Spinal disc herniation , also known as slip disc , is a medical condition that affects the spine where the tear outside, the fibrous ring of the intervertebral disc allows the soft, centered portion out in outside the broken outer ring. Disk herniation is usually caused by age-related outer age degeneration, known as annulus fibrosus, although trauma, raised injury, or straining are also involved. Tears are almost always postero-lateral (behind the sides) due to a posterior longitudinal ligament in the spinal canal. This tear on the disc ring can lead to the release of chemicals that cause inflammation, which can directly cause severe pain even in the absence of nerve root compression.
Disk herniation is usually a further development of the pre-disc protrusion, a condition in which the outer layers of the annulus fibrosus are intact, but may swell when the disk is under pressure. In contrast to herniation, no central part exits the outer layer. Most minor herniations heal within a few weeks. Anti-inflammatory treatments for pain relating to disc herniation, bulge, bulge, or disc rupture are generally effective. Severe herniation may not heal by itself and may require surgery. This condition can be referred to as a "slip disc" , but the term is not accurate because the spinal discs are firmly attached between the vertebrae and can not "slip" out of place.
Video Spinal disc herniation
Signs and symptoms
The symptoms of disc herniation may vary depending on the location of the herniation and the type of soft tissue involved. They can range from little or no pain if the disc is the only tissue injured, to severe and non-stop neck pain or lower back pain that will spread to areas served by irritated or affected neural roots hit by herniation material. Often, herniated discs are not diagnosed immediately, because patients come with pain in the thighs, knees, or legs. Other symptoms may include sensory changes such as numbness, tingling, paresthesia, and motor changes such as muscle weakness, paralysis, and reflex affection. If the disc herniation is located in the lumbar region, the patient may also experience sciatica due to irritation of one of the sciatic nerve roots. Unlike the throbbing pain or pain that comes and goes, which can be caused by muscle spasms, the pain of a herniated disc is usually continuous or at least continuous in a certain position of the body. It is possible to have a herniated disc without any pain or obvious symptoms, depending on its location. If the extruded nucleus pulposus material does not suppress the soft tissue or nerves, it may not cause symptoms. A small sample study examining the cervical spine on symptom-free volunteers has found a focus disc bulge on 50% of participants, which suggests that most populations can have focal hernia discs in their cervical area that do not cause any apparent symptoms.
Prolapsed disks on the lumbar spine may cause nerve pain to radiate. This type of pain is usually felt in the lower extremity or groin area. A radiating nerve pain caused by a prolapsed disc may also cause intestinal and bladder incontinence.
Usually, symptoms are experienced only on one side of the body. If prolapse is very large and compresses the nerves within the spine or cauda equina, both sides of the body may be affected, often with serious consequences. Compression of cauda equina can cause permanent nerve damage or paralysis. Nerve damage can lead to loss of bowel and bladder control as well as sexual dysfunction. This disorder is called cauda equina syndrome.
Other complications include chronic pain.
Maps Spinal disc herniation
Cause
Most authors favor intervertebral disc degeneration as a major cause of spinal herniation and cite trauma as a low cause. Disc degeneration occurs both with degenerative disc disease and aging. With degeneration, disc contents, nucleus pulposus and annulus fibrosus, exposed to a changed load. In particular, the nucleus becomes fibrous and rigid and less able to withstand loads. The load is transferred to the annulus, which if it fails to withstand an increased load, may lead to the development of the gap. If the gap reaches the edges of the annulus, nuclear material can pass through as disc herniation.
Disc herniation can occur due to general wear, such as sitting or squatting constantly, driving, or an inactive lifestyle. However, herniation can also occur due to heavy lifting weights. Professional athletes, especially those who play contact sports like American football, are also vulnerable to herniation. In an athletic context, herniation is often the result of a sudden blunt effect on, or a sudden, bending or torsional movement, the lower back. When the spine is straight, like standing or lying, internal pressure is equated to all parts of the disc. While sitting or bending to lift, internal pressure on the disc can move from 17 psi (lying down) to over 300 psi (lifting with a rounded back).. Herniation of the contents of the disc into the spinal canal often occurs when the anterior side (stomach) of the disc compressed while sitting or bending forward, and the contents (nucleus pulposus) are pressed toward the stretched and thinning membrane (annulus fibrosus) on the posterior side (back side) of the disc. The combination of membrane thinning from stretching and an increase in internal pressure (200 to 300 psi) results in the breaking of the limited membrane. The jelly-like contents of the disk then move into the spinal canal, suppressing the spinal cord, which can produce strong and potentially disabling pains and other symptoms.
