Herniated discs (slipped discs or bulging discs) occur when the soft cushion between vertebrae moves out of position. Read more at Meri Sehat.

Herniated Disc

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Syed Intisar Hussain

Overview

A herniated disc is a spinal (backbone) injury. It&#39;s an issue with one of the rubbery cushions (discs) that sit between the vertebrae of your spine. 
&nbsp;

Each disc is divided into two parts:

<ul>
	<li>The soft and gelatinous inner portion.</li>
	<li>A hard outer ring.</li>
</ul>

The inner portion of the disc may protrude through the outer ring due to injury or weakness. This type of injury is known as a herniated disc. 
&nbsp;

It is also referred to as

<ul>
	<li>Slipped disc</li>
	<li>Ruptured disc</li>
	<li>Bulging disc</li>
</ul>

The management of disc herniation necessitates the collaboration of a multidisciplinary team. Initially, the treatment should be conservative (no use of surgery), unless a patient has extreme neurological compromise. 
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Discs that herniate are typically in the early stages of degeneration. A herniated disc can cause back pain, discomfort or sensation in other body parts, and physical disability. Core strength and an awareness of body mechanics, including posture, provide the best protection against disc herniation.

A herniated disc occurs in about 5 to 20 adults per 1000 each year1. It is most common in people between 30 and 50 years of age, with a male-to-female ratio of 2:11. Symptomatic herniated disc of the lumbar spine is estimated to affect 1-3 percent of patients1. 
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There are three kinds of herniated discs based on the severity of back pain they cause. They are as follows: 
&nbsp;

<ul>
	<li>
	<h5>Contained Herniation (Protrusion)</h5>
	</li>
</ul>

Contained herniations, also known as &lsquo;bulging discs&rsquo; exert pressure between the vertebrae, causing the discs to stick outward. While there is backache and discomfort linked with these kinds of herniations, they can frequently go undetected. Back pain induced by contained herniations is typically minimal and is caused by the vertebrae compressing the discs, putting pressure on the nearby nerves. 
&nbsp;

<ul>
	<li>
	<h5>Non-Contained Herniation (Disc Extrusion)</h5>
	</li>
</ul>

A non-contained herniation is frequently known as disc extrusion. These herniations typically cause severe back pain. They can also induce insensibility or tingling in the extremities due to the increased pressure on the nearby nerves. While this ache and discomfort can occasionally be extreme, if you have been suffering from chronic back pain, you may try to overlook it. 
&nbsp;

If you have any of these signs and symptoms, consult your medical professional or request a referral to an orthopaedic specialist to determine the additional steps you need&nbsp; to keep your back and spine healthy. 
&nbsp;

<ul>
	<li>
	<h5>Sequestered Herniation</h5>
	</li>
</ul>

Generally, non-contained herniations can induce sequestered herniations if they go undetected or untreated. This happens when the vertebrae squeeze the discs so firmly that they break. This can result in severe pain for the patient and a loss of mobility. If you have any of these signs and symptoms, make an appointment with your doctor immediately. 
&nbsp;

Regarding backache, you want to ensure you find the source as soon as possible. If you&#39;re experiencing problems with herniations, talk to your medical professional about your options. 
&nbsp;

<h5>Stages</h5>

Herniated discs are classified into four stages:

<ul>
	<li>Disc degeneration</li>
	<li>Prolapse</li>
	<li>Extrusion</li>
	<li>Sequestration</li>
</ul>

1. Disc Degeneration

Discs weaken due to chemical modifications linked with ageing, but no herniation exists.

The first stage is not a very extreme condition. Patients will not&nbsp; usually experience much pain. They will only feel pain when walking or sitting for long periods. 
&nbsp;

2. Prolapse

With a little impingement into the spinal canal, the shape or position of the disc alters. It is also known as a bulge or protrusion.

In the second stage, you will experience pain when you get up from a lying position while sitting, riding a bike, or driving a car. You will face difficulty walking, significantly disrupting your everyday routine. 
&nbsp;

3. Extrusion

The nucleus pulposus, which is gel-like, pushes through the tire-like wall (annulus fibrosus) but persists within the disc.

It is a serious stage of slipped disc. The disc has herniated and is severely compressing the nerve. The nerve compression causes immense pain in the lower back and leg. 
&nbsp;

4. Sequestration 

The nucleus pulposus protrudes through the annulus fibrosus and is found in the spinal canal outside the disc (HNP).

