Disc Herniation

Herniated nucleus pulposus (HNP), more commonly referred to as a “ruptured” or “slipped” disc, is a common spinal condition affecting one to two percent of all adults with a peak incidence at age 42. It occurs when the cartilage shock absorber between the bones of the spine displaces into the spinal canal, causing compression of one of the spinal nerves. It may be caused by trauma, stress to the area or degenerative changes over time.

Symptoms of lumbar disc herniation (in the lower back) include pain that radiates from the back to the buttocks, thigh and calf; numbness or tingling in the thigh and calf; and weakness of the muscles that control ankle function. Cervical disc herniation (in the neck) may cause pain, tingling, numbness or weakness in the neck, arms or hands. In general, disc herniation symptoms often intensify with coughing, sneezing or sitting.

Diagnosis may be made with X-rays to rule out other causes, computed tomography (CT or CAT scan), magnetic resonance imaging (MRI) or discogram. Treatment options include rest, physical therapy, medication, chiropractic care, steroid injections or surgery, such as cervical discectomy, lumbar discectomy, lumbar laminectomy or spinal fusion. Cardiovascular exercise, maintaining a healthy weight and a regimen to improve strength and flexibility in the area of herniation may help relieve symptoms and prevent muscle spasms in the future.

Low Back Pain and Lumbar Radiculopathy

Low back pain with or without associated leg pain is a common cause of disability. Risk factors for back pain include smoking, obesity, particularly excess weight around the abdomen, and repetitive motion, such as that found in some occupations. Somewhere between 75-80% of adults will experience low back pain at some point in their lives, usually from muscle strain. Some other common causes of low back pain include disc injury, degeneration (aging, drying) of the disc or lumbar stenosis. Additional causes include compression fractures and spinal tumors.

When pain radiates from the back down the legs, the condition is called lumbar radiculopathy. The pain may radiate down one or occasionally both legs. It my travel down the front, back or side of the leg. It may involve the foot and toes, or it may stop anywhere in the leg. It can be quite disabling and is responsible for over 100 million lost days of work per year.

The spinal column is composed of 33 vertebral bodies and other bony structures that house the spinal cord. Spinal nerves exit from the cord at different levels and provide a path for sensory information from the body to travel to the brain and for motor information from the brain to travel to the body. There are seven cervical (neck), twelve thoracic (chest), and five lumbar (low back) vertebrae. The remainder of the vertebrae are fused into the sacral/coccygeal (tailbone) area. Between the vertebrae are the discs, which are cushion-like structures that absorb shock. The disc is named for the vertebral bodies directly above and below it. For example the L4-5 disc is located between the fourth and fifth lumbar vertebrae.

If the outer rim of the disc (also know as the annulus fibrosus) is torn, the disc contents (nucleus pulposus) can press out into the spinal canal. When this happens, a nerve root can be compressed by the disc contents. This may cause pain, numbness and/or tingling to travel down the leg. The specific nerve root affected will determine the exact area of the symptoms. There may or may not be associated back pain with this condition, known as disc herniation.

To diagnose low back pain, a neurosurgeon will use a combination of complete medical history and physical examination and appropriate radiological imaging. In many cases a magnetic resonance imaging scan (MRI) is indicated. Other tests, including computed tomography (CT or CAT scan), electromyelogram (EMG), myelogram or discogram, may be necessary. An EMG involves inserting needles into nerves on the arms or legs, a myelogram involves contrast dye injected into the spinal column prior to X-ray, and a discogram involves inserting a needle and injecting dye into the disc.

Lumbar stenosis is a condition where the spinal column is narrowed, either since birth or from degeneration through the years. This narrowing will compress the spinal cord and can cause symptoms such as low back pain, lower extremity pain and weakness. The leg pain and weakness are often brought on by activity such as walking.

As with a disc herniation, lumbar stenosis is diagnosed through a combination of complete patient history and physical examination with appropriate radiological imaging. MRI, CAT scan, EMG and/or myelography may be necessary.