Some genes are also associated with intervertebral disc degeneration. Possible candidate genes such as type I collagen (sp1 sites), type IX collagen, vitamin D receptor, aggrecan, asporin, MMP3, interleukin-1, and interleukin-6 polymorphism have been implicated in disc degeneration. Mutation of genes encoding proteins involved in the regulation of extracellular matrices, such as MMP2 and THBS2, has been shown to contribute to lumbar herniation.
Pathophysiology
Although many minor herniations heal themselves with conservative treatment, sometimes disc herniation requires surgery for correction. The main focus of surgery is to remove the pressure or reduce the mechanical compression of the nerve element - either the spinal cord, or the nerve roots. But it is increasingly recognized that back pain, not merely due to compression, may also be due to chemical inflammation. There is evidence pointing to specific inflammatory mediators of this pain. This inflammatory molecule, called tumor necrosis factor alpha (TNF), is released not only by a herniated disk, but also in cases of disc rupture (annular tear), by facet joints, and in spinal stenosis. In addition to causing pain and inflammation, TNF can also contribute to disc degeneration.
The majority of cases of spinal herniation occur in the lumbar region (95% in L4-L5 or L5-S1). The second most common site is the cervical area (C5-C6, C6-C7). The thoracic region accounts for only 0.15% to 4.0% of cases. Herniation usually occurs posterolaterally, in which the annulus fibrosus is relatively thin and is not reinforced by the posterior or anterior posterior ligament. In the cervical spinal cord, a symptomatic posterolateral herniation between the two vertebrae will override the nerve coming out of the spinal canal between the two vertebrae on that side. Thus, for example, right posterolateral disc herniation of the discus between the C5 and C6 vertebrae will impale on the right C6 spinal nerve. The rest of the spinal cord, however, is oriented differently, so a simplexumateral herniation between two vertebrae will actually pierce on the outgoing nerve in the next intervertebral foramen. Thus, for example, disc herniation between the L5 and S1 vertebrae will overwrite the spinal nerve S1, which exits between the S1 and S2 vertebrae.
Cervical herniation
Cervical herniation occurs in the neck, most commonly between the vertebral bodies of the fifth and sixth (C5/6) and sixth and seventh (C6/7) vertebrae, especially in younger populations; as a shift in shift from disc disease primarily associated with the central location of the disc and associated myelopathy press with increasing age observed. Symptoms may affect the back of the skull, neck, shoulder girdle, shoulder blades, arms, and hands. The nerves of the cervical plexus and brachial plexus may be affected. Usually, a posterolateral disc hernia will affect the nerve roots that come out at the disk level. The nerve roots are numbered according to the vertebral body beneath them (except the C8 nerve roots). Thus, the C5/6 disc hernia usually affects the C6 nerve roots.
Lumbar herniation
Lumbar herniation occurs in the lower back, most commonly between fourth and fifth vertebral lumbar or between the fifth and the sacrum. Symptoms may affect the lower back, buttocks, thighs, anal/genital area (via the perineal nerve), and may spread to the feet and/or toes. The sciatic nerve is the most commonly affected nerve, causing symptoms of sciatica. The femoral nerve can also be affected and cause the patient to experience numbness, a tingling sensation along one or both legs and even feet or even a burning sensation in the hips and legs. Hernias in the lumbar region often suppress the nerve roots that come out at the level below the disc. Thus, the L4/5 disc herniation suppresses the nerve root L5.
Intradural herniation
Intranural disc herniation is a rare form of disc herniation with an incidence of 0.2-2.2%. Preoperative imaging may be helpful, but intraoperative findings are needed to confirm.
Diagnosis
Diagnosis is made by a practitioner based on history, symptoms, and physical examination. At some point in the evaluation, tests may be performed to confirm or exclude other causes of symptoms such as spondylolisthesis, degeneration, tumors, metastasis and space occupying lesions, and to evaluate the efficacy of potential treatment options.
Terminology
Some of the terms commonly used to describe conditions include herniated disc , prolapsed disk , disc split , and disk slipping . Other closely related phenomena include disc protrusion, radiculopathy (pinched nerve), sciatica, disc disease, disc degeneration, degenerative disc disease, and black discs.
The popular term slipped discs is wrong, because the intervertebral disc is tightly flanked between the two vertebrae where they are attached, and can not actually "slip", or even get out of place. The disk actually grows along with adjacent vertebrae and can be squeezed, stretched and twisted, all in a small degree. It can also tear, tear, herniate, and degenerate, but can not "slip". Some authors assume that the term "discs are slipping" is dangerous, because it leads to a false notion of what has happened and thus the possible outcome. However, during growth, one vertebral body may slip relative to the adjacent vertebral body, a disorder called spondylolisthesis.