It is a critical stage in which, in addition to being bedridden, there is a risk of developing paralysis. So, at this point, your surgeon, neurosurgeon, and the orthopaedic surgeon will advise you on surgery. So make your choice accordingly. 
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Signs and Symptoms

Lower back herniated discs are the most common. However, they can occur in the neck too. The signs and symptoms vary depending on the location of the disc and whether it is pressing on a nerve. Herniated discs most frequently affect one side of the body.

A herniated disc does not always cause symptoms, so some individuals may remain asymptomatic. Symptoms tend to alleviate over time in symptomatic individuals, which include: 
&nbsp;

<ul>
	<li>Arm or Leg Pain</li>
</ul>

If your herniated disc is in the lower back, you will typically experience pain in your buttocks, thigh, and calf, in addition to lower back pain. You may also experience pain in a portion of your foot. 
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The pain from a herniated disc in your neck is typically felt in your shoulder and arm. This pain may shoot into your arm or leg when you cough, sneeze or move into certain positions. 
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<ul>
	<li>Numbness or Tingling</li>
</ul>

People with herniated discs frequently experience radiating insensibility or tingling in the body part provided by the affected nerves. 
&nbsp;

<ul>
	<li>Weakness</li>
</ul>

Muscles served by affected nerves tend to deteriorate. Weakness can cause you to stumble, or make it difficult for you to lift or hold objects. 
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Additional Symptoms 
 
A herniated disc can also cause the following symptoms: 
&nbsp;

<ul>
	<li>A dull ache on one side of the body.</li>
	<li>Discomfort or pain on coughing, sneezing, or moving into certain positions.</li>
	<li>Numbness, tingling, or burning sensations, usually caused by a compressed nerve.</li>
	<li>Discomfort worsening on sitting, standing, walking, and bending.</li>
	<li>Muscle weakness or spasms that impair your ability to lift or hold objects.</li>
	<li>Balance problems or limping as a result of weakness and pain</li>
	<li>Slow reaction times</li>
	<li>Difficulties rising from a seated position.</li>
	<li>Inability to remain in one location for a long duration.</li>
	<li>Bad posture.</li>
	<li>Bowel or bladder control problems (which can indicate cauda equina syndrome, a medical emergency). 
	&nbsp;</li>
</ul>

Different people experience different types of pain. Consult your doctor if your pain causes numbness or tingling that interferes with your ability to control your muscles. 
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Causes

Similar to a jelly doughnut, discs have a soft, gel-like centre and a firmer outer layer. The outer layer can deteriorate and crack over time. A herniated disc occurs when the inner &lsquo;jelly&rsquo; substance pushes through the crack. The leaking material may put pressure on nearby spinal nerves.

A variety of factors can cause a disc rupture, including

<ul>
	<li>
	<h5>Age</h5>
	</li>
</ul>

Age is a significant factor in disc herniation. Degenerative disc disease occurs when your spinal discs gradually lose fluid volume over time. As the discs wear down over time, microscopic cracks or tears can form on the outer surface, allowing the gel-like interior to escape.

<ul>
	<li>
	<h5>Trauma</h5>
	</li>
</ul>

The second most typical cause of a herniated disc is trauma. When you twist or lift something heavy, you can put a strain on your spinal disc. A disc can also rupture due to high-impact trauma, such as a car accident or a fall. 
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Diagnosis

You can consult an orthopedist or your primary care physician to determine if you have a herniated disc. A herniated disc is presumed if radiating leg pain accompanies low back pain. 
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Your doctor will likely ask you to perform the &lsquo;straight leg raise test&rsquo;. This involves lifting one leg straight up while lying down. If you have a herniated disc compressing a nerve, moving your leg will worsen the compression and induce pain throughout that leg. In addition, your doctor will inquire about numbness, weakness, and slow reflexes. 
&nbsp;

Imaging studies are typically ordered. You may require the following:

<ul>
	<li>
	<h5>X-ray</h5>
	</li>
</ul>

The use of radiation to produce a film or image of the spine can reveal the structure of the vertebrae as well as the outline of the joints. X-rays of the spine are taken to rule out other possible causes of pain, such as tumours, infections, and fractures. 
&nbsp;

<ul>
	<li>
	<h5>Computed Tomography Scan (CT or CAT scan)</h5>
	</li>
</ul>

A CT scan can depict the shape and size of the spinal canal, its contents, and the structures surrounding it. 
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<ul>
	<li>
	<h5>Magnetic Resonance Imaging (MRI)</h5>
	</li>
</ul>

MRI is a diagnostic test that uses powerful magnets and computer technology to generate 3D images of body structures. It can display the spinal cord, nerve roots, and nearby areas. Moreover, it can show enlargement, degeneration, and tumours too. 
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<ul>
	<li>
	<h5>Myelogram</h5>
	</li>
</ul>

It is an X-ray of the spinal canal after a contrast material has been injected into the surrounding cerebrospinal fluid spaces. It can reveal pressure on the spinal cord or nerves caused by herniated discs, bone spurs, or tumours. 
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<ul>
	<li>
	<h5>Electromyogram and Nerve Conduction Studies (EMG/NCS)2(2)</h5>
	</li>
</ul>

These studies employ electrical impulses to assess the extent your nerves may be impacted by herniated disc compression. NCS and EMG are not routine tests for herniated disc diagnosis and are only used if you have signs of nerve trouble, such as numbness and radiating pain. These tests are typically used only if MRIs and physical exams are indecisive and your medical professional suspects other conditions. 
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Treatment

Most of the time, your herniated disc problems should resolve within a few weeks. Meanwhile, try one or more treatments to alleviate your symptoms. 
&nbsp;

<ul>
	<li>
	<h5>&nbsp;Rest</h5>
	</li>
</ul>

Take it easy for a couple of days. Rest can help reduce swelling and allow your back to heal. Avoid exercise and other activities that require you to bend or lift while your back is hurting.

Your doctor may advise you to stay in bed. Bed rest is fine for a short time, but don&#39;t be off your feet for more than a day or two. It would be best to keep moving so your joints and muscles would not stiffen. 
&nbsp;

<ul>
	<li>
	<h5>&nbsp;Medications</h5>
	</li>
</ul>

You can take the following medications to relieve your symptoms of a herniated disc: 
&nbsp;

Nonprescription Pain Medications

If your pain is minimal to moderate, your medical professional may advise you to take over-the-counter pain relievers such as

<ul>
	<li>Acetaminophen (Tylenol)</li>
	<li>Ibuprofen (Advil, Motrin IB)</li>
	<li>Naproxen sodium (Aleve) 
	&nbsp;</li>
</ul>

Neuropathic Drugs

These medications act on nerve impulses to reduce pain. Some examples are:

<ul>
	<li>Gabapentin (Gralise, Horizant, Neurontin)</li>
	<li>Pregabalin (Lyrica)</li>
	<li>Duloxetine (Cymbalta, Drizalma Sprinkle)</li>
	<li>Venlafaxine (Effexor XR) 
	&nbsp;</li>
</ul>

Muscle Relaxers

You might be suggested to take these medications by your doctor if you experience muscle spasms. The most typical side effects are sedation and dizziness. 
&nbsp;

Opioids

Many medical professionals are hesitant to prescribe them for disc herniation because of the adverse effects of opioids and the potential for addiction. If other medications fail to relieve your pain, your doctor may recommend that you take codeine or an oxycodone-acetaminophen (Percocet, Oxycet) combination for a short period. These drugs may cause sedation, nausea, confusion, and <a href="https://merisehat.pk/disease/constipation">constipation</a>. 
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Physical Therapy

Some exercises can help with herniated disc symptoms. A physical therapist can show you which activities will help you strengthen the muscles that support your back. 
&nbsp;

Stretching exercises to maintain muscle flexibility:

<ul>
	<li>Aerobic exercises &ndash; for example, walking or riding a motionless cycle</li>
	<li>Massage</li>
	<li>Heat and ice</li>
	<li>Therapy with ultrasound</li>
	<li>Muscle stimulation with electricity 
	&nbsp;</li>
</ul>

Injections

If rest, pain relievers, and physical therapy are ineffective, your doctor may inject steroid medicine into the space around your spinal nerve. This is known as an epidural injection. The steroid can help reduce swelling, allow you to move more freely, and relieve pain caused by a herniated disc.

Your doctor will use an X-ray or CT scan to determine the best location to inject the medication. You may require more than one steroid injection to relieve your pain. 
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<ul>
	<li>
	<h5>Surgery</h5>
	</li>
</ul>

For 9 out of 10 people, herniated discs heal independently or with nonsurgical treatment3. Your doctor may suggest surgery if other treatments fail to relieve your symptoms. Surgery is rarely required for herniated discs. If conservative treatments fail to alleviate your signs and symptoms after six weeks, your medical professional may recommend surgery, especially if you continue to experience: 
&nbsp;

<ul>
	<li>Poorly managed pain and discomfort.</li>
	<li>Weakness or insensibility.</li>
	<li>Problem standing or walking.</li>
	<li>Inability to control one&#39;s bladder or bowels. 
	&nbsp;</li>
</ul>

There are several surgical techniques available to relieve pressure on the spinal cord and nerves, such as

1. Lumbar Laminotomy

Your surgeon may also need to remove a small piece of bone from the vertebra known as the lamina. The lamina protects your spinal cord. Removing a portion, or all of it, allows the surgeon to access your herniated disc better. It can also relieve nerve pressure and alleviate symptoms of leg pain and sciatica. In some cases, the lamina may be removed; this procedure is called a laminectomy. 
&nbsp;

2. Discectomy

This involves the removal of the damaged disc to alleviate pressure on your nerves. It can be carried out in two ways: 
&nbsp;

<ul>
	<li>Open Discectomy</li>
</ul>

Your surgeon will perform an open discectomy through a cut in your back or neck. 
&nbsp;

<ul>
	<li>Microdiscectomy</li>
</ul>

Microdiscectomy is a surgical procedure used to treat extrusions and sequestrations. A much smaller incision is used for microdiscectomy. To see and remove the damaged disc, your surgeon inserts a thin tube with a camera at one end.

3.Spinal Fusion

To stabilise your spine following a discectomy or laminotomy, your surgeon may fuse the two vertebrae on either side of the disc, known as spinal fusion. Bone grafts from another part of the body or a donor may be required for the procedure. Fusing the two discs will prevent the bones from moving and relieve your pain.

4. Artificial Disc Surgery

It is only appropriate for a small number of people because artificial disc surgery only works on certain discs in your lower back. However, if your doctor believes it is necessary, they will replace your damaged disc with one made of plastic or metal. The new disc will help to stabilise your spine and allow you to move more freely. 
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Untreated herniated discs can deteriorate. This is especially true if you continue the actions that produced it, such as if it developed as a result of your way of working. Chronic (ongoing) discomfort and loss of control or feeling in the affected area may result from a deteriorating ruptured disc. Consult your doctor if your symptoms persist after four to six weeks of treatment. 
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The following factors can also cause a herniated disc: 
&nbsp;

<ul>
	<li>&nbsp;Weight</li>
</ul>

Excess body weight puts additional strain on the discs in the lower back. 
&nbsp;

<ul>
	<li>&nbsp;Occupation</li>
</ul>

People who do physically demanding jobs are more likely to develop back problems. Lifting, pulling, pushing, bending sideways, and twisting repeatedly can also increase the risk of a herniated disc. 
&nbsp;

<ul>
	<li>&nbsp;Genetics</li>
</ul>

A few individuals are genetically predisposed to herniated discs. 
&nbsp;

<ul>
	<li>&nbsp;Smoking</li>
</ul>

It is believed that smoking reduces the oxygen supply to discs, causing them to break down faster. 
&nbsp;

<ul>
	<li>&nbsp;Driving Often</li>
</ul>

Long periods of sitting, combined with vibration from the motor vehicle engine, can strain the spine. 
&nbsp;

<ul>
	<li>&nbsp;Being Sedentary</li>
</ul>

An inactive lifestyle can also put stress on the spine. Exercising regularly can help prevent a herniated disc. 
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Oxygen&ndash;Ozone Therapy Associated with Alpha Lipoic Acid Plus Palmitoylethanolamide and Myrrh versus Ozone Therapy in the Combined Treatment of Sciatic Pain Due to Herniated Discs4

A team of researchers compared the therapeutic efficacy of combined oxygen-ozone therapy and oral treatment with alpha-lipoic acid (ALA) + palmitoylethanolamide (PEA) and myrrh. These studies were conducted in patients with peripheral neuropathic pain (sciatica) or radicular disc conflict from disc herniation. The study enrolled a total of 318 patients with a disc herniation diagnosis confirmed by CT or MRI scans. One group (Group A) only received oxygen-ozone therapy with CT-guided intraforaminal technique, while the remaining (Group B) underwent combined oral treatment with ALA + PEA and myrrh. 
&nbsp;

At the clinical check-up, 126/165 patients in Group A had completely resolved their pain (76.4%), whereas 119/153 patients in Group B had completely resolved theirs (77.8%)4.

They concluded that the treatment associated with ozone therapy and oral administration of alpha-lipoic acid + palmitoylethanolamide and myrrh is preferred over the treatment using only ozone. Such patients seem to have better pain management. 
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Key Points

<ul>
	<li>When a disc slides out of its natural location between the vertebrae, it herniates. If it produces inflammation or irritates a nerve, this could be unpleasant.</li>
	<li>A herniated disc can induce pain in the neck and back. Pain, numbness, or tingling may spread down a leg or an arm in rare circumstances.</li>
	<li>Symptoms of disc herniation can sometimes resolve on their own. If not, a variety of therapeutic options are available, including physical therapy, medicines, and injections. Some patients may require surgery. 
	&nbsp;</li