HERNIATED DISC (Slipped Disc)

What is a Herniated Disc?

A Herniated disc, also called a slipped disc, is a common spinal condition that can cause significant pain and discomfort.

• It is one of the most common diseases that produces low back pain and/or leg pain in adults.
• A herniated disc occurs when the fibrous outer portion of the disc ruptures or tears, and the jelly-like core squeezes out.
• A herniated disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. This herniation process begins from failure in the innermost annulus rings and progresses radially outward.
• The damage to the annulus of the disc appears to be associated with fully flexing the spine for a repeated or prolonged period of time. The nucleus loses its hydrostatic pressure and the annulus bulges outward during disc compression.

ANATOMY OF IV DISC AND VERTEBRAE

• Your backbone, also called your vertebral column, provides support and protection. It consists of 33 vertebrae (bones).
• There are discs between each of the vertebra that act like pads or shock absorbers. Each disc is made up of a tire-like outer band called the annulus fibrosus and a gel-like inner substance called the nucleus pulposus.
• Together, the vertebrae and the discs provide a protective tunnel (the spinal canal) to house the spinal cord and spinal nerves. These nerves run down the center of the vertebrae and exit to various parts of the body.
• Your back also has muscles, ligaments, tendons, and blood vessels. Muscles are strands of tissues that act as the source of power for movement. Ligaments are the strong, flexible bands of fibrous tissue that link the bones together, and tendons connect muscles to bones and discs. Blood vessels provide nourishment. These parts all work together to help you move about.
• A herniated disc most often occurs in the lumbar region (low back). This is because the lumbar spine carries most of the body’s weight. Sometimes the herniation can press on a nerve, causing pain that spreads or radiates to other parts of the body. The amount of pain associated with a disc rupture often depends on the amount of material that breaks through the annulus fibrosus and whether it compresses a nerve.

FUNCTION OF INTERVERTEBRAL DISC:-

The discs throughout the spine have three primary functions:

• They act as a shock absorber in the spine, positioned between each bony vertebra.
• They act as tough ligaments that hold the vertebrae of the spine together.
• They are cartilaginous joints that allow for slight mobility in the spine.

STAGES OF DISC HERNIATION:-

There are four types of herniated discs described in Clinical Anatomy and Management of Back Pain:-

1. degeneration:
   extension of the disc margin beyond the margins of the adjacent vertebral end-plates

2. Protrusion/prolapse
the posterior longitudinal ligament remains intact but the nucleus pulposus impinges on the annulus fibrosus

3. Extrusion
the nuclear material emerges through the annular fibers but the posterior longitudinal ligament remains intact

4. Sequestration
the nuclear material emerges through the annular fibers and the posterior longitudinal ligament is disrupted. A portion of the nucleus pulposus has protruded into the epidural space.

WHICH ARE CAUSES/RISK FACTORS Herniated Disc?

Herniated disks can occur at any age, but they are most common for men between the ages of 20 and 50 years.

Factors that increase the likelihood include:

• WEIGHT:
  Being overweight puts additional stress on the lower back.
• GENETICS:
  A person might inherit a predisposition to herniated disks.
• OCCUPATION:
  Individuals with physically demanding jobs or pastimes that involve pushing, pulling, or twisting are prone to herniated disks. Any repetitive activities that strain the spine can cause them.
• UNSAFE LIFTING TECHNIQUE:
  People should always apply force from the legs, not the back when lifting heavy items. Incorrect technique can lead to a herniated disk.
• DRIVING OFTEN:
  A combination of being seated for long periods and the vibrations and movements of the car can damage the disks and spinal structure.
• SEDENTARY LIFESTYLE:
  A lack of exercise can lead to a herniated disk.
• SMOKING:
  This might reduce oxygen supply to the disks and lead to a grinding-down of the tissue.

Which Symptoms are seen in the Herniated Disc?

