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Cover Stories

A Pain in the Back

Many treatment options available for herniated discs

Although the term “slipped disc” has become commonplace as a description of a herniated disc, the phrase does not adequately depict the underlying issue.

A herniated disc occurs when the softer center of the disc pushes through its tougher exterior. This can be caused by severe trauma to the body, overexertion of the back or sometimes for unknown reasons. Millions of people suffer from herniated discs, but not many realize it because a large percentage of cases are asymptomatic. For those who do experience symptoms, a herniated disc can be a mild irritation to a full-on disability.

Dr. Art Nitz, professor of physical therapy at the University of Kentucky and co-owner of Pro Active Therapy in Frankfort (http://proactivetherapy.org), says the most common symptoms of a herniated disc are pain in the spine and limb (leg or arm), sensory disturbance such as numbness or tingling in the limb and muscle weakness that conforms to a specific nerve root level.

Since the symptoms of herniated discs and their causes can vary so greatly, different specialists may be required to intervene, depending on the individual patient’s case. Medications such as muscle relaxants and anti-inflammatories may be used. In specific cases, epidural steroid injections have also proven effective in reducing swelling around the affected nerve root, helping alleviate symptoms.

Another, more conservative approach for individuals with moderate symptoms is physical therapy. A physical therapist could utilize treatments ranging from mechanical traction to gentle joint mobilization and specific exercises to decrease disc pressure on the affected nerve root. With extreme cases that involve continuous, uncontrollable pain, muscle weakness or sensory disturbances, a referral to a neurosurgeon might be necessary.

“A more thorough neurological work up may be offered by a neurologist,” Nitz said. “A physical medicine and rehabilitation physician may be consulted for chronic symptoms of disc herniation in an individual who elects to avoid surgical intervention.” The primary care provider might consider referring a patient displaying symptoms and signs of a disc herniation to a physician who specializes in treatment for pain as a final option.

Conservative intervention alleviates symptoms for many patients to the point of returning them to a desired level of activity. If a patient has an extreme case, such as a lumbosacral disc herniation that could cause progressive muscle weakness, bowel and bladder issues and severe intractable pain, immediate surgical intervention may be the only option to reduce symptoms.

If a patient opts for surgical intervention, the type of herniated disc involved will determine the type of surgery necessary. “In the cervical region, disc herniations are most often excised surgically with an anterior approach,” said Nitz. “It seems that most surgeons prefer to stabilize the surgically treated region with a screw and plate arrangement, effectively fusing the level treated. In the lumbar region disc, lesions are usually treated by a posterior surgical approach and rarely involve implanting instrumentation. In the event of failure of a simple discectomy, additional surgical interventions may involve fusion with or without instrumentation.”

As with all major surgeries, infection and developing blood clots are the primary concerns for the first several weeks. Prolonged bed rest could cause complications and delay the benefits associated with having the surgery in the first place. A worst-case scenario is that the surgery could potentially do more harm than good because there is a risk of nerve injury or paralysis due to accidental manipulation of the spinal nerve during surgery.

In addition to the risks for all herniated disc surgeries, other complications can arise, depending on the region of the spine affected. “In the cervical region, the anterior approach involves moving vital vascular structures to the side during the procedure, which may result in injury to them,” Nitz said. “The nerve that supplies the vocal cords is also intimately related to this area and can be inadvertently injured by the surgery, resulting in speech difficulty following the surgery. In the lumbar spine, the posterior approach necessarily involves dividing a number of spinal muscles to reach the herniated disc. This invariably results in back muscle denervation, which can produce muscle weakness for months following surgery.”

After surgery, pain medications are typically needed during the immediate postoperative phase, but other factors play a serious role in determining what individual patients need for recovery. A patient who had a lumbar spine discectomy is usually encouraged to start walking and performing gentle exercise activity soon after surgery; a patient who has had a cervical spine discectomy may be required to wear a protective hard cervical collar for two to three weeks and limit activity level dramatically during this phase. Physical therapy is a common requirement for most patients, utilizing gentle motion and strength training exercises to help them recover.

Within three to six weeks after surgery, most patients can start getting back to their normal lives and activities with some minor limitations on activities such as heavy lifting. Recreational activities and manual labor take longer, typically three to six months, and some patients might have permanent restrictions depending on their individual case.

Even with surgery, there is no absolute “cure” for a herniated disc. The main objective is to alleviate symptoms to help patients return to their normal activities.

“Disc herniation is a recoverable condition, most often by conservative management,” Nitz said. “Patients should be taught how to control disc forces to alleviate pain and reduce pressure on affected nerve roots. Ultimately, strength of the surrounding musculature support system and general cardiovascular fitness are closely associated with good outcomes following disc injury, whether treated surgically or by conservative means.”

By Erin Jensen, Staff Writer

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