its symptoms, diagnosis, and how it can be managed by simple home remedies or when to seek professional medical care.

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Our vertebral column

Our vertebral column is a tall bony structure that consists of smaller units called vertebrae. We have 33 vertebrae arranged in 5 groups, 2 of which are not mobile and the upper 3 are. The first group is called the cervical group and is in the neck. It consists of 7 vertebrae and is highly mobile. The second group is the thoracic group and is the one attached to the ribs forming the chest cage, the number of its vertebrae is 12 and its mobility is quite limited. The third group is the lumbar spine and consists of 5 vertebrae. The lumbar spine is wider than that of the chest and neck and is responsible for the movement of our back while bending over. The last 2 groups form the sacrum -which is part of the pelvis- and the coccyx which is the small tailbone. Both groups are immobile and their vertebrae are fused together.

The intervertebral discs

The intervertebral discs are small cartilaginous discs that separate vertebrae and provide some cushion-like action in absorbing shock and preventing friction between vertebrae during movement. They are soft enough to allow smooth movement and lubrication and hard enough to prevent slippage. The intervertebral discs -like all cartilage- are affected by the body’s state of hydration. Their degree of elasticity and flexibility is affected by age, and older individuals are at a higher risk of disc injury and herniation. They are only found in mobile parts of the vertebral column and are, therefore, not found in the sacrum or coccyx.

The intervertebral discs are not soft enough to herniate, but their center is. Structurally, they are formed of a soft part called nucleus pulposus and a firmer part called the annulus fibrosis. The latter firm part surrounds the softer one completely, preventing its herniation, but when increased pressure is exerted, the firm part is torn and the softer part bulges. The herniated disc then compresses either the nerves that come out of the spinal cord in most cases or, much less commonly, the spinal cord itself, causing severe disability. The lumbar group of vertebrae (those found in our lower back) is the most prone to such injury.

Causes of a herniated disc

The main cause of a herniated disc is a traumatic event that occurred suddenly or gradually, but what makes the disc prone to such injury are called risk factors, and there are several including:

Smoking: Smokers were found to have less flexible intervertebral discs, predisposing them to such injury.
Obesity: Abdominal obesity, in particular, puts lots of strain on the lumbar group of muscles and discs, making them weaker over time.
Genetic predisposition: It was found that some people are genetically more liable to develop this injury owing to the defective structure of their collagen, the protein forming cartilage found in the intervertebral discs.
Males were found to be more liable to have herniated discs than females, almost twice as often. The cause behind this phenomenon is not well understood, but it is believed to be due to the nature of men’s work or their smoking habits rather than any inherent gender difference.

Symptoms of disc herniation

There are several symptoms of disc prolapse, mostly resulting from the structure compressed by the herniated disc. They include:

Limb pain: Pain is the main symptom of a herniated disc owing to the compression of nerve roots. In the case of lumbar vertebrae disc prolapse, the nerves compressed are those supplying the leg and buttocks. Most patients believe the pain is in the leg itself and not in the back since not all of them have back pain at the time. If the herniated disc is in the neck, arm pain occurs instead of the lower extremity. Pain feels like burning, aching, or stabbing in character.
Numbness or tingling: Patients may also experience numbness or tingling in their arms or legs. The site of such numbness depends on the location of the herniated disc. Our arms and legs are distributed into sensory zones and each one originates from a specific level on the spinal cord. For example, most herniated discs are at the level of L5, which means that the most commonly affected area with pain and numbness is the outermost leg and the front of the thigh.
Back pain: Back pain usually occurs when the muscles overlying the herniated disc go into spasm. This can be seen following acute trauma as in road traffic accidents or following lifting heavy objects.
Limb weakness: Although not as common as pain, muscle weakness due to a herniated disc can occur, and its severity varies depending on the amount of disc herniation and its encroachment upon the motor nerve.
Cauda equina: Cauda equina means horse tail in Latin. It is a medical condition that occurs when the herniated disc affects the lower part of the spinal nerves and herniates significantly. In this condition, patients feel severe numbness around their genitalia and their inner thigh. There may also be urinary or bowel incontinence in more severe cases.

How is a herniated disc diagnosed?

Your doctor will listen to your complaint and do some physical examination with tests to confirm the source of your pain. Afterward, they may order some lab tests and imaging studies. Laboratory tests are not done routinely in all patients and may only be done before an operation as a part of a preoperative regimen to test for anemia and blood coagulation problems.

Regarding imaging studies, the most commonly performed is an MRI, which stands for magnetic resonance imaging. MRI helps detect disc herniation, unlike a traditional X-ray or CT scanning which only shows bones. MRI scanning can detect the extent of disc herniation and whether it compresses a certain nerve or causes cauda equina. In some cases, it can detect whether another condition is causing the symptom as in tumors or bony fractures -even though they are much less common than disc herniation-.

