Lumbar Disc Herniation
The herniation or rupture of a lumbar disc occurs when the center or soft part of the disc (the nucleus palpasus) bulges or ruptures through the peripheral or fibrous portion of the disc (the annulus). Also known as a ruptured disc, herniated nucleus pulposus (HNP), or a slipped disc, this injury may occur when the ligaments surrounding the intervertebral disc become damaged or are weakened due to injury or from advancing age of the spine.
The injury can result from a from a sudden strenuous movement, trauma, or after degenerative changes in the spine. The result is a herniated disc that may compress, irritate or even permanently damage the nerve root. The severity and level of the lumbar disc herniation determines the type of signs and symptoms experienced by the patient.
- Lumbar Disc herniations are seen in all age groups, but are most prevalent in men between the ages of 35 and 45.
- The severity of symptoms of a disc herniation can vary from mild discomfort to disabling pain and nerve dysfunction.
- The pain associated with a lumbar disc herniation is characterized by a sharp, burning, or stabbing sensation, which radiates down one or both legs. The symptoms associated with a herniated disc are sometimes referred to and confused with the condition of sciatica.
- Initial treatment is non-surgical dependent on symptoms. Surgery is required to remove the herniated disc material, when symptoms of pain and/or nerve or when non-surgical therapies have failed.
- Both non-surgical and surgical treatment options result in good outcomes.
- The onset low back pain is usually sudden and severe.
- Weakness, numbness, or a tingling sensation may be present in one or both legs.
- Pain running from one buttock to the lower leg or foot.
- Pain that worsens with sitting, bending, lifting, coughing or straining.
- Severe nerve compression may cause changes in bowel and bladder functions (immediate medical care is essential in these cases).
- The pain of a herniated disc is usually worse with movement.
- If any signs and symptoms of a lumbar disc herniation are present, an evaluation by an orthopaedic specialist is recommended.
- If severe pain, weakness and/or bowel and bladder dysfunction are present at any time.
- If the pain following the injury, has not been relieved through rest and medication.
- A lumbar disc herniation can occur when normal degenerative changes (wear and tear arthritis) of the spine have weakened the ligament, which surround and support the discs within the spinal column, the lack of support results in collapse and compression of the disc. The increased pressure causes the disc to be squeezed out from between two vertebrae.
- A lumbar disc herniation can result from a sudden impact to or twisting motion of the spine.
- The risk of disc herniation increases when the patient lifts heavy objects with poor posture, or participates in an occupation where excess strain and twisting are placed on the spine.
- Participation in sports such as diving, weightlifting, golf, are examples of recreational activities that may increase the risk for lumbar disc herniation.
- With proper medical care and rehabilitation, recovery utilizing non-surgical therapy can be expected within three to six months of the injury.
- Surgery is required in only 10% of the patients who are diagnosed with a disc herniation.
A lumbar strain is the result of a sudden, traumatic injury or the long-term overuse/misuse of the lumbar spine. The injury can be caused by the stretching, tearing or rupture of the muscles that support the low back. The majority of all low back pain is due to sprains and strains of the lumbar muscles.
- A lumbar strain may take from 4-12 weeks to heal and is managed with non-surgical treatment.
- A lumbar strain is the most common injury of the low back and is caused by improper lifting, poor posture and/or trauma.
- The muscles in the low back give support and stability to the upright spine and when strained, severe, debilitating pain is a common symptom.
- A lumbar strain may be misdiagnosed. An underlying injury may be present, including the possibility of a herniated disc.
- Symptoms commonly resolve within 2 weeks.
- Pain is diffuse over a broad area of the low back. The discomfort is usually felt in the muscular ridges along each side of the spine, but not directly on the midline.
- Painful muscle spasms frequently are part of this injury.
- Pain does not radiate down into the lower legs but may be perceived in the upper buttocks and thigh. This pain rarely radiates farther than the knee.
- Normal range of motion can be limited, as well as the ability to maintain a normal upright posture.
- Sitting, standing, walking and driving may be extremely painful and uncomfortable during the first few days after the injury.
- Swelling, increased warmth, and tenderness of the paraspinal muscles are all suggestive of a lumbar strain
- Any signs and symptoms are present.
- After three (3) weeks of treatment, symptoms remain unchanged or increase in severity.
- Unexplained symptoms appear, a significant increase in the level of pain occurs, or unexpected side effects are present from taking over the counter or prescription medications.
- An overuse or misuse of the lumbar paraspinal muscles in the low back. These muscles are frequently strained as the result of improper lifting which places excessive stress on these muscles.
- A forceful twisting or other unnatural motion of the lower back.
- Overuse of a poorly conditioned or previously injured low back.
- Participants in sports and activities like football, golf and hockey are at a higher risk for lumbar strain.
- Patients who seek treatment for a lumbar strain and follow the recommended course of therapy, should expect a complete and full recovery within three to eight weeks.
- With a severe strain, where actual tearing of the muscle occurred, small amounts of scar tissue may remain in the lumbar muscles after healing from the initial injury.
- Scar tissue is less flexible than muscle and may be the site of re-injury.
Spinal stenosis is a condition that results in a narrowing of the spinal canal due to a degenerative process. The spinal canal contains the spinal cord and nerve roots. As the canal narrows, the nerve roots and the spinal cord are compressed. The progressive increase of the pressure on the nerves and spinal cord result in symptoms of pain, numbness, tingling, or weakness in the extremities. Futhermore, it significantly decreases walking endurance.
