What Is a Disc Prolapse?
Disc prolapse or popularly known as sciatica is the protrusion of disc material outside its usual place. That protruded disc may cause compression of the nerve and may present as radiating pain to the respective limb.
Our spine is divided into the cervical, thoracic, lumbar, sacral, and coccygeal parts. Out of all these, the cervical and lumbar region are most mobile. Hence, disc prolapse is more common in these two areas. Out of these two, it is more common in lumbar. So, this article will discuss lumbar disc prolapse.
What Is Normal Disc?
First of all, let us try to understand what a normal disc is like and what are its normal functions. The disc is a gel-like material present between two vertebrae. This gel-like material is called nucleus pulposus. It is contained by a covering known as annulus fibrosus. So the lumbar spine has five vertebrae, and between each vertebra, we have nucleus pulposus contained by annulus fibrosus.
Why Is the Disc There?
The disc is a kind of joint between two vertebrae, which helps in the mobility of the spine. Moreover, it acts as a cushion during movements. Behind the disc runs the spinal cord and nerves. Whenever the part of disc prolapses or extrude backward, it irritates the nerves, which causes pain.
Cause of Pain in Disc Prolapse:
There are two reasons for pain in disc prolapse. Either chemical or mechanical reason. To all of your surprise, disc material in our body is considered a foreign material; that is, our immune system thinks the disc as its enemy. Typically, the disc material is not in direct contact with blood, and the annulus surrounds it.
But whenever there is disc prolapse, the small amount of material (though not compressing the nerve) comes in direct contact of blood. In response to this, our immune system gets activated and synthesizes a lot of chemical mediators, which promote inflammation. So, this inflammation causes pain.
The second reason is whenever the size of the prolapsed disc fragment is large, it causes direct compression of the nerve behind the disc.
How Does It Present?
Now, we divide even lumbar spine into two:
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Upper lumbar spine.
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Lower lumbar spine.
Out of these two, the lower lumbar spine (L4-5, L5-S1) is considered having maximum mobility. Hence most of the patients of disc prolapse are at this level. It is most commonly seen in middle-aged people. The reason for disc prolapse is not known clearly but it is more commonly seen in people with a sedentary lifestyle or those involved in heavy weight lifting activities. Overall, the symptoms are as follows:
- Back pain.
- Pain gets aggravated with movements of the lumbar spine, that is, difficulty in bending forward and backward.
- Pain to either one or both lower limbs (sciatica).
- Pain while walking and lying down.
- Body pain.
- Pain in the lower limbs.
Lower limb symptoms may be seen in very large disc prolapse and it is an emergency situation that requires emergency surgery. Hence, we being a doctor, educate every patient of disc prolapse about these symptoms and ask them to report immediately if such symptoms arise.
Patients of disc prolapse may notice an increase in pain during coughing, sneezing or any activity which increases intra-abdominal pressure. This feature is typical of disc prolapse.
Well, the most important thing a person should know is that per se prolapse of disc prolapse may or may not cause symptoms in the patient. Hence, the patient should leave this decision on the doctor if his or her symptoms are due to disc prolapse or something else.
How to Diagnose?
The prolapsed disc presents with typical features most of the time and the doctor can have suspicion with proper history and clinical examination. But to confidently make the diagnosis, doctors need radiological investigations. In these, the best investigation is MRI. But sometimes an X-ray or CT scan may be required depending on the situation. Few people are claustrophobic and MRI is difficult in them. But nowadays, open MRI is available at a few centers where these people can easily get their MRI done.
What Is The Treatment?
Coming to the most important part of the article. Well, most of the disc prolapse (80 %) respond to conservative management. In conservative management, we have medicines, physiotherapy, and few lifestyle changes. 10 to 15 % of patients of disc prolapse respond to other invasive procedures like transforaminal selective nerve root block and only 5 % of patients need surgical intervention. So let us see all these interventions one by one.
Conservative Management
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We have a few medications available like Pregabalin, Gabapentin, Duloxetine, etc., which are known as nootropic drugs. The action of these drugs is to enhance a certain kind of neurotransmitter in the brain, that is, GABA, which helps alleviate neuropathic or radicular pain. The dose of these medications differs and should not be taken without a prescription. The most common side effect associated with these medications is excessive sleepiness, hence these medications are preferred at night. Other side effects are water retention, which may cause weight gain and is reversible. Overall these drugs are safe but should be avoided during pregnancy and lactation.
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Your physiotherapist will tell you some dos and don’ts. Also, they will make you learn some exercises for strengthening your back muscles. In addition to these, they can also provide you with SWD/IFT and TENS therapy.
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Though the exact reason for disc prolapse is not known it is mostly seen in people with a sedentary lifestyle. So one should live a healthy lifestyle. For example, maintain good posture especially during office time and also at home. Daily walking for 4 km at a stretch will help to strengthen back muscles.
Transforaminal Selective Nerve Root Block
This is a temporary measure between conservative management and surgery. Those patients not getting relief with conservative management can try this injection. In short, we give mixture of local anesthetic and steroid around the nerve responsible for pain. This procedure is mostly safe with some theoretical complications. If the reason for pain is mostly chemical, then this injection works best. The duration of relief is widely variable. This injection also has diagnostic value.
Surgery
There are many different surgical options available, the decision of which depends on treating surgeon. Nowadays, spine surgery has become advanced and in turn safe for the patients.
