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Slipped Disk / Herniated Disk

Definition :
When your back hurts, everyday activities can become difficult or even intolerable. Sitting, bending and twisting can cause sharp pain, a dull ache, or annoying tingling and numbness. One cause of back pain is a herniated disk, sometimes called a slipped disk or a ruptured disk.

Your spinal column is made up of bones (vertebrae) that are cushioned by small disks consisting of a tough outer layer (annulus) and a soft, jelly-like inner layer (nucleus). These disks act as shock absorbers, protecting the spine and nerves from the stress of everyday tasks as well as strenuous work such as heavy lifting. When a disk herniates, a tear or weakness in the annulus allows the jelly-like nucleus to push out into the spinal canal. If it puts pressure on a spinal nerve, the herniated disk can cause pain, numbness or weakness in the back, legs or arms, depending on where the disk is located.

Herniated disks are most common in the lower (lumbar) spine, but about 10 percent occur in the neck (cervical spine). Anyone can get herniated disks, but herniations in the lumbar spine are most common between 35 and 45 years of age. Cervical disk herniation is more common between 50 and 60 years of age.

Causes:
Disk herniation is most often the result of a gradual, aging-related degeneration of the disks. As you age, your spinal disks lose some of their water content. That makes them less flexible and more prone to tearing or rupturing with even a minor strain or twist.

Using your back muscles instead of your leg and thigh muscles to lift large, heavy objects can lead to a herniated disk, as can twisting and turning while lifting. More rarely, a traumatic event such as a fall or a blow to the back can cause a herniated disk.

Risk Factor :
Several factors make you more susceptible to a herniated disk :

  • Age. Herniated disks are most common in middle age due to aging-related degeneration of the disks. However, herniated disks are less likely to occur after age 60.
  • Smoking. Smoking tobacco increases the risk of disk herniation because it decreases oxygen levels in the blood, depriving your body tissues of vital nutrients.
  • Weight. Excess body weight causes extra stress on the disks in the lower back.
  • Diabetes. Diabetes can deplete oxygen levels in the blood, making spinal disks more prone to herniation and disease.
  • Occupations that strain the spine. Several studies have found higher rates of herniated disks in people with physically demanding jobs, such as farming, concrete reinforcement, lumber work, quarry work, food packing, trucking and warehousing. The job activities most closely linked to herniated disks are repetitive lifting, pulling and pushing, particularly when they also involve bending sideways and twisting. Jobs that require prolonged sitting or standing in one position also may increase the risk of disk herniation.

When to seek medical advice :
If you experience back pain that interferes with your normal activities for longer than a few days, call your doctor to be evaluated. If the pain increases when you're sitting, coughing or sneezing, a herniated disk might be the cause.

If you lose control of your bladder or bowels, if your pain increases rather than staying about the same or decreasing over time, or if you develop numbness or weakness in both legs, seek prompt medical attention. A disk herniation or a spinal tumor may be compressing several nerve roots in your spine. This compression, known as cauda equina syndrome, is rare but potentially disabling. It may require emergency surgery.

Symptoms :
You can have a herniated disk without knowing it — herniated or bulging disks sometimes show up on spinal images of people who have no symptoms of a disk problem. But some herniated disks can be painful. The most common signs and symptoms of a herniated disk are:

  • Sciatica — a radiating, aching pain, sometimes with tingling and numbness, that starts in the buttock and extends down the back of one leg
  • Pain, numbness or weakness in the lower back and one leg, or in the neck, shoulder, chest or arm
  • Low back pain that worsens when you sit, cough or sneeze

Diagnosis:
To determine whether you have a herniated disk, your doctor reviews your medical history and performs a physical examination, including these tests :

  • Straight-leg-raising test. You lie flat and your doctor raises your symptomatic leg.
  • Cross straight-leg-raising test. You lie flat and the doctor raises your unaffected leg.

If these tests cause pain in your leg or back, it may indicate a herniated disk. Your doctor will also perform :

  • Screening neurological examination. This thorough screening includes testing your reflexes, muscle strength, walking ability and sensation. The doctor may include a test for sensation in the area around the rectum, because this area can be affected by a herniated disk.

In most cases of herniated disk, the physical exam is all that's needed to make a diagnosis. If your doctor suspects another condition or needs to see which nerves are affected, or if there is no symptom improvement after four weeks of conservative treatment, one or more of these diagnostic tests may be performed :

  • Magnetic resonance imaging (MRI) scan. A magnetic field is used to create images of your body. This test can be used to confirm the location of the herniated disk and to see which nerves are affected.
  • Computerized tomography (CT) scan. An X-ray unit creates cross-sectional images of your spinal column and the structures around it.
  • Myelogram. A dye is injected into the spinal fluid, and then X-rays are taken. This test can show pressure on the spinal cord or nerves due to multiple herniated disks or other conditions.
  • X-rays. Plain X-rays don't detect herniated disks, but they may be performed to rule out other causes of back pain, such as an infection or a broken bone.

