Spinal disc herniation I. st chapter

Spinal disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including posture.

When a tear in the outer, fibrous ring of an intervertebral disc allows the soft, central portion to bulge out beyond the damaged outer rings, the disc is said to be herniated.

Disc herniation is frequently associated with age-related degeneration of the outer ring, known as the anulus fibrosus, but is normally triggered by trauma or straining by lifting or twisting. Tears are almost always postero-lateral (on the back of the sides) owing to the presence of the posterior longitudinal ligament in the spinal canal. A tear in the disc ring may result in the release of chemicals causing inflammation, which can result in severe pain even in the absence of nerve root compression.

Disc herniation is normally a further development of a previously existing disc protrusion, in which the outermost layers of the anulus fibrosus are still intact, but can bulge when the disc is under pressure. In contrast to a herniation, none of the central portion escapes beyond the outer layers. Most minor herniations heal within several weeks. Anti-inflammatory treatments for pain associated with disc herniation, protrusion, bulge, or disc tear are generally effective. Severe herniations may not heal of their own accord and may require surgery.

The condition may be referred to as a slipped disc, but this term is not accurate as the spinal discs are firmly attached between the vertebrae and cannot “slip” out of place.

Signs and symptoms

Typically, symptoms are experienced on one side of the body only.

Symptoms of a herniated disc can vary depending on the location of the herniation and the types of soft tissue involved. They can range from little or no pain, if the disc is the only tissue injured, to severe and unrelenting neck pain or low back pain that radiates into regions served by nerve roots which have been irritated or impinged by the herniated material. Often, herniated discs are not diagnosed immediately, as patients present with undefined pains in the thighs, knees, or feet.

Symptoms may include sensory changes such as numbness, tingling, paresthesia, and motor changes such as muscular weakness, paralysis, 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 continuous in a specific position of the body.

It is possible to have a herniated disc without pain or noticeable symptoms if the extruded nucleus pulposus material doesn’t press on soft tissues or nerves. A small-sample study examining the cervical spine in symptom-free volunteers found focal disc protrusions in 50% of participants, suggesting that a considerable part of the population might have focal herniated discs in their cervical region that do not cause noticeable symptoms.

A herniated disc in the lumbar spine may cause radiating nerve pain in the lower extremities or groin area and may sometimes be associated with bowel or bladder incontinence.

Typically, symptoms are experienced only on one side of the body, but if a herniation is very large and presses on the nerves on both sides within the spinal column or the cauda equina, both sides of the body may be affected, often with serious consequences. Compression of the cauda equina can cause permanent nerve damage or paralysis which can result in loss of bowel and bladder control and sexual dysfunction. This disorder is called cauda equina syndrome. Other complications include chronic pain.

Cause

When the spine is straight, such as in standing or lying down, internal pressure is equalized on all parts of the discs. While sitting or bending to lift, internal pressure on a disc can move from 17 psi (lying down) to over 300 psi (lifting with a rounded back). Herniation of the contents of the disc into the spinal canal often occurs when the anterior side (stomach side) of the disc is compressed while sitting or bending forward, and the contents (nucleus pulposus) get pressed against the tightly stretched and thinned membrane (anulus fibrosus) on the posterior side (back side) of the disc. The combination of membrane-thinning from stretching and increased internal pressure (200 to 300 psi) results in the rupture of the confining membrane. The jelly-like contents of the disc then move into the spinal canal, pressing against the spinal nerves, which may produce intense and potentially disabling pain and other symptoms.

Some authors favour degeneration of the intervertebral disc as the major cause of spinal disc herniation and cite trauma as a minor cause. Disc degeneration occurs both in degenerative disc disease and aging. With degeneration, the disc components – the nucleus pulposus and anulus fibrosus – become exposed to altered loads. Specifically, the nucleus becomes fibrous and stiff and less able to bear load. Excess load is transferred to the anulus, which may then develop fissures as a result. If the fissures reach the periphery of the anulus, the nuclear material can pass through as a disc herniation.

Several genes have been implicated in intervertebral disc degeneration. Probable candidate genes include type I collagen (sp1 site), type IX collagen, vitamin D receptor, aggrecan, asporin, MMP3, interleukin-1, and interleukin-6 polymorphisms. Mutation in genes – such as MMP2 and THBS2 – that encode for proteins involved in the regulation of the extracellular matrix has been shown to contribute to lumbar disc herniation.

Disc herniations can result from general wear and tear, such as constant sitting or squatting, driving, or a sedentary lifestyle. Herniations can also result from the lifting of heavy loads.

Professional athletes, especially those playing contact sports such as American football, are known to be prone to disc herniations. Within athletic contexts, herniation is often the result of sudden blunt impacts against, or abrupt bending or torsional movements of, the lower back.

Pathophysiology

The majority of spinal disc herniations occur in the lumbar spine (95% at L4–L5 or L5–S1). The second most common site is the cervical region (C5–C6, C6–C7). The thoracic region accounts for only 1–2% of cases. Herniations usually occur postero-laterally, at the points where the anulus fibrosus is relatively thin and is not reinforced by the posterior or anterior longitudinal ligament. In the cervical spine, a symptomatic postero-lateral herniation between two vertebrae will impinge on the nerve which exits the spinal canal between those two vertebrae on that side. So, for example, a right postero-lateral herniation of the disc between vertebrae C5 and C6 will impinge on the right C6 spinal nerve. The rest of the spinal cord, however, is oriented differently, so a symptomatic postero-lateral herniation between two vertebrae will impinge on the nerve exiting at the next intervertebral level down.

Another information you can find in chapter II.