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

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

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

What Disabled Veteran Should Know About Special Rules For Certain Claims

Congress, and in some cases VA, has recognized that some conditions resulting from service are so widespread or unique that they require special procedures. Two of the most common of these conditions, herbicide exposure in Vietnam Era veterans and undiagnosed or multisymptom illnesses in Persian Gulf War veterans, are described below.

Herbicide-Exposed Veterans

Congress has established a “presumption” of exposure to herbicides, most infamously including “Agent Orange,” for veterans who served in the Republic of Vietnam during the period from January 9, 1962, to May 7, 1975. A presumption is a legal term that means that VA has to assume a fact unless there is evidence against the fact. For Vietnam veterans this means that evidence of actual exposure Agent Orange is not required – those veterans is presumed to have been exposed to Agent Orange – if they meet the requirements for the presumption.

For claimants, this means that if a veteran can show he or she was in Vietnam during the specific period and currently has a medical condition listed in VA regulations as being caused by Agent Orange which began within the listed time periods, VA must service connect that condition. Conditions that are presumptively service-connected for herbicide exposure include chloracne, Type 2 diabetes (also know as Type II diabetes mellitus or adult-onset diabetes), Hodgkin’s disease, Non-Hodgkin’s lymphoma, B cell leukemia, Parkinson’s disease, and ischemic heart disease. Other presumptive conditions are listed, so a Vietnam veteran with a health condition should review the entire list. [link to CFR]

Just who is eligible for the herbicide presumption has been the topic of extensive debate and litigation. As it currently stands, having earned a Vietnam Service Medal is not enough to obtain the presumption. A veteran must show that he or she put “boots on the ground” in Vietnam or have been a “brown water” (inland waters) sailor to qualify. A single layover or shore leave is enough to receive the presumption. In addition, some veterans with service in Korea are also eligible for the presumption. For veterans with service in Thailand the key to claims for exposure are military duties that took the veteran out to and alongside the perimeter of bases where defoliants were acknowledged to have been used. Such duties include dog handling, security, and some maintenance activities.

Many veterans have challenged this definition, especially “blue water” (open ocean) sailors and Air Force ground support personnel who believe that they were exposed to Agent Orange or other herbicides during service. VA, backed by the courts, will not apply the presumption unless they have evidence of “boots on the ground” from these veterans.  Air Force members and reservist who served

On June 19th, 2015 the Federal Register published that Air Force Servicemembers and Air Force Reservists who served during the period of 1969 through 1986 and whose service required that they regularly and repeatedly operate, maintain, or serve onboard C-123 aircraft that was exposed to Agent Orange are now eligible for VA disability compensation for presumptive conditions due to Agent Orange Exposure.

In addition, any veteran who believes that he or she was exposed to a herbicide can file a claim and attempt to show actual herbicide exposure. This can be done by providing evidence of actual exposure, such as photographs showing Agent Orange barrels. In addition, veterans who served in other locations, such as Guam, have occasionally been able to show actual exposure although the government does not officially acknowledge Agent Orange was stored or used in those locations.

A unique aspect of Agent Orange claims is the possible retroactive assignment of effective dates. A series of court orders in the class-action litigation in Nehmer v. United States Department of Veterans Affairs, requires VA in certain cases to make an award effective on the date of the claimant’s application or the date of a previously-denied application, even if such date is earlier than the effective date of the regulation establishing the presumption. In other words, the Nehmer case created an exception to the rules for calculating effective dates and requires VA to assign retroactive effective dates for certain awards of disability compensation and DIC.

Another result of the Nehmer case is that if an individual was entitled to retroactive benefits as a result of the court orders but died prior to receiving such payment, VA must pay the entire amount of the retroactive payments to the veteran’s estate, regardless of any statutory limits on payment of benefits following a veteran’s death. Veterans and surviving spouses, dependent children, and dependent parents of veterans with service in Vietnam who previously filed claims for conditions associated with herbicide exposure should carefully review current VA regulations to determine if they are eligible for retroactive benefits.

Polytraumatic Injuries Requiring Specialized Rehab

Recent combat has resulted in new patterns of polytraumatic injuries and disability requiring specialized intensive rehabilitation processes and coordination of care throughout the course of recovery and rehabilitation. While serving in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), military service members are sustaining multiple severe injuries as a result of explosions and blasts. Improvised explosive devices, blasts, landmines, and fragments account for 65 percent of combat injuries (see subpar. 17a). Congress recognized this newly emerging pattern of military injuries with the passage of Public Law 108-422, Section 302, and Public Law 108-447.

Combat injuries are often the result of a blast. Blasts cause injuries through multiple mechanisms. Severe blasts can result in total body disruptions and death to those closest to the blast site or they can result in burns and inhalation injuries. Blast injuries typically are divided into four categories: primary, secondary, tertiary, and quaternary or miscellaneous injuries.