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Physical exam
The increase in straight legs may be positive, since these findings have a low specificity; however, the sensitivity is high. Thus finding negative SLR marks is important in helping to "exclude" the possibility of lower lumbar herniation. Variation is lifting the leg when the patient is sitting. However, this reduces the sensitivity of the test.
Imaging
- Radiographic projection (X-ray imaging): Although plain X rays are limited in their ability to describe soft tissues such as discs, muscles, and nerves, they are still used to confirm or exclude other possibilities such as tumors, infections, , etc. Despite these limitations, X-rays can still play a relatively inexpensive role in confirming the suspicion of a herniated disk. If suspicion is strengthened, other methods may be used to provide final confirmation.
- Computed tomography scan (CT or CAT scan): A diagnostic image created after the computer reads x-rays. Can show the shape and size of the spinal canal, its contents, and surrounding structures, including soft tissue. However, visual confirmation of disc herniation can be difficult with CT. Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structure using powerful magnets and computer technology. It can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. This shows soft tissue better than CAT scans. MRI performed with high magnetic field strength usually provides the most convincing evidence for the diagnosis of disc herniation. The T2-weighted image allows clear visualization of the prominent disc material in the spinal canal.
- Myelogram: X-ray from the spinal canal after injection of the contrast material into the surrounding cerebrospinal fluid space. By revealing the displacement of the contrast material, it can indicate the presence of structures that can cause pressure on the spinal cord or nerves, such as disc herniation, tumors, or bone spurs. Because myelography involves injecting foreign substances, an MRI scan is now preferred for most patients. Myelograms still provide an excellent outline of the lesions that occupy space, especially when combined with CT scan (CT myelography).
- Study of electromyogram and nerve conduction (EMG/NCS): These tests measure electrical impulses along the nerve roots, peripheral nerves, and muscle tissue. It will indicate whether there is ongoing neurological damage, if the nerves are in a healing state from a past injury, or whether there is another site of nerve compression. The EMG/NCS study is usually used to determine the source of distal nerve dysfunction to the spine.
- The presence and severity of myelopathy can be evaluated by using transcranial magnetic stimulation (TMS), a neurophysiological method that allows the measurement of the time required for a neural impulse to cross the pyramid tract, starting from the cerebral cortex and ending. on the anterior horn cells of the cervical, thoracic, or lumbar spine. This measurement is called Central Conductive Time ( CCT ). TMS can help doctors to:
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- determines whether myelopathy exists
- identifies the level of the spinal cord where the myelopathy is located. This is particularly useful in cases where more than two lesions may be responsible for symptoms and clinical signs, such as in patients with two or more cervical hernia
- follow up the development of myelopathy in time, eg before and after cervical spine surgery
- TMS can also assist in the differential diagnosis of the causes of pyramidal channel damage.
Differential diagnosis
- Mechanical pain
- Diskogenic pain
- Myofascial pain
- Spondylosis or spondylolisthesis
- Spinal stenosis
- Abscess
- Hematoma
- Discitis or osteomyelitis
- Mass or malignant lesions
- Myocardial infarction
- Aortic dissection
Prevention
Because there are various causes of back injury, prevention should be comprehensive. The back injury is dominant in manual labor so most of the prevention methods of low back pain have been applied mainly to biomechanics. Prevention should come from a variety of sources such as education, proper body mechanics, and physical fitness.
Education
Education should emphasize not lifting beyond one's ability and giving the body a rest after a strenuous effort. Over time, poor posture can cause the IVD to tear or become damaged. Fighting to maintain proper posture and alignment will help prevent disk degradation.
Exercise
Exercises that increase back strength can also be used to prevent back injuries. Back exercises include prone to tap-ups, upper back extensions, transverse abdominus bracing, and floor bridges. If pain is present in the back, it can mean that the muscles of the back stability are weak and one needs to train the trunk muscles. Other preventive measures are to lose weight and not work beyond fatigue. Signs of fatigue include shaking, poor coordination, muscle burning, and loss of transverse abdominal brace. Heavy lifting should be done with the feet doing the work, and not the back.
Swimming is a common tool used in strength training. The use of a lumbarsacral support belt may limit movement in the spine and support the back when lifting.
Treatment
In most cases, spinal herniation does not require surgery. A study of sciatica, which can be caused by spinal herniation, found that "after 12 weeks, 73% of people showed no sense for major repair without surgery." However, this study did not determine the number of individuals in the group who experienced sciatica caused by disc herniation.
