IVDP

A spinal disc herniation (prolapsus disci intervertebralis), informally and misleadingly called a "slipped disc", is a medical condition affecting the spine, in which a tear in the outer, fibrous ring (annulus fibrosus) of an intervertebral disc (discus intervertebralis) allows the soft, central portion (nucleus pulposus) to bulge out. Tears are almost always posterior-ipsilateral in nature owing to the presence of the posterior longitudinal ligament in the spinal canal. This tear in the disc ring may result in the release of inflammatory chemical mediators which may directly cause severe pain, even in the absence of nerve root compression (see "chemical radiculitis" below). This is the rationale for the use of anti-inflammatory treatments for pain associated with disc herniation, protrusion, bulge, or disc tear.

It is normally a further development of a previously existing disc protrusion, a condition in which the outermost layers of the annulus fibrosus are still intact, but can bulge when the disc is under pressure.

Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue that become involved. They can range from little or no pain if the disc is the only tissue injured, to severe and unrelenting neck or low back pain that will radiate into the regions served by affected nerve roots that are irritated or impinged by the herniated material. Often, herniated discs are not diagnosed immediately, as the patients come with undefined pains in the thighs, knees or feet. Other symptoms may include sensory changes such as numbness, tingling, muscular weakness, paralysis, paresthesia, and affection of reflexes. If the herniated disc is in the lumbar region the patient may also experience sciatica due to irritation of one of the nerve roots of the sciatic nerve. Unlike a pulsating pain or pain that comes and goes, which can be caused by muscle spasm, pain from a herniated disc is usually continuous or at least is continuous in a specific position of the body.

It is possible to have a herniated disc without any pain or noticeable symptoms, depending on its location. If the extruded nucleus pulposus material doesn't press on soft tissues or nerves, it may not cause any symptoms. A small-sample study examining the cervical spine in symptom-free volunteers has found focal disc protrusions in 50% of participants, which shows that a considerable part of the population can have focal herniated discs in their cervical region that do not cause noticeable symptoms.

Typically, symptoms are experienced only on one side of the body. If the prolapse is very large and presses on the spinal cord or the

cauda equina in the lumbar region, affection of both sides of the body may occur, often with serious consequences.

There is now recognition of the importance of “chemical radiculitis” in the generation of back pain.A primary focus of surgery is to remove “pressure” or reduce mechanical compression on a neural element: either the spinal cord, or a nerve root. But it is increasingly recognized that back pain, rather than being solely due to compression, may also be due to chemical inflammation. There is evidence that points to a specific inflammatory mediator of this pain.This inflammatory molecule, called tumor necrosis factor-alpha (TNF), is released not only by the herniated disc, but also in cases of disc tear (annular tear), by facet joints, and in spinal stenosis.In addition to causing pain and inflammation, TNF may also contribute to disc degeneration.

Diagnosis

Straight leg raise

The Straight leg raise may be positive; this finding has low specificity, however it has high sensitivity. Thus the finding of a negative SLR sign is an important in helping to "rule out" the possibility of a lower lumbar disc herniation. A variation is to lift the leg while the patient is sitting.[23] However, this reduces the sensitivity of the test.

X-ray: Although traditional plain X-rays are limited in their ability to image soft tissues such as discs, muscles, and nerves, they are still used to confirm or exclude other possibilities such as tumors, infections, fractures, etc.. In spite of these limitations, X-ray can still play a relatively inexpensive role in confirming the suspicion of the presence of a herniated disc. If a suspicion is thus strengthened, other methods may be used to provide final confirmation.

Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads x-rays. It can show the shape and size of the spinal canal, its contents, and the structures around it, including soft tissues.

Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology. It can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors. It shows soft tissues even better than CAT scans.

Myelogram: An x-ray of the spinal canal following injection of a contrast material into the surrounding cerebrospinal fluid spaces. By revealing displacement of the contrast material, it

can show the presence of structures that can cause pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurs. Because it involves the injection of foreign substances, MRI scans are now preferred in most patients. Myelograms still provide excellent outlines of space-occupying lesions, especially when combined with CT scanning (CT myelography).

Electromyogram and Nerve conduction studies (EMG/NCS): These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue. This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether there is another site of nerve compression.

Conservative treatment

Pain medications are often prescribed to alleviate the acute pain and allow the patient to begin exercising and stretching.

There are a variety of non-surgical alternatives used in treatment of the condition, including:

1. Bed rest and lumbo-sacral support belt. 2. Physical therapy 3. Massage therapy 4. Non-steroidal anti-inflammatory drugs (NSAIDs) 5. Oral steroids (e.g. prednisone or methylprednisolone) 6. Epidural (cortisone) injection 7. Intravenous sedation, analgesia-assisted traction therapy

(IVSAAT) 8. Weight control 9. Chiropractic 10. Emerging treatments: The identification of tumor

necrosis factor-alpha (TNF) as a central cause of inflammatory spinal pain now suggests the possibility of an entirely new approach to selected patients with severe pain due to disc herniation, protrusion, bulge, or disc tear. Specific and potent inhibitors of TNF became available in the U.S. in 1998, and were demonstrated to be potentially effective for treating sciatica in experimental models beginning in 2001. Targeted anatomic administration of one of these anti-TNF agents, etanercept, a patented treatment method, has been suggested in published pilot studies to be effective for treating selected patients with severe pain due to disc herniation, protrusion, bulge, or disc tear. The scientific basis for pain relief in these patients is supported by the most current review articles. In the future new imaging methods may allow non-invasive identification of sites of neuronal inflammation,

thereby enabling more accurate localization of the "pain generators" responsible for symptom production.