1. Primary Blast Injuries. Primary blast injuries are caused by overpressure to gas- containing organ systems, with most frequent injury to the lung, bowel, and inner ear (tympanic membrane rupture). These exposures may result in traumatic limb or partial limb amputation.

2. Secondary Blast Injuries. Secondary blast injuries occur via fragments and other missiles, which can cause head injuries and soft tissue trauma.

3. Tertiary Blast injuries. Tertiary Blast injuries result from displacement of the whole body by combinedpressure loads (shock wave and dynamic overpressure).

4. Miscellaneous Blast-related Injuries. These are miscellaneous blast-related injuries such as burns and crush injuries from collapsed structures and displaced heavy objects. Soft tissue injuries, fractures, and amputations are common.

Animal models of blast injury have demonstrated damaged brain tissue and consequent cognitive deficits. Indeed, the limited data available suggests that brain injuries are a common occurrence fromblast injuries and often go undiagnosed and untreated as attention is focused on more “visible” injuries. A significant number of casualties sustain emotional shock and may develop PTSD. Individuals may sustain multiple injuries from one or more of these mechanisms. Explosions can produce unique patterns of injury seldom seen outside combat.

Center for Disease Control and Prevention (CDC) Classification of Blast Injuries

Auditory or Vestibular
Tympanic membrane rupture, ossicular disruption, cochlear damage, foreign body, hearing loss, distorted hearing, tinnitus, earache, dizziness, sensitivity to noise.

Eye, Orbit or Face
Perforated globe, foreign body, air embolism, fractures.

Respiratory
Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, atrioventricular fistula (source of air embolism), airway epithelial damage, aspiration pneumonitis, sepsis.

Digestive
Bowel perforation, hemorrhage, ruptured liver or spleen, mesenteric ischemia from air embolism, sepsis, peritoneal irritation, rectal bleeding.

Circulatory
Cardiac contusion, myocardial infarction from air embolism, shock, vasovagal hypotension, peripheral vascular injury, air embolism-induced injury.

Central Nervous System
Concussion, closed or open brain injury, petechial hemorrhage, edema, stroke, small blood vessel rupture, spinal cord injury, air embolism- induced injury, hypoxia or anoxia, diffuse axonal injury.

Renal and/or Urinary Tract
Renal contusion, laceration, acute renal failure due to rhabdomyolysis, hypotension, hypovolemia.

Extremity
Traumatic amputation, fractures, crush injuries, burns, cuts, lacerations, infections, acute arterial occlusion, air embolism-induced injury.

Soft Tissue
Crush injuries, burns, infections, slow healing wounds.

Emotional or Psychological
Acute stress reactions, PTSD, survivor guilt, post-concussion syndrome, depression, generalized anxiety disorder.

Pain
Acute pain from wounds, crush injuries, or traumatic amputations; chronic pain syndromes.

Recognizing the specialized clinical care needs of individuals sustaining multiple severe injuries, VA has established four PRCs. The PRC mission is to provide comprehensive inpatient rehabilitation services for individuals with complex physical, cognitive and mental health sequelae of severe and disabling trauma, to provide medical and surgical support for ongoing and/or new conditions, and to provide support to their families. Intensive clinical and social work case management services are essential to coordinate the complex components of care for polytrauma patients and their families. Coordination of rehabilitation services must occur seamlessly as the patient moves from acute hospitalization through acute rehabilitation and ultimately back to the patient’s home community. Transition to the home community may include a transfer from a PRC to a less acute facility.

The Secretary of Veterans Affairs designated five PRCs, co-located with TBI Lead Centers, at VA Medical Centers in Richmond, VA; Tampa, FL; Minneapolis, MN; San Antonio, TX, and Palo Alto, CA (see App. A). It is VHA policy that the PRCs provide a full-range of care for all patients eligible for VA care, who have sustained varied patterns of severe and disabling injuries including, but not limited to: TBI, amputation, visual and hearing impairment, spinal cord injury (SCI), musculoskeletal injuries, wounds, and psychological trauma. Due to the medical complexity of these patients, PRCs must be prepared to admit individuals who may have a higher level of medical acuity and require interdisciplinary management by various medical specialists. The general admission criteria to the PRC include:

1.The individual with polytrauma is an eligible veteran or an active duty military service member; and
2.The individual has sustained multiple physical, cognitive, and/or emotional impairments secondary to trauma; and
3.The individual has the potential to benefit from inpatient rehabilitation; or
4.The individual has the potential to benefit from a transitional community re-entry program; or
5.The individual requires an initial comprehensive rehabilitation evaluation and care plan.