- Initial treatment usually consists of nonsteroidal anti-inflammatory drugs (NSAIDs), but the long-term use of NSAIDs for people with persistent back pain is complicated by their cardiovascular and gastrointestinal toxicities.
- Epidural corticosteroid injections provide short and questionable short-term improvement in patients with sciatica, but no long-term benefits. Complications occur in 0 to 17% of cases when performed on the neck, and most are small. In 2014, the US Food and Drug Administration (FDA) suggested that "corticosteroid injections into the epidural space of the spine can lead to rare but serious adverse events, including vision loss, stroke, paralysis, and death." and that "The effectiveness and safety of epidural corticosteroid delivery has not been established, and the FDA has not approved corticosteroids for this use."
Lumbar herniation
Non-surgical treatment methods are usually tried first, leaving the operation as a last resort. Pain medications are often prescribed as the first attempt to reduce acute pain and allow patients to start exercising and stretching. There are various other non-surgical methods used in an attempt to relieve the condition after it occurs, often combined with pain killers. They are either considered indicated, contraindicated, relatively contraindicated, or unconvincing based on their safety risk-benefit ratio profile and whether they may or may not help:
Expressed
- Education about the right body mechanics
- Physical therapy, to overcome mechanical factors, and may include modalities to relieve temporary pain (eg traction, electrical stimulation, massage)
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Weight control Spinal manipulation: Moderate proof of quality suggests that spinal manipulation is more effective than placebo for acute treatment (less than 3 months duration) of lumbar herniation and acute sciatica. The same study also found "low to very low" evidence for its usefulness in treating chronic lumbar symptoms (more than 3 months) and "Quality of evidence for... cervical spine-related limb symptoms of any low or very low duration". A review of a study published in 2006 suggests that spinal manipulation may be safe when used by properly trained practitioners, "and current research shows that spinal manipulation is safe for the treatment of pain associated with the disc.
Contraindications
Spinal manipulation is contraindicated for disc herniation when there is progressive neurologic deficit such as cauda equina syndrome.
A non-surgical spinal decompression review found flaws in most published studies and concluded that there is only "very limited evidence in scientific literature to support the effectiveness of non-surgical spinal decompression therapy." Its use and marketing is highly controversial.
Surgery
Surgery may be useful in those who have a herniated disk that causes pain that radiates to the feet, significant leg weakness, bladder problems, or loss of bowel control. Discectomy (removal of some discs that cause leg pain) can provide pain relief more quickly than non-surgical treatment. Dysectomy has better results in one year but not in four to ten years. Less invasive microsysectomy has not been shown to produce significantly different results than ordinary discectomy with respect to pain. However, it may have less risk of infection.
The presence of cauda equina syndrome (where there is incontinence, weakness, and genital numbness) is considered a medical emergency requiring immediate attention and possibly surgical decompression. Regarding the role of surgery for medical therapy failed in people without significant neurological deficits, Cochrane's review concluded that "limited evidence is now available to support some aspects of surgical practice".
Epidemiology
Disc herniation can occur on any disc in the spine, but the two most common forms are lumbar disc herniation and cervical herniation. The first is the most common, causing lower back pain (back pain) and often also leg pain, in this case is usually referred to as sciatica. Lumbar herniation occurs 15 times more often than cervical herniation (the neck), and this is one of the most common causes of low back pain. Cervical disc is affected 8% of the time and the upper back (thoracic) disc is only 1-2% of the time.
The following locations do not have discs and are therefore freed from the risk of disc herniation: the upper two cervical intervertebral spaces, the sacrum, and the coccyx. Most herniation occurs when a person is in his thirties or forties when the nucleus pulposus is still a gelatin-like substance. With age the core pulposus changes ("dries") and the risk of herniation is greatly reduced. After the age of 50 or 60 years, osteoarthritic degeneration (spondylosis) or spinal stenosis is more likely to cause back pain or foot pain.
- 4.8% of men and 2.5% of women older than 35 have sciatica during their lifetime.
- Of all individuals, 60% to 80% experience back pain during their lifetime.
- In 14%, pain lasts more than 2 weeks.
- Generally, men have a slightly higher incidence than women.
Etymology
A spinal herniation is known in Latin as an intervertebral disc prolapse [i].
Research
Future treatments may include stem cell therapy.
References
External links
- disc herniation in Curlie (based on DMOZ)
- Herniated Disc - WebMD
- Lower Back Pain with Skiathic Infection, information on spinal herniation - Mount Sinai Hospital, New York
Source of the article : Wikipedia
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