Surgery

Surgical options include:

IDET (a minimally invasive surgery for disc pain) Laminectomy - to relieve spinal stenosis or nerve compression Hemilaminectomy - to relieve spinal stenosis or nerve

compression Lumbar fusion (lumbar fusion is only indicated for recurrent

lumbar disc herniations, not primary herniations) Anterior cervical discectomy and fusion (for cervical disc

herniation) Disc arthroplasty (experimental for cases of cervical disc

herniation) Dynamic stabilization Artificial disc replacement, a relatively new form of surgery in

the U.S. but has been in use in Europe for decades, primarily used to treat low back pain from a degenerated disc.

Nucleoplasty

 Discectomy

The Anne Arundel Medical Center's Center for Spine Surgery describes a discectomy as spinal surgery during which surgeons remove herniated discs, which relieves pressure on the nerves of the back. A discectomy is a procedure to remove a portion of the disc that rests between each vertebrae. A herniated disc is the most common reason for spine surgery. In this type of spine surgery, the herniated disc is removed and relieve the pressure on the nerves. They use a 2-inch incision to remove the discs, resulting in minimal blood loss. This spinal surgery at one time required a two- or three-day hospital stay. Now, a discectomy is an outpatient procedure.

Microdiscectomy microdiscectomy uses microscopic magnification. This procedure is performed to remove a herniated or ruptured disc. The advantage to microdiscectomy is that the procedure is minimally invasive. The incision and instruments are small, which enables the patient to recover quickly.

The endoscopic microdiscectomy is a procedure that accomplishes the same goal as a traditional open discectomy, removing the herniated disc, but uses a smaller incision. Instead of actually looking at the herniated disc fragment and removing it, surgeon uses a small camera to find the fragment and special instruments to remove it. The procedure may not require general anesthesia, and is done through a smaller incision with less tissue dissection. surgeon uses x-ray and the camera to "see" where the disc herniation is, and special instruments to remove the fragment.

ForamenotomyHighland Medical Centers Highland Pain Institute says that a foramenotomy relieves pressure caused by a pinched nerve. A foramenotomy is also a procedure used to relieve pressure on a nerve, but in this case, the nerve is being pinched by more than just herniated disc. This type of spinal surgery consists of removing bone and other tissue that compresses nerves on the spinal column. A foramenotomy can be part of a major medical procedure or a minimally invasive procedure in which doctors make a tiny incision.

Lumbar LaminectomyThe Center for Spine Surgery states that a lumbar laminectomy relieves pressure on the spinal nerve by removing herniated discs and bone spurs. This type of spinal surgery is an outpatient procedure that requires a 2- or 3-inch incision in the middle of the lower back. A laminectomy is done to relieve pressure on the spinal cord itself. A laminectomy is most commonly used to treat conditions such as spinal stenosis and spondylolisthesis. Depending on the amount of bone removed, this procedure may be done with a spinal fusion to prevent instability.

Laminotomy: Lamina Partially Removed

Laminectomy: Lamina Entirely Removed

Lumbar Spine FusionLumbar fusion is a type of spinal surgery used when a person suffers from a spinal condition that causes instability in the vertebrae. The instability puts pressure on nerves in the spinal column. A spine fusion is surgery that is done to eliminate motion between adjacent vertebrae. The spine fusion may be done because to treat a problem such as spondylolisthesis (unstable spine), or it may be done because of the extent of other surgery (such as a laminectomy). Lumbar fusion is a major surgical procedure in which surgeons use screws and plates to fix bones. Using bone grafts, doctors create a bridge between the bones in the lumbar region of the spine. Bone comes from the person's body or from a bone bank.

Interbody Cage Fusion is a newer spinal implant designed to be filled with bone graft and inserted into the empty space created by a discectomy (disc removal). A cage is similar to a tiny birdcage. Bone graft is packed around the cage following implantation. Like instrumentation and fusion, the bone graft grows into and around the cage and creates a stable construct.

Interbody Cage

Kyphoplasty

The Center for Spine Surgery states that a kyphoplasty is a type of spinal surgery used on patients with osteoporosis and compressed fractures. Surgeons make a small incision and insert and inflate a balloon in the affected area until it expands back to normal. Surgeons use cement to fill the void. This procedure helps stops deformities, decreases height loss and reduces pain in patients with osteoporosis and compressed fractures. Patients are placed under anesthesia and stay in the hospital overnight.

Spinal Disc ReplacementSpinal disc replacement is a new surgery that is still quite uncommon. Spine disc replacement is done to treat specific types of back pain, while avoiding the problems associated with spine fusion surgery.

IDET, or Intradiscal Electrothermal Therapy, is a procedure that is being done to treat discogenic back pain. IDET uses a probe inserted into the disc to heat the tissues within the affected disc. Heating the inside of the disc causes the tissues to shrink. It also cauterizes, or burns, the small nerve fibers in the periphery of the disc. Whether or not it is one of these factors, or something else, that accounts for the results of IDET is not exactly known.

Minimally Invasive Spine Surgery The trend in spine surgery has moved toward minimally invasive procedures. Devices are now available that use microscopic fiber optics that transmit anatomical images to a monitor similar to a television. The equipment is made with built-in magnification that enables the surgeon to view tiny structures through a portal.