Most herniated disks occur in your lower back (lumbar spine), although they can also occur in your neck (cervical spine). The most common signs and symptoms of a herniated disk are:

• ARM OR LEG PAIN:
  If your herniated disk is in your lower back, you’ll typically feel the most intense pain in your buttocks, thigh, and calf. It may also involve part of the foot. If your herniated disk is in your neck, the pain will typically be most intense in the shoulder and arm. This pain may shoot into your arm or leg when you cough, sneeze, or move your spine into certain positions.
• TINGLING OR NUMBNESS:
  People who have a herniated disk often experience numbness or tingling in the body part served by the affected nerves.
• WEAKNESS:
  Muscles served by the affected nerves tend to weaken. This may cause you to stumble, or impair your ability to lift or hold items.
• These are some general characteristics of lumbar herniated disc pain:
• LEG PAIN:
  The leg pain is typically worse than low back pain. If the pain radiates along the path of the large sciatic nerve in the back of the leg, it is referred to as sciatica or radiculopathy.
• NERVE PAIN:
  The most noticeable symptoms are usually described as nerve pain in the leg, with the pain being described as searing, sharp, electric, radiating, or piercing.
• VARIABLE LOCATION OF SYMPTOMS:
  Depending on variables such as where the disc herniates and the degree of herniation, symptoms may be experienced in the lower back, buttock, front or back of the thigh, the calf, foot, and/or toes, and typically affects just one side of the body.
• NEUROLOGICAL SYMPTOMS:
  Numbness, a pins-and-needles feeling, weakness, and/or tingling may be experienced in the leg, foot, and/or toes.
• FOOT DROP:
  Neurological symptoms caused by the herniation may include difficulty lifting the foot when walking or standing on the ball of the foot, a condition known as foot drop.
• LOWER BACK PAIN:
  Lower back pain may be present, but not always. The low back pain may be described as dull or throbbing and may be accompanied by stiffness. If the herniated disc causes lower back muscle spasms, the pain may be alleviated somewhat by a day or two of relative rest, applying ice or heat, sitting in a supported recliner, or lying flat on the back with a pillow under the knees.
• PAIN THAT WORSEN WITH MOVEMENT:
• Pain may follow prolonged standing or sitting, or after walking even a short distance. A laugh, sneeze, or other sudden action may also intensify the pain.
• PAIN THAT WORSEN FROM HUNCHING FORWARD:
• Many find that positions such as slouching or hunching forward in a chair, or bending forward at the waist, make the leg pain markedly worse.
• QUICK ONSET:
  Lumbar herniated disc pain usually develops quickly, although there may be no identifiable action or event that triggered the pain.
• Lumbar herniated disc symptoms are usually more severe if the herniation is extensive. Pain can be milder and limited to the lower back if the disc herniation does not affect a nerve.
• In some cases, low back pain or leg pain that occurs for a few days and then goes away is the first indication of a herniated disc.

HOW TO DIAGNOSIS Herniated Disc?

PHYSICAL EXAMINATION:

These tests may include:

• Muscle strength tests:
  Your doctor will test the strength of specific muscles (in your legs or feet) for signs of a pinched nerve.
• Sensory testing:
  Sensory testing measures your ability to feel light touch, a pinprick, or hot and cold.
• Deep tendon reflexes (knee and ankle jerk):
  Your doctor will tap your knees and ankles with a reflex hammer. If there is nerve root compression in your lower back, you may have little or no reflex in either the knee (patellar tendon) or the ankle (Achilles tendon).
• Lying straight-leg test:
  You will lie on your back with both legs extended. Your doctor will raise the affected leg toward your head. A positive test for herniated disc produces pain down the back of the leg, below the knee, when the leg is raised up.
• Sitting straight-leg test:
  You will sit on the exam table with both knees hanging over the edge of the table, bent at 90 degrees. Your doctor will slowly extend one leg until the knee is straight. Your leg is released, and the test is done on your other leg. A positive test for herniated discs produces pain down the back of the leg, below the knee, when the leg is raised.
• Femoral stretch test:
  You will lie face down on the exam table with your legs extended. Your doctor will raise one leg toward the ceiling and then bend your knee. If this test produces pain that travels (radiates) toward the front of the thigh, it is likely that one of the nerve roots located high in the lumbar region (lower back) is irritated.
• Valsalva maneuver:-
  You will cough or bear down, as during a bowel movement. If you have a herniated disc, a Valsalva maneuver may increase pain or other disc-related symptoms.

IMAGING TEST:

X-rays:
Plain X-rays don’t detect herniated disks, but they may be performed to rule out other causes of back pain, such as an infection, tumor, spinal alignment issues or a broken bone.

Computerized tomography (CT scan):
A CT scanner takes a series of X-rays from many different directions and then combines them to create cross-sectional images of your spinal column and the structures around it.

