Basics
- Occurs when the intervertebral disk between 2 vertebrae (bones of the spine) bulges outward thus putting pressure on the spinal cord or nerve roots
- The disk will often cause radiating pain, weakness, and sensory changes.
- A large percentage of protruding disk will resolve spontaneously with the use of anti-inflammatory medications
- A large number (though small percentage overall) of patients will require surgery thus making the lumbar discectomy the most common surgical procedure performed in the US
- Disc herniations can occur in the cervical, thoracic, and lumbar spine (Upper, Middle, and Lower back)
Symptoms and Signs
- Symptoms depend on the location and direction of the herniation
- Back pain that is often aggrevated by weight bearing or movement
- Pain that radiates down the leg/arm (aka radicular pain)
- The pain often worsens with coughing or sneezing
- Weakness or decreased sensation
- May have bladder or other neurological problems
What is sciatica?
- Sciatica is a term often used in conjunction with a herniated disc and refers to the pain produced by compression of the sciatic nerve roots or of the nerve itself.
- Sciatica is a way to describe a particular set of symptoms and does not necessarily mean that the patient has a herniated disc (this is where a lot of the confussion surrounding this term is derived)
- A characteristic pain that radiates down the lower back, into the buttock, and down the leg
- Just a few causes of sciatica include:
- Herniated disc
- Spinal stenosis
- Piriformis syndrome
- Tumors
- or even pregnancy
Demographics
Diagnosis
Treatment
- Medical management: Medication and physical therapy will lead to pain resolution in a large percentage of patients
- Surgery- most surgeons will wait 5-8 weeks unless the patient has experienced cauda equina syndrome, worsening motor weakness, or intolerable pain
- Multiple surgical options from a standard removal to a minimally invasive operation
- Complications: Occur in about 10% of operations and consist of bleeding, infection, dural tear, nerve root injury, spinal stenosis, etc
- Disc recurrence after a discectomy occurs in about 5-15% of patients
- SPORT Trial- large study in the New England Journal of Medicine that demonstrated patients who chose to have an operation for lumbar disc herniation reported a greater improvement than patients who elected for nonoperative care (but this does not necessarily mean surgery is better than conservative management)
Prognosis
- 85% of acute disc herniations will improve without surgery in an average of 6 weeks
Differential Diagnosis
- Numerous types of spinal pathology
- Tumor
- Infection
- Inflammation
- Spinal stenosis
- Subarachnoid hemorrhage
- Dural AV Fistula
References
- NEJM SPORT Trial
- Handbook of Neurosurgery: Greenberg