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IVDP

A spinal disc herniation (prolapsus disci intervertebralis), informally


and misleadingly called a "slipped disc", is a medical condition
affecting the spine, in which a tear in the outer, fibrous ring
(annulus fibrosus) of an intervertebral disc (discus intervertebralis)
allows the soft, central portion (nucleus pulposus) to bulge out.
Tears are almost always posterior-ipsilateral in nature owing to the
presence of the posterior longitudinal ligament in the spinal canal.
This tear in the disc ring may result in the release of inflammatory
chemical mediators which may directly cause severe pain, even in
the absence of nerve root compression (see "chemical radiculitis"
below). This is the rationale for the use of anti-inflammatory
treatments for pain associated with disc herniation, protrusion,
bulge, or disc tear.

It is normally a further development of a previously existing disc


protrusion, a condition in which the outermost layers of the annulus
fibrosus are still intact, but can bulge when the disc is under
pressure.

Symptoms of a herniated disc can vary depending on the location


of the herniation and the types of soft tissue that become involved.
They can range from little or no pain if the disc is the only tissue
injured, to severe and unrelenting neck or low back pain that will
radiate into the regions served by affected nerve roots that are
irritated or impinged by the herniated material. Often, herniated
discs are not diagnosed immediately, as the patients come with
undefined pains in the thighs, knees or feet. Other symptoms may
include sensory changes such as numbness, tingling, muscular
weakness, paralysis, paresthesia, and affection of reflexes. If the
herniated disc is in the lumbar region the patient may also
experience sciatica due to irritation of one of the nerve roots of the
sciatic nerve. Unlike a pulsating pain or pain that comes and goes,
which can be caused by muscle spasm, pain from a herniated disc is
usually continuous or at least is continuous in a specific position of
the body.

It is possible to have a herniated disc without any pain or noticeable


symptoms, depending on its location. If the extruded nucleus
pulposus material doesn't press on soft tissues or nerves, it may not
cause any symptoms. A small-sample study examining the cervical
spine in symptom-free volunteers has found focal disc protrusions in
50% of participants, which shows that a considerable part of the
population can have focal herniated discs in their cervical region
that do not cause noticeable symptoms.

Typically, symptoms are experienced only on one side of the body.


If the prolapse is very large and presses on the spinal cord or the
cauda equina in the lumbar region, affection of both sides of the
body may occur, often with serious consequences.

There is now recognition of the importance of “chemical radiculitis”


in the generation of back pain.A primary focus of surgery is to
remove “pressure” or reduce mechanical compression on a neural
element: either the spinal cord, or a nerve root. But it is increasingly
recognized that back pain, rather than being solely due to
compression, may also be due to chemical inflammation. There is
evidence that points to a specific inflammatory mediator of this
pain.This inflammatory molecule, called tumor necrosis factor-alpha
(TNF), is released not only by the herniated disc, but also in cases of
disc tear (annular tear), by facet joints, and in spinal stenosis.In
addition to causing pain and inflammation, TNF may also contribute
to disc degeneration.

Diagnosis

Straight leg raise

The Straight leg raise may be positive; this finding has low
specificity, however it has high sensitivity. Thus the finding of a
negative SLR sign is an important in helping to "rule out" the
possibility of a lower lumbar disc herniation. A variation is to lift the
leg while the patient is sitting.[23] However, this reduces the
sensitivity of the test.

• X-ray: Although traditional plain X-rays are limited in their


ability to image soft tissues such as discs, muscles, and
nerves, they are still used to confirm or exclude other
possibilities such as tumors, infections, fractures, etc.. In spite
of these limitations, X-ray can still play a relatively
inexpensive role in confirming the suspicion of the presence of
a herniated disc. If a suspicion is thus strengthened, other
methods may be used to provide final confirmation.
• Computed tomography scan (CT or CAT scan): A diagnostic
image created after a computer reads x-rays. It can show the
shape and size of the spinal canal, its contents, and the
structures around it, including soft tissues.

