Ruptured/Herniated Disc

Living with a ruptured, or herniated, disc can be an extremely painful and debilitating experience. It can impair your ability to perform even the most basic physical tasks, such as bending over or walking. Even something simple like crawling out of bed can be a daunting task. According to the National Center for Biotechnology Information (NCBI), this condition can occur at any age but is most common in people between the ages of 30-50 years old with a male to female ratio of 2:1. Most pain associated with a herniated disc often occurs in the upper cervical and lower lumbar regions of the spine.

Symptoms of a herniated disc can range from no symptoms at all to severe symptoms affecting the ability to perform everyday tasks. However, advancements in technology and surgical medicine have allowed for patients to recover and return to most of their normal activities.

A complete overview of the spinal column is discussed in greater detail below along with risk factors and treatment options available for a herniated disc.

Structure of the Spinal Column

• Spine Anatomy Overview
• Identifying Vertebral Segments
• Identifying Vertebral Regions
• Anatomy of the Vertebral Segment

The spinal column, also known as the vertebral column, serves as the body’s main support structure and consists of a series of vertebral segments stacked on top of each other. The main function of the vertebral column is to enclose and protect the spinal cord, which runs down from the brainstem to nearly the bottom of the spine. The vertebral column supports about half of the body’s weight, with the other half supported by muscles. It provides attachment for the pectoral, pelvic girdles, and many other muscles. The vertebral column forms the central axis of the body and has roles in both posture and movement.

The vertebral column is commonly described as being divided into three major regions: cervical, thoracic, and lumbar. However, there are two regions located just below the lumbar region called the sacral region and coccygeal region. The sacral region contains five bony segments fused together to make up the sacrum, which connects the base of the spine to the pelvis.

The sacrum forms the posterior pelvic wall, stabilizing and strengthening the pelvis. The sacrum extends down to the triangular-shaped coccyx, commonly known as the tailbone, which is made up of four bones called caudal vertebrae. These two regions of the spine are considered part of the pelvis, however, the vertebral segment located where the lumbar and sacral region meet, known as L5 to S1, is prone to degeneration and is the cause for many common back issues.

The three major sections, or regions, of the spine are made up of 24 individual bony structures called vertebrae. The cervical or upper neck area has seven, the thoracic or middle torso area has 12, and the lumbar or lower back area has five vertebrae. An individual vertebra can be identified by the first initial of the region it belongs to and the position number within the region it is located, starting from the top. A specific vertebral segment of the spine can be referred to by identifying the upper vertebra and the lower vertebra of the segment in question. For example, “L5 to S1” referenced in the first tab (Spinal Anatomy Overview), refers to the segment of the spine between the last vertebra in the lumbar region (L5) and the first vertebra in the sacral region (S1).

Cervical Region: This neck region is made up of seven vertebrae, labeled C1 to C7. The first cervical vertebra (C1) is called the atlas. The second (C2) is called the axis. Together they form the joint that connects the skull to the spine, which allows movement to the head and gives it the ability to swivel around, tilt side to side, and nod up and down. This flexibility in movement, however, does make it susceptible to injury and degeneration, leading to neck problems. These problems usually result in neck pain and/or pain that radiates down the arms to the hands and fingers.

Thoracic Region: This upper torso region is the longest region of the spine and is made up of 12 vertebrae, labeled T1 to T12. This section of the spine is also considered the most complex. The thoracic spine runs from the base of the neck down to the abdomen. The vertebrae of the thoracic region serve as firm attachment points to the rib cage which limits its flexibility in comparison to the cervical and lumbar regions. The limited flexibility allows this section of the spine to be very stable; therefore, it typically has fewer back issues associated with it.

Lumbar Region: The lumbar region, often referred to as the lower back, is made up of five vertebrae, labeled L1 to L5. This region has a great deal of flexibility and is also the most weight-bearing section of the spine. These two attributes combine to make the lumbar region the most associated with back issues. Pain is normally experienced in the lower back and/or radiates down the leg to the feet.

Each vertebral segment consists of several parts: two vertebrae, an intervertebral disc located in between each vertebra, two nerve roots that extend out from the spinal cord exiting through either side of the vertebra, and two sets of facet joints which connect each vertebra to one another.

Vertebral Body/Spinal Canal- Each vertebra contains a cylinder-shaped bone in the front called the vertebral body. The vertebral body makes up the bulk of the vertebra and serves as the main weight-bearing structure. Behind the vertebral body is an opening called the vertebral foramen. These openings in the vertebrae create a channel for the spinal cord to travel through. This channel is known as the vertebral canal, also called the spinal canal.

Spinal Cord/Cauda Equina- The spinal cord consists of nerves that branch out at each level of the vertebral segment and travel to various parts of the body. The main function of the spinal cord is to carry messages to and from the brain. This allows us the ability to move our bodies, as well as being able to feel sensations, such as pleasure or pain. The spinal cord begins at the bottom of the brainstem and ends in the lumbar region near the L1/L2 vertebrae where it separates into bundles of nerve roots called the cauda equina.

Pedicle/Lamina- On either side of the vertebral canal are pedicle bones. These bones connect the vertebral body to the lamina. The lamina forms the outer wall of the vertebral canal, enclosing it. This provides cover and protection for the spinal cord.

Spinous & Transverse Processes- Protruding from the back of the lamina is the spinous process. This is the bony ridge that can be felt by running your hand down the center of your backbone. It provides an attachment point for ligaments and muscles that move and help stabilize the vertebrae. Transverse processes protrude out from the sides of each vertebra and they also provide attachment points for ligaments and muscles.