Initial treatment for lower back pain is focused on pain relief and return to work and daily activities. Medications such as non-steroidal anti-inflammatory medications may reduce swelling and thereby discomfort. Physical therapy and exercises to stretch and strengthen the lower back and abdomen may be beneficial. In many cases, epidural steroid injections may provide relief of discomfort. The treatments are individualized based upon the patient’s symptoms.

If symptoms persist despite conservative therapy, surgical intervention may be considered. The specific type of surgery will vary depending upon the structural defect. Possible surgeries include a lumbar microdiscectomy, lumbar laminectomy or spinal fusion with or without instrumentation. Microdiscectomy involves removing a disc with the aid of a surgical microscope. Laminectomy is removal of vertebral bone. Spinal fusion uses bone chips, with or without screws, rods or metal cages, to fuse together two vertebrae after the disc in between has been removed.

The goal of treatment is return to everyday activity. All patients will need to make routine exercise and proper body mechanics part of their everyday lifestyle to reduce the risk of injury. The majority of back pain patients will recover with conservative treatment and surgery is not necessary. When surgery is indicated, the majority of patients will recover in one to three months. Most patients will require medications for the immediate post-operative period, and some will require mild analgesia for longer periods. Most patients find that they have a significant return of function and are able to live healthy, productive lives. Using good body mechanics and following the physician’s instructions regarding bracing and lifting restrictions enhances the chances of successful recovery.          

Lumbar Stenosis

Lumbar spine stenosis is a narrowing of the lumbar spinal canal caused by a gradual enlargement of the bone and soft tissue structures surrounding it. The lumbar spinal canal, located in the lower spine, carries nerves to the legs. When this space shrinks, it compresses or “pinches” the nerves that go through it, causing pain in the back and lower extremities, weakness or numbness in the legs, and in severe cases, bowel or bladder disturbances. The condition most commonly affects middle-aged and older adults and is often caused by arthritis. Diagnosis may be made with X-rays, computed tomography (CT or CAT scan) or magnetic resonance imaging (MRI). Treatment options include exercise, physical therapy, medication for pain or inflammation, and surgery, such as lumbar laminectomy.

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Neck Pain and Cervical Radiculopathy

Neck and arm pain are common complaints for a large potion of the population at any given time in their life. It can be due accident, injury or natural progression of a disease process. Cervical radiculopathy is characterized by pain that radiates from the neck to the limbs, usually the arms. Important factors that suggest need for more specific evaluation or treatment are severity of pain, duration of symptoms, and/or weakness in the neck or limbs.

Pain to the neck itself can be nonspecific and is more frequently of a muscular source. Pain to the neck after an injury to the neck or head can also be of a muscular source, but should be approached with a higher degree of suspicion and studied more readily as suggested by the mechanism of injury or presence of specific symptoms such as numbness or weakness along pathways of nerve distribution.

Arm pain can present independent of neck pain and still be from problems in the neck. This is called radiculopathy (disease or symptoms radiating along the course of a nerve). Areas of the arms or hands can develop numbness (anesthesias) or tingling (paraesthesia). This can be in the same or different areas of the arm or hand than the area of pain. These symptoms can be from pressure or injury to the nerves in the neck or spinal cord. Such symptoms can also be the result of pressure or injury to the nerves along their course after they have left the spine; this is called peripheral neuropathy.

Weakness in the arms or legs or decline in muscle size or tone can also be a symptom of pressure on the nerves. This situation is often more subtle. It occurs over a period of time and often is unnoticed or overlooked because it is not as noticeable as pain or numbness.

Muscle strain is a common cause of cervical radiculopathy, but is usually temporary in nature. More long-term effects may come from whiplash injuries caused by acceleration/deceleration injury to the neck, primarily from motor vehicle accidents. Whiplash can cause pain in the neck and arms, as well as headaches, facial pain, dizziness, irritability, sleep disturbance and swallowing difficulties (dysphagia). About 65% of whiplash victims make a full recovery, 25% have residual symptoms and 5-10% develop chronic pain syndromes.