Treatment of disc herniation

Contrary to what you might think, only a minority of patients need surgery for their herniated discs. In fact, all patients except for emergency cases undergo medical therapy first before resorting to surgery. Medical therapy includes:

Rest: This cannot be stressed enough. Rest following disc herniation can be enough for the body to heal the problem. Most of the disc herniation and the pain it causes is the result of swelling, and the swelling cannot subside if you keep putting stress on the disc.
Pain killers: Pain killers especially non-steroidal anti-inflammatory drugs are the cornerstone of medical therapy. They are given until the patient feels better, commonly for 1-2 weeks. Anti-inflammatory drugs are not only pain killers, but they also reduce the inflammation and swelling of the disc, which contributes greatly to symptoms. Anti-inflammatory drugs include Aspirin, Diclofenac, and Naproxen.
Steroids: Steroids are the strongest anti-inflammatory drugs available, and they can be used in more severe cases to reduce swelling more quickly and when other anti-inflammatory drugs fail. They have to be given under medical supervision and should be withdrawn gradually to avoid side effects.
Muscle relaxants: Muscle relaxants are given to relieve muscle spasms that overlie the herniated disc. Muscle spasm contributes to the pain and its relief greatly improves symptoms.

Medical therapy is continued for at least 2 weeks before deeming it as unsuccessful. Afterward, surgery is considered. There are a few cases where surgery is considered first before medical therapy including:

Cauda equina syndrome: Cauda equina syndrome is an absolute indication for surgery before medical therapy. Any delay can cause neurological damage.
In case of muscle weakness accompanying the pain or numbness.

Surgery

Surgical treatment is the definitive one in cases not responding to medical therapy. The main principle behind it is the removal of the part of the disc that is herniated. This operation is called discectomy It can be done either by the open technique through a traditional incision or using an endoscope. Endoscopy is quickly gaining popularity where laser or heat is used to destroy the excess part and relieve the compression.

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Most patients recover fully after the operation and a minority can have lasting symptoms following it. Symptoms can be due to an incomplete decompression -and in such cases, a reoperation is an option- or due to lasting neurological complications, which can heal by themselves or may need medical therapy.

Side effects and response to the surgery

Although discectomy can be the only possible treatment in many cases, its response can vary widely. In most cases, patients’ symptoms improve, and they can resume their normal lives, but in others, symptoms can still persist. There is a clear line as to who will respond and who will not. It is generally thought that the longer a patient suffers from sciatica and the more severe their symptoms, the less likely it is that they will recover following surgery. Recurrence of symptoms after resolution following surgery has been attributed to strenuous exercise during recovery. Unfortunately, for those patients who have a recurrent disc herniation, the probability that the condition will improve on surgery is less likely.

One of the most concerning thoughts of patients undergoing spine surgery is the side effects. Many patients think that such surgery puts their mobility at risk. However, this is not the case because the commonly operated upon the region of the vertebral column -lumbar spine- does not have a spinal cord. The spinal cord terminated before reaching the lumbar spine and it is very rare to injure the cauda equina in spine surgery. Endoscopic surgery has even made it safer with fewer patients complaining of post-operative pain. Many endoscopic surgeries are even done in an outpatient setting without the need for general anesthesia with its side effects.

Side effects of the surgery include:

Post-operative pain: This is the commonest side effect of any surgery. After all, any surgery involves incisions that, however carefully placed and sutured, remain a wound that needs healing. Post-operative pain is treated by analgesics and usually improves within days of the operation.
Persistence of symptoms: Persistence of symptoms for one or two days following the operation does not mean that the operation had failed. The nerve that was being compressed for months is unlikely to heal and resume its function in a few hours. Waiting for a few days and regularly informing your surgeon of your symptoms on follow-up will show the success of your operation.
Infection: Infection is one of the complications of any operation. It is rare nowadays owing to the operations of the sterile techniques are being done with as well as the use of antibiotics. If infection occurs it can interfere with wound healing and rapid treatment is a must.
Blood clots: Blood clots had been a common complication of many surgeries in the past, but the use of anticoagulants following surgery and during hospital stay has significantly reduced it. Leg blood clots are the commonest and manifest by leg swelling and pain, commonly in one limb.
Nerve injury: According to the level of surgery, there is a varying risk of injury to nerves during the operation. Such injury varies from a simple contusion that heals with time to a severe laceration requiring further therapy. This can result in chronic pain or muscle weakness. It is very rare for such injuries to be permanent.