What is a herniated disc?
The intervertebral discs lie between the vertebral bodies (the small bones that go up and down the spine). They consist of a gelatinous, elastic core (nucleus pulposus), which is kept in shape by a surrounding fibre ring (annulus). The concept of a jelly doughnut is commonly used to illustrate how the outer ring of the disc (like the pastry portion of the doughnut) keeps the gel-like center (the jelly) from leaking into the spinal column.
These discs act like shock absorbers for the spine, helping to reduce friction between the vertebrae. Further, healthy intervertebral discs are integral to maintaining spinal stability and mobility.
Over the course of normal aging processes, the nucleus pulposus becomes gradually drier and less elastic, thereby becoming less absorbent of the daily stresses on the spine. This alone can leave spinal discs vulnerable to rupture, however repeatedly overloading it can cause cracks in the fibre ring to occur more rapidly. Parts of the nucleus pulposus may then be pushed out through the annulus and into the spinal canal. This is known a herniated disc.
In some cases, the protruding portion of the herniated disc applies pressure on nerve roots which can cause symptoms in the areas affected by those nerves including radiating pain, loss of sensation, reduced mobility, and – in rare cases – even paralysis. Some patients may experience axial pain, or pain that is caused by degeneration of the disc itself. Both axial and radicular pain can occur in relation to one or more discs in the cervical (neck), thoracic (upper), or lumbar (lower) portions of the back. Determining the precise location of the origin of the presenting symptoms is one of the primary objectives in the process of a herniated disc diagnosis, beginning with the first appointment with your usual physician.
It is worth noting that herniated disc is often used interchangeably with ruptured disc, slipped disc, and bulging disc. While there is not consensus on the phrase used to describe disc-related spine problems, most medical professionals agree that the best way to resolve the symptoms of a herniated disc is through accurate diagnosis of their source and nature, as well as appropriate, individualized treatment.
What causes a herniated disc?
A sudden rotational movement of the trunk or heavy lifting can cause a herniated disc. A traumatic injury of any kind affecting the neck or back can result in damage to intervertebral discs. Moreover, a herniated disc can also be the result of poor posture in daily life (for example, incorrect sitting or permanent and long-lasting driving) or the lack of consistent and appropriate exercise. Dehydration can also cause disc degeneration and subsequent herniation – if there is not enough liquid available for the body, the disc can dry out and it will lose its elasticity and become vulnerable to rupture. Other risk factors for a herniated disc include obesity, pregnancy, smoking, and malnutrition, as well as general weakness of connective tissue.
Also, the aging process causes gradual damage to all components of the spine and body. Over time, this age-related degeneration can result in injuries such as a herniated disc. This kind of damage can occur relatively early in life, and can often be observed in young adults through imaging tests like an MRI. In many cases, affected individuals are asymptomatic (not experiencing pain or other symptoms) and may not even be aware that they have a herniated disc.
Age-related degeneration of and consequent injury to the intervertebral discs can be mediated through a variety of preventative measures. Maintaining a nutritionally-balanced diet and healthy weight, staying sufficiently hydrated, and getting good sleep on a spine-friendly bed are all ways that individuals can reduce the daily stress on their spines. Additionally, making sure to engage in frequent, gentle to moderate exercise helps to keep the muscles supporting the spine strong and flexible. This maintains spinal stability and mobility, helping to prevent any one piece of the spine from putting too much repeated pressure on another.
What are the symptoms of a herniated disc?
Not all cases of a herniated disc cause pain. In fact, a large number of people with a herniated disc are not at all aware of their condition. However, if tissue from the disc nucleus presses on the surrounding nerves, this can lead to severe radiating pain, dysesthesia (such as reduced or absent sensation in certain areas), or even paralysis. Most commonly, discs in the lumbar spine are affected, as the lower portion of the back often carries the most physical stress in daily activities.
In addition to back pain, a herniated disc can cause pain in the buttocks, legs and sometimes in the feet. Such radicular pain is characteristic of a herniated disc and is popularly referred to as “sciatica”. Generally, the symptoms of a herniated disc appear in areas that are supplied by the affected nerve root. The technical name of these areas is “dermatomes” and the level of the herniated disc can often be readily determined based on this characteristic distribution of pain.
The pain burden associated with a herniated disc is high and it can have a significant impact on the quality of life. Continuous pain can drive people into isolation because often the patients hardly dare leaving the house. A trip with the family or even a meeting with friends can become a treacherous experience riddled with risk for increased pain.
Stop the pain in time
Anyone who suffers from chronic pain (e.g. permanent back pain) should urgently seek medical help. Otherwise there is a danger that the nervous system virtually learns the pain. Scientists refer to this phenomenon as “the pain memory”: ongoing pain renders the nerve cells hypersensitive and eventually they will signal “pain” without obvious reason. Just a slight touch will then lead to pain.
How is a herniated disc diagnosed?
The first step towards a clear diagnosis is medical consultation purely based on the patient’s symptoms. This typically involves a thorough diagnostic interview, physical examination of the affected area, and basic neurological testing. In case of persistent discomfort or in the event of a clear suspicion of a herniated disc, special imaging of the spine is done. Using magnetic resonance imaging (MRI), cross-sectional images of the spine are created, which are a great help to identify the source of the pain. This gentle, non-radioactive imaging technique helps to make disc protrusions or herniations clearly visible. Good results can also be achieved with computed tomography (CT) in those cases where an MRI is not advisable.
When do I need disc surgery?
Luckily, most cases of a herniated disc do not require surgery. It is typically only in those cases in which all active and passive conservative therapy options have been exhausted and symptoms continue to persist that herniated disc surgery is likely to be recommended by your physician. Patients will usually be instructed to try physical therapy in conjunction with temperature therapy, rest, lifestyle adjustments and sometimes medication for weeks to months before being advised to consider surgery. This is because surgery always carries risks and if possible, it is usually considered ideal to resolve back pain issues non-surgically. However, it is important to note that in cases of paralysis or other severe complications associated with a herniated disc, surgery may be immediately necessary.
Without question, no one likes the thought of avoidable surgery. However, for certain patients, a spinal disc surgery is the only chance to get rid of their herniated disc symptoms permanently and to regain their original quality of life.
If there are progressing neurologic deficits, paralyses, or even organic functional problems like bladder and bowel problems – a quick referral to surgery will be required. In these cases there is a risk that nerve roots may be – or at imminent risk of becoming – irreversibly damaged.
For all other cases of a herniated disc, surgery is recommended only if modern imaging techniques and the pain symptoms of the patient indicate that nerve roots are compromised. During a herniated disc surgery, the tissue that presses on the nerve will be removed. Usually, the pain will disappear immediately. The following rule of thumb can be applied: If the leg pain is greater than the back pain, an intervention may be promising. In pure back pain, an operation often does not lead to the desired results.
If you and your treatment team determine that in your case of a herniated disc surgery is necessary, there are a number of effective options available. The precise type of surgery you need will depend on the location and nature of your injury, but herniated disc procedures are usually focused on decompression (for example, removing the herniated disc or a portion of it) and stabilization (for example, replacing the removed disc with a synthetic one). Traditional open surgery is sometimes necessary, particularly in emergencies. Otherwise, minimally invasive surgical treatments for the herniated disc are often preferred as they are associated with less trauma to the muscles and other tissues surrounding the target area, less time required to perform the surgery, a quicker recovery time, and fewer post-operative (surgery-related) complications.
After being diagnosed with a herniated disc, it is important to spend some time researching your treatment options and discussing them with your treatment team. The best course of treatment for another individual may not be the best course of treatment for you.