HERNIATED DISC

CONDITION

Discs are hockey-puck-shaped structures that sit between the spine bones (vertebrae). Discs act as shock absorbers, or cushions, for the spine and they allow it to bend forward and backward. They have a soft, gelatinous center (the nucleus) surrounded by a firm outer covering of tough, fibrous material (the annulus). A disc herniates when the nucleus pushes out through the annulus (Figure 1 below).

Figure 1

Many people use the terms “herniated disc” and “bulging disc” interchangeably but with a bulging disc, the nucleus pushes out and stretches the fibers of the annulus without breaking through them.
Both injuries can cause similar symptoms, although true herniations usually cause more severe symptoms.

The spinal column is basically a stack of bones and discs held together by ligaments. The bones at the front of the column are shaped like the discs. At the back of the column, the bones extend beyond the discs to form a hollow canal through which the spinal cord and its nerves pass. The spinal cord and spinal nerves carry electrical signals to and from your brain and the rest of your body.

Most of the symptoms that occur with herniated discs are caused by pressure on the spinal cord or spinal nerves.
Discs usually herniate backward toward the spinal canal or in the spaces between the bones where the nerves leave the canal.
The spinal column is divided into three areas: cervical (neck area), thoracic (mid- and upper back behind the chest and ribs) and lumbar (lower back).
Disc herniations can happen anywhere in the spinal column, but are most common in the lower back, followed by herniations in the neck.
Herniations are most common in people 30 to 50 years old, but they can happen to almost anyone.
People often refer to herniated discs as “slipped” or “ruptured” discs.
Over time, herniated or bulging disc material will usually shrink or be resorbed by the body.
Most herniated discs will eventually stop hurting without surgery, but some herniations, especially if they are large, may require surgery.

Causes

Age: Those in middle age (30 to 50 years old) are at highest risk for disc injury.
- Discs become weaker with age. Beyond age 50, however, they lose their water content and become dehydrated and more firm so they don’t herniate as easily.
- Discs in children and adolescents have a high water content and are very flexible so they herniate less frequently.
Position: Bending forward or sideways or rotating or a combination of these movements increases the risk of disc injury, especially with lifting.
Injury: Falls from heights, motor vehicle accidents, athletic injuries or other traumatic injuries can result in herniated discs.
- Sports associated with disc injuries include football, hockey, gymnastics and diving.
- Athletes experience fewer disc injuries than people in the general population, probably because they are in good physical condition.
Other risk factors include:
- smoking
- overweight
- a family history of disc herniation
- repetitive, strenuous activities
- improper lifting
- prior disc injury
- out-of-condition and inflexible back, leg and buttock muscles.

Symptoms and Signs

You will have symptoms specific to the area of the spine (cervical, thoracic or lumbar) affected. Symptoms that are common to most herniations include:

pain over the spine at and around the level of the herniation
muscle spasm around the herniation
discomfort when you:
- bend, sit or stand for a long time
- strain, such as when you cough laugh, sneeze, lift something or have bowel movement
- lie flat on your back
- make transitional movements such as getting up from sitting to standing
- ride in a car over bumps.
decreased motion and stiffness, especially after resting.

You may notice that changing positions frequently, leaning to one side and lying on your side curled up in a fetal position sometimes helps reduce pain.

Lumbar disc herniations are most common, especially at the two lowest lumbar levels, just above the buttocks or sacrum, the bone at the base of the spine.

Symptoms specific to lumbar injuries include pain, muscle weakness, burning, numbness, tingling and/or loss of sensation anywhere between your buttocks and your feet.
These symptoms most frequently start in one buttock and travel through the outside of the hip to the outside or the back of the thigh, to the outside and the front of the lower leg, and almost anywhere on the foot. People often refer to this condition as sciatica.
Having symptoms in both legs may indicate a large and very serious disc herniation.
- A large disc herniation that causes symptoms in both legs, especially numbness and/or pain and weakness that causes you to trip over your toes, is a medical emergency.
- With such an injury, you sometimes lose bowel and bladder control and experience numbness or loss of sensation in the skin over your bottom or around your anus.

Cervical disc herniations occur less often than lumbar herniations.

Symptoms specific to cervical injuries include pain, muscle weakness, burning, numbness, tingling and/or loss of sensation anywhere between your neck and your fingers.
These symptoms most often start in one side of your neck and travel through the outside of the shoulder, down the outside or back of the upper arm, into the outside of the forearm and into the hand and fingers, especially the thumb and middle fingers.
A large disc herniation that causes symptoms in both arms, especially numbness, pain and weakness, can be a medical emergency.
- If you have muscle twitching and tightness in your arms, weakness in both hands, and/or symptoms at lower spinal levels (described above), you may have a large disc herniation that is pressing on your spinal cord and filling up most of your spinal canal.

Thoracic disc herniations are uncommon. Symptoms specific to thoracic herniations include:

pain in the middle or upper back that sometimes goes across the ribs at the same level on one side of your body
band-like pain, numbness or tingling that wraps around one side of your body into your chest or belly.

WHEN TO CALL YOUR DOCTOR

Call 911 if:

You have sudden onset of any of these symptoms, especially after a fall, motor vehicle accident or other traumatic injury: pain, numbness, tingling, loss of sensation and/or weakness in both arms or legs.
You have any numbness, tingling or loss of sensation around or between your buttocks or anus.
You have any loss of bowel or bladder control.
You have any problems breathing after a neck injury. Some injuries high in your neck can damage the nerves responsible for your breathing.

