What Veterans Should Know About LUMBAR DISC HERNIATION

What is a herniated disc?

The spine is made up of a series of connected bones called “vertebrae.“The disc is a combination of strong connective tissues which hold one vertebra to the next and acts as a cushion between the vertebrae.The disc is made of a tough outer layer called the “annulus fibrosus” and a gel-like center called the “nucleus pulposus.”As you get older, the center of the disc may start to lose water content, making the disc less effective as a cushion.

A herniated lumbar disc can press on the nerves in the spine and may cause pain, numbness, tingling or weakness of the leg called “sciatica.” Sciatica affects about 1-2% of all people, usually between the ages of 30 and 50.A herniated lumbar disc may also cause back pain, although back pain alone (without leg pain) can have many causes other than a herniated disc.

Anatomy – Normal Lumbar Disc

In between each of the five lumbar vertebrae (bones) is a disc, a tough fibrous shock-absorbing pad.Endplates line the ends of each vertebra and help hold individual discs in place.Each disc contains a tire-like outer band (called the annulus fibrosus) that encases a gel-like substance (called the nucleus pulposus).

Nerve roots exit the spinal canal through small passageways between the vertebrae and discs.

Pain and other symptoms can develop when the damaged disc pushes into the spinal canal or nerve roots

Disc herniation occurs when the annulus fibrous breaks open or cracks, allowing the nucleus pulposus to escape.This is called a Herniated Nucleus Pulposus (HNP) or herniated disc.

Signs and Symptoms

The lumbar spine consists of the five vertebrae in the lower part of the spine, each separated by a disc, also called a lumbar disc.

The discs in this part of the spine can be injured by certain movements, bad posture, being overweight and disc dehydration that occurs with age.

Although the lumbar vertebrae are the biggest and strongest of the spinal bones, risk of lumbar injury increases with each vertebrae down the spinal column because this part of the back has to support more weight and stress than the upper spinal bones.

The lumbar disc is the most frequent site of injury in several sports including gymnastics, weightlifting, swimming and golf, although athletes in general have a reduced risk of disc herniation and back problems.

Symptoms of disc herniation in the lower back are slightly different from symptoms in the cervical or thoracic parts of the spine.
The spinal cord ends near the top lumbar vertebrae but the lumbar and sacral nerve roots continue through these spinal bones.
lumbar disc herniation may cause:
Lower back pain
Pain, weakness or tingling in the legs, buttocks and feet
Difficulty moving your lower back
Problems with bowel, bladder or erectile function, in severe cases

L4 Quads/Tibialis Anterior Patellar reflex

Sensory Great toe and medial leg

L5 Strength of Ankle and great toe dorsiflexion

Extensor Hallucis Longus

Sensory to dorsum of foot

It should be noted that among patients without a pathological cause, most patients under 30 have an intact ankle reflex. However absent ankle reflexes are found in 30 percent of those between and 50 percent of those 81 to 90. Unilateral absence, however, is very rare.

S1 Ankle reflexes and sensation of posterior calf and lateral foot

Peroneals/Gastroc
Achilles reflex
Sensory to lateral and plantar foot

Diagnosis

Initial diagnosis of lumbar herniation generally is based on the symptoms of lower back pain.
Your doctor will examine your sensation, reflexes, gait and strength. Your doctor also may suggest the following tests:
X-ray — High-energy radiation is used to take pictures of the spine.
Magnetic Resonance Imaging (MRI) — An MRI provides detailed pictures of the spine that are produced with a powerful magnet linked to a computer.
Computed Tomography (CT) Scan — A CT scan uses a thin X-ray beam that rotates around the spine area. A computer processes data to construct a three-dimensional, cross-sectional image.
Electromyography (EMG) — This test measures muscle response to nervous stimulation.

Treatment

Conservative treatment of lower disc pain usually is successful over time.
It includes:
Pain medication or pain therapies such as ultrasound, massage or transcutaneous electrical nerve stimulation
Anti-inflammatory medication such as aspirin, ibuprofen and acetaminophen
Physical therapy
Steroid injections
Education in proper stretching and posture
Rest

Treatment

However, if your pain doesn’t respond to conservative treatment in two to four weeks, your condition affects your bowel or bladder function, or if it threatens permanent nerve damage, your doctor may suggest surgery.
Modern methods of surgery allow some spine operations to be performed through tiny incisions using miniature instruments while a microimaging instrument called an endoscope is used to view the surgery site

Treatment

The surgery usually includes removing the part of the disc that has squeezed outside its proper place, called a discectomy. The surgeon also may want to remove the back part of the vertebrae, called the lamina, in a laminectomy; or to surgically open the foramen, the holes on the side of the vertebrae through which the nerves exit, in a foramenotomy.Only about 10 percent of adult lumbar disc patients require surgery and even fewer children and adolescents

Treatment

UCSF Spine Center orthopedic surgeons also are investigating the effectiveness of an implant that may replace damaged lower back discs.

