Introduction
Disk herniation refers to a condition that occurs along the spine or vertebral column, often in the body's lower back or lumbar region. The layperson's term is a bulging disk, a protruding disk, or a ruptured disk. Being a significant cause of pain in the lower back along with the spine and leg pain, or sciatica, it affects around 60 % to 80 % of people at some point in their lifetimes.
What Are the Components of the Spine?
The typical human spine comprises 24 bones, known as vertebrae, stacked on top of one another to form the vertebral column. The centers of these bones are hollowed and connected to form the spinal canal that protects the delicate bundle of nerves known as the spinal cord. The lower back is created by the stacking up of five vertebrae and the lumbar spine.
The other parts of the spine include the following components;
1. Spinal cord.
2. Spinal nerves.
3. Intervertebral disks.
4. Intervertebral disks.
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Annulus fibrosus.
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Nucleus pulposus.
Why Does a Disk Herniate?
When the internal jelly-like structure called nucleus pulposus pushes against the outer fibrous ring known as annulus fibrosus due to wear and tear from regular use leading up to old age or sudden injuries or trauma to the spine. The pressure against the outer ring may initially result in lower back pain, and the jelly-like nucleus may push all the way through if the stress on the disk's outer ring is prolonged or the pain is ignored for the long term resulting in ring-bulging. This puts pressure on the spinal cord and the nearby nerve roots that exit the spine through lateral holes known as foramen (neural foramina). The mechanical compression of the nerves aside, the disk material releases chemical irritants such as cytokines and chemokines that result in nerve inflammation or neuritis. An irritated nerve root may show pain, numbness, and weakness in one or both of the legs, and the condition is called sciatica.
Who Is At Risk for Disk Herniation?
The factors that may increase the risks of disk herniation are as follows;
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Age and Sex Predilection: Males between the ages of 20 and 50 years are more prone to develop disk herniation due to trauma and aging.
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Improper Lifting Action: Using the muscles on the back instead of those in the lower limbs to lift or carry heavy objects can cause a herniation. Twisting to the sides while lifting can also make the back vulnerable.
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Weight of the Individual: Obesity puts added stress on the disks in your lower back as additional weight compresses the spine.
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Repetitive Strain Injuries to the Spine: Professional hazards in jobs that require an individual to constantly lift, pull, bend, or twist result in repetitive strain on the spine that, in time, results in disk herniation.
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Driving for Extended Periods: Professionals such as truckers, freighters, and professional chauffeurs, who stay seated for prolonged periods and are exposed to vibrations from the car engine, can strain their spine and disks over extended periods.
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The Lifestyle of the Individual: Several medical conditions, such as a herniated disk, can be prevented by changes in lifestyle. A sedentary patient has more chances of developing such diseases than those who follow a regimen of exercise.
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Smoking: Studies have shown that smoking lessens the oxygen supply to the disk and causes more rapid degeneration.
What Are the Symptoms of Disk Herniation?
Pain is the first symptom a patient with a herniated disk experiences, especially in the lower back region. The duration of the pain may range from a few days to weeks, then improve, only to aggravate if it is left unchecked or neglected.
Other symptoms may include the following:
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Sciatica: A sharp, shooting pain extending from the buttock area to the back of one or both legs caused by pressure exerted by the disk on the spinal nerve roots.
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Pins and Needles: Numbness or a tingling sensation in the lower extremities.
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Weakness: Loss of strength in the lower extremities.
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Loss of Bladder and Bowel Control: Cauda equina syndrome is a rare situation caused by compressed spinal nerve roots and requires immediate medical attention.
How Does the Specialist Diagnose a Possible Disk Hernia?
After discussing the patient's symptoms and recording medical history, the doctor performs a physical examination that includes the following:
Neurological Examination: This helps determine if there are muscle weaknesses or loss of sensation. During the exam, the doctor will:
- Check muscle strength in the lower limbs.
- Detect loss of sensation.
- Test the reflexes at the knee and ankle.
Straight Leg Raise (SLR) Test: It is a specialized test for disk herniation in younger patients. The patient is supine, and the doctor lifts the leg carefully to assess pain and check if the patient lowers the leg below knee level.
Diagnostic Imaging Studies
- Magnetic resonance imaging (MRI) scans.
- Computed tomography (CT) scan.
- CT myelogram.
What Are the Lines of Treatment for Disk Hernias?
A herniated lumbar disk slowly shows improvement over several days to weeks in most cases, with many instances showing absolute relief within three to four months, seldom showing episodes of intermittent pain during the recovery phase.
Nonsurgical Treatment: The initial treatment prescribed for a herniated disk is usually nonsurgical that includes the following:
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Required to take rest but avoid sitting for prolonged periods.
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Make forward bending and lifting a controlled activity.
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Changing daily activities to avoid movements that trigger or aggravate pain and tenderness.
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To relieve pain, use nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen or Naproxen.
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Physiotherapy.
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Gabapentin, Pregabalin and Duloxetine help in symptomatic relief.
Surgical Treatment: A small percentage of lumbar disk herniation cases require surgical intervention, which is typically recommended after a period of nonsurgical treatment has not relieved painful symptoms or for patients who are experiencing the following:
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Muscle weakness.
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Difficulty walking.
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Loss of bladder or bowel control.
What Is Microdiscectomy Surgery and When Is it Done?
Microdiscectomy is the most common procedure used to treat a single herniated disk. A small incision is made at the level of the herniation, and the surgery is done using a microscope. The surgery aims to remove the herniated part of the disk with any additional fragments exerting pressure on the spinal nerves. The procedure may require a larger incision and more extensive removal if disk herniations are at more than one level.
Overall, the results of microdiscectomy surgery are generally excellent. Patients tend to see more improvements in lower limb pain than back pain. Most patients resume their everyday activities after a prescribed period of recovery postoperatively. The doctor will be able to guide the patient on the advantages and disadvantages of both surgical and nonsurgical treatment.
What Does Postoperative Rehabilitation Look Like in the Case of Disc Hernia Surgeries?
The doctor or a physical therapist may recommend simple walking programs and specific exercises to restore strength, flexibility, and functionality to the back and lower limbs. The patient may be prohibited from bending, lifting, and twisting for the first few weeks after surgery to reduce the risk of recurrences.
What Are the Presurgical Considerations Before Microdiscectomy Is Done?
The chances of recurrence are 20 % to 25 % within the patient's lifespan. Nonsurgical treatments may relieve symptoms over an extended period, and patients who try nonsurgical treatment for too long before electing a surgical intervention may experience minor improvement. Studies suggest that after 9 to 12 months of nonsurgical therapy, the surgical outcomes are not as beneficial as if the surgery was done before nine months.
What Are the Postoperative Risks After Surgical Procedures?
As with any surgical procedure, minor risks are associated, including bleeding, infection, and reaction to anesthesia. Specific complications from surgery for a herniated disk include:
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Nerve injury.
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Infection tear of the sac covering the nerves (dural tear).
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Hematoma causing nerve compression.
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Recurrent disk herniation.
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Need for further surgery.
Conclusion
Being a significant cause of pain in the lower back and the spine and leg pain, or sciatica, disk hernias affect around 60 % to 80 % of people at some point in their lifetimes. A herniated lumbar disk slowly shows improvement over several days to weeks in most cases, with many instances showing absolute relief within three to four months, seldom showing episodes of intermittent pain during the recovery phase. A small percentage of lumbar disk herniation cases require surgical intervention, which is typically recommended only after a period of nonsurgical treatment has not relieved painful symptoms. Overall, the results of microdiscectomy surgery are generally outstanding.
