herniated disk
Introduction
Vertebrae are the bone building blocks of the spine. The discs are located between the vertebral bodies. The ligaments are located around the spine and discs. The spine has seven vertebrae in the neck (cervical vertebrae), 12 vertebrae in the middle of the back (thoracic vertebrae) and five vertebrae in the lower back (lumbar vertebrae). In addition, in the middle of the buttock, under the fifth lumbar vertebra, is the sacrum then the coccyx.Description - causes
As the disc degenerates due to age or injury, the nucleus pulposus can break through the surrounding outer ring (annulus fibrosus). This abnormal rupture of the central part of the disc is called disk herniation. The herniated disc is most often located at the disc located between the fourth and fifth lumbar vertebrae in the lower back. This area permanently absorbs the weight of the upper body. This is especially important when we are standing or sitting. The lower back is also critically involved in the movements of our body throughout the day, when we twist the torso in rotation and we articulate the back in flexion and extension.
Risk factors
Age: the most common between 35 and 50 years old. The disease rarely causes symptoms after 80 years
Sex: The risk of herniated disc in men is about twice as high as in women.
Work physically demanding. Jobs requiring heavy loads and other physical work have been associated with an increased risk of developing lumbar disc herniation. Pulling, pushing and twisting are actions that can increase the risk of twisting and repeated damage to the spine.
Symptoms
The symptoms of a herniated disk vary greatly depending on the location of the hernia and your own reaction to the pain. If you have lumbar disk herniation, you may feel pain radiating from the lumbar region, in one or both legs and sometimes in the feet (radiculalgia or sciatica / cruralgia). You may feel an electric shock-like pain when you are standing or sitting. Activities such as leaning, standing up, twisting and sitting can increase the pain. Lying flat on your back with your knees bent can be the most comfortable, as it relieves the pressure on the disc. Sometimes the pain is accompanied by numbness and tingling in the leg or foot. You may experience muscle cramps or spasms in your back or leg. In addition to pain, you may have leg muscle weakness or loss of knee or ankle reflex. In severe cases, you may experience a fall of the foot (your foot sags when you walk) or loss of bowel or bladder control.
Diagnosis
The doctor will suspect a herniated disk when the symptoms described above are present. Neurological examination may reveal abnormal reflexes. Pain can often be caused when the right leg is raised while lying or sitting. It is a sign of positive Lasegue. There may be an abnormal sensation in the foot or leg.
Various blood tests can be done to determine if there are signs of inflammation or infection. Simple X-rays may indicate "wear" (degeneration) of the spine. However, they do not demonstrate the state of the disks. In order to determine whether a disc is herniated or not, an MRI or CT scan is performed for diagnosis.
Simple X-rays may indicate "wear" (degeneration) of the spine. However, they do not demonstrate the state of the disks. In order to determine whether a disk is herniated or not, an MRI or CT scan is performed for diagnosis. Sometimes a CT myelogram is used to further define the structures affected by a herniated disck This allows better viewing of the discs in some difficult cases. An electromyogram (EMG) can be used to determine the severity of the attack of a particular root.
Treatment
Medical
Fortunately, the majority of herniated discs do not require surgery.
The initial treatment of a herniated disk is usually conservative and nonsurgical. (A doctor may prescribe bed rest or advise the patient to maintain a low and painless level of activity for a few days to a few weeks, which helps reduce spinal nerve inflammation and is not recommended for bed rest. )
A herniated disk is frequently treated with a nonsteroidal anti-inflammatory drug if the pain is mild to moderate. An epidural injection of steroids can be performed under radiographic guidance to direct the drug to the exact level of the herniated disc.
The doctor may recommend a physical therapy. The therapist will conduct a thorough assessment that, combined with the physician's diagnosis, will dictate a treatment specifically designed for patients with herniated disks. Treatment may include pelvic traction, gentle massage, ice and heat therapy, ultrasound, electrical muscle stimulation and stretching exercises. Analgesics and muscle relaxants can also be beneficial with physical therapy.
Surgery
A doctor may recommend surgery if conservative treatment options, such as physical therapy and drugs, do not reduce or stop the pain. He will discuss with the patient the types of spinal surgery available and, as the case may be, help determine which procedure might be appropriate treatment. As with any surgical procedure, the patient's age, general health and other problems are taken into account during surgery.
The benefits of surgery should always be carefully weighed against its risks. Although a high percentage of patients with herniated disks report significant pain relief after surgery, there is no guarantee that surgery will help each individual.
Types of surgeries
A large scar may be performed if additional gestures are required to release the nerve root (laminectomy in case of large hernia or associated narrow lumbar canal, arthrectomy in case of associated bone compression, foraminotomy in case of foraminal hernia), or case of spinal arthrodesis gesture (1st or 2nd recurrence of herniated disk). Arthrodesis consists of a fusion of one or more disc stages by fusion and graft material. Minimally invasive surgery is often possible in virtually all cases (see article Minimally Invasive Surgery)
With surgical and nonsurgical treatment, there is a 5% to 10% chance that the disk presents a new hernia. The risk of non-surgical treatment is that the resolution of your symptoms can be long. Patients who try nonsurgical treatment for too long before choosing a surgical procedure may experience less pain and function improvement than those who choose surgery earlier. Your doctor will tell you how long you should try nonsurgical measures before
to consider surgery.
Surgical risks: bleeding, infections and adverse events to anesthesia. The specific complications of disc herniation surgery include: nerve injury, infection, dural tear, hematoma causing nerve compression, recurrence of herniated disk, reintervention.
A very debilitating complication is the FBSS or "failed back surgery syndrome" or chronic pain after spinal surgery.
Generally, you have so to be treated by pain center or to discuss with your medical/surgical team a new surgical procedure.
My message
Apart from the 3 formal indications well identified requiring rapid care (most often surgery):
1 - intolerable pain despite a well-conducted medical treatment,
2 - sensitivo-motor disorders of the lower limbs (decrease in muscle strength and sensitivity disorders),
3- sphincter disorders (urinary loss ...),
please do not have systematic surgery. Get yourself surrounded by your family by explaining that it will be long and difficult for everyone, put in place a coordination of several doctors dedicated to your back problem (your GP, a rheumatologist, an interventional radiologist, a spine surgeon: this kind of structure exists in the major centers of the spine, I will come back to it), and do not operate as a last resort. The time required to pass a herniated disk related radiculalgia with well-conducted medical treatment may be several months.
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