Lumbar Disc
Spinal discs play a crucial role in the lower back, serving as shock absorbers between the vertebrae, supporting the upper body, and allowing a wide range of movement in all directions.
If a disc herniates and leaks some of its inner material, though, the disc can quickly go from easing daily life to aggravating a nerve, triggering back pain and possibly pain and nerve symptoms down the leg.
What causes lumbar disc disease?
Lumbar disc disease is caused by a change in the structure of the normal disc. Most of the time, disc disease happens as a result of aging and the normal break down that occurs within the disc. Sometimes, severe injury can cause a normal disc to herniate. Injury may also cause an already herniated disc to worsen.
What are the symptoms of lumbar disc disease?
The symptoms of lumbar disc disease vary depending on where the disc has herniated, and what nerve root it is pushing on. These are the most common symptoms of lumbar disc disease:
Intermittent or continuous back pain. This may be made worse by movement, coughing, sneezing, or standing for long periods of time
Spasm of the back muscles- Sciatica – pain that starts near the back or buttock and travels down the leg to the calf or into the foot
- Muscle weakness in the legs
- Numbness in the leg or foot
- Decreased reflexes at the knee or ankle
- Changes in bladder or bowel function
Testing & Diagnosis
Testing modalities are listed below. The most common imaging for this condition is MRI. Plain x-rays of the affected region are often added to complete the evaluation of the vertebra. Please note, a disc herniation cannot be seen on plain x-rays. CT scan and myelogram were more commonly used before MRI, but now are infrequently ordered as the initial diagnostic imaging, unless special circumstances exist that warrant their use. An electromyogram is infrequently used.
- X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine are obtained to search for other potential causes of pain, i.e. tumors, infections, fractures, etc.
- Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads X-rays; can show the shape and size of the spinal canal, its contents and the structures around it.
- Magnetic resonance imaging (MRI): A diagnostic test that produces 3D images of body structures using powerful magnets and computer technology; can show the spinal cord, nerve roots and surrounding areas as well as enlargement, degeneration and tumors.
- Myelogram: An X-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces; can show pressure on the spinal cord or nerves due to herniated discs, bone spurs or tumors.
- 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. This test is infrequently ordered.
Treatment
Non-Surgical Treatments
The initial treatment for a herniated disc is usually conservative and nonsurgical. A doctor may advise the patient to maintain a low, painless activity level for a few days to several weeks. This helps the spinal nerve inflammation to decrease. Bedrest is not recommended.
A herniated disc is frequently treated with nonsteroidal anti-inflammatory medication, if the pain is only mild to moderate. 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.
The doctor may recommend physical therapy. The therapist will perform an in-depth evaluation, which, combined with the doctor’s diagnosis, dictates a treatment specifically designed for patients with herniated discs. Therapy may include pelvic traction, gentle massage, ice and heat therapy, ultrasound, electrical muscle stimulation and stretching exercises. Pain medication and muscle relaxants may also be beneficial in conjunction with physical therapy.
Surgery
A doctor may recommend surgery if conservative treatment options, such as physical therapy and medications, do not reduce or end the pain altogether. Doctors discuss surgical options with patients to determine the proper procedure. As with any surgery, a patient’s age, overall health and other issues are taken into consideration.
The benefits of surgery should be weighed carefully against its risks. Although a large percentage of patients with herniated discs report significant pain relief after surgery, there is no guarantee that surgery will help.
A patient may be considered a candidate for spinal surgery if:
- Radicular pain limits normal activity or impairs quality of life
- Progressive neurological deficits develop, such as leg weakness and/or numbness
- Loss of normal bowel and bladder functions
- Difficulty standing or walking
- Medication and physical therapy are ineffective
- The patient is in reasonably good health
Lumbar Spine Surgery
Lumbar laminotomy is a procedure often utilized to relieve leg pain and sciatica caused by a herniated disc. It is performed through a small incision down the center of the back over the area of the herniated disc. During this procedure, a portion of the lamina may be removed. Once the incision is made through the skin, the muscles are moved to the side so that the surgeon can see the back of the vertebrae. A small opening is made between the two vertebrae to gain access to the herniated disc. After the disc is removed through a discectomy, the spine may need to be stabilized. Spinal fusion often is performed in conjunction with a laminotomy. In more involved cases, a laminectomy may be performed.
In artificial disc surgery, an incision is made through the abdomen, and the affected disc is removed and replaced. Only a small percentage of patients are candidates for artificial disc surgery. The patient must have disc degeneration in only one disc, between L4 and L5, or L5 and S1 (the first sacral vertebra). The patient must have undergone at least six months of treatment, such as physical therapy, pain medication or wearing a back brace, without showing improvement. The patient must be in overall good health with no signs of infection, osteoporosis or arthritis. If there is degeneration affecting more than one disc or significant leg pain, the patient is not a candidate for this surgery.
Cervical Spine Surgery
The medical decision to perform the operation from the front of the neck (anterior) or the back of the neck (posterior) is influenced by the exact location of the herniated disc, as well as the experience and preference of the surgeon. A portion of the lamina may be removed through a laminotomy, followed by removal of the disc herniation for the posterior approach. Patients, who are a candidate for posterior surgery, frequently do not need surgical fusion. For anterior surgery, after the disc is removed, the spine needs to be stabilized. This is accomplished using a cervical plate, interbody device and screws (instrumentation). In a select group of candidates, artificial cervical disc is an option vs. fusion.
What Dr. Vardan suggests:
The symptoms of lumbar disc disease may look like other conditions or medical problems. Always see your healthcare provider for a diagnosis.
When & How to Seek Medical Care
- Limit activities for 2 to 3 days. Walking as tolerated is encouraged, along with an anti-inflammatory, such as ibuprofen, if not contraindicated for the patient. Bedrest is not recommended.
- Primary care evaluation during this time may lead to considering other non-surgical treatments such as physical therapy.
- Referral to a spine specialist, such as a neurosurgeon, is also recommended if symptoms persist for greater than four weeks.