Herniated Nucleus Pulposus
Definition
A herniated disc is a fragment of the disc nucleus which is pushed out of the
outer disc margin, into the spinal canal through a tear or "rupture." In the
herniated disc's new position, it presses on spinal nerves, producing pain
down the accompanying leg. This produces a sharp, severe pain down the
entire leg and into the foot. The spinal canal has limited space which is
inadequate for the spinal nerve and the displaced herniated disc fragment.
The compression and subsequent inflammation is directly responsible for the
pain one feels down the leg, termed "sciatica." The direct compression of the
nerve may produce weakness in the leg or foot in a specific patter,
depending upon which spinal nerve is compressed.
A herniated disc is a definite displaced fragment of nucleus pushed out
through a tear in the outer layer of the disc (annulus). For a disc to become
herniated, it typically is in an early stage of degeneration.
In this situation there is a portion of the annulus that has isolated
itself from the rest of the disc and all or part of its displaced will out
into the canal. This situation is the one that responds best surgery.
It may not respond to conservative therapy, including manipulation
and even chemonucleolysis.
Types of herniated nucleus pulposus
A herniated nucleus pulposus can occur on any disc in the spine, but most
frequently appears in the cervical spine (in the neck region) and the lumbar
spine (in the lower back). These areas of the spine are particularly
susceptible to disc injury because of their weight-bearing responsibilities and
the repeated strain they endure from regular use over the years.
While not all types of herniated nucleus pulposus injuries cause pain, you can
experience a wide variety of symptoms depending on a few factors. These
factors include the type of tear in the annulus fibrosus and whether the
nucleus pulposus materials are compressing or irritating other elements of
the spine (such as the disc wall, local nerve roots or the spinal cord).
Symptoms also can vary according to the specific location of the injured disc
in the spinal column.
Herniated Nucleus Pulposus
Symptoms of the types of herniated nucleus pulposus
Cervical nerve roots, labeled C1-C8, that become inflamed by a herniated
nucleus pulposus can cause the corresponding symptoms:
C1 and C2 There is no intervertebral disc between the first two
cervical vertebrae (C1 and C2), but if the nerve roots in this area are
affected by disc herniation between the next pair of cervical vertebrae (C2
and C3), symptoms could include a tingling discomfort in the neck and
base of the skull, problems with neck and head mobility, headaches and
pain in the temples
C3 and C4 Pain at the base of the neck, a pins-and-needles feeling in
the upper shoulders or headaches behind the eyes and ears
C5 and C6 Weakness or pain that radiates through the upper arms,
biceps, forearms, wrists and thumbs
C7 and C8 Numbness, weakness or a pins-and-needles sensation that
travels through the triceps, hands and fingers
A herniated nucleus pulposus (HNP) causes many patients to experience
aches and pains in the neck and back. This spinal condition occurs when the
jellylike center (nucleus pulposus) of an intervertebral disc seeps through a
tear in the tough exterior (annulus fibrosus) and into the spinal column.
While there are several factors that can lead to developing a herniated disc,
there are two main causes:
Age An HNP typically occurs as the result of a degenerative
condition that can develop as a patient ages. Our necks and backs receive
continued stress and pressure from the weight of our bodies, and this can
cause intervertebral discs to break down (or degenerate) over time.
Overexertion This spinal condition can also occur in younger
patients who are overweight, participate in high-impact sports or
continually lift heavy objects.
Symptoms
An HNP causes most patients to feel pain in the affected area of the neck or
back. The degree of pain may vary from patient to patient, with some not
experiencing any discomfort at all. For those who are symptomatic, though,
the pain sometimes worsens during physical activities or while sitting,
Herniated Nucleus Pulposus
coughing or leaning forward. Numbness, a pins and needles feeling and
weakness may also occur due to HNP.
Typical Pain and Findings
Typically, a herniated disc is preceded by an episode of low back pain or a
long history of intermittent episodes of low back pain. However, when the
nucleus actually herniates out through the annulus and compresses the
spinal nerve, then the pain typically changes from back pain to sciatica.
Sciatica is sharp pain which radiates from the low back area down through
the leg, into the foot in a characteristic pattern, depending upon the spinal
nerve affected. This pain often is described as sharp, electric shock-like,
sever with standing, walking or sitting. The pain is frequently relieved by
lying down or utilizing a lumbar support chair or insert.