Superior & Inferior Articular Facet Joints- There are four articular facets that form the joints connecting the upper and lower adjacent vertebrae. There is an upper set called the superior articular facet joints and a bottom set called the inferior articular facet joints. Each facet has a covering of cartilage where they attach that allows the vertebrae to move and flex.

Intervertebral Disc/Annulus Fibrosus/Nucleus Pulposus- In between each vertebral body are flexible intervertebral discs, which act as shock absorbers to the spine, such as when you are running or jumping. These discs are made up of two parts: the annulus fibrosus outer ring and the nucleus pulposus inner core.

The annulus fibrosus is the tough outer ring of the intervertebral disc. Its radial, tire-like structure consists of dense layers of collagen fibers that surround the soft inner core. The two main purposes of the annulus fibrosus is to securely connect the spinal vertebrae above and below the disc as well as to contain the inner core called the nucleus pulposus. The nucleus pulposus is mostly made of water and a loose network of collagen fibers. Its main purpose is to distribute pressure evenly across the disc, preventing a concentration of stress in one area. This allows it to act as a shock absorber for the vertebrae, as well as keeping separation in between them. Its main purpose is to distribute pressure evenly across the disc, preventing a concentration of stress in one area.

What is a Herniated Disc?

Spinal discs can dehydrate and stiffen, causing them to become less able to handle compression. Over time, this can weaken the outer ring and cause the nucleus pulposus to herniate through the protective layer of the annulus fibrosus. This is known as a ruptured or herniated disc and most common in the cervical and lumbar regions of the spine. When this occurs, the nucleus pulposus puts pressure on the nerve root, compressing or “pinching” it. A pinched nerve can cause numbness, tingling, weakness as well as severe pain which can radiate through parts of the body where the nerve root branches out. For the cervical region, pain, numbness, or tingling usually radiates down the arms and/or into the hands and fingers. In the lumbar region, the pain is usually in the lower back and can radiate down the leg and/or into the calf and feet.

Symptoms of a Herniated Disc

Symptoms can include:

• Arm or leg pain, usually described as a sharp, shooting pain or burning sensation that may occur when moving into certain positions or when sneezing or coughing. In the neck, you will typically feel the most pain in your shoulder or arm. In the lower back, you will typically feel the most pain in your buttocks, thigh and/or calf.
• Numbness or tingling can be experienced at the herniation site, as well as the part of the body affected by the compressed nerve root.
• Weakness is normally experienced in the muscles that are affected by the compressed nerve root.
• Bladder or bowel control can be impaired by a pinched spinal cord or pinched nerves. Loss of bladder or bowel control is an indication for early surgery.

Diagnosis & Treatment Options

Diagnosis

A herniated disc can be diagnosed by a physician after discussing a patient’s symptoms, reviewing medical history, and performing a physical examination. The examination will usually involve a neurological exam to help determine if there is muscle weakness or loss of sensation.

The most common and preferred imaging for this condition is a magnetic resonance imaging (MRI) scan. This type of diagnostic test can produce 3-D images of the body structure surrounding the affected area. This includes soft tissue—such as the intervertebral discs—the spinal cord, nerve roots, and other key structures. It can detect degeneration, tumors, and other anomalies which can cause similar symptoms. If an MRI is not available, a computerized tomography (CT) scan or a myelogram may be ordered instead.

Treatment Options

Conservative Treatments:

Initial treatments of a herniated disc should be conservative. Approximately 50% of patients with Lumbar disc herniations improve with time. Many cases of a herniation can be treated by non-surgical means, such as:

• Rest– One to two days of bed rest may help relieve back pain symptoms. Activities that cause stress to the affected area should also be limited and controlled.
• Medications– The use of nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen or naproxen can help to relieve pain.
• Physical therapy– Specific exercise regimens can help strengthen the muscles that help support the lower back and spine.
• Epidural steroid injection– An injection of a steroid medicine into the space around the affected nerve root has shown to successfully relieve pain in many patients who have not seen improvement following six weeks or more of other non-surgical care.

Surgical Treatments:

Most cases of a herniated disc can be resolved without the need for surgery. However, a patient should speak with their physician about surgery if:

• The patient has progressive loss of nerve function.
• Symptoms have not improved with non-surgical treatment.
• The patient’s level of pain is severe.
• The patient is having trouble standing or walking.
• The patient is unable to control their bowels or bladder.
• The patient has trouble with coordination of fine motor skills

Surgical treatments for a herniated disc include:

• Microdiscectomy– This is the most common surgical procedure to treat a single herniated disc. This is a minimally invasive procedure involving the removal of the damaged or protruding portion of the disc without removing the entire disc.
• Laminectomy/laminotomy– This procedure is used to remove some or all of the portion of the vertebra called the lamina. This allows access to the spinal canal and relieves pressure on the nerve root.
• Spinal Fusion– This procedure is not usually a first line in the surgical treatment of isolated disc herniations in the lumbar spine but in the neck it is commonly used after a discectomy has been performed. It involves fusing the two vertebrae on either side to help stabilize the spine and reduce movement of the bones preventing more pain from occurring.
• Artificial Disc Replacement– This procedure involves removing the damaged disc and replacing it with an artificial disc made of plastic or metal. This type of surgery has gained popularity among surgeons aiming to preserve normal motion and has emerged as an alternative to spinal fusion.

If you are experiencing the above symptoms, be sure to schedule an appointment to talk to your doctor. Our team of experienced and certified orthopaedic surgeons are here to help ease your pain and get you on the road to recovery.