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A herniated disc is a fragment of the disc nucleus which is pushed out of the outer disc margin,
into the spinal canal through a tear or "rupture." In the herniated disc's new position, it presses on
spinal nerves, producing pain down the accompanying leg. This produces a sharp, severe pain
down the entire leg and into the foot. The spinal canal has limited space which is inadequate for
the spinal nerve and the displaced herniated disc fragment.

The compression and subsequent inflammation is directly responsible for the pain one feels
down the leg, termed "sciatica." The direct compression of the nerve may produce weakness in
the leg or foot in a specific patter, depending upon which spinal nerve is compressed.

A herniated disc is a definite displaced fragment of nucleus pushed out through a tear in the outer
layer of the disc (annulus). For a disc to become herniated, it typically is in an early stage of
degeneration.

In this situation there is a portion of the annulus that has isolated itself from the rest of the disc
and all or part of its displaced will out into the canal. This situation is the one that responds best
surgery. It may not respond to conservative therapy, including manipulation and even
chemonucleolysis.
  

The initial treatment for a herniated disc is usually conservative, i.e. nonoperative. One usually
begins with resting the low back area, maintaining a comfortable posture and painless activity
level for a few days to several weeks. This in in order to allow the spinal nerve inflammation to
quiet down and resolve.

A herniated disc is frequently aided by non-steroidal anti-inflammatory medication such as


Motrin, Voltaren, Naprosyn, Lodine, Feldene, Clinoril, Tolectin, Dolobid, Advil or Nuprin. An
epidural steroid injection may be performed utilizing a spinal needle under x-ray guidance to
direct the medication to the exact level of the disc herniation.

Physical therapy may be beneficial, under the direction of a physical therapist. The therapist will
perform an in-depth evaluation; this information, combined with a physician's diagnosis, will
dictate a treatment based on successful physical therapy treatment modalities which have proven
beneficial for herniated disc patients. These may include traction, ultrasound, electrical muscle
stimulation, etc., to relax the muscles which are in spasm and secondarily inflamed from the
compressed spinal nerve. Pain medication and muscle relaxing medications may also be
beneficial to help physical therapy or other conservative, non-operative treatment to relieve the
pain while the spinal nerve root inflammation resolves and the body heals itself. If these
conservative treatments are not successful and the pain is still severe or muscle weakness is
increasing, then surgery is necessary. Surgery may be in the form of a percutaneous discectomy
if the disc herniation is small and not a completely extruded disc fragment.

If the herniation is large, or is a "free fragment" as described above, then a microlaminotomy


with disc excision is necessary. A micro-laminotomy requires one to two days of hospitalization
after the surgery for the wound to heal and postoperative physical therapy to begin. The sciatic
pain down the leg should be resolved immediately after the surgery. However, there will be some
discomfort in the low back area where the operation is performed, lasting several days to a
couple of weeks. This is controlled with pain medication.
  

A person who has sustained one disc herniation is statistically at increased risk for experiencing
another. There is an approximate 5% rate of recurrent disc herniation at the same level, and a
lesser incidence of new disc herniation at another level. Factors involved may be weight related
level of physical conditioning, work or behavioral habits. Since these factors are typically the
same after surgery, there is an increased risk of herniated disc in this group, over the general
population.

However, the good news is that the majority of disc herniations (90%) do not require surgery,
and will resolve with conservative, nonoperative treatment, without significant long-term
sequelae. Unfortunately, approximately 5% of patients with herniated, degenerated discs will go
on to experience symptomatic or severe and incapacitating low back pain which significantly
affects their life activities and work. This unfortunate result is not always specifically the result
of surgery. The causes of this unremitting pain are not always clear or agreed on, and my be from
several sources. When this occurs, the prognosis is poor for returning to normal life activities
regardless of age.

After a successful laminotomy and discectomy, 80-85% of patients do extremely well and are
able to return to their normal job in approximately six weeks time. There may be small
permanent patches of numbness in the involved leg which, fortunately, are not disabling. Flare-
ups or exacerbations of less severe and less significant sciatic type pain may develop in the
future (usually on an infrequent basis).


  
Our advice to those who have herniated disc disease is to become knowledgeable in ï

 

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 from your physical therapist. Making your back
strong through exercises performed for approximately 30 minutes daily will restore normal
flexibility in the lumbar spine region, as well as strengthen muscles which can resist strain and
repeat injury. Always avoid heavy lifting, especially in association with twisting of the lumbar
spine. Protect your back for at least nine months to a year after sustaining the herniated disc.

ANATOMY AND PHYSIOLOGY

Atlas and Axis

Atlas and Axis


The top two vertebrae in the spinal column are specialized to allow the head a greater
range of movement than would be possible with normal vertebrae. A stable ball-and-socket
joint accommodates both side-to-side and up-and-down motion.



 
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The spinal column forms the major part of the skeleton. To it are attached the skull, shoulder
bones, ribs, and pelvis. In very primitive animals having a vertebral column, the spine consists of
a solid cartilaginous rod known as the notochord. Although remnants of the notochord persist in
the cartilages that form part of the apparatus connecting adjoining vertebrae, in higher animals
the notochord is replaced by a series of separate bones called vertebrae.