Complications :
While it can be painful, a herniated disk isn't typically a medical emergency. Rarely, disk herniation can cause cauda equina syndrome, which is the compression of spinal nerve roots. Relieving the pressure that causes cauda equina syndrome often requires emergency surgery, because it can cause permanent paralysis if it's not corrected. The following signs and symptoms, which suggest cauda equina syndrome, warrant a trip to the emergency room :

  • Significant or increasing pain, numbness or weakness spreading to one or both legs
  • Bladder or bowel dysfunction, including incontinence or difficulty urinating even with a full bladder
  • Progressive loss of sensation in areas that would touch a saddle (inner thighs, back of legs and area around the rectum)
  • Loss of movement

Treatment:
Conservative treatment — mainly avoiding painful positions and following a planned exercise and pain-medication regimen — relieves symptoms in nine out of 10 people with a herniated disk. Within a couple of months of starting this treatment, you should be back to normal. Imaging studies show that the protruding or displaced portion of the disk shrinks over time, corresponding to the improvement in symptoms. Depending on your symptoms, your doctor may recommend :

  • Modified activity. Take it easy when you have severe back pain. Try to stay away from activities that aggravate your symptoms, such as improper reaching, bending and lifting, using a rowing machine, and prolonged sitting.

    However, remember that the spine and disks rely on motion and use for their nutrition. Intermittent activity to maintain fitness and minimize stiffness is very important, so physical therapy and exercises to increase flexibility and strength may be prescribed. A herniated disk isn't a fragile spine problem, and physical activity shouldn't be avoided altogether. In fact, staying at work is best, even if you need to reduce your workload or assume lighter duties. No two people have quite the same levels of discomfort with different activities. That's why you should work with your doctor or a physical therapist to find the right combination of rest and activity. Over several weeks, your activity level can gradually increase until you're comfortable with everyday tasks.

  • Physical therapy. A physical therapist can apply heat, ice, traction, ultrasound and electrical stimulation for pain relief. Physical therapists can also show you positions and exercises designed to minimize the pain of a herniated disk. As the pain improves, physical therapy can advance you to a rehabilitation program of core strength and stability to maximize your back health and help protect against future injury.
  • Heat or cold. Initially, cold packs can be used to relieve pain and inflammation. After a few days, you may switch to gentle heat to give relief and comfort.
  • Pain medication. If your pain is mild to moderate, your doctor may tell you to take an analgesic medication, such as aspirin, ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or naproxen (Aleve, others). Muscle relaxants such as diazepam (Valium) or cyclobenzaprine (Flexeril) may be prescribed for a few days if you have back or limb spasms.

    If your pain doesn't improve with these medications, your doctor may prescribe narcotics, such as codeine or a hydrocodone-acetaminophen combination (Lortab, Vicodin) for a short time. Recently, neuropathic pain medications or "nerve pain" pills, such as gabapentin (Neurontin, others) also have been prescribed for this type of pain. Alternatively, inflammation-suppressing corticosteroids may be prescribed orally or given by injection directly into the area around the spinal nerves.

  • Bed rest. Constant, severe back pain from a herniated disk sometimes requires one or two days in bed on a firm surface or mattress. Strict bed rest for longer than a day or two, however, can inhibit recovery by causing loss of muscle tone.
  • Time. Herniated disk symptoms generally take four to six weeks to significantly improve. If your symptoms have not resolved after six weeks, more aggressive therapies may be effective and prevent you from needing surgery.

Surgery
About 10 percent of people with herniated disks eventually need surgery. You may be a good candidate for surgery if conservative treatment fails to improve your symptoms after four to six weeks. Surgery also may be considered if a disk fragment lodges in the spinal canal, pressing on a nerve, or if you're having trouble standing or walking.

The most common surgery for a herniated disk is a microdiskectomy. This procedure has the best success rate among healthy people with single disk herniations.

Microdiskectomy is related to standard or open diskectomy, a spinal surgery that involves cutting away some of the spinal bones (vertebrae) to access the herniated disks and compressed nerve roots. In microdiskectomy, surgeons use a surgical microscope or magnifying lens to allow smaller incisions in the skin, muscles and bone overlying a herniated disk. Smaller incisions and less disruption to surrounding tissue lessen pain and shorten recovery time. During a microdiskectomy :

  • You're placed under general anesthesia, which means you won't be conscious during the surgery. In some cases, though, microdiskectomy is possible without general anesthesia, using injections that cause temporary numbness (local anesthesia) in the back.
  • The surgeon makes a small incision over the herniation and moves the back muscles away from the spine as much as possible. Small amounts of bone and ligaments may be removed to gain access to the herniated disk and nerve root.
  • Small instruments are used to remove the herniated portion of the disk and other disk tissue and fragments, relieving pressure on the nerve.
  • The incision is closed with stitches or staples.
  • Some people go home the same day, while others stay in the hospital for one to two days after surgery.
  • Most people make a full recovery and return to work within two to six weeks.

Prevention:
To help prevent a herniated disk :

  • Exercise. Regular exercise slows aging-related degeneration of the disks, and core muscle strengthening stabilizes the spine. In the first few months after a herniated disk, remember to avoid high-impact activities such as jogging, tennis and high-impact aerobics.
  • Maintain good posture. Good posture reduces the pressure on your spine and disks. Keep your back straight and aligned, particularly when sitting for longer periods. Also, lift heavy objects properly, making your legs — not your back — do most of the work.
  • Maintain a healthy weight. Excess weight puts more pressure on the spine and disks, making them more susceptible to herniation.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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