herniated lumbar disc 2006

8/6/2019 Herniated Lumbar Disc 2006

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North American

Spine Society

Public Education

Series

HerniatedLumbar disc


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WHat is a

Herniated disc?

The spine is made up of a series of connected

bones called vertebrae. The disc is a combi-nation of strong connective tissues which hold

one vertebra to the next, and acts as a cushionbetween the vertebrae. The disc is made of a

tough outer layer called the annulus brosusand a gel-like center

called the nucleuspulposus. As youget older, the cen-

ter of the disc maystart to lose water

content, makingthe disc less effec-

tive as a cushion.This may cause a

displacement of thediscs center (called

a herniated or ruptured disc) through a crackin the outer layer. Most disc herniations occur

in the bottom two discs of the lumbar spine, atand just below the waist.

A herniated lumbar disc can press on thenerves in the spine and may cause pain, numb-

ness, tingling or weakness of the leg calledsciatica. Sciatica affects about 1-2% of all

people, usually between the ages of 30 and 50.

A herniated lumbar disc mayalso cause backpain, although back pain alone (without legpain) can have many causes other than aherniated disc.


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WHat treatments

are avaiLabLe?

Most (80-90%) patients with an acute lumbar

disc herniation will improve without surgery.

Your health care provider will usually begintreatment with nonoperative methods. If thepain still keeps you from your normal lifestyle

after completing treatment, your health careprovider might recommend surgery.

Although surgery may not return leg strength

to normal, it can stop your leg from gettingweaker, and help relieve leg pain. Surgery is

usually recommended for relief of leg pain(>90% success); surgery is less effective in

relieving back pain.

H wh


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nonoperative treatment

Your health care provider may prescribe non-operative treatments including a short periodof rest, antiinammatory medications to re-

duce the swelling, analgesic drugs to controlthe pain, physical therapy, exercise or epiduralsteroid injection therapy. If you are told torest, follow the directions on how long to stayin bed. Too much bed rest may give you stiff

joints and weak muscles, which will make itharder to do activities that could help reducethe pain. Ask your health care provider wheth-er you should continue to work while you arebeing treated.

Your health care provider may start treat-ment and, with the help of a nurse or physicaltherapist, begin education and training aboutperforming the activities of daily living withoutplacing added stress on your lower back.

The goals of nonoperative treatment are toreduce the irritation of the nerve and disc andto improve the physical condition of thepatient to protect the spine and increase overallfunction. This can be accomplished in themajority of herniated disc patients with anorganized care program that combines anumber of treatment methods.


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Some of the rst treatments your health care

provider may prescribe include therapies suchas ultrasound, electric stimulation, hot packs,

cold packs and manual (hands on) therapy toreduce your pain and muscle spasm, which will

make it easier to start an exercise program. Trac-tion may also provide limited pain relief for some

patients. Occasionally, your doctor may ask youto wear a lumbar corset (soft, exible back brace)at the start of treatment to relieve your back

pain, although it doesnt help heal the herniateddisc. Manipulation may provide short-term relief

from nonspecic low back pain, but should beavoided in most cases of herniated disc.

At rst, the exercises you learn may be gentle

stretches or posture changes to reduce the backpain or leg symptoms. When you have less pain,more vigorous exercises will likely be used to

improve exibility, strength, endurance and the

ability to return to a more normal lifestyle.

Exercise instruction should start right away and

be modied as recovery progresses. Learning andcontinuing a home exercise and stretching

program are important parts of treatment.


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Medications used to control pain are calledanalgesics. Most pain can be treated with non-

prescription medications such as aspirin, ibu-profen, naproxen, or acetaminophen. Some-times, but not often, a doctor will prescribe

musclerelaxants. If you have severe persistent pain,

your doctor might prescribe narcotics for ashort time. However, you want to take only

the medication you need because taking moredoesnt help you recover faster, might cause

unwanted side effects (such as constipation anddrowsiness), and can result in dependency.

All medication should be taken only as direct-ed. Make sure you tell your doctor about any

kind of medication you are takingeven over-the-counter drugsand if he/she prescribes

pain medication, let him/her know how it isworking for you.

Nonsteroidal antiinfammatory medications(NSAIDs) are analgesics and are also used toreduce swelling and inammation that occur

as a result of disc herniation. These include

aspirin, ibuprofen, naproxen and a variety ofprescription drugs. If your doctor gives youantiinammatory medications, you should

watch for side effects like stomach upset or

bleeding. Chronic use of prescription or over-the-counter NSAIDs should be monitoredby your physician for the development of any

potential problems.

medication and

pain management


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There are other medications that also have an

antiinammatory effect. Corticosteroid

medicationseither orally or by injection aresometimes prescribed for more severe backand leg pain because of their very power-

ful antiinammatory effect. Corticosteroids,like NSAIDs, can have side effects. Risks and

benets of this medication should be discussedwith your physician.

Epidural injections or blocks may be

recommended if you have severe leg pain.These are injections of corticosteroid intothe epidural space (the area around the spinal

nerves), performed by a doctor with specialtraining in this technique. The initial injection

may be followed by one or two more injectionsat a later date. This should bedone as part ofa comprehensive rehabilitation and treatmentprogram. The purpose of the injection is to

reduce inammation of the nerve and the disc.

Trigger point injections are injections of localanesthetics (sometimes combined with corti-

costeroids) directly into painful soft tissue or

muscles along the spine or over the back of thepelvis. While occasionally useful for paincontrol, trigger point injections do not help

heal a herniated lumbar disc.


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surgicaL treatment

The goal of surgery is to make the herniateddisc stop pressing on and irritating the nerves,

causing symptoms of pain and weakness. The

most common procedure is called a discec-tomy or partial discectomy, in which partof the herniated disc is removed.In order tosee the disc clearly, sometimes it is necessary to

remove a small portion of the lamina, the bonebehind the disc. Bone removal may be minimal(hemi-laminotomy) or more extensive (hemi-

laminectomy). Some surgeons use an endo-scope or microscope in some cases.

Discectomy can be done under either local,

spinal or general anesthesia. The patient laysface down on the operating table, generally in

a kneeling position. A small incision is made inthe skin over the herniated disc and the muscles

over the spine are pulled back from the bone. Asmall amount of bone may be removed so the

surgeon can see the compressed nerve. The her-

niated disc and any loose pieces are removeduntil they are no longer pressing on the nerve.Any bone spurs (osteophytes) are also taken

out to make sure that the nerve is free of pres-

sure. Usually, there is very little bleeding.


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WHat can i expect

after surgery?

If your main symptom is leg pain (rather thanlow back pain), you can expect good results

from surgery. Before surgery, your doctor will

do an examination and tests to make sure thatthe herniated disc is pressing on a nerve andcausing your pain. Physical examination should

show a positive-straight leg raise test demon-

stratingsciatica and possibly muscle weakness, numb-ness or reex changes. Additional tests can

include an imaging test (magnetic resonanceimage [MRI], computed tomography [CT] or

myelography) that clearly shows nerve com-pression. If these tests are all positive for you,

and your doctor is sure that you have nervecompression, your chance of signicant relief

from leg pain after surgery is approximately90%. Although you should not expect to be

pain-free every day, you should be able to keepthe pain under control and resume a fairly nor-

mal lifestyle.

Most patients will not have complications afterdiscectomy, but it is possible you may have

some bleeding, infection, tears of the protective

lining of the spinal nerve roots (dura mater), orinjury to the nerve. It is also possible that thedisc will rupture again and cause symptoms.

This occurs in about 5% of patients.


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Ask your doctor for recommendations on

post-surgical activity restrictions. It is usuallya good idea to get out of bedand walk aroundimmediately after recovering from anesthesia.Most patients go home within 24 hours after

surgery, often later the same day.

Once home, you should avoid driving, pro-longed sitting, excessive lifting, and bending

forward for the rst four weeks. Some patientswill benet from a supervised rehabilitation

program after surgery. You should ask yourdoctor if you can use exercise to strengthen

your back to prevent recurrence.


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DO I NEED

EMERGENCY SURGERY?

Very rarely, a large disc herniation may press

on the nerves which control the bladder andbowel, causing loss of bladder or bowel con-

trol. This is usually accompanied by numbnessand tingling in the groin or genital area, and is

one of the few indications that you need sur-gery immediately for a herniated lumbar disc.

Call your doctor at once if this happens.


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North AmericAN SpiNe Society

public educAtioN SerieS

discLaimerThis brochure is for general information and under-standing only and is not intended to represent ofcialpolicy of the North American Spine Society. Pleaseconsult your physician for specic information about

your condition.Illustrations courtesy of Camp International, Inc.,Drs. David Selby and Joel S. Saal. 2006 North American Spine Society

for more information,

pLease contact:

nortH american spine society

7075 veterans bouLevard

burr ridge, iL 60527

pHone (866) 960-nass (6277)

fax (630) 230-3700

visit us on tHe internet at:

WWW.spine.org

herniated lumbar disc 2006

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