Various treatments strive to alleviate pain
Problems with bulging or herniated discs manifest themselves in distinct ways and require specific types of treatment.
“Disc bulges and disc herniations are common conditions afflicting the spine,” said Dr. Steven Kiefer with Neurosurgical Associates at Central Baptist Hospital. “These entities comprise a significant portion of the numerous spinal problems we deal with.”
Different terms, including ruptured disc or slipped disc, are used to describe the problem. Kiefer said lumbar and cervical disc herniations are degenerative processes. While there can be an element of trauma in some patients or an inherited component, the majority of the patients he sees have some drying out of the disc, which makes it brittle.
“There’s a seal around the disc,” he said. “That outside seal (capsule) around the disc can become brittle, develop a tear and allow the nucleus material (the nucleus pulposis)to make its way out of the space.”
Symptomatic disc herniations that present in the neck or back often create nerve pain.
“In patients that have a frank disc herniation, the cartilaginous material gets out of place and can trap a nerve,” Kiefer said. “A trapped nerve in the neck or lower back will often precipitate arm or leg symptoms respectively.”
A patient with a cervical disc herniation will experience severe arm pain, numbness or weakness. “The same would occur with a symptomatic lumbar disc herniation,” Kiefer said. “Patients can present with leg numbness, pain and weakness. These are the typical presenting symptoms for disc herniations.”
To diagnose a disc herniation, physicians rely on MRI examinations – what Kiefer calls the “gold standard” for looking at cervical and lumbar disc disease. Treatment for disc herniations may involve medication, physical therapy, spinal injection, discectomy or even spinal fusion.
“Assuming the patient is afflicted with pain, we would typically manage the patient for weeks or months with non-operative measures,” Kiefer said. “One of the mainstays would be physical therapy, non-steroidal anti-inflammatories and stronger doses of pain medicines if necessary.”
Sometimes patients will undergo injection therapy such as epidural injections, Kiefer added, but results can often be unpredictable. Surgery is often a consideration in those patients who do not improve with less invasive measures.
“If the patient has ongoing symptoms despite these non-operative measures, or if they have a pronounced neurologic deficit, then we would pursue surgery,” Kiefer said. “We would be much more aggressive and probably consider surgery earlier on in the setting of a significant neurological deficit.”
With a lumbar or cervical discectomy, the neurosurgeon removes the extruded piece of cartilaginous material that is pinching the nerve.
“It is essentially just freeing up a nerve,” said Kiefer. “In doing so, the main benefit is alleviation of pain. With nerve decompression, weakness and numbness can also improve.”
Kyphoplasty is a procedure performed in patients with pathologic fractures – that is, those due to osteoporosis or tumor, Kiefer explained. “It is usually an outpatient procedure,” Kiefer said. “We insert one or two small needles into the bone through the back, and through those needles we place a balloon. The balloon goes in and after it’s inflated, it opens up the broken bone. It can also compress some of the shards of bone that are fractured.”
The balloon is deflated and removed, and the cavity is filled with a bone cement. “It goes in with a toothpaste consistency but it sets up hard as a rock over a number of minutes,” Kiefer said. “That serves to bolster and stabilize the bone.”
Spinal fusion is utilized to address instability in the spine that can arise from degeneration or trauma.
Abnormal movement or alignment of the spine can cause compromise of a nerve with resultant pain, numbness or weakness. A spinal fusion allows for stabilization, often in conjunction with nerve decompression. A spinal fusion entails the binding of bones together. Fusion often involves the use of bone graft materials. Hardware such as plates, screws and rods serve as an “internal cast.”
“Some of these procedures can be quite substantial. Our capabilities have advanced and in general we do things in this day and age we wouldn’t have done 20 years ago when I was training,” Kiefer said.
By Tanya J. Tyler, Associate Editor