There also may be resulting leg muscle weakness from a compromise of the
spinal nerve affected. Most commonly, the back pain has resolved by the
time sciatica develops, or there is minimal back pain compared to the severe
leg pain. The location of the leg pain is usually so specific that the doctor can
indentify the disc level which is herniated. In addition to leg muscle
weakness, there may also be knee or ankle reflex loss.
What Diagnostic Tests are Used for Evaluations
X-rays of the low back area are obtained to search for unusual causes of leg
pain, i.e. tumors, infections, fractures, etc. An MRI of the lumbar spine area is
obtained, as this will demonstrate the degree of disc degeneration at the
herniated level, in addition to the condition of other lumbar discs in the low
back.
A quality MRI will accurately demonstrate the size of the spinal canal and
most other medically significant factors. A nerve test may be indicated to
demonstrate whether there is ongoing nerve damage, or if the nerves are in
a state of healing a past insult, or whether there is another site of nerve
compression.
Herniated Nucleus Pulposus
Treatment
The initial treatment for a herniated disc is usually conservative, i.e.
nonoperative. One usually begins with resting the low back area, maintaining
a comfortable posture and painless activity level for a few days to several
weeks. This in in order to allow the spinal nerve inflammation to quiet down
and resolve.
A herniated disc is frequently aided by non-steroidal anti-inflammatory
medication such as Motrin, Voltaren, Naprosyn, Lodine, Feldene, Clinoril,
Tolectin, Dolobid, Advil or Nuprin. An epidural steroid injection may be
performed utilizing a spinal needle under x-ray guidance to direct the
medication to the exact level of the disc herniation.
Physical therapy may be beneficial, under the direction of a physical
therapist. The therapist will perform an in-depth evaluation; this information,
combined with a physician's diagnosis, will dictate a treatment based on
successful physical therapy treatment modalities which have proven
beneficial for herniated disc patients. These may include traction, ultrasound,
electrical muscle stimulation, etc., to relax the muscles which are in spasm
and secondarily inflamed from the compressed spinal nerve. Pain medication
and muscle relaxing medications may also be beneficial to help physical
therapy or other conservative, non-operative treatment to relieve the pain
while the spinal nerve root inflammation resolves and the body heals itself. If
these conservative treatments are not successful and the pain is still severe
or muscle weakness is increasing, then surgery is necessary. Surgery may be
in the form of a percutaneous discectomy if the disc herniation is small and
not a completely extruded disc fragment.
Herniated Nucleus Pulposus
If the herniation is large, or is a "free fragment" as described above, then a
microlaminotomy with disc excision is necessary. A micro-laminotomy
requires one to two days of hospitalization after the surgery for the wound to
heal and postoperative physical therapy to begin. The sciatic pain down the
leg should be resolved immediately after the surgery. However, there will be
some discomfort in the low back area where the operation is performed,
lasting several days to a couple of weeks. This is controlled with pain
medication.
Prognosis
A person who has sustained one disc herniation is statistically at increased
risk for experiencing another. There is an approximate 5% rate of recurrent
disc herniation at the same level, and a lesser incidence of new disc
herniation at another level. Factors involved may be weight related level of
physical conditioning, work or behavioral habits. Since these factors are
typically the same after surgery, there is an increased risk of herniated disc
in this group, over the general population.
However, the good news is that the majority of disc herniations (90%) do not
require surgery, and will resolve with conservative, nonoperative treatment,
without significant long-term sequelae. Unfortunately, approximately 5% of
patients with herniated, degenerated discs will go on to experience
symptomatic or severe and incapacitating low back pain which significantly
affects their life activities and work. This unfortunate result is not always
specifically the result of surgery. The causes of this unremitting pain are not
always clear or agreed on, and my be from several sources. When this
Herniated Nucleus Pulposus
occurs, the prognosis is poor for returning to normal life activities regardless
of age.
After a successful laminotomy and discectomy, 80-85% of patients do
extremely well and are able to return to their normal job in approximately six
weeks time. There may be small permanent patches of numbness in the
involved leg which, fortunately, are not disabling. Flare-ups or exacerbations
of less severe and less significant sciatic type pain may develop in the future
(usually on an infrequent basis).