• Magnetic resonance imaging (MRI): A diagnostic test that


produces three-dimensional images of body structures using
powerful magnets and computer technology. It can show the
spinal cord, nerve roots, and surrounding areas, as well as
enlargement, degeneration, and tumors. It shows soft tissues
even better than CAT scans.
• Myelogram: An x-ray of the spinal canal following injection of a
contrast material into the surrounding cerebrospinal fluid
spaces. By revealing displacement of the contrast material, it
can show the presence of structures that can cause pressure
on the spinal cord or nerves, such as herniated discs, tumors,
or bone spurs. Because it involves the injection of foreign
substances, MRI scans are now preferred in most patients.
Myelograms still provide excellent outlines of space-occupying
lesions, especially when combined with CT scanning (CT
myelography).
• Electromyogram and Nerve conduction studies (EMG/NCS):
These tests measure the electrical impulse along nerve roots,
peripheral nerves, and muscle tissue. This will indicate
whether there is ongoing nerve damage, if the nerves are in a
state of healing from a past injury, or whether there is another
site of nerve compression.

Conservative treatment

Pain medications are often prescribed to alleviate the acute pain


and allow the patient to begin exercising and stretching.

There are a variety of non-surgical alternatives used in treatment of


the condition, including:

1. Bed rest and lumbo-sacral support belt.


2. Physical therapy
3. Massage therapy
4. Non-steroidal anti-inflammatory drugs (NSAIDs)
5. Oral steroids (e.g. prednisone or methylprednisolone)
6. Epidural (cortisone) injection
7. Intravenous sedation, analgesia-assisted traction therapy
(IVSAAT)
8. Weight control
9. Chiropractic
10. Emerging treatments: The identification of tumor necrosis
factor-alpha (TNF) as a central cause of inflammatory spinal
pain now suggests the possibility of an entirely new approach
to selected patients with severe pain due to disc herniation,
protrusion, bulge, or disc tear. Specific and potent inhibitors of
TNF became available in the U.S. in 1998, and were
demonstrated to be potentially effective for treating sciatica in
experimental models beginning in 2001. Targeted anatomic
administration of one of these anti-TNF agents, etanercept, a
patented treatment method, has been suggested in published
pilot studies to be effective for treating selected patients with
severe pain due to disc herniation, protrusion, bulge, or disc
tear. The scientific basis for pain relief in these patients is
supported by the most current review articles. In the future
new imaging methods may allow non-invasive identification of
sites of neuronal inflammation, thereby enabling more
accurate localization of the "pain generators" responsible for
symptom production.

Surgery

Surgical options include:

• IDET (a minimally invasive surgery for disc pain)


• Laminectomy - to relieve spinal stenosis or nerve compression
• Hemilaminectomy - to relieve spinal stenosis or nerve
compression
• Lumbar fusion (lumbar fusion is only indicated for recurrent
lumbar disc herniations, not primary herniations)
• Anterior cervical discectomy and fusion (for cervical disc
herniation)
• Disc arthroplasty (experimental for cases of cervical disc
herniation)
• Dynamic stabilization
• Artificial disc replacement, a relatively new form of surgery in
the U.S. but has been in use in Europe for decades, primarily
used to treat low back pain from a degenerated disc.
• Nucleoplasty

Discectomy

The Anne Arundel Medical Center's Center for Spine Surgery


describes a discectomy as spinal surgery during which surgeons
remove herniated discs, which relieves pressure on the nerves of
the back. A discectomy is a procedure to remove a portion of the
disc that rests between each vertebrae. A herniated disc is the most
common reason for spine surgery. In this type of spine surgery, the
herniated disc is removed and relieve the pressure on the nerves.
They use a 2-inch incision to remove the discs, resulting in minimal
blood loss. This spinal surgery at one time required a two- or three-
day hospital stay. Now, a discectomy is an outpatient procedure.

Microdiscectomy microdiscectomy uses microscopic magnification.


