Herniated Lumbar DiscHerniated Lumbar Disc
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| Lumbar disc herniation is an extremely common problem. Each disc begins as a "pancake" which is sometimes a little thicker at the center than at the front or back. It is rounded in front and around the sides to match the contours of the vertebral column and it is a bit concave on the back surface to accommodate the spinal canal. If one could look at a disc from the top or bottom, it would have a "kidney bean" shape. There is an outer ring of rather tough, gristly cartilage (the annulus) and an inner core of different, softer cartilage (the nucleus). Either or both materials can be displaced or "herniated" out of the space between the vertebral bodies but usually it is the nucleus that breaks through the annulus. Once this happens, there is nothing that can cause this material to move back into place between the bones. If the herniation is toward the front, neurological symptoms are not expected. However, if it happens toward the rear or toward the openings for the exiting nerves (to the side-rear), the spinal cord or the nerves can be compressed. In some individuals, over time, the herniated disc can flatten out or migrate a little. In most people, it just stays there. When symptoms of a "pinched nerve" spontaneously improve, it is usually because the nerve adapted. |  |
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| Due to the frequent occurrence of low back problems in the population, disc degeneration as a pre-existing condition to disc herniation is recognized most commonly in the lumbar spine. Disc degeneration occurs in probably every human but at varying ages from one individual to the next, sometimes even as early as the teenage years. It is seen in people who have been engaged only in "normal" activities of living which indicates that it is a naturally occurring process. Prior to degenerating, it would probably require a very major injury to displace the disc material. A degenerated disc can be seen on MRI scan as different than other non-degenerated discs. Mechanical stresses, pressure, lack of direct blood supply or nutritional factors might all play a role in herniation. In the lumbar spine, the lower 2 discs are the most likely to be degenerated and to herniate. Degeneration causes the disc cartilage, especially the nucleus, to soften and become more deformable. Due to weight and forces on the spine during movements which squeeze the disc between the vertebral bodies, the nucleus tries to bulge outward. Sometimes the annulus is thinned out or pushed ahead as the nucleus material deforms. Sometimes a piece of the nucleus works its way through a crack in the annulus. This is called a disc herniation. I like to describe it as if a jelly doughnut were being squeezed. Once softened, herniation or bulging of the disc can occur during relatively normal physical exertions or even spontaneously. When a herniation happens, it is very probably the end result of many years of degeneration, movements, muscular straining and perhaps unusual stresses such as accidents. Studies have shown that a surprising proportion of individuals with practically no symptoms will have disc herniations if tested. For an individual who is found to have a disc herniation following some type of activity, we usually cannot know exactly how the herniation evolved because we do not have testing immediately prior to the activity in question. Likewise, continuous testing after an accident would not be feasible but might be the only way to document a slowly evolving herniation. Some individuals have been tested to find such impressive disc herniation following an accident marking the onset of symptoms that we are compelled to believe that most or all of the herniation occurred as a direct result of the accident. In others, the fact that symptoms began following very minor action or activity suggests that the problem was "waiting to happen". The practical approach taken by our society has been to blame the final condition of the patient on the event(s) which seem most associated with the onset of symptoms while occasionally acknowledging pre-existing conditions. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Unless a lumbar disc herniation is very large and threatens to crush the collection of nerves in the spinal canal, treatment depends entirely on the symptoms. These nerves in
the lowest part of the spine, collectively called the "cauda equina", can be displaced by a disc herniation without necessarily causing any malfunction. It would be unreasonable and meddlesome to consider surgery on every individual with some degree of
disc herniation because we would be operating on nearly everyone who walks into the office. If there are no signs of neurological malfunction in the muscles, other symptoms such as radiating pain can improve over the first several weeks if time can be
allowed for conservative treatment in which case a surgery might be avoided. Pain from a "pinched nerve" can be addressed with physical modalities such as heat, ultrasound, aquatherapy, exercises, etc. Actually, most of these these treatments are not
likely to affect the nerves directly but, rather, they can alleviate the secondary muscular symptoms and reduce the irritability of the spinal structure. Irritability of the nerve itself may diminish over the first several weeks based on its own ability
to adapt (which is what nervous systems are supposed to do!). In some individuals, the herniated disc can flatten out or shrink over the course of many months or years but, in most people, it just stays there. Anti-inflammatory medications like those
in the ibuprofen family might also help early-on. Some patients have had success with additional treatments such as acupuncture, steroid and/or anesthetic injections, and spinal manipulations but the long-range benefits are less clear. Persons who have
a disc herniation but do not require surgery must remain mindful of the possibility that further herniation and perhaps new consequences of this could happen in the future. |
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| The financial impact of lumbar disc herniation on society and the relatively common need for surgical intervention have prompted the medical system to continuously look for new
innovations in treatment. The goal of removing pressure from the symptomatic nerve has been designed into numerous surgical strategies ranging from insertion of needle-like instruments or endoscopes for limited removal of disc material to aggressive
decompression with extensive direct visualization of the nerves followed by a spinal fusion. The type of surgery, if recommended, depends heavily on the exact nature of the problem as well as the surgeon's personal experience and preferences. The
advantage of minimal disruption of spinal structures during some procedures with limited direct visualization must be weighed against the advantages of better visualization and surgical access during procedures which are more disruptive to the normal
structures of the spine. Over the course of several decades, refinement of "typical" lumbar disc surgery through an incision with removal of some bone, ligament and disc material has caused it to remain the "gold standard" with a generally excellent
success rate. This approach from the back side of the spinal canal frequently makes use of the mobility of nerves inside to allow the degree of "exploration" which is often necessary to fully treat the problem. Spinal fusion for lumbar disc disease has been a recurring consideration for certain types of lumbar disc problems including severe isolated disc degenerations with mechanical pain and repeated herniations from the same lumbar disc. The advantage of fusion is that, if it solidifies correctly, it will prevent further disc herniation and possibly eliminate pains due to irritable spinal structures at that spinal segment. The disadvantage is that it is much more extensive than a typical disc surgery and diverts more stress during spinal movement to the adjacent segments which are not fused. The desired achievement of any surgery should be to make the patient better in the long run than he otherwise would have been. |
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| The outcome of lumbar disc herniation with or without surgery spans a wide range possibilities but the result is excellent for the vast majority of people. Dramatic improvement
of radiating leg pain is highly likely following surgery. Numbness or muscular weakness, if they occur, are less likely to completely resolve but they can substantially improve with time and should not progress any further. Since the weight of the body
and forces during upper body exertion transmit through the lumbar spine, the mechanical structure is ultimately "put to the test" again. Very possibly, removal of a portion of a disc might be no worse than natural degeneration of the disc when it comes
to future mechanical discomforts. Most patients cannot attribute any pain specifically to the operated disc within several months to a year and many are nearly recovered within a few weeks. Healing of fusions takes more time. Not surprisingly, people who perform manual labor at work often discover or develop symptoms of disc herniation following some type of physical exertion and they often wish to return to the same job following surgery. Acknowledging degenerations of other discs, muscular or ligament irritability and "inflammations" which can all contribute to pains not necessarily related to the disc in question, the physical capabilities of some people can continue to deteriorate despite very successful disc surgery. Fortunately, the spinal "fate" of most individuals does not involve total disability. An arbitrary light duty restriction is preferable if it does not interfere with regular work duties or if modified duty is available on an indefinite basis. Otherwise, some added risk for future aggravation of lumbar conditions must be accepted if heavier weights are to be handled. If there seems to be no easily applied arbitrary restriction, a test called "functional capacity assessment" can help identify the current objective limitations and capabilities. |
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