Herniated lumbar disk

Definition
A herniated disk develops when the nucleus pulposus (the jelly-like center of a disk in your spine) bulges through the annulus fibrosa (the tough, fibrous ring), potentially putting pressure on the spinal cord or on a spinal nerve. Sometimes a herniated disk is simply called a ruptured or slipped disk (even though the disk cannot slip out of place). Although a herniated disk can develop in any part of the spine, the condition is most common in the lower back (lumbar region). A herniated disk can cause debilitating pain. Fortunately, various treatment options are available.

Anatomy
The vertebrae (the bones that make up the spine) support and protect the spinal cord. These bones are separated by disks, which are cushions made of fibrous tissue and cartilage. The disks act as shock absorbers for the spine and allow the spine to be flexible. The spinal cord itself runs through an opening in the center of the vertebrae called the spinal canal. Nerves branch off the spinal cord and exit the spinal canal through spaces between the vertebrae known as foramen.

Causes/associated factors
A sudden or gradual weakening of the outer portion of a disk can allow the jelly-like pulposus to push through the outer ring, causing a herniated disk. The disk can then press on the spinal cord or the spinal nerves that branch off the spinal cord. Most disk herniations are thought to develop after years of repetitive minor injuries to the back, which slowly weaken the outer ring and ultimately allow herniation of the pulposus. Repetitive heavy lifting, obesity, and back trauma or injury can also lead to a herniated disk.
Common risk factors include:

repetitive back motion (such as lifting, bending and twisting)
repetitive or prolonged vibration (such as driving a vehicle or using a jack hammer)
participating in high-risk sports, such as football, wrestling and skiing
poor posture
smoking (which leads to spinal degeneration)
osteoporosis (the loss of bone mass that leads to brittle bones)
osteoarthritis (the most common form of arthritis, caused by the breakdown of cartilage after long-term wear and tear of a joint or certain diseases)
poor physical condition
stress, which contributes to tight muscles
Most people with low back pain recover without treatment and resume normal activity within one month. If your pain does not fade spontaneously or respond to conservative treatment, aggressive treatment such as surgery may be appropriate. If left untreated, you may develop chronic pain and disability.


Signs/symptoms
Sometimes, a herniated disk has no symptoms at all. If symptoms develop, they may include:
back pain
sciatic pain (often described as burning pain from the low back, through the buttocks and beyond the knee area, possibly into the foot)
pain that increases with activity such as walking, standing, sitting, lifting or bending
back pain that worsens with straining (during a bowel movement or coughing, for example)
numbness or tingling in the back, groin or legs
abnormal reflexes or loss of reflexes in the legs
muscle spasms in the lower extremities
weakness of the leg muscles or buttocks
back pain that is relieved by lying in a fetal or flexed position
incontinence or difficulty emptying your bowel or bladder (Note: This is a medical emergency. Consult your doctor right away if you experience this symptom.)

Diagnosis
The doctor will review your medical history and do a physical exam. You may need special tests such as a spinal X-ray, magnetic resonance imaging (MRI, an imaging technique based on computer analysis of the body's response to a magnetic field) or computed tomography (CT scan -- a computer-generated, cross-sectional picture of internal body parts). The MRI and CT scan can help your doctor see the internal structures of the spine, including the soft tissues of the lumbar disks and nerves.
Myelography (injection of a special X-ray dye into a layer of the spinal cord covering) may be used in combination with a CT scan to clarify the extent and location of a herniated disk. Electromyography (a technique used to measure a muscle's electrical activity) can help your doctor determine if there is nerve or muscle damage.


Treatment
Treatment varies, depending on the extent of your symptoms. Most herniated disks can be managed conservatively. As time passes, the body often spontaneously reabsorbs the herniated disk material.
If the herniated disk does not cause severe symptoms, your doctor may recommend the following self-care tips.

