Herniated Disk NY: Long Island Neurosurgeon
A spinal disc herniation, incorrectly called a "slipped disc", is a medical condition affecting the spine, in which a tear in the outer, fibrous ring of an intervertebral disc allows the soft, central portion to bulge out.
It is normally a further development of a previously existing disc protrusion, a condition in which the outermost layers of the fibrous ring are still intact, but can bulge when the disc is under pressure.
Some of the terms commonly used to describe the condition include herniated disc, prolapsed disc, ruptured disc, and the misleading expression "slipped disc." Other terms that are closely related include disc protrusion, bulging disc, pinched nerve, sciatica, disc disease, disc degeneration, degenerative disc disease, and black disc. The popular term "slipped disc" is quite misleading, as an intervertebral disc, being tightly sandwiched between two vertebrae to which the disc is attached, cannot actually "slip," "slide," or even get "out of place." The disc is actually grown together with the adjacent vertebrae and can be squeezed, stretched, and twisted, all in small degrees. It can also be torn, ripped, herniated, and degenerated, but it cannot "slip".
Causes of a disc herniation can include general wear and tear on the disc over time, repetitive movements, stress on the disc that occurs while twisting and lifting, or other injuries.
While the chief complaint for spinal disc herniation is lower back pain, symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue that become involved. They can range from little or no pain if the disc is the only tissue injured to severe and unrelenting neck or low back pain that will radiate into the regions served by an affected nerve root when it is irritated or impinged by the herniated material. Other symptoms may include sensory changes such as numbness, tingling, muscular weakness, paralysis, paresthesia, and affection of reflexes. If the herniated disk is of the Lumbar region the patient may also experience sciatica due to irritation of the sciatic nerve. Unlike a pulsating pain or pain that comes and goes, which can be caused by muscle spasm, pain from a herniated disc is usually continuous.
It is possible to have a herniated disc without any pain or noticeable symptoms, depending on its location. If the extruded nucleus pulposus material doesn't press on soft tissues or nerves, it may not cause any symptoms. It has been estimated that as many as 50% of the population have focal herniated discs in their cervical region that do not cause noticeable symptoms.
Typically, symptoms are experienced only on one side of the body. If the prolapse is very large and presses on the spinal cord or the cauda equina in the lumbar region, affection of both sides of the body may occur, often with serious consequences.
The majority of herniated discs will heal themselves in about six weeks and do not require surgery. Pain medications are often prescribed to alleviate the acute pain and allow the patient to begin exercising and stretching.
The presence of cauda equina syndrome (in which there is incontinence, weakness and genital numbness) is considered a medical emergency requiring immediate attention and possibly surgical decompression.
There are a variety of non-surgical care alternatives to treat the pain, including:
- Physical therapy
- Osteopathic/chiropractic manipulations
- Massage therapy
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Oral steroids (e.g. prednisone or methyprednisolone)
- Epidural (cortisone) injection
- Intravenous sedation, analgesia-assisted traction therapy (IVSAAT)
If pain is severe and continuous, or if there are neurological deficits, surgery may be recommended. Surgical goals include relief of nerve compression, allowing the nerve to recover, as well as the relief of associated back pain and restoration of normal function. Classical surgery for lumbar disc herniation is carried out by using a vertical median incision over the level which has an herniation. The dorsolumbar fascia is incised about 0.5 cm laterally on the affected side. The paravertebral muscles are dissected free from underlying bony structures, namely the spinous process and laminae, and retracted laterally. The level of disc herniation is identified using C-arm fluoroscopy or palpating the sacrum. The lamina is then fenestrated with bone rongeurs after which the exposed ligamentum flavum (the yellow ligament) is excised. The epidural soft tissue and venous plexus is gently explored to find the nerve root exiting from the associated neural foramina. The herniated disc is usually found beneath the nerve root. The nerve root is protected using root retractors. The posterior longitudinal ligament is incised with a fine blade and herniated disc material and degenerated nucleus pulposus are evacuated using different kinds of disc forcepses. Meticulous control of haemostasis is employed and irrigation with warm saline is essential. The muscle layers and the fascia are repaired, generally, without using a drain. The skin wound is closed. Surgical options include:
- Microdiscectomy[12]
- Lumbar fusion (lumbar fusion is only indicated for recurrent lumbar disc herniations, not primary herniations)
- Anterior cervical discectomy and fusion (for cervical disc herniation)
- Disc arthroplasty (experimental for cases of cervical disc herniation)
- Dynamic stabilization (dynamic stabilization is an experimental procedure with no data supporting its use for primary disc herniations)