The intervertebral disc consists of a soft gelatinous core (nucleus pulposus) surrounded by a fibrocartilage ring (annulus fibrosus). It is located between the vertebrae and serves there as a damper.
A herniated disc occurs when this gelatinous nucleus shifts and breaks the fibrocartilage ring. The bulging mass can press on the adjacent nerves and the spinal cord, causing discomfort.
Most often it is because the ring of fibrocartilage becomes too weak. In many cases, this is due to the natural aging process.
Often, an overload or incorrect load, such as: lifting heavy objects, is suspected as the reason, but this is usually not the case. More often, lack of sports and overweight are the causes of a herniated disc, because usually then the muscles of the abdomen and back are not well trained and it comes to an incorrect load on the intervertebral discs. Because actually the trunk muscles should support the spine and be strong enough.
Sometimes herniated discs can also occur after accidents in which the trunk was injured.
A herniated disc does not necessarily cause discomfort. It depends on whether nerve fibers, the spinal cord or the horse's tail (cauda equina) are affected.
If the gelatinous nucleus presses on a nerve root, the result is ant tingling, numbness, even paralysis and other sensory disturbances, as well as very severe pain, often affecting only one arm or leg. In the leg, this is called sciatica when the sciatic nerve (thickest nerve in humans) is affected. Nevertheless, pain in the leg with back pain is not proof of a herniated disc, because it often cannot be assigned to a nerve root and is then no longer considered an indication.
It runs from the truncus cerebri (brain stem) to the first or second lumbar vertebra. When the spinal cord is impinged, there is ant tingling, numbness, tingling sensation, and a piercing pain in an arm or leg. There may also be problems with the sphincter muscles of the bowel and bladder, as well as increasing weakness in both arms and legs. When such symptoms occur, one must immediately go to a hospital for an examination and subsequent treatment, because this is an emergency situation.
When the cauda equina (horse's tail), which extends to the os sacrum (sacral bone), is affected, the function of the rectum and bladder often get out of control. There may also be paralysis and sensitivity problems in the genital area, around the anus, and on the inside of the thigh. An immediate visit to the doctor is also absolutely necessary here.
The anamnesis (medical history) and testing of muscle strength, reflexes and sensation in the legs, i.e. a clinical neurological examination, are particularly important for this. Paralysis can be quickly ruled out if the patient can do the toe or heel test. Often by examining the pain and paralysis, the doctor can locate the affected nerve structure and quickly find out if it is a herniated disc and if so, between which vertebrae it is located.
MRI is the preferred imaging technique because it is best able to delineate soft tissue structures. CT (computed tomography) is also possible, but is clearly inferior to MRI. X-ray examinations are often unnecessary, since they can show neither nerves nor intervertebral discs, but only bone tissue.
Studies have found that there are also many asymptomatic herniated discs. This means that 30% of people in their thirties and 60% of people older than 50 have had a herniated disc detected on an MRI or CT scan, but have not had any symptoms to date.
An exception must be made if the back pain, with typical symptoms of a tumor occur, such as night sweats, weight loss and fever. In this case, a myelography or myelo-CT must be performed in order to exclude a possible tumor. The dural space (the space between the spinal cord and the spinal sack) is imaged with the help of a contrast medium.
If one wants to clarify whether a possible sensory disturbance or paralysis is directly related to a herniated disc, one should do an electromyography (EMG), which measures the electrical activity of the muscles, or an electroneurography. Electroneurography can be used to find out if there is pressure on certain nerves, which would decrease electrical conductivity, or if there is a disease of the nerves, such as polyneuropathy.
If a diagnosis cannot be made using imaging techniques, cerebrospinal fluid (nerve fluid) and blood are tested for Lyme disease, herpes zoster, and other pathogens.
Over 90% of herniated discs do not require surgical treatment. Surgery is not required until symptoms persist or paralysis occurs.