Prof.Dr.Hidayet Sarı

Physical Medicine and Rehabilitation Department

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What Veterans Should Know About HERNIATED DISC

 Cause

Disks are soft rubbery pads that are found between the vertebrae. The spinal cord and other nerve roots are located in the spinal canal. The disks are between the vertebrae and act as shock absorbers and allow flexibility. When a herniated or ruptured disk occurs, a portion of the nucleus center pushes through the outer edge of the disk and back toward the spinal canal where the nerves are located. The nerves are very sensitive even to the slightest pressure. When we are young, disks have high water content and the content lessens as we age. The disks become less flexible, decrease in size and the space between the vertebrae narrows.

Often a herniated disc by itself does not cause pain. Pain occurs when the membrane on the outside of the spinal cord or spinal nerves is irritated. Loss of function, such as weakness or altered sensation, can be caused by pressure from the herniated disc on the nerve roots or spinal cord. Pain or numbness may occur in the area of the body to which the nerve travels

The sciatic nerve is formed by the nerve roots coming out of the spinal cord into the lower back (lumbar region). Branches of the sciatic nerve extend through the buttocks and down the back of each leg to the ankle and foot.

A herniated disc may compress one or more of the nerve roots that form the sciatic nerve. Pressure on one of these nerve roots will often produce distinctive symptoms of sciatica, such as pain, numbness, weakness, and tingling in the affected leg. Although a herniated disc is the most common cause of sciatica, sciatica can also be a symptom of other problems, such as narrowing of the spinal canal (spinal stenosis), nerve root compression resulting from injury, and certain rare tumors.

Risk Factors

Age – Middle age is the most common age group 35 – 45, due to degenerative disks.

Weight – Cause more stress on the disks

Smoking – Decreases oxygen levels in your blood, which deprives them of vital nutrients

Height – Men taller than 5’ 11” and women taller than 5’ 7” have increased chances of a herniated disk Physically demanding jobs that require repetitive movements or sitting or standing too long.

 Signs and Symptoms

Symptoms include pain, numbness or weakness in neck chest, arms and hand. Sometimes there will be pain in the legs. Also, muscle spasm or cramping, sciatica. Sciatica is a symptom frequently associated with a lumbar herniated disk. Pressure on one or several nerves that contribute to the sciatic nerve causing pain, burning, tingling and numbness that extends from the buttock into the leg and sometimes foot. Diagnosis is made by a medical exam from a doctor, X-Rays, MRI or CT Scan.

Treatment

Herniated disks are usually first treated with non-surgical treatments including rest activities, physical therapy, medicines to relieve pain and inflammation. A doctor will recommend surgery if there are nerves being pinched or spinal pain.
Alternative treatments
Acupuncture
Acupressure
Massage
Non-Invasive Treatment
Chiropractic Care
Drugs – OTC
Acetaminophen (Tylenol)
NSAIDS (non-steroidal anti-inflammatory drugs (aspirin, ibuprofen, naproxen)

Treatment Continued

Prescription Medications Prescription NSAIDs Muscle relaxants (i.e.. Valium) alleviates spasms Oral steroids – used to reduce swelling Uploads Codeine, morphine – alleviates intense pain Anti-depressants – block pain messages from being received by your brain and increase the effects of endorphins, which are your bodies natural pain relievers. They also help you sleep better. Spinal Injections – Epidural steroid Injections contain corticosteroids which are potent anti-inflammatory agents. May take a few days to work and no more than three injections can be given in a year.

Exercise

Exercise is an effective way to strengthen and stabilize low back muscles, helps prevent further injury and pain. Being at your ideal weight is important. Extra weight constantly strains your back. Simple stretching and aerobic exercises can effectively control pain. Stretching programs such as yoga and pilates, moderate aerobic activities like waling, bicycling, swimming. Start any new aerobic activity slow and gradually increase. Active Treatments Improve flexibility, posture, strength, core stability and joint movement. Surgery most common is discectomy which removes all or part of the damaged disc.

Dr. Ryan Lambert-Bellacov, chiropractor in West Linn, OR

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For Cases & Decisions that Could Save Your VA Service-Connected Claims! Visit: VAClaims.org ~ A Non-Profit Non Governmental Agency