The shape and number of vertebrae vary among different animals. In general, the vertebrae are
stacked like a column of poker chips and are held together by ligaments, the connective tissue
that holds bones together at a joint. In humans the spinal column contains 33 vertebrae: 7
cervical vertebrae in the neck; 12 thoracic, or dorsal, vertebrae in the region of the chest, or
thorax, providing attachment for 12 pairs of ribs; 5 lumbar vertebrae in the small of the back; 5
fused sacral vertebrae forming a solid bone, the sacrum (à Sacroiliac Joint), which fits like a
wedge between the bones of the hip; and a variable number of vertebrae fused together to form
the coccyx at the bottom of the sacrum.
Human Spinal Column

Human Spinal Column


Although individual vertebrae move little from one to the next, the human spinal column
as a whole is a chain flexible enough to allow us to touch our toes. Its unique S-shape
centers the weight of our long bodies over our feet, keeping us from toppling. Animals that
walk on all four legs have straighter spines that provide even support for their horizontal
bodies.



 
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Before birth, the human spinal column forms a single curve with the convex surface toward the
back; at birth, two primary curvatures are present, both of which are concave forward. The upper
one is located in the thoracic and the lower one in the sacral region. If the child develops
normally, two compensatory forward curvatures develop in the cervical and lumbar regions, just
above the primary curvatures. These normal curvatures provide a degree of resilience that would
not be possible in a series of rigid, straightly stacked bones.

Most of the individual vertebrae are shaped somewhat like rings; the body, or thick portion of the
ring, is located toward the front portion of the body. Between each of the separate vertebrae is a
thick, fibrous disk of cartilage²called an intervertebral disk²that forms the principal joint
between the bodies of adjoining vertebrae; however, the vertebrae also move with each other at
several other joints.

Thoracic Vertebrae, Top and Back Views


Thoracic Vertebrae, Top and Back Views
Twelve thoracic vertebrae are stacked in the chest, each with a shallow socket on either
side where the ribs join the spine. Vertebrae are larger and sturdier in the lower back than
in the upper back in order to support more weight. The ten uppermost vertebrae, those that
support the neck and head, emphasize stability. Their structure includes additional bumps
and hollows that lock neighboring links in the spinal column together.



 
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Most vertebrae consist of a body, a large mass of solid bone that is the weight-bearing part of the
vertebra. Extending backward on each side of the body is a thick pillar of bone, or pedicle. The
pedicles and back of the body help to form a circular opening, the vertebral foramen, through
which the spinal cord passes. Two plates of bone, known as the laminae, meet the pedicles and
join with each other in an angle at the back of the vertebra to complete the circular opening. The
canal formed by the juxtaposition of the intervertebral foramens of all the vertebrae is called the
neural canal. On each side, at the junction of the pedicle and lamina, is a projection known as the
transverse process. At the angle formed by the junction of the two laminae is another projection,
the spinous process. At the base of each transverse process is a smooth, movable structure that
forms joints with the adjacent vertebrae. In erect animals, one pair of these processes is located
on the top surface and another pair on the bottom surface of each vertebra.

The vertebrae of each region of the mammalian spinal cord have definite characteristics. In the
upper cervical vertebrae, each transverse process is pierced by a hole through which the vertebral
artery passes. The spinous processes of these vertebrae are very short. The first two cervical
vertebrae are unlike any of the others. The first cervical vertebra, known as the atlas, has no
body; the body is replaced by an arch of bone enclosing a depression. The superior articular
processes of the axis are jointed to the occipital condyles, or rounded projection of bone, of the
skull. The second cervical vertebra, known as the axis or epistropheus, has a projection on the
top of its body that fits like a pivot into the special depression in the atlas (à Joints). On the
transverse processes of the thoracic vertebrae are special articulating surfaces for the ribs; the
spinous processes, which are long, project downward and overlap each other. The lumbar
vertebrae have large, heavy bodies and reduced transverse and spinous processes. The fused
sacrum and coccyx are described above.

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The vertebral column seen from the side

Different regions (curvatures) of the vertebral column


In human anatomy, the   ï 
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33 vertebrae,[1] the sacrum, intervertebral discs, and the coccyx situated in the dorsal aspect of
the torso, separated by spinal discs. It houses and protects the spinal cord in its spinal canal.

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Viewed laterally the vertebral column presents several curves, which correspond to the different
regions of the column, and are called cervical, thoracic, lumbar, and pelvic.

The cervical curve, convex forward, begins at the apex of the odontoid (Y Y ) process, and
ends at the middle of the second thoracic vertebra; it is the least marked of all the curves.