Try to continue with normal activities, such as going to work. Avoid high-risk activities such as heavy lifting, bending or twisting.
Don't sit in one position for too long. This may increase pressure inside the herniated disk.
Apply heat or ice to the painful area.
Use aspirin or other nonsteroidal anti-inflammatory medications (NSAIDs) to help reduce inflammation around the ruptured disk and relieve pain.
Use good posture when sitting or standing. Slouching can increase pressure on the disk.
Lose weight.
Medications
Various other medications may be used alone or in combination with NSAIDs.

Narcotic medications: Narcotic medications play a limited role in the treatment of low back pain. They may be used for the initial treatment of severe pain, but usually not longer than two weeks because they can be addictive. They can also cause side effects, such as drowsiness and constipation.

Antidepressants: Low-dose antidepressants are sometimes prescribed to treat chronic pain conditions. Research does not support the use of antidepressants for acute low back pain, however.

Muscle relaxants: Muscle relaxants are effective for treating acute back pain, but their benefit for treating chronic back pain has not been proved. They have not been found to be more effective then NSAIDs, and they have more serious side effects, such as dependency, drowsiness and dizziness. They are usually prescribed only for a short time.

Steroid medications: Oral steroids can reduce inflammation and relieve pain, but they are not the first course of treatment for most acute back pain. NSAIDs are often avoided or minimized when oral steroids are used.

Benefits of medications: Most over-the-counter (OTC) medications have fewer side effects than prescription medications, cost less, and are effective and safe to use for most people.

Risks of medications: Ask your doctor about possible side effects, such as drowsiness, stomach irritation, bleeding, nausea, rash or dizziness. If you develop any side effects, stop taking the medication and call your doctor for medical advice. Side effects may be more frequent or severe in people over age 60. Always discuss any medication use during pregnancy or while breastfeeding with your doctor.
Back exercises
A structured exercise program has been found to benefit people recovering from chronic back pain. For acute back pain, it does not seem to be better than other treatments. Although a specific exercise program has not been found to be more beneficial than another, it's important to follow the recommendations of your doctor or physical therapist. Some exercises can cause more harm to the back.

Benefits of back exercises: Exercises are helpful for chronic back pain.

Risks of back exercises: Be sure to follow your doctor's or physical therapist's instructions so you don't injure your back.
Multidisciplinary treatment programs
Intensive treatment programs that involve many disciplines, such as a doctor, physical therapist, psychologist, social worker and occupational therapist, working together have been found to be helpful for people with chronic back pain. Programs that offer some sort of treatment every day seem to be most effective.

Benefits of multidisciplinary treatment programs: This type of program seems to be most helpful for people who have chronic back pain.

Risks of multidisciplinary treatment programs: Results may not be as good if the person doesn't participate every day.
Spinal manipulation
Spinal manipulation involves adjusting the joints of the spine by pressing on the backbone or manipulating limbs to realign any misplaced segments. The best known technique, called high velocity thrust, often produces the sound of a joint cracking. It has not yet been established how many manipulations are necessary, who is the best candidate, or what technique is the best. Spinal manipulation is not recommended if you have damage to spinal nerves. Also, this type of treatment may be expensive, depending on the frequency of your treatments.

Benefits of spinal manipulation: People with acute and chronic pain do seem to get some relief with this technique.

Risks of spinal manipulation: It should only be done by experienced professionals, such as chiropractors or osteopaths. Few complications from appropriate treatment have been reported. If you have rheumatoid arthritis, spinal stenosis or severe spinal arthritis, sciatica or osteoporosis, however, consult your doctor before undergoing spinal manipulation due to possible risk of injury.
Acupuncture
One of the major clinical uses for acupuncture is pain control. It's performed by placing thin needles into the skin at specific points in the body according to principles of Chinese medicine.

Benefits of acupuncture: It's thought to stimulate the release of natural chemicals that block pain sensations in the brain and spinal cord. Several studies on the management of chronic back pain have shown acupuncture may be helpful. No studies have been done to evaluate acupuncture for acute back pain.

