Article updated and reviewed by Scott J. Luhmann, MD, Instructor in Surgery, Department of Orthopaedic Surgery, Washington University School of Medicine on June 24, 2005.
An intervertebral disc is a soft cushion which is sandwiched between the vertebral bodies. A ruptured disc, also called a herniated disc, occurs when the peripheral disc capsule tears and disc material protrudes into the spinal canal, pressing on the spinal canal or nerve roots. Central disc material can escape from the disc capsule and cause more pressure on the spinal cord or the nerve roots through inflammation or direct pressure. Over time, the disc usually shrinks and the symptoms may be partially or fully relieved.
Prior to disc rupture, the disc has undergone some degeneration or aging. When a disc ruptures, however, the pad between the two vertebrae is diminished, causing increased stress on the vertebral bodies which leads to the development of spine arthritis (spondylosis). This can cause serious pain if the arthritic spurs of the vertebrae press on nerve roots. The pain will typically worsen as years go by without treatment.
The pain of a ruptured disc is usually sharp and sudden. Initially, the pain will be passed along the course of the nerve impinged by the ruptured disc. A disc pressing on the sciatic nerve root causes sciatica, sending pain from the buttock down the back of the leg and into the foot. Low back pain may or may not be a significant component of the individual’s complaints.
A bulging disc, involving no fragmentation, cannot be seen on a normal x-ray but can be picked up easily on a CT myelogram or mri scan. Many ruptured discs will respond to very limited bed rest. A back brace may help relieve the stress on the disc, and physical therapy can help relieve any muscle spasms associated with a ruptured disc.
The leg and back pain may have associated leg numbness and muscle weakness. If the symptoms do not subside, surgery may be needed to remove some or all of the disc. Surgery is usually recommended early (weeks) after the disc herniation occurs if there is progressive or significant numbness or weakness. The symptom of leg pain can fairly consistently be improved regardless of the length of time between herniation and surgery. What used to be a crude, major operation requiring long-term disability has become a much more sophisticated procedure with little difficulty afterward. Advances in surgical technique and technologies in minimally-invasive surgeries have permitted removal of the disc herniation through smaller incisions with less muscle damage. Faster recovery to activities of daily living and work activities has been reported. However, long-term outcomes of the minimally-invasive techniques have not demonstrated better long-term outcomes.
Most individuals requiring discectomy (removal of disc herniation) do well over the long-term with lesser degrees of back pain. However, recurrent disc herniation do occur and can be managed in a similar manner as primary or first-time herniations. Depending on the individual’s symptoms and underlying problem, two other surgical procedures may be potential options beyond discectomy: lumbar fusions and disc replacement. Lumbar fusions have a long track record of success and are performed thousands of time each year in the U.S. The downsides of this surgery are few, but it does require the fusion of two or more motion segments in the low back, which can limit the individual’s back range of motion and increases the risk of the levels above and below the fusion to degenerative breakdown and further surgery. Disc replacement or disc arthroplasty has recently become available in the U.S. as an option for individuals with discogenic (disc-centered) back pain. The benefits of this procedure are the preservation of back motion, quicker recovery, and lack of dependence on bony fusion for a successful outcome. Since these motion-preserving implants do not limit motion at the painful level, pre-existing arthritis in the posterior spinal facet joints can be exacerbated. Hence not all patients with low back pain are candidates for this new technology, and evaluation by a spine surgeon is necessary to determine which surgery, if any, is optimal for each individual.Questions
Are there other non-surgical kinds of treatment instead of surgery?
Are selective nerve blocks/injections an option?
What will happen if the surgery isn't performed?
What are the risks?
How much improvement (in terms of pain, weakness, numbness, etc.) can be expected from this surgery?
What are the goals of the surgery?
Will a second surgery be necessary?
How long will the hospital stay be?
What medications will be prescribed and for how long?
When will normal activities be resumed (such as work or sports)?
Editorial review provided by VeriMed Healthcare Network.