Disc herniation is a neurological disorder which is characterized by the sliding of nucleus pulposus along the spinal cord and spine, which translates clinically by the appearance of a very intense back pain in that area.
The diagnosis of a disc herniation can be made sometimes, only by the symptoms if the intensity and nature of the pain are high. Complete history of the patient have to be centered on the character of the pain and its evolution in time and physical examination can highlight disturbances in neurological reflexes, muscle strength and sensory disturbances.
Some characters of the pain may suggest a disc herniation:
- Pain that is localized to the lumbar region and gluteal areas (buttock) is often associated with disc herniation;
- Pain associated with sciatic radiculopathy, which radiates along the leg, below the knee;
- Pain that appear on flexion, rotation of the leg or in prolonged standing and have a sharp character is suggestive of a disc herniation.
Other information suggestive for the diagnosis of disc herniation are:
- Acute onset of the symptoms, usually after a traumatism;
- Pain that is localized unilateral, which is aggravated by movement and relieved by resting in a certain position.
From the patient’s medical history is important to know if there have been recent trauma, if the patient have a profession that is requiring intense physical activity or if in his family exist other members with this condition.
Physical examination may reveal:
- Reduced physiological curvature of the spine in the area that is involved in the disease process;
- Abnormal position of the patient;
- Pain in the leg that appeare after the patient lift the leg as high as he can.
Also, can be performed a series of specific tests that may suggest cervical and lumbar radiculopathy. For example, the patient is asked to tilt the head forward and then to the sides while the doctor applies a slight pressure on top of the head. If the patient will experience pain or any sensory change in this test, the patient is suspected of cervical radiculopathy.There are several tests that can be practiced for the discovery of lumbar radiculopathy.
For a certain diagnosis of disc herniation are indicated imaging studies like, X-rays, computer tomography (CT), magnetic resonance imaging (MRI) and myelography.
X-ray of the spine is especially indicated to exclude other diseases which may have symptoms like disc herniation. The most common diseases that enter in the differential diagnosis are: pelvic fractures, horse tail syndrome, spinal infection, epidural and subdural infections, spinal stenosis and spondylolisthesis. Radiographic examination is limited, because it can not offer useful information about the state of the soft tissue that is surrounding the spine.
Computer tomography (CT) can provide useful information about the diameter of the spinal canal and about the soft tissue that is surrounding the spine.
Magnetic resonance imaging (MRI) is more indicated than CT in diagnosing pathologies of the spine, because has a greater accuracy. Three-dimensional images are obtained and in this way are very well visualized both spine and nerve roots, the nucleus pulposus and it can be determine the degree of the condition. Currently, MRI is the imaging method of first intention for diagnosing disc herniation and can be used even in patients without clinical symptoms. Studies have shown that over 60% of asymptomatic patients who did an MRI, have some degree of disc herniation.
Myelography is a very accurate paraclinical examination, which can reveal the diagnosis of disc herniation, but is an invasive technique, because is requiring a lumbar puncture and the injection of a contrast substance. After the injection of contrast agents is made a radiography of the spinal canal and depending on the aspect can be determine if there are processes that are applying pressure on spinal nerves, if there are hernias and what is their degrees, if there are other pathological processes of the spine. Myelography has better results when is combined with CT.
Other specific tests are the electromyogram (EMG) and tests that determine the conduction velocity of a nerve impulses. EMG is done to determine exactly the nerve root that is involved in disc herniation. EMG can be performed simultaneously with tests that determine the conduction velocity of a nerve impulses and purpose of the two methods is to determine if there is an active pathological process which is affecting the nerves, the nerve roots or the muscles.
In general, patients with symptoms that are suggestive for disc herniation do not require further investigation. But if the patients are elderly, have symptoms that are not improving at the administration of a correct treatment and the pain is atypical, the specialst may request some laboratory tests, like: complete blood count, erythrocyte sedimentation rate (ESR), the level of alkaline phosphatase, serum calcium level and serum protein electrophoresis.
The goal of disc herniation treatment is pain relief and stop the evolution of etiopathogenic process. For this is indicated a period of rest, administration of NSAIDs and physiotherapy. Most patients respond well to these combined treatments and they can resume their daily activities, because the symptoms are adequately controlled. There are a relatively small percentage of patients who need long-term treatment, corticosteroids or even surgery.
Pharmacological treatment includes the use of general analgesics or opioids, of muscle relaxants and anti-inflammatory drugs. The goal of pharmacological treatment is to reduce local pain and inflammation and restoring the patient’s freedom of movement.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are mainly indicated for moderate pain relief. Among NSAID, ibuprofen is best, if the patient has no contraindications. It is administrated 200-400 mg, but not exceeding 2 or 3 grams / day. Is not indicated in patients with peptic ulcer, renal failure and coagulation disorders.
Besides ibuprofen can be used other analgesics such as ketoprofen, naproxen or acetaminophen. Acetaminophen is not an NSAID, it has a different mechanism of action and has no side effects so important as NSAIDs (in particular on the stomach) but it has no anti-inflammatory activity. Opioid analgesics can be administered to patients with severe pain that can not be controlled by analgesics. The administration of opioid medication must be done under medical supervision because exist the risk of addiction. Unlike treatment with NSAIDs that can be administrated for a long period of time, opioids are administered only in short periods. Their indications are limited, like a disc herniation which is secondary to a severe trauma.
Muscle relaxants are given only if the patient has muscle spasms. Some patients may receive, corticosteroids (oral or intravenous) if the inflammation is important and it can not be reduced by the treatment with NSAIDs.
Epidural cortisone injections
A therapeutic option used to control pain and inflammation in disc herniation is represented by the injection of corticosteroids into the affected area. The beneficial effects are lasting several months. The procedure has some risks because it is invasive. For a good localization of the affected area, the injections are performed under radiological control.
Surgery is rarely used for uncomplicated disc herniation. Surgery should be considered as a measure of treatment, only if symptoms persist and are greatly affecting patient’s quality of life, by limiting daily activities and movements.
The most used and indicated surgical procedures are:
- Discectomy and micro-discectomy represents the removal of a disc that is protruding. The procedure is performed under general anesthesia and the patient remains hospitalized 3-4 days or until health status will allow discharge. To avoid the risk of blood clots, patients are stimulated to mobilize even in the first day, postoperative. Full recovery takes several weeks. If the disc herniation was not unique or whether there are other disorders that have to be treated, recovery will be difficult and longer. Micro-discectomy represents the removal of a fragment of disc which is involved in very small hernia, through a small incision;
- Laminectomy and hemi-laminectomy, involves to relieve spinal stenosis or nerve compression;
- Chemonucleolysis, is a procedure that involves injecting an enzyme (chimopapain) inside the herniated disc in order to dissolve the gelatinous substance (nucleus pulposus) that is responsible for the symptoms. In some cases chemonucleolysis can be an alternative to discectomy.