Disc disease or a herniated/ruptured disc can also cause neck pain. Discs are the rubbery cartilage cushions that separate the vertebrae as they are stacked on top of each other. Discs can degenerate over time causing them to shrink and become less flexible. They can also rupture and at times may even have portions of the disc contents push out into the space surrounding the normal confines of the disc. This is call herniation.

When the herniation is significant enough and in the right area to cause pressure on the nerves, this will usually cause radicular symptoms. Disc contents that press on the spinal cord itself can cause weakness in the arms, hands or legs. If significant enough, herniation can also injure the spinal cord itself and be more problematic.

Cervical radiculopathy can also be caused by degenerative changes that occur as a result of the age-, genetic- and activity-related wearing-out process of the discs. This will often appear as flatter discs and smaller disc spaces on X-ray or magnetic resonance imaging (MRI) studies. Degenerative changes can cause changes in the vertebrae, as well, which often appear as bony spurs.

Fractures or other injuries to the neck and spine may occur from a particular activity or accident. Neurosurgical evaluation is often required to determine the type and extent of the effect on the spine and spinal cord. This may not require any surgery but may require bracing or follow-up studies to appropriately repair or protect the spinal cord and nerves.

Testing can include simple tests such as X-rays, computed tomography (CT or CAT) scans and MRI’s to evaluate the source of problems. Further, more invasive testing can include nerve conduction studies; myelograms (a test where contrast dye is injected into the sack around the spinal cord followed by imaging studies to see what areas might be causing pressure on the spinal cord or nerve roots); or discograms (contrast dye is injected into the disc itself to determine whether the disc is herniated and to what extent the disc might be contributing to whatever symptoms are present).

Treatments range in variety from simple and basic to more invasive and complex. Simple interventions can be as basic as instruction on posture and range of motion exercises aimed at minimizing further irritation to the nerve roots and strengthening the neck. Other simple treatments include: cervical traction where the head is pulled up or pushed away from the shoulders for short periods of time each day. Additional treatments include physical therapy, activity modification, use of medications in the categories of non-steroidal anti-inflammatories, steroidal anti-inflammatories, pain medication (either narcotic or non-narcotic), and/or muscle-relaxants. More invasive treatments include epidural steroid injections and surgery. Surgical options include, but are not limited to, discectomy to remove a portion of a disc, or fusion, which removes a disc and replaces it with bone chips and/or metal instruments to keep the area from bending.

Spinal Tumors

A spinal tumor is an abnormal growth of tissue in the spinal cord, spinal canal or between the membranes covering the spinal cord. Tumors that originate within the spine are rare. Most spinal tumors begin elsewhere in the body and spread through the bloodstream to the spinal cord. Spinal tumors can be benign (non-cancerous) or malignant (cancerous). Because both malignant and benign tumors can compress the spinal cord and nerves that carry messages to and from the brain, they are a serious health risk and must be promptly diagnosed and treated.

Symptoms are diverse and affect different parts of the body depending upon the location of the tumor. They may include pain or numbness in the arms, neck, legs or back; loss of muscle strength, motor skills or feeling in the extremities; decreased skin sensitivity to temperature changes; and loss of bladder and/or bowel control. Diagnosis may be made with X-rays, computed tomography (CT or CAT scan) or magnetic resonance imaging (MRI). Treatment options may involve a combination of surgery, to reduce the size of the lesion, plus radiation and/or chemotherapy (cancer drugs).

Cervical Discectomy and Arthrodesis

An anterior cervical discectomy involves removing a portion of a cartilage disc that separates bones (vertebrae) of the spine in the neck. A discectomy is performed to treat conditions such as disc herniation in which the disc or its gel-like contents rupture and press against nerves in the spine, causing pain, tingling, weakness or numbness. A discectomy may be performed after more conservative treatments, such as rest, medication, physical therapy, massage or chiropractic care, have proved unsuccessful.