Magnetic resonance imaging (MRI):
Radio waves and a strong magnetic field are used to create images of your body’s internal structures. This test can be used to confirm the location of the herniated disk and to see which nerves are affected.

Myelogram:
A dye is injected into the spinal fluid, and then X-rays are taken. This test can show pressure on your spinal cord or nerves due to multiple herniated disks or other conditions.

PREVENTION MEASURES:

It is not always possible to prevent a herniated disc, but there are steps you can take to reduce your risk:

• Use proper lifting techniques. Do not bend at the waist. Bend your knees while keeping your back straight and use your strong leg muscles to help you support the load.
• Maintain a healthy weight. Excess weight puts pressure on the lower back.
• Practice good posture when walking, sitting, standing, and sleeping. For example, stand up straight with your shoulders back, abdomen in, and the small of your back flat. Sit with your feet flat on the floor or elevated. Sleep on a firm mattress, and sleep on your side, not your stomach.
• Stretch often when sitting for long periods of time.
• Do not wear high-heeled shoes.
• Exercise regularly to keep the muscles of your back, legs, and stomach strong. Engage in regular aerobic exercise. Try to balance flexibility with strengthening in a regular exercise program.
• Stop smoking.
• Eat healthy, well-balanced meals.

Treatment of Herniated Disc

MEDICAL TREATMENT:

Over-the-counter medication (OTC): Ibuprofen- or naproxen-based drugs can help with mild to moderate pain.

Nerve pain medications:
Medications for treating nerve pain include gabapentin, pregabalin, duloxetine, and amitriptyline.

Narcotics:
If OTC medications do not relieve discomfort, a doctor might prescribe codeine, a combination of oxycodone and acetaminophen, or another type of narcotic. Side effects include nausea, sedation, confusion, and constipation.

Cortisone injections:
These can be injected directly into the area of the herniation to help reduce inflammation and pain.

Epidural injections:
A doctor injects steroids, anesthetics, and anti-inflammatory medications into the epidural space, which is an area around the spinal cord. This can help minimize pain and swelling in and around the spinal nerve roots.

Muscle relaxants:
This helps reduce muscle spasms. Dizziness and sedation are common side effects.

SURGICAL TREATMENT

A patient may be considered a candidate for spinal surgery if:

-Back and leg 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

Surgical Terms:

ARTIFICIAL DISC SURGERY

Surgical replacement of a diseased or herniated lumbar disc with a manufactured disc.

DISCECTOMY:
Surgical removal or partial removal of an intervertebral disc.

LAMINECTOMY

Surgical removal of most of the bony arch, or lamina, of a vertebra.

LAMINOTOMY

An opening is made in a lamina to relieve pressure on the nerve roots.

SPINAL FUSION

A procedure in which bone is grafted onto the spine, creating a solid union between two or more vertebrae; instrumentation such as screws and rods may be used to provide additional spinal support

PHYSIOTHERAPY TREATMENT:

1. MASSAGE
   There are more than 100 types of massage, but deep tissue massage is an ideal option if you have a herniated disc because it uses a great deal of pressure to relieve deep muscle tension and spasms, which develop to prevent muscle motion at the affected area.

2. HOT AND COLD THERAPY
Both hot and cold therapies offer their own set of benefits, and your physical therapist may alternate between them to get the best results.
Your physical therapist may use heat to increase blood flow to the target area. Blood helps heal the area by delivering extra oxygen and nutrients. Blood also removes waste byproducts from muscle spasms.
cold therapy (also called cryotherapy) slows circulation. This reduces inflammation, muscle spasms, and pain. Your physical therapist may place an ice pack on the target area, give you an ice massage, or even use a spray known as fluoromethane to cool inflamed tissues.

3. TRACTION
The goal of traction is to reduce the effects of gravity on the spine. By gently pulling apart the bones, the intent is to reduce the disc herniation. The analogy is much like a flat tire “disappearing” when you put a jack under the car and take pressure off the tire. It can be performed in the cervical or lumbar spine.

4. ULTRASOUND
Ultrasound is used to penetrate the tissues and transmit heat deep into the tissues. The aim of ultrasound is to increase local metabolism and blood circulation, enhance the flexibility of connective tissue, and accelerate tissue regeneration, potentially reducing pain and stiffness, while improving mobility.

