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Wednesday, November 6, 2013

Patient Information: Diagnosis and Treatment of Lumbar (low back) Disc Herniations

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 How do spine specialists make the diagnosis of a Lumbar Disc Herniation?

Spine specialists use information from the patient history, the physical examination and special spine tests to make the diagnosis.

 

1.     History

The patient history often points to a disc herniation. A patient’s description of coughing, sneezing or lifting a weight prior to having low-back pain or leg pain is very common. Some patients have a history of prior disc herniations and can pinpoint that the current problem is “just like when I herniated it before”.

Often questions are asked about sensation and strength in the legs.

The spine specialists may also ask specific questions about your bowel and bladder function. The reason for that is the fact that very large disc herniations can affect the spinal cord or cauda equina. When these structures are compressed, we often lose the ability to urinate and cannot control our bowels. This is rarely the case, but if it is may require emergency surgery.

 2.     Examination

On the examination, patients often walk with a limp and have limited mobility of their back. Here are some common examination techniques done for disc herniations:

 
a.     Palpation (touching and pushing on the spine)
b.     Reflex Testing of the legs
c.      Sensation Testing of the legs
d.     Straight Leg Raising Test
e.     Muscle Strength Testing (motor testing) of the legs
f.       Valsalva Test
g.     Ankle Clonus Test
h.     Babinsky Test
 
 
3.     Imaging 
The following images are often used to diagnose a disc herniation:
1.     X-Rays
 
 
This image is an X-Ray of the low-back (lumbar spine) showing the spine from the side. The front of the spine is to the left, the back to the right. The vertebrae are shown in orange, separated by the discs in green. The nerve channels (foramen) are seen in yellow. They are located just behind the disc.
A basic X-Ray of the spine cannot show the disc itself, but it shows the space between the vertebrae where the disc is located. The height of each disc can be seen. However this may not point towards a disc herniation.
 
2.     MRI
This image is an MRI scan of the low-back (lumbar spine). The front of the spine is to the right, the back to the left. The vertebrae are shown in orange, separated by the discs in green. A large disc herniation is shown in red where the disc material has leaked out of the center of the disc and has been pushed into the spinal canal next to the spinal nerves.
 
MRI technology is the most advanced tool to actually see a disc herniation and is the study of choice. The images created by the MRI will show the discs, the spinal nerves and the spinal cord in detail. When a re-herniation following a disc surgery is suspected, intravenous dye is often given to be able to know what might be scar tissue as opposed to a new disc herniation.
3.     CT Myelogram
 

This image is a CT Myelogram which shows the spine from the side. The front of the spine is to the left. The Vertebrae are shown in orange, separated by the discs in green. The spinal cord is shown in yellow. The spinal fluid around the spinal cord is seen in blue. A disc herniation is shown by the red arrow.
.
This study is sometimes used if other imaging studies cannot show a disc herniation, yet the spine specialist is suspecting one. For instance when a patient has had metal inserted in the spine at the time of a previous surgery, the MRI images may be less than optimal in that area. A myelogram may help in this situation.



 
4.     Lumbar Discogram
 

This image is a Color MRI scan showing the Lumbar (low back) Spine from the side. The front of the Spine is to the left. Two needles (blue) have been placed into two of the discs. Dye (green) has been injected for a Discogram.
A discogram is a study where a spine specialist injects medication into a disc to help make a diagnosis. A disc may look suspicious for degeneration on an MRI study, however that may not be enough proof to recommend surgery. A discogram can get more information from the disc, such as whether a particular disc is painful.
 
 
What Treatments do Spine Specialists offer for Lumbar Disc Herniations?
 
 
Most disc herniations will heal with time and do not require surgery. In fact, only 5% of all disc herniation will require an operation. Over 90% of patients with a disc herniation will improve in the first 6 weeks. However, patients often have significant pain during this time and can benefit from non-surgical care.
 