It is recommended that all patients experiencing a polytraumatic injury be referred to a VA PRC. The PRC team has specialized expertise to determine the most appropriate setting for care. If the patient does not require admission to a PRC, the team can assist with coordination of care at the most appropriate facility. Referral to a PRC also ensures that the patient and family are integrated into the VA system of care with the appropriate rehabilitation services. NOTE: The SCI Chief for the applicable region needs to be contacted by the PRC admissions clinical case manager to consult on the transfer of patients with a diagnosis of TBI and SCI.

Referrals to the PRC must be given the highest priority and the screening process needs to be expedited to ensure that there are no delays in transferring a patient to the Center. The PRC must accept admissions on a 24/7 basis. To establish the medical needs and acuity of the patient, there is a need to review medical documentation, consult with the referring treatment provider, and coordinate a plan for transfer.

Referral of service members with polytrauma to a PRC is initiated by DOD, typically by the MTF social worker or case manager, or other DOD representative. Where assigned, the VA- DOD liaison social worker is actively involved in the referral process, facilitating communications, information exchange, transition of care, and family support. The PRC’s admissions clinical case manager coordinates the referral and screening process for the accepting VA PRC. NOTE: For those referral sources that do not have VA-DOD liaisons, admission screening is to be coordinated between the PRC admission clinical case manager and the MTF.

Points of Contact
VA Polytrauma Points of Contact are available at 39 VAMCs without specialized rehabilitation teams. These Points of Contact, established in 2007, are knowledgeable about the VA Polytrauma/TBI System of care and coordinate case management and referrals throughout the system and may provide a more limited range of rehabilitation services.

Polytrauma Points of Contact (PPOC)
VISN Facility/Health Care System Contact Information
1. Louis A. Johnson VAMC- Clarksburg, WV (304) 623-3461
2. Beckley VA Medical Center, WV (304) 255-2121
3. Asheville VA Medical Center- Asheville NC (828) 298-7911
4. Fayetteville VA Medical Center- Fayetteville, NC (910) 488-2120
5. Carl Vinson VA Medical Center- Dublin, GA (334) 727-0550
6. Central Alabama Veterans Health Care System: East Campus- Tuskegee, AL (478) 272-1210
7. Columbus Outpatient Clinic- Columbus, OH (614) 257-5327
8. Chillicothe VA Medical Center- Chillicothe, OH (740) 773-1141
9. VA Northern Indiana Health Care System- Marion, IN (989) 497-2500
10. Aleda E. Lutz VA Medical Center- Saginaw, MI (260) 426-5431
11. Battle Creek VA Medical Center- Battle Creek, MI (269) 966-5600
12. Iron Mountain, MI VAMC (906) 774-3300
13. Marion VA Health Care System- Marion, IL (618) 997-5311
14. VA Eastern Kansas Health Care System: Colmery-O’Neill VA Medical Center Topeka, KS (785) 350-3111
15. Harry S. Truman Memorial Veterans’ Hospital- Columbia, MO (573) 814-6638
16. John J. Pershing VA Medical Center- Poplar Bluff, MO (573) 778-4359
17. Southeast Louisiana Veterans Health Care System- New Orleans, LA (504) 556-7245
18. Kerville VA Medical Center- Kerville, TX (830) 896-2020
19. Waco VA Medical Center- Waco, TX (254) 0743-0711
20. VA Texas Valley Coastal Bend Health Care System (956) 291-9000
21. Amarillo VA Health Care System- Amarillo, TX (806) 355-9703
22. West Texas VA Health Care System- Big Spring, TX (432) 263-7361
23. El Paso VA Health Care System- El Paso, TX (915) 564-6159
24. Northern Arizona VA Health Care System- Prescott, AZ (505) 265-1711
25. VA Montana Health Care System- Ft. Harrison, MT (406) 442-6410
26. Cheyenne VA Medical Center- Cheyenne, WY (307) 778-7550
27. Sheridan VA Medical Center- Sheridan, WY (307) 672-1677
28. Alaska VA Healthcare System- Anchorage, AK (907) 257-4854/6911
29. VA Roseburg Healthcare System- Roseburg, OR (541) 440-1000
30. VA Puget Sound Health Care System-American Lake (206) 277-3693
31. VA Southern Oregon Rehabilitation Center and Clinics- White City, OR (541) 826-2111
32. Spokane VA Medical Center- Spokane, WA (509) 434-7018
33. Jonathan M. Wainwright Memorial VA Medical Center- Walla Walla, WA (509) 525-5200
34. Sierra Nevada Health Care System- Reno, NV (775) 786-7700
35. VA Central California Health Care System- Fresno, CA (559) 225-6100
36. VA Pacific Islands Health Care System- Honolulu, HI (808) 433-0605
37. Manila Outpatient Clinic-Manila, Philippines (632)-318-8387 or (632)-833-4566
38. VA Southern Nevada Healthcare System- Las Vegas, NV (702) 636-3000
39. Fargo VA Medical Center- Fargo, ND (701) 239-3700

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

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