Discectomy is performed under general anesthesia while the patient is unconscious. An incision is made over the affected area. The ruptured disc is removed and often a bone plug is placed in the area to fuse the adjacent vertebrae. A plate may be placed over the plug to stabilize it. The hospital stay averages about 24 hours, but varies by the type of discectomy performed and its complexity. Medication and a neck collar may be prescribed. Recovery may take 3-4 weeks and may involve physical therapy and learning proper body mechanics, as well as strengthening and flexibility exercises and lifestyle modifications. A micro-discectomy involves a smaller incision and removal of disc fragments with use of the microscope.

Lumbar Discectomy

A lumbar discectomy involves removing a portion of a cartilage disc that separates bones (vertebrae) of the spine in the lower back. A discectomy is performed to treat conditions such as disc herniation in which the disc or its gel-like contents rupture and press against nerves in the spine, causing pain, tingling, weakness or numbness. A discectomy may be performed after more conservative treatments, such as rest, medication, physical therapy, massage or chiropractic care, have proved unsuccessful.

Discectomy is performed under general anesthesia while the patient is asleep. An incision is made over the affected area. The hospital stay averages about three days, but varies by the type of discectomy performed and its complexity. Medication may be prescribed. Recovery takes several 3-4 weeks and may involve physical therapy and learning proper body mechanics, as well as strengthening and flexibility exercises and lifestyle modifications. Cardiovascular exercise and maintaining an appropriate weight may aid recovery and prevent pain. A micro-discectomy involves a smaller incision and removal of disc fragments with use of the microscope.

Lumbar Laminectomy

Lumbar laminectomy is a surgical procedure used to treat disorders of the spine in the lower back. It is typically used to treat conditions such as lumbar stenosis or spinal tumors in which bone or other tissues in the area have grown in such a way as to put pressure on nerves, causing pain, tingling, numbness or weakness. Diagnosis may be made with X-rays, computed tomography (CT or CAT scan), magnetic resonance imaging (MRI) and/or myelogram.

Lumbar laminectomy is performed under general anesthesia in which the patient is asleep. An incision is made over the affected area of the spine. Typically, the bone covering the spinal column (lamina) and any other tissue pressing against spinal nerves is removed. The opening through which the nerves pass may also be enlarged to relieve pressure. Sometimes a rod and screws and/or a bone graft may be used to strengthen the area, in a process known as spinal fusion. Depending on the complexity of the surgery, the patient will stay in the hospital several days to a week. Medication, physical therapy and a brace may be prescribed. Recovery takes about 4 weeks. Lifestyle modifications may be necessary to promote a rapid return to normal activity.

Spinal Fusion

Spinal fusion is a surgical treatment for abnormal spine conditions such as disc herniation, spinal tumors, spinal fractures, arthritis, scoliosis or infection. Spinal fusion stabilizes the spine by replacing a cartilage disc that separates the bones of the spine (vertebrae) with a bone graft that fuses together the vertebrae above and below the removed disc. Instrumentation, such as rods, plates, screws or “cages,” may also be used to fuse the spine. Sometimes instrumentation is used without a bone graft; other times, instrumentation supports the bone graft and helps it heal properly.

The procedure is done under general anesthetic in which the patient is asleep. Lumbar fusion may involve an incision along the back (posterior) or at the front of the abdomen (anterior). Cervical fusion may involve an incision at the front or side of the neck. Thoracic fusion usually involves an incision in the chest and abdomen.

Spinal fusion requires about five days of hospitalization. It is a more invasive surgery than discectomy or laminectomy. Pain medication will be needed during and after the hospital stay. A back brace is worn for about three months. Physical therapy to strengthen muscles and learn proper body mechanics and posture may be prescribed. Cardiovascular exercise as well as a regimen to increase strength and flexibility in the back and abdomen may also be prescribed.