5. TENS [TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION]
A TENS machine uses an electrical current to stimulate your muscles. It sounds intense, but it really isn’t painful. Electrodes taped to your skin send a tiny electrical current to key points on the nerve pathway. TENS reduces muscle spasms and is generally believed to trigger the release of endorphins, which are your body’s natural painkillers.

6. HYDROTHERAPY
hydrotherapy involves water. As a passive treatment, hydrotherapy may involve simply sitting in a whirlpool bath or warm shower. Hydrotherapy gently relieves pain and relaxes muscles.

7. EXERCISES

HANGING:

– Use a bar or the top of a door (or anything you can hang from) and allow your body to “just hang”.
– Hang for 30 seconds and do 3 sets.
– If you feel worse doing this technique stop and try some of the other exercises instead.

BACK EXTENSION IN STANDING:

– Begin this exercise by standing up with good posture. Now take both hands and place them on both sides of your lower back. Now with the help of your hands push your pelvis forward and extend your spine back. Follow the extension with your neck so that you end up facing the ceiling.
– Start with 10 repetitions and do 2-3 sets.
– This one is particularly great to do when you need a break from sitting at your desk…

BIRD DOG:

– Begin on your hands and knees with your hands positioned under your shoulders and knees positioned under your hips.
– Raise your left arm and reach it forward until it is aligned with your torso; at the same time, kick your right leg backward until is it aligned with your torso.
– Hold this position for 2-3 seconds before slowly returning to the starting position.
– Repeat with your right arm and left leg.
– Alternate sides for 10 repetitions and do 2-3 sets.
Ensure that your head, neck, and back maintain a neutral alignment to minimize stress on your neck.

PRONE LYING ON FOREARM:

– Begin this exercise by lying on your stomach (prone position) and slowly prop yourself up on your elbows while keeping your hips in contact with the floor.
– Hold the prop-up position for 10-15 seconds before returning to the prone position (lying face down).
– Gradually increase to holding the end position for 30 seconds. Aim for 10 repetitions of this stretch.

Initially, you may not be able to tolerate this position very well, so make sure you start slowly and carefully.

PRONE LYING ON HAND

– Once you’ve mastered the half cobra pose, you can increase the difficulty by moving to the advanced version of this stretch. Begin this exercise by lying on your stomach in the prone position (lying facing down) and slowly press up on your hands while keeping your pelvis in contact with the floor and lower back relaxed.
– Hold the prop-up position for 10 seconds. Aim for 10 repetitions of this stretch.
– Eventually, try to hold this pose for longer if it feels good (20-30 seconds).

CAT AND CAMEL

– Begin this stretch on your hands and knees. Inhale and let your stomach “drop” towards the floor as you look up towards the ceiling.
– Follow this by exhaling and slowly rounding your spine while pressing into the floor with your hands and slightly curving your neck to look at your feet.
– Aim for 10 repetitions of this stretch and do 2-3 sets.

PLANK

– Begin lying on your stomach with your forearms against the mat.
– Engage your core and lift your body so that you are resting on your forearms and toes.
– Hold the plank position for 20-30 seconds.
– Aim for 5 to 10 repetitions of this exercise.
– When you’re ready, increase the intensity by increasing the time you hold the plank in 10-second increments.
Ensure to keep your back straight throughout the entire exercise.

STATIC ABDOMINIS:

• Lie on your back with your feet flat on the floor.
• As you exhale, squeeze your abdominal muscles, push your belly button toward the floor, and flatten your lower back.
• Hold for 5 seconds. Relax.
• Repeat 10 times, holding for 5 seconds each time

BRIDGING:

• Lie on your back with both knees about 90 Degrees.
• Then push your feet into the floor, squeeze or tighten your buttocks, and lift your hips off the floor until the shoulders, hips, and knees are all in a straight line.
• Hold for about 5 sec, and then slowly lower your hips back down to the floor and rest for up to TEN seconds.
• Repeat 10 times.

HAMSTRING STRETCH:

• Start off by lying flat on your back, flexing your hip and knee to a 90-degree angle.
• Taking your bent knee slowly extend it to the ceiling until you feel a stretch; while keeping your opposite foot still planted on the floor.
• Keep your spine vertical without moving it.
• Hold this position for 15 to 30 seconds and switch feet.

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