The thoracic curve, concave forward, begins at the middle of the second and ends at the middle
of the twelfth thoracic vertebra. Its most prominent point behind corresponds to the spinous
process of the seventh thoracic vertebra. This curve is known as a YY 

The lumbar curve is more marked in the female than in the male; it begins at the middle of the
last thoracic vertebra, and ends at the sacrovertebral angle. It is convex anteriorly, the convexity
of the lower three vertebrae being much greater than that of the upper two. This curve is
described as a   Y .

The pelvic curve begins at the sacrovertebral articulation, and ends at the point of the coccyx; its
concavity is directed downward and forward. .

The thoracic and pelvic curves are termed  


 , because they alone are present
during fetal life. The cervical and lumbar curves are   à Y 
or à   
, and are
developed after birth, the former when the child is able to hold up its head (at three or four
months) and to sit upright (at nine months), the latter at twelve or eighteen months, when the
child begins to walk.

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There are a total of 33 vertebrae in the vertebral column, if assuming 4 coccygeal vertebrae.

The individual vertebrae, named according to region and position, from superior to inferior, are:

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When viewed from in front, the width of the bodies of the vertebrae is seen to increase from the
second cervical to the first thoracic; there is then a slight diminution in the next three vertebrae;
below this there is again a gradual and progressive increase in width as low as the sacrovertebral
angle. From this point there is a rapid diminution, to the apex of the coccyx.

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The posterior surface of the vertebral column presents in the median line the spinous processes.
In the cervical region (with the exception of the second and seventh vertebrae) these are short
and horizontal, with bifid extremities. In the upper part of the thoracic region they are directed
obliquely downward; in the middle they are almost vertical, and in the lower part they are nearly
horizontal. In the lumbar region they are nearly horizontal. The spinous processes are separated
by considerable intervals in the lumbar region, by narrower intervals in the neck, and are closely
approximated in the middle of the thoracic region. Occasionally one of these processes deviates a
little from the median line ² a fact to be remembered in practice, as irregularities of this sort are
attendant also on fractures or displacements of the vertebral column. On either side of the
spinous processes is the vertebral groove formed by the laminae in the cervical and lumbar
regions, where it is shallow, and by the laminae and transverse processes in the thoracic region,
where it is deep and broad; these grooves lodge the deep muscles of the back. Lateral to the
vertebral grooves are the articular processes, and still more laterally the transverse processes. In
the thoracic region, the transverse processes stand backward, on a plane considerably behind that
of the same processes in the cervical and lumbar regions. In the cervical region, the transverse
processes are placed in front of the articular processes, lateral to the pedicles and between the
intervertebral foramina. In the thoracic region they are posterior to the pedicles, intervertebral
foramina, and articular processes. In the lumbar region they are in front of the articular
processes, but behind the intervertebral foramina.

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The lateral surfaces are separated from the posterior surface by the articular processes in the
cervical and lumbar regions, and by the transverse processes in the thoracic region. They present,
in back, the sides of the bodies of the vertebrae, marked in the thoracic region by the facets for
articulation with the heads of the ribs. More posteriorly are the intervertebral foramina, formed
by the juxtaposition of the vertebral notches, oval in shape, smallest in the cervical and upper
part of the thoracic regions, and gradually increasing in size to the last lumbar. They transmit the
special spinal nerves and are situated between the transverse processes in the cervical region, and
in front of them in the thoracic and lumbar regions.

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T3 is at level of medial part of spine of scapula. T7 is at inferior angle of the scapula. L4 is at


highest point of iliac crest. S2 is at the level of posterior superior iliac spine. T12 can be found
by identifying the lowest pair of ribs and tracing them to their thoracic attachment.[2]
Furthermore, C7 is easily localized as a prominence at the lower part of the neck.[3]
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The vertebral canal follows the different curves of the column; it is large and triangular in those
parts of the column which enjoy the greatest freedom of movement, such as the cervical and
lumbar regions; and is small and rounded in the thoracic region, where motion is more limited.

  

Discs consist of an outer à  àà, which surrounds the inner  à àà. The
à  àà consists of several layers of fibrocartilage. The strong annular fibers contain the
 à àà and distribute pressure evenly across the disc. The  à àà contains
loose fibers suspended in a mucoprotein gel with the consistency of jelly. The nucleus of the disc
acts as a shock absorber, absorbing the impact of the body's daily activities and keeping the two
vertebrae separated. The disc can be likened to a doughnut: whereby the annulus fibrosis is
similar to the dough and the nucleus pulposis is the jelly. If one presses down on the front of the
doughnut the jelly moves posteriorly or to the back. When one develops a prolapsed disc the
jelly/ nucleus pulposus is forced out of the doughnut/ disc and may put pressure on the nerve
located near the disc. This can give one the symptoms of sciatica.

There is one disc between each pair of vertebrae, except for the first cervical segment, the Y à.
The Y à is a ring around the roughly cone-shaped extension of the à (second cervical
segment). The axis acts as a post around which the atlas can rotate, allowing the neck to swivel.
There are a total of twenty-three discs in the human spine, which are most commonly identified
by specifying the particular vertebrae they separate. For example, the disc between the fifth and
sixth cervical vertabrae is designated "C5-6".

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