Disc Herniation
What's a herniated disc, pinched nerve, bulging disc?
There are many different terms to describe spinal disc pathology, and all are used differently by different healthcare practitioners. Some examples of terms used to describe spinal disc abnormalities include:
- Pinched nerve
- Sciatica
- Herniated disc (or herniated disk)
- Bulging disc, ruptured disc, or slipped disc
- Disc protrusion
- Disc degeneration (or degenerative disc disease)
- Disc disease
There is no agreement in the medical field as to the precise definition of any of these terms. Often the patient hears his or her diagnosis referred to in different terms by different practitioners and is left wondering if there is any consensus on what is wrong.
Rather than focus on the terminology referring to spinal anatomy, it's most helpful for patients to focus on understanding the clinical diagnosis. It should be kept in mind that all the terms-- herniated disc, pinched nerve, bulging disc, slipped disc, ruptured disc, etc. --refer to radiographic findings seen on a CT scan or MRI scan (x-rays can indicate disc degeneration but cannot actually image the disc itself). While radiographic findings are important, they are not as meaningful in determining the source of the pain (the clinical diagnosis) as the patient's specific symptoms and the spine specialist's findings on physical exam.
Clinical diagnosis of Disc Herniation
The key factor in the clinical diagnosis is to determine if the patient has pinched nerve or if the disc space itself is generating the pain.
- Pinched nerve. A pinched nerve will generate radicular pain (nerve root pain or sciatica).
- Disc pain. If the disc itself is painful, then this will generate either referred pain or axial pain.
It's important to accurately diagnosis the pain generator, because the type of pain created by the spinal disc dictates the type of treatment, and the treatments for the different diagnoses vary considerably.
Treatment options for a lumbar herniated disk
The care of a patient with a lumbar herniated disk is far from standardized and, to a certain extent, needs to be individualized for each patient. A lumbar disk herniation usually causes leg pain (sciatica or a radiculopathy) and is often referred to as a pinched nerve, bulging disk, ruptured disk, or a slipped disk.
The treatment will largely depend on the length of time the patient has had his or her symptoms and the severity of the pain. Generally, patients will be advised to start with 6 to 12 weeks of conservative treatment (such as physical therapy).
If conservative treatment does not provide pain relief after 6 to 12 weeks it is reasonable to consider surgery. At times, if there is severe pain and the patient is having difficulty maintaining a reasonable level of functioning, surgery may be recommended prior to completing a full 6 weeks of conservative care.
Most patients will heal a lumbar disk herniation on their own, but it may take a prolonged period of time. While there are no hard and fast guidelines, this article outlines some general guidelines for conservative treatment options and surgical treatments.
Conservative treatments for disc herniation
There's a wide variety of conservative treatment options for patients to try. The primary goals of treatment are to provide relief of pain and to allow return to a normal functional level.
The most common conservative treatment options include:
- Rest, followed by slow mobilization
- Pain medications
- Chiropractic/osteopathic manipulations
- Physical therapy
- Epidural steroid injections
The recommended amount of conservative treatment for patients needs to be individualized. For those patients who are not in severe pain and can function well, a longer period of conservative treatment is reasonable (e.g. 12 weeks). For those patients with severe pain that is not responsive to conservative treatment, surgery to decompress the nerve is a reasonable option.
Surgery for disc herniation
Any patient who has progressive neurological deficits, or develops the sudden onset of bowel or bladder incontinence, should have an immediate surgical evaluation as these conditions may represent a surgical emergency. Fortunately, both of these conditions are very rare, and most surgery for a lumbar herniated disk is an elective procedure.
Conservative treatments for disc herniation
Within the first six weeks it is probably reasonable to try different medications, modalities and therapies to try to alleviate the pain and give the disk herniation time to heal. With time the body can resorb the disk herniation, and if the symptoms start to abate within the six-week period, continued conservative treatment is warranted.
At the very least, at the onset of pain it is usually considered reasonable to start with a couple of days of bedrest followed by slow mobilization.
If the pain is more than uncomfortable and/or if symptoms have persisted for 5 to 7 days, an immediate trial of chiropractic treatments, and progressive body movement is warranted. The goals of chiropractic treatment and physical therapy are to reduce pain and to allow the patient to return to a normal level of functioning.
See low load exercise, progressive body movement, and muscle length evaluation
Medications may also help reduce the pain, and non-steroidal anti-inflammatory drugs (NSAID's) can reduce the inflammation caused by the disk herniation.
Either oral steroid medication or an epidural injection may achieve a stronger anti-inflammatory effect, although their use is a little riskier, and neither has been clearly shown to change the natural history of whether or not a patient will need surgery. Approximately 50% of the time, an epidural steroid injection will provide pain relief that may last from one week up to one year. Up to three epidural injections may be done in a one-year time frame (at least two weeks apart).
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