This includes rest, warmth and painkillers, and care should be taken to take these medications regularly, especially in the acute phase, in an attempt to relieve the muscle tension caused by the pain.
In addition, physiotherapy can also help the patient, in which movements that do not cause pain are practiced.
The pain may also improve on its own, as the gelatinous core may dry up or become smaller. There is also the possibility that the bile nucleus becomes smaller, but the pain remains and a so-called independent pain disease has developed. Due to incorrect postures to reduce the pain, certain muscles may become weak (muscle hypotrophy) or he may completely refrain from certain painful movements (fear-avoidance persuasion). If there is no severe paralysis, it is advisable to intervene surgically only after 3 months and until then to apply the above-mentioned forms of therapy.
In the future it is important to train and strengthen the muscles of the back and abdomen with the guidance of a physiotherapist.
Caution: The longer massive muscle paralysis persists, the greater the likelihood that it will not go away.
The patient and doctor decide together whether surgery is necessary. The arguments in favour of surgery are:
- If the paralysis is severe or spreading, surgery must be performed immediately.
- Another reason for immediate surgery is if the cauda equina (horse's tail) is depressed.
- If there are symptoms indicating that the spinal cord is crushed, surgery should also be performed soon.
- It is especially dangerous if the pain diminishes but the paralysis increases, for this symptom is indicative of death of the nerve roots. Here, too, immediate surgical intervention is indicated.
Therefore, one should pay attention to whether the symptoms change, for example, whether the paralysis increases and/or there is incontinence. In this situation, one should definitely consult the doctor.
In order to take the pressure off the nerves (decompression), the damaged, disturbing disc tissue is removed. Unfortunately, in some cases the so-called "failed-back-surgery-syndrome" occurs, which means that the pain is not gone despite the operation, sometimes even another herniated disc occurs in the same region.
The usual surgical procedures are microsurgical and minimally invasive, because with these the risk of scarring and pain after surgery is the lowest.
Over 90% of herniated discs do not require surgical treatment. Therefore, conservative treatment is often the best therapy.
After a disc surgery, it is possible for a herniated disc to recur, so it is especially important to strengthen the back and abdominal muscles for a long time.
Every operation on the intervertebral discs involves certain risks. It can happen that:
- The vessels and nerves are damaged
- scars or even inflammations occur after the operation.
- It can also happen that the spine, where it was operated, is no longer as stable as before.
In the long run, 80% of the patients will have a successful operation. The other 20% may actually get worse afterwards and may need surgical intervention again. Therefore, if there is no severe paralysis, surgical intervention is not necessarily recommended. Non-surgical therapies should be used at the outset.
Unfortunately, it is not always easy to determine in which patients surgery is necessary and in which it is not worth taking the risks of such an intervention.
In 5-11% of patients treated with standard surgical procedures, recurrent herniations, i.e. disc herniations in the same region of the spine, occur again. To determine the long-term success rate of newer disc surgery techniques, such as minimally invasive procedures, remains to be seen.
It is especially important that the muscles of the abdomen and back are strong, healthy and well trained. If you also take the other clues seriously and follow them, the likelihood of a herniated disc can be significantly reduced.
- Exercise regularly. For example; jogging, cross country skiing, crawling, backstroke, gymnastics in the water, controlled strength training in the back.
- relaxation exercises such as Tai Chi, Yoga and Pilates are also recommended because they are particularly good for the posture.
- Sitting upright
- Pay attention to your own body weight: more weight also means greater strain on the intervertebral discs.
- Low and very soft chairs should be avoided.
- Change your sitting position frequently
- It would be good to have a high workstation where you can work standing upright.
- Lifting very heavy objects should be avoided. But if it must be, then the spine must remain straight and only the legs should be bent. Never should a heavy load be picked up with the back bent and the legs extended. - When carrying a load, it is important that the spine is not loaded on one side, so hold the object with both hands, close to the body and without a hollow back.
- Also, when sleeping, try to support the shape of the spine with padding.
Danilo Glisic
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