Herniated disk

Alternative Names

Lumbar radiculopathy; Cervical radiculopathy; Herniated intervertebral disk; Prolapsed intervertebral disk; Slipped disk; Ruptured disk; Herniated nucleus pulposus

Causes, incidence, and risk factors

The bones (vertebrae) of the spinal column protect nerves that come out of the brain and travel down your back to form the spinal cord. Nerve roots are large nerves that branch out from the spinal cord and leave your spinal column between each vertebrae.

The spinal bones are separated by disks. These disks cushion the spinal column and put space between your vertebrae. The disks allow movement between the vertebrae, which lets you bend and reach.

• These disks may move out of place (herniate) or break open (rupture) from injury or strain . When this happens, there may be pressure on the spinal nerves. This can lead to pain, numbness, or weakness.
• The lower back (lumbar area) of the spine is the most common area for a slipped disk. The neck (cervical) disks are affected a small percentage of the time. The upper-to-mid-back (thoracic) disks are rarely involved.

Radiculopathy is any disease that affects the spinal nerve roots. A herniated disk is one cause of radiculopathy.

Slipped disks occur more often in middle-aged and older men, usually after strenuous activity. Other risk factors include conditions present at birth (congenital) that affect the size of the lumbar spinal canal.

Symptoms

Low back or neck pain can feel very different. It may feel like a mild tingling, dull ache, or a burning or pulsating pain. In some cases, the pain is severe enough that you are unable to move. You may also have numbness .

The pain most often occurs on one side of the body.

• With a slipped disk in your lower back, you may have sharp pain in one part of the leg, hip, or buttocks and numbness in other parts. You may also feel pain or numbness on the back of the calf or sole of the foot. The same leg may also feel weak.
• With a slipped disk in your neck, you may have pain when moving your neck, deep pain near or over the shoulder blade, or pain that moves to the upper arm, forearm, or (rarely) fingers. You can also have numbness along your shoulder, elbow, forearm, and fingers.

The pain often starts slowly. It may get worse:

• After standing or sitting
• At night
• When sneezing, coughing, or laughing
• When bending backwards or walking more than a few yards

You may also have weakness in certain muscles. Sometimes, you may not notice it until your doctor examines you. In other cases, you will notice that you have a hard time lifting your leg or arm, standing on your toes on one side, squeezing tightly with one of your hands, or other problems.

The pain, numbness, or weakness will often go away or improve a lot over a period of weeks to months.

Signs and tests

A careful physical exam and history is almost always the first step. Depending on where you have symptoms, your doctor will examine your neck, shoulder, arms, and hands, or your lower back, hips, legs, and feet.

Your doctor will check:

• For numbness or loss of feeling
• Your muscle reflexes, which may be slower or missing
• Your muscle strength, which may be weaker
• Your posture, or the way your spine curves

Your doctor may also ask you to:

• Sit, stand, and walk. While you walk, your doctor may ask you to try walking on your toes and then your heels.
• Bend forward, backward, and sideways
• Move your neck forward, backward, and sideways
• Raise your shoulders, elbow, wrist, and hand and check your strength during these tasks

Leg pain that occurs when you sit down on an exam table and lift your leg straight up usually suggests a slipped disk in your lower back.

In another test, you will bend your head forward and to the sides while the health care provider puts slight downward pressure on the top of your head. Increased pain or numbness during this test is usually a sign of pressure on a nerve in your neck.

DIAGNOSTIC TESTS

• EMG may be done to determine the exact nerve root that is involved.
• Myelogram may be done to determine the size and location of disk herniation.
• Nerve conduction velocity test may also be done.
• Spine MRI or spine CT will show that the herniated disk is pressing on the spinal canal.
• Spine x-ray may be done to rule out other causes of back or neck pain. However, it is not possible to diagnose a herniated disk by a spine x-ray alone.

Treatment

The first treatment for a slipped disk is a short period of rest with medications for the pain, followed by physical therapy. Most people who follow these treatments will recover and return to their normal activities. A small number of people will need to have more treatment, which may include steroid injections or surgery.

MEDICATIONS

People who have a sudden herniated disk caused by injury (such as a car accident or lifting a very heavy object) will get nonsteroidal anti-inflammatory medications (NSAIDs) and narcotic painkillers if they have severe pain in the back and leg.

If you have back spasms, you will usually receive muscle relaxants. Rarely, steroids may be given either by pill or directly into the blood through an IV.

NSAIDs are used for long-term pain control, but narcotics may be given if the pain does not respond to anti-inflammatory drugs.

LIFESTYLE CHANGES

Diet and exercise are crucial to improving back pain in overweight patients.

Physical therapy is important for nearly everyone with disk disease. Therapists will tell you how to properly lift, dress, walk, and perform other activities. They will work on strengthening the muscles that help support the spine. You will also learn how to increase flexibility in your spine and legs.

You may want to reduce your activity for the first couple of days. Then, slowly restart your usual activities. Avoid heavy lifting or twisting your back for the first 6 weeks after the pain starts. After 2 - 3 weeks, gradually start exercising again.

See Taking care of your back at home for more about exercise and how to prevent your back pain from returning.

INJECTIONS

Steroid injections into the back in the area of the herniated disk may help control pain for several months. These injections reduce swelling around the disk and relieve many symptoms. Spinal injections are usually done in your doctor's office, using x-ray or fluoroscopy to find the area where the injection is needed.

SURGERY

Surgery may be an option for the few patients whose symptoms do not go away with other treatments and time.

See Diskectomy for more about how the surgery is done and who is most likely to benefit from it.

Ask your doctor which treatment options are best for you.

Expectations (prognosis)

Most people will improve with treatment. However, you may have back pain even after treatment.

It may take several months to a year or more to go back to all of your activities without having pain or straining your back. People who work in jobs that involve heavy lifting or back strain may need to change their job activities to avoid injuring their back again.

Complications

• Long-term back pain or leg pain
• Loss of movement or feeling in the legs or feet
• Loss of bowel and bladder function
• Permanent spinal cord injury (very rare)

Calling your health care provider

Call your health care provider if:

• You have severe back pain that does not go away
• You have any numbness, loss of movement, weakness, or bowel or bladder changes

Prevention

Being safe at work and play, using proper lifting techniques, and controlling weight may help prevent back injury in some people.

Some health care providers recommend the use of back braces to help support the spine. Such braces can help prevent injuries in people who have to lift heavy objects at work. However, using these devices too much can weaken the abdominal and back muscles, making the problem worse.

References

Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:505-514.

Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147:492-504.

Jegede KA, Ndu A, Grauer JN. Contemporary management of symptomatic lumbar disc herniations. Orthop Clin North Am. 2010;41:217-224.

Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine. 2009;34(10):1078-93. Review.