1.    Non-Surgical Care
a.     Rest
Taking time off from activities which stress the spine is important. If work exposes a patient to lifting, work restrictions may have to be placed. Staying in bed for longer periods of time has not been shown to help disc herniations. Typically it is recommended to do activities as tolerated except for lifting, running, excessive bending and twisting of the back, as well as high-impact activites.
b.     Alternative Health Care
Alternative Health care options can often complement conventional medical care. Massage Therapy, Acupuncture, Meditation exercises and Herbal Remedies can all help with the pain from this condition. Massage Therapy can help with the muscle components of a lumbar disc herniation.  
c.      Nutrition and Weight Loss
Proper nutrition and weight loss can have a positive impact on many spine conditions. Excess weight on the spine often contributes to the symptoms of pain and spasms (Spine and Obesity).
d.     Tabaco Cessation
Smoking reduces the amount of oxygen available to tissues. In the presence of a disc herniation, oxygen is needed to assist in healing from the inflammation resulting from the herniation. Nicotine may also interfere with the disc’s nutrition. In addition, nicotine appears to cause some sensitivity to pain. 
e.     Chiropractic Care
Chiropractic care including manipulation and adjustments of the spine can help with the pain and spasms from this condition. One limitation of spine manipulation is the presence of a spinal cord or nerve compression problem. This is called a “neurological” problem and often results in weakness in the legs. In this situation, spinal manipulation should be minimal if at all, for fear of pushing out more disc material making the neurological problems worse.
In absence of this, manipulation can be helpful in relieving some or all of the symptoms of nerve compression.
f.       Spine Exercises
      Spine exercises can help with the muscle pain and tightness from this condition. Exercise also increases the amount of oxygen delivered to the spine which can help with healing. Pilates, Yoga and T’ai Chi can help maintain the spine’s flexibility.
 
g.     Physical Therapy (PT)
PT has many modalities to offer for this condition. They can range from Manual Therapy and Exercises to Traction and Ultrasound Treatments. PT can help disc herniations through a variety of means. This includes exercises, change in spine posture, and conditioning of certain muscles at risk for atrophy (loss of muscle bulk due to nerve damage). Physical therapists can also explain in detail what activities to avoid and which are best for a disc herniation. They can use modalities such as ultrasound and muscle stimulation to help with back spasms.
 
h.     Self Help Tools
Self Help Tools are items which can be purchased to help with back pain. They range from Back Braces to Back Mattresses and Ergonomic Devices such as chairs and computer accessories. There are also a variety of Non-Surgical Decompression devices on the market which may offer some benefit.
 
      i. Spine Medications
Below are the most commonly used groups of the medications for disc herniations. They can be used alone or in combinations depending on the severity of the symptoms and the doctor’s advice.
1.     Non-steroid Anti-inflammatory Drugs (NSAIDS)
This group of medications which includes Ibuprofen and Naproxen Sodium amongst many others can have some benefit for disc herniations. However, higher doses are typically needed which may be difficult to tolerate.
2.     Steroids
Steroid type anti-inflammatories can be very helpful especially for nerve pain in the arm. They are usually just used for the short term due their side effects. 
3.     Muscle Relaxants
Muscle relaxants are helpful when neck or back spasms are present. They may be able to interrupt the cycle of spasticity.
 
4.     Pain Killers
Narcotic pain medications are usually reserved for severe pain or pain not relieved by the medications above. They should be used for the short term to avoid addiction.
5.     Nerve Pain Medications
These medications can be very helpful for nerve pain from a compressed spinal nerve.
6.     Antidepressants
These medications can help with nerve pain and the depression some patients suffer from pain.
 
                   j. Injections
1.     Trigger Point Injections/Muscle Blocks
Sometimes a muscle which is in severe spasm can be injection with medications such as steroids or local anesthetics for relief.
 
2.     Lumbar Epidural Injections
Epidural injections can deliver medication such as steroids and local anesthetics directly to the disc and a spinal nerve. This can help significantly in reducing the inflammation and pain from a disc herniation.
 
1. Lumbar Interlaminar ESI
2.  Lumbar Transforaminal ESI
3. Lumbar Nerve Root Block)
4. Caudal Epidural Steroid Injection
 
                    k.     Minimally Invasive Procedures
      Percutaneous Lumbar Discectomy
      Lumbar IDET
      Endoscopic Lumbar Discectomy Surgeries
 
 
 
2. Surgical Care
 
Surgical care for lumbar disc herniations is usually reserved for patients who do not get better after non-surgical care for 6-12 weeks and have significant symptoms. Only 5% of patients with disc herniations undergo surgery. Exceptions are patients who have signs of severe spinal cord or spinal nerve compression, who may need urgent surgery to avoid permanent nerve damage.
 Here are some of the spine surgeries commonly performed for Lumbar Disc Herniations:
 
1.   Endoscopic Lumbar Spine Surgery
2.   Lumbar Micro Discectomy
3.     Lumbar Discectomy
4.     Lumbar Fusion
 
5.     Lumbar Artificial Disc Replacement
  



 

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