- The condition has many causes, the most common are the degenerative changes occurring in the spine as we grow older.
- The low back (lumbar) and neck (cervical) regions of the spine are common sites of involvement. The mid-back (thoracic) is less often involved with the development of stenosis.
- Absolute indication for surery is Cauda Equina Syndrome, which presents loss of bowel and bladder control.
- Surgery is indicated when non-surgical measures have failed or presentation with profound neurologic deficit.
- The surgical treatment of spinal stenosis is dependent on the underlying cause of the nerve compression.
- A tingling sensation, numbness (paresthesia), and/or weakness in any or all of the extremities.
- Dull to severe aching pain in the back, buttocks and thighs that develops when walking or with prolonged standing, and which may radiate into the lower legs (neurogenic claudication).
- Clumsiness, frequent tripping or falling when walking, and/or an altered pattern of walking (gait).
- Improvement of sympotms with sitting or bending forward. Patients often feel relief pushing a cart in a supermarket (flexing their spine) or laying in areclining position. This flexion increases the size of the canal and temporarily relieves the symptoms.
- Any of the signs and symptoms are present. An evaluation by an orthopedic surgeon is recommended.
- Symptoms persist, become increasingly severe and/or bowel and bladder function becomes impaired.
- Medications are not providing relief or are causing unexpected side effects.
- The most common cause of spinal stenosis is osteoarthritis, which results in bony outgrowths (bone spurs) from hypertrophied facet joints projecting into the spinal canal, compressing nerve roots and resulting in pain and dysfunction.
- Degenerative disc disease coupled with a degeneration of the smaller joints (facet joints) connecting each vertebrae. This condition is known as spondylosis.
- The shifting of one vertebrae on another as a result of degenerative disc disease. A condition known as spondylolisthesis.
- Spinal stenosis can result from inherited conditions such as achondroplasia, in which the patient is born with a narrow spinal canal.
- Recovery from spinal stenosis, when treated non-surgically is limited to control of the pain and the symptoms of nerve compression.
- The goal of surgical treatment is to relieve pain and decompress the spinal cord by enlarging the spinal canal by removal of the narrowed or damaged sections of the spine.
- Operative results are commonly favorable with relatively quick resolution of symptoms.
Degenerative Disc Disease
Degenerative disc disease is a condition of advancing age, and/or the result of the development of post-traumatic arthritis. This process is a deterioration or change in the consistency of the intervertebral disc, caused by a loss of water content in the disc (discs are 80% water) and a decrease in the height of the involved intervertebral disc. As a disc degenerates, it will lose height and supporting ligaments become loose. An increase in the motion of the spine as seen with twisting or sliding of one vertebrae or another creates tears in the vertebral ligaments and in the outer fibrous ring disc (annulus).
- The disc is one of the first structures in the musculoskelatal system to be affected by degenerative changes.
- Degeneration of a disc results in instability and an increase in the amount of motion between contiguous vertebrae. This increase in motion may cause one vertebrae to slip forward on vertebrae below. This slip of the disc is known as degenerative spondylolisthesis.
- The low back (lumbar spine) and the neck (cervical spine) are the regions of the spine most frequently affected by degenerative changes in the disc.
- An orthopedic surgeon diagnoses degenerative disc disease after completion of a detailed history and physical examination. The exam may also include imaging tests to confirm the diagnosis.
- Symptoms usually develop slowly and gradually increase in intensity, although a single traumatic event may trigger the onset of persistent symptoms.
- Pain is centered in the midline of the back, and may be associated with bending, lifting, stooping and twisting.
- Pain is greater when sitting or standing than when lying down. Finding a comfortable position while sitting or standing may be difficult.
- Pain will often radiate to the buttocks, pelvis, back of the hips and thighs, but will not radiate down the leg farther than the knee.
- If compression of a nerve or the spinal cord is involved, symptoms may include a tingling sensation, numbness, and/or weakness in one or both legs.
- Any of the signs and symptoms of degenerative disc disease or nerve compression are present.
- Pain or weakness significantly increase, or if bowel and bladder dysfunction are present at any time.
- Unexplained symptoms appear, or unexpected side effects are experienced from over the counter or prescription medications.
- Degenerative changes associated with the aging process, result in the lose of water content and weakening of the disc. This weakening can cause the outer layer of the disc (the annulus fibrosus) to tear and allow for the extrusion of or herniation of the softer, central portion of the disc. A tear in the outer annulus fibrosus or supporting ligaments can be very painful.
- Occupational activities can place a high level of pressure on the spine over an extended period of time. These activities may involve repetitive lifting of heavy objects and repetitive activities while standing (assembly line work).
- Activities which repetitively place stress on the back includes sports such as soccer, golf, and tennis.
- Traumatic injury to the spine that results in the development of post-traumatic arthritis.
- Pre-existing conditions/ diseases of the spine which pre-dispose the spine to degenerative changes.
- Recovery from degenerative disc disease, is dependent on the understanding of the condition and the realistic expectations of the patient. Through therapy and the use of pain management techniques, the symptoms may be controllable with non-surgical methods.
- The goal of non-surgical treatment is to relieve pain and provide the patient with the ability to participate in normal daily activities, commonly referred to as ADL (Activities of Daily Living).