Herniated Disk (Ruptured Disk)

Description

Herniation is the term used to describe a sudden or gradual break in the supportive ligaments surrounding a spinal disk, which functions as a cushion between the bony vertebrae, the bones in the spinal column. The jellylike contents of the disk then protrude and may push on the spinal cord or nerves coming from the spinal cord, which causes symptoms. Herniation may occur in the neck and mid or lower back.

Common signs and symptoms

• Pain in the back that usually affects one side, is worse with movement, and may be worse with sneezing, coughing, or straining

• Muscle spasms of the muscles in the back

• Pain, numbness, or weakness affecting one arm or leg (depending on whether injury is in the neck or low back, respectively)

• If chronic, wasting of the affected muscles

• Loss of bowel or bladder function

Causes

Weakening and rupture of the disk material creates pressure on nearby spinal nerves. A ruptured disk is caused by sudden injury or chronic stress, such as from constant lifting or from obesity.

Factors that increase risk

• Any sport in which movement causes downward or twisting pressure on the neck or spine, most commonly football, weightlifting, horseback riding or equestrian competition, bowling, tennis, jogging, track, racquetball, and gymnastics

• Poor physical conditioning (strength, flexibility)

• Inadequate warm-up before practice or play

• Family history of low back pain or disk disorders

• Previous back surgery, especially fusion

• Preexisting spondylolisthesis

• Poor mechanics with lifting

• Prolonged sitting, especially with poor mechanics

Preventive measures

• Use proper mechanics when sitting or lifting.

• Appropriately warm up and stretch before practice and competition.

• Maintain appropriate conditioning that includes cardiovascular fitness, back and hamstring flexibility, and muscle strength and endurance training.

• Maintain an ideal body weight.

• If previously injured, avoid any vigorous physical activity that requires twisting of the body under uncontrollable conditions.

Expected outcome

Most herniated disks (80%) resolve within 6 weeks with appropriate conservative treatment; however, some patients will require surgery.

Possible complications

• Permanent numbness, weakness, or paralysis and muscle wasting

• Chronic back pain

• Loss of bowel or bladder function

• Decreased sexual function

• Risks of surgery, including infection, bleeding, injury to nerves (persistent or increased numbness, weakness, or paralysis), persistent back pain, and spinal headache

General treatment considerations

Injury to the back results in pain and inflammation. The pain and inflammation result in muscle spasms of the back muscles, which in turn result in more pain. Thus the initial treatment usually consists of rest, medication, and ice to relieve pain, inflammation, and muscle spasm. As pain and spasm subside, exercises to improve strength and flexibility and proper back mechanics are started. Referral to a physical therapist or athletic trainer may be recommended for these exercises, education regarding back mechanics, and possibly other therapies such as transcutaneous electronic nerve stimulation (TENS) or ultrasound. Traction (neck), a cervical collar (neck), or a corset or back brace (low back) may be recommended. Biofeedback and psychotherapy may also be recommended. Prolonged bed rest is felt to do more harm than good, but proper body mechanics should be encouraged. Bending your knees to pick things up off the ground, as opposed to bending at the waist; sleeping flat on your back on a firm mattress with a pillow under your knees; and using good posture when sitting are helpful.

Often a trial of oral steroids or epidural steroid injections, placed into the space around the lining of the spinal cord, may be attempted to reduce the inflammation around the herniated disk and inflamed nerve. For patients with loss of bowel or bladder function or persistent pain, numbness, weakness, or paralysis, surgery is often recommended to remove those portions of the disk that are pushing on the nerves or spinal cord.

Medication

• Nonsteroidal antiinflammatory medications, such as aspirin and ibuprofen (do not take for 7 days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your physician, and contact your doctor immediately if any bleeding, stomach upset, or signs of an allergic reaction occur.

• Topical analgesic ointments may be of benefit.

• Pain relievers and muscle relaxers may be prescribed. Use these only as directed, and do not use any heavy machinery or drive a car while taking these medications.

• Injections of corticosteroids into the epidural space may be given to reduce inflammation, although they are not usually given for acute injuries.

• Oral steroids may be given to reduce inflammation, although they are not usually given for acute injuries.

Heat and cold

• Cold is used to relieve pain and reduce inflammation. It should be applied for 10 to 15 minutes every 2 to 3 hours as needed and immediately after any activity that aggravates your symptoms. Use ice packs or an ice massage.

• Heat may be used before performing stretching and strengthening activities prescribed by your physician, physical therapist, or athletic trainer. Use a heat pack or a warm soak.

When to call your doctor

• Symptoms get worse or do not improve in 2 to 4 weeks despite treatment.

• You develop loss of bowel or bladder function.

• New, unexplained symptoms develop. Drugs used in treatment may produce side effects.

Figure 1

From Economou SG, Economou TS: Instructions for surgery patients, Philadelphia, 1998, W.B. Saunders, p 317.

Range of Motion and Stretching Exercises

Herniated Disk

The exact range of motion and stretching exercises appropriate for you usually need to be determined on an individual basis. Some individuals respond better to flexion (pulling your knees to your chest), whereas others respond better to extension (placing an arch in your back). The key point to remember is that if any exercise (range of motion, stretching, or strengthening) causes pain to radiate away from your back and toward your buttocks or legs, you should stop immediately. The purpose of these exercises is to begin to decrease the intensity and the size of the area of your pain.

These are some of the initial exercises you may start your rehabilitation program with until you see your physician, physical therapist, or athletic trainer again or your symptoms resolve. The specific exercises that are appropriate for you must be specified by your physician, physical therapist, or athletic trainer before you start them. Please remember:

• Flexible tissue is more tolerant of the stresses placed on it during activities.

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