Call your doctor right away (day or night) if:

You have sudden onset or worsening of any of these symptoms: pain, numbness, tingling, loss of sensation and/or weakness in one arm or leg.
You have sudden onset of severe back pain, especially after a fall, motor vehicle accident or other injury.
You have fever, chills, neck stiffness and/or redness or warmth over your spine, which can indicate an infection.
You have pain that awakens you at night. This can be a symptom of infection or a growth such as tumor.
You had recent back surgery and your pain, numbness, tingling or weakness suddenly gets worse.
You are more than 50 years old or you have been taking steroid medication and you suddenly notice back pain, especially after coughing, sneezing or bending over. This can be caused by a compression (or “collapse”) fracture of your vertebrae.
You notice that it burns when you urinate, you urinate more frequently, have blood in your urine, have nausea or vomiting and have back pain located above the area of your lower back that is over your lower ribs. These can be symptoms of a kidney infection.

Call your doctor during regular office hours if:

Your back pain has lasted more than a week or two, started slowly without an injury and you do not have pain, numbness, tingling, loss of sensation or weakness in your legs or feet.
You have had chronic problems with (and may have been seen by a doctor for) weakness, numbness, tingling, or difficulty feeling one leg or foot that persist but are not getting worse.
You have mild, tolerable pain that lasts more than a week or two but does not limit your daily activities. The pain may have started slowly or begun right away after an injury, it stays in your back only and does not go into your legs or feet.

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SELF-CARE AT HOME

The following instructions apply to mild back pain of less than two weeks’ duration that started slowly and is not associated with pain, numbness, tingling, loss of sensation or weakness in your legs or feet, or any of the other serious symptoms listed above:

Avoid positions and activities that increase your pain, such as bending forward and twisting or leaning sideways.
Avoid lifting anything over five pounds until your back is better or you have been seen by a doctor.
Do not stay in bed. Bed rest is an outdated recommendation that can make your pain worse. Stay gently active, if you can, by doing simple things like walking or moving around your house and engaging in activities of daily living. It is okay to decrease some activities for a few days.
Avoid athletic activities that require bending, twisting or straining such as weightlifting, football, basketball, dancing, golf, jogging, gymnastics and skiing.
The lower back is an area where you may use cold, heat or both to help relieve pain. There are many recommendations, but you may start by using a cold pack for 10 to 15 minutes. If this does not help much, then try using a heat pack for 10 to 15 minutes over the most painful area in your back. You may repeat this as often as you need to. If your pain gets better, gradually back off using cold and heat.
You may take ibuprofen (Motrin®, Advil®), naproxen (Aleve®) or acetaminophen (Tylenol®) as directed for pain. (See labels for dosing and risks.)
Be creative to find a comfortable sleeping position. You may need to put a pillow under your knees while lying flat on your back. You can use a small pillow under the curve of your lower back, or if lying down is uncomfortable, you may try sleeping in a recliner for a few days. Also, lying curled on your side with your hips and knees bent and a pillow between your knees sometimes helps.
Stretching and strengthening exercises can often help back pain, but starting too soon after injury or pain that begins abruptly can set you back or make your injury worse. Time is what resolves most acute back pain, but as mentioned above, if your pain is not getting better over one to two weeks, your doctor will help guide you to exercises that can help your back.

PREVENTION

Avoid risky behaviors in certain sports such as:
- spear-tackling (tackling head first) in football
- jumping (especially flipping) on trampolines
- diving in water more shallow than at least twice your height
- boarding and cross-checking in hockey.
Stay active and do aerobic or cardiovascular exercise regularly. Walking is especially good.
Keep your hamstrings (the muscles on the back of your upper legs) flexible. Do lying hamstring stretches (Figure 2 below) daily. Repeat them two or three times and hold each stretch for 20 to 30 seconds without bouncing. Gradually pull each leg straight until you feel a stretch in your muscles. Without causing too much discomfort, try to pull your leg slightly straighter each time you exhale.

Figure 2

Lift things using proper technique. Get close to the object you want to lift and directly face it. Bend at the knees and hips while keeping your back relatively straight. Grasp and hold the object close to your body, then pick it up using your legs and hips. Avoid any twisting. Ask for help lifting very heavy things so as not to exceed your limits.
When you are moving heavy objects by sliding or rolling them, push rather than pull, and use a partner to stabilize the object.
Practice good posture when you are sitting for a long time, especially at a desk or in a car. Sit as straight as possible and maintain the curve in your lower back. Using a lumbar support or a back pillow in your seat can sometimes help. Avoid slumping forward. Take frequent breaks to walk around.
Wear good-quality athletic shoes and avoid high heels when you have back pain.
Avoid smoking, eat a healthful diet and keep your weight at a level appropriate for your height.

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FOR MORE INFORMATION

REFERENCES

Carragee EJ: Diagnostic evaluation of low back pain. Orthopaedic Clinics of North America 35(1) 7-16, 2004.
McKamey K: Low back pain. Primary Care 34(1) 71-82, 2007.
Melegar A: Neck and back pain: musculoskeletal disorder. Neurology Clinics. 25(2):419-38, 2007.
Press J, Young J: Low back pain. In Mellion M, Putukian M, Madden C: Sports Medicine Secrets, p 344-347, Hanley & Belfus, Philadelphia, 2003.

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Authored by Christopher Madden, M.D.

Favorably reviewed by The American Medical Society for Sports Medicine

http://amssm.org

Disclaimer: This content is reviewed periodically and is subject to change as new healthcare information becomes available. The information is intended to inform and educate and is not a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional.