Neuro (Disk Herniation)

7/30/2019 Neuro (Disk Herniation)

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DISC HERNIATION


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Epidemiology

Many patients with back pain, leg pain, or weakness of the lowerextremity muscles are diagnosed with a herniated disc. When a discherniation occurs, the cushion that sits between the spinal vertebrais pushed outside its normal position. A herniated disc would not bea problem if it weren't for the spinal nerves that are very close to

the edge of these spinal discs.

A herniated disk can irritate nearby nerves and result in pain, numbness or

weakness in an arm or leg. On the other hand, many people experience no

symptoms from a herniated disk. Most people who have a herniated disk don't

need surgery to correct the problem.


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Definition

A herniated disk refers to a problem with one

of the rubbery cushions (disks) between the

individual bones (vertebrae) that stack up to

make your spine.

A spinal disk is a little like a jelly donut, with a softer center

encased within a tougher exterior. Sometimes called a slipped disk

or a ruptured disk, a herniated disk occurs when some of the softer"jelly" pushes out through a crack in the tougher exterior.


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You can have a herniated disk withoutknowing it herniated disks sometimes showup on spinal images of people who have no

symptoms of a disk problem. But someherniated disks can be painful. The location ofyour symptoms may vary, depending onwhere the herniated disk is located along your

spine. Most herniated disks occur in yourlower back (lumbar spine), although they canalso occur in your neck (cervical spine).


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What is the spinal disc?

The spinal disc is a soft cushion that sitsbetween each vertabrae of the spine. Thisspinal disc becomes more rigid with age. In a

young individual, the disc is soft and elastic,but like so many other structures in the body,the disc gradually looses its elasticity and ismore vulnerable to injury. In fact, even in

individuals as young as 30, MRIs showevidence of disc deterioration in about 30% ofpeople.


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What happens with a 'herniated disc'?

As the spinal disc becomes less elastic, it canrupture. When the disc ruptures, a portion of thespinal disc pushes outside its normal boundary--

this is called a herniated disc. When a herniateddisc bulges out from between the vertebrae, thespinal nerves and spinal cord can becomepinched. There is normally a little extra space

around the spinal cord and spinal nerves, but ifenough of the herniated disc is pushed out ofplace, then these structures may be compressed.


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Sign and Symptomps

The most common signs and symptoms of aherniated disk are:

Arm or leg pain.

Numbness or tingling.

Weakness.

Electric Shock Pain

Bowel or Bladder Problems


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Causes

Disk herniation is most often the result of a gradual, aging-relatedwear and tear called disk degeneration. As you age, your spinaldisks lose some of their water content. That makes them lessflexible and more prone to tearing or rupturing with even a minorstrain or twist.

Most people can't pinpoint the exact cause of their herniated disk.Sometimes, using your back muscles instead of your leg and thighmuscles to lift large, heavy objects can lead to a herniated disk, ascan twisting and turning while lifting. Rarely, a traumatic eventsuch as a fall or a blow to the back can cause a herniated disk.

When the herniated disc ruptures and pushes out, the nerves may

become pinched (straining of the spine)

(Often already have spinal stenosis, a problem that causesnarrowing of the space around the spinal cord and spinal nerves.When a herniated disc occurs, the space for the nerves is further

diminished, and irritation of the nerve results.


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Location

The majority of spinal disc herniation cases occurin lumbar region (95% in L4-L5 or L5-S1).The secondmost common site is the cervical region (C5-C6, C6-C7).The thoracic region accounts for only 0.15% to 4.0% of

cases. Herniations usually occur posterolaterally, where the

annulus fibrosis is relatively thin and is not reinforcedby the posterior or anterior longitudinal ligament. Inthe cervical spinal cord, a symptomatic posterolateral

herniation between two vertebrae will impinge on thenerve which exits the spinal canal between those twovertebrae on that side


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Cervical

Thoracic

Lumbar


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Cervical

Cervical disc herniations occur in the neck, most often

between the fifth & 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 plexus and brachial

plexus can be affected.


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Thoracic

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 lower discs can mimic lumbar

herniations.


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LumbarLumbar disc herniations occur in the lower back, most often between

the fourth and fifth lumbar vertebral bodies or between the fifth and

the sacrum. Symptoms can affect the lower

back, buttocks, thigh, anal/genital region (via the Perineal nerve), andmay radiate into the foot and/or toe. The sciatic nerve is the most

commonly affected nerve, causing symptoms of sciatica. The femoral

nerve can also be affectedand 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


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Pathophysiology

There is now recognition of the importance of chemicalradiculitis in the generation ofback pain. A primary focusof surgery is to remove pressure or reduce mechanicalcompression on a neural element: either the spinal cord, ora nerve root. But it is increasingly recognized that back

pain, rather than being solely due to compression, may alsobe due to chemical inflammation. There is evidence thatpoints to a specific inflammatory mediator of this pain.Thisinflammatory 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, andin spinal stenosis.In addition to causing pain andinflammation, TNF may also contribute to discdegeneration


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Stages of disc herniation

Like the balloon sandwich, the disc doesnt burst immediately

unless squeezed extremely hard. Instead it will get stretchedgradually over time. More accurately, each disc fibre gets stretchedover time. So it is a gradual process happening over each fibre at atime. It is rarely a sudden process. You dont wake up one morningto find a bulging disc when the disc was perfectly fine the daybefore.


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Bulging Disc(degeneration)

At this early stage, the disc isstretched and doesntcompletely return to itsnormal shape when pressure

is relieved. It retains a slightbulge at one side of the disc.Some of the inner disc fibrescould be torn and the soft

jelly (nucleus pulposus) isspiling outwards into the discfibres but not out of the disc.


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Prolapsed Disc

At this stage, the bulge is

very prominent and the soft

jelly centre has spilled out

to the inner edge of theouter fibres, barely held in

by the remaining disc fibres.


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Herniated Disc or Extrusion

Herniation is a term to

mean protrusion. In the

case of a herniated spinal

disc, the soft jelly hascompletely spilled out of

the disc and now

protruding out of the discfibres.


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Sequestered Disc

Here some of the jellymaterial is breaking off

away from the disc into

the surrounding area.


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Diagnosis of a herniated disc

Most often, your physician can make the diagnosis of aherniated disc by physical examination. By testingsensation, muscle strength, and reflexes, yourphysician can often establish the diagnosis of a

herniated disc.

At some point in the evaluation, tests may beperformed to confirm or rule out other causes ofsymptoms such as spondylolisthesis,

degeneration, tumors, metastases and space-occupying lesions, as well as to evaluate the efficacy ofpotential treatment options.


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Imaging


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X-ray

Although traditional plain X-rays are limited intheir ability to image soft tissues such as discs,muscles, and nerves, they are still used to

confirm or exclude other possibilities such astumors, infections, fractures, etc. In spite of theselimitations, X-ray can still play a relativelyinexpensive role in confirming the suspicion of

the presence of a herniated disc. If a suspicion isthus strengthened, other methods may be usedto provide final confirmation.


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Computed tomography 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.However, visual confirmation of a disc

herniation can be difficult with a CT.


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Magnetic resonance imaging (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, andsurrounding areas, as well as enlargement,

degeneration, and tumors. It shows soft

tissues even better than CAT scans


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Myelogram

An x-ray of the spinal canal following injection ofa contrast material into the surroundingcerebrospinal fluid spaces. By revealingdisplacement of the contrast material, it can

show the presence of structures that can causepressure on the spinal cord or nerves, such asherniated discs, tumors, or bone spurs. Because itinvolves the injection of foreign substances, MRI

scans are now preferred for most patients.Myelograms still provide excellent outlines ofspace-occupying lesions, especially whencombined with CT scanning (CT myelography).


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Electromyogram 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 astate of healing from a past injury, or whether

there is another site of nerve compression.

EMG/NCS studies are typically used topinpoint the sources of nerve dysfunction

distal to the spine.


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Treatment

Initial treatment usually consists of non-steroidal anti-inflammatory pain medication (NSAIDs), but the long-termuse of NSAIDs for patients with persistent back pain iscomplicated by their possible cardiovascular and

gastrointestinal toxicity.

An alternative often employed is theinjection of cortisone into the spine adjacent to the suspectedpain generator, a technique known as epidural steroidinjection.Epidural steroid injections "may result in someimprovement in radicular lumbosacral pain when assessed

between 2 and 6 weeks following the injection, compared tocontrol treatments.Complications resulting from poortechnique are rare.


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Surgical options

Chemonucleolysis - dissolves the protruding disc

IDET (a minimally invasive surgery for disc pain)

Discectomy/Microdiscectomy - to relieve nervecompression

Tessys method - a transforaminal endoscopic method toremove herniated discs

Laminectomy - to relieve spinal stenosis or nervecompression

Hemilaminectomy - to relieve spinal stenosis or nerve

compression Lumbar fusion (lumbar fusion is only indicated for recurrent

lumbar disc herniations, not primary herniations)


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Anterior cervical discectomy and fusion (forcervical disc herniation)

Disc arthroplasty (experimental for cases ofcervical disc herniation)

Dynamic stabilization

Artificial disc replacement, a relatively new formof surgery in the U.S. but has been in use inEurope for decades, primarily used to treat lowback pain from a degenerated disc.

Nucleoplasty

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Neuro (Disk Herniation)