This procedure is performed to remove a herniated or ruptured disc.
The advantage to microdiscectomy is that the procedure is
minimally invasive. The incision and instruments are small, which
enables the patient to recover quickly.
The endoscopic microdiscectomy is a procedure that accomplishes
the same goal as a traditional open discectomy, removing the
herniated disc, but uses a smaller incision. Instead of actually
looking at the herniated disc fragment and removing it, surgeon
uses a small camera to find the fragment and special instruments to
remove it. The procedure may not require general anesthesia, and
is done through a smaller incision with less tissue dissection.
surgeon uses x-ray and the camera to "see" where the disc
herniation is, and special instruments to remove the fragment.

Foramenotomy
Highland Medical Centers Highland Pain Institute says that a
foramenotomy relieves pressure caused by a pinched nerve. A
foramenotomy is also a procedure used to relieve pressure on a
nerve, but in this case, the nerve is being pinched by more than just
herniated disc. This type of spinal surgery consists of removing bone
and other tissue that compresses nerves on the spinal column. A
foramenotomy can be part of a major medical procedure or a
minimally invasive procedure in which doctors make a tiny incision.

Lumbar Laminectomy
The Center for Spine Surgery states that a lumbar laminectomy
relieves pressure on the spinal nerve by removing herniated discs
and bone spurs. This type of spinal surgery is an outpatient
procedure that requires a 2- or 3-inch incision in the middle of the
lower back. A laminectomy is done to relieve pressure on the spinal
cord itself. A laminectomy is most commonly used to treat
conditions such as spinal stenosis and spondylolisthesis. Depending
on the amount of bone removed, this procedure may be done with a
spinal fusion to prevent instability.
Laminotomy: Lamina Partially Removed

Laminectomy: Lamina Entirely Removed


Lumbar Spine Fusion
Lumbar fusion is a type of spinal surgery used when a person
suffers from a spinal condition that causes instability in the
vertebrae. The instability puts pressure on nerves in the spinal
column. A spine fusion is surgery that is done to eliminate motion
between adjacent vertebrae. The spine fusion may be done because
to treat a problem such as spondylolisthesis (unstable spine), or it
may be done because of the extent of other surgery (such as a
laminectomy). Lumbar fusion is a major surgical procedure in which
surgeons use screws and plates to fix bones. Using bone grafts,
doctors create a bridge between the bones in the lumbar region of
the spine. Bone comes from the person's body or from a bone bank.
Interbody Cage Fusion is a newer spinal implant designed to be
filled with bone graft and inserted into the empty space created by
a discectomy (disc removal). A cage is similar to a tiny birdcage.
Bone graft is packed around the cage following implantation. Like
instrumentation and fusion, the bone graft grows into and around
the cage and creates a stable construct.

Interbody Cage

Kyphoplasty
The Center for Spine Surgery states that a kyphoplasty is a type of
spinal surgery used on patients with osteoporosis and compressed
fractures. Surgeons make a small incision and insert and inflate a
balloon in the affected area until it expands back to normal.
Surgeons use cement to fill the void. This procedure helps stops
deformities, decreases height loss and reduces pain in patients with
osteoporosis and compressed fractures. Patients are placed under
anesthesia and stay in the hospital overnight.

Spinal Disc Replacement


Spinal disc replacement is a new surgery that is still quite
uncommon. Spine disc replacement is done to treat specific types of
back pain, while avoiding the problems associated with spine fusion
surgery.

IDET, or Intradiscal Electrothermal Therapy, is a procedure that is


being done to treat discogenic back pain. IDET uses a probe inserted
into the disc to heat the tissues within the affected disc. Heating the
inside of the disc causes the tissues to shrink. It also cauterizes, or
burns, the small nerve fibers in the periphery of the disc. Whether or
not it is one of these factors, or something else, that accounts for
the results of IDET is not exactly known.

Minimally Invasive Spine Surgery


The trend in spine surgery has moved toward minimally invasive
procedures. Devices are now available that use microscopic fiber
optics that transmit anatomical images to a monitor similar to a
television. The equipment is made with built-in magnification that
enables the surgeon to view tiny structures through a portal.