Risks of acupuncture: For most health professionals, the biggest concern is that people may delay seeking necessary medical attention by relying solely on acupuncture treatments. Possible complications include tissue injury and infection.
If you're considering acupuncture, ask the practitioner if he or she uses sterile, disposable needles, according to U.S. Food and Drug Administration (FDA) directives. This is a must! Also ask about the practitioner's qualifications.

Epidural steroid injections
A specialist, such as anesthesiologist or radiologist, uses fluoroscopy (a live X-ray) to guide a needle into the lower back to the epidural space (space surrounding the spinal cord). A steroid solution is injected that helps reduce the swelling and inflammation to try to relieve pain. Epidurals are more appropriate for people with chronic back pain.

Benefits of epidural injections: The injection may numb the nerve roots and reduce inflammation, but exactly how it works is unknown. Practitioners consider this treatment to be relatively safe. Treatment may reduce or relieve pain.

Risks of epidural injections: The injections are expensive. Headache is the most common complication. Serious, but rare, complications include infection, meningitis and neurologic problems.
Surgery
In severe cases, surgery may be an option. Indications for surgery may include cauda equina syndrome (an emergency condition in which nerves are compressed, causing loss of bladder or bowel control), a persistent or worsening neurological deficit, and disabling pain that does not respond to four to six weeks of conservative therapy. Several surgical techniques are available to remove the herniated disk, depending on your symptoms. Diskectomy is removal of the entire disk. If part of the vertebral bone is removed, it's called a laminectomy. With microdiskectomy, the surgeon uses a smaller incision and microscope to remove the damaged disk material. With percutaneous diskectomy, the surgeon uses a very small incision and a cutting and suction instrument to remove the damaged disk material.

Benefits of surgery: Surgery may speed recovery of low back pain for some people by taking the pressure off the affected nerve or nerves.

Risks of surgery: Surgery may increase the likelihood for future surgeries with the potential for higher complication rates from repeat surgery. Infection or bleeding occurs in a small percentage of first-time surgeries. Certain studies have shown that the long-term results of some back surgery may be comparable to the long-term results of nonsurgical treatment.

Complications
Complications of a herniated disk may include:
loss of bowel or bladder control
paralysis
foot drop (difficulty lifting the front part of the foot)
increasing weakness
limited movement interfering with daily activities
chronic pain and related depression
Recurrent herniated disks are also possible.


Pregnancy-specific information
As your baby grows, your center of gravity will change and your body may be thrown off balance. You will probably change the way you walk, stand and sit, which may contribute to back problems. Practice good body mechanics, and discuss any back or leg pain with your doctor. X-rays, certain medications and surgery are usually avoided during pregnancy. Talk to your doctor before taking any medications or starting any treatment. Also, remember that sudden back pain during pregnancy can be a sign of labor.

Senior-specific information
The degenerative effects of aging on the spine and injuries that may occur over time increase the risk of herniated disks for older adults. The general treatment options for back pain are the same, but healing may occur more slowly. Treatment choice will be influenced by your medical history and general health status.

Prevention
Consider the following steps to reduce your chances of developing a herniated lumbar disk:
Sleep on a firm mattress. Place a pillow between your legs when lying on your side, and use a pillow under your knees when lying on your back.

Concentrate on good posture and proper body mechanics. Avoid frequent bending and twisting at the waist, and try not to lift heavy objects. If you must lift something heavy, use your legs, keep your back straight, and hold the item as close to your body as possible.

Avoid sitting or standing for long periods of time.

Adjust your workstation to a comfortable height, and sit in a chair with good back support. If you must sit for long periods of time, rest your feet on a stool. Take frequent breaks and walk around periodically.

Avoid constipation or straining during bowel movements.

Maintain a healthy weight, and exercise regularly.

Wear comfortable, low-heeled shoes.

Avoid stress as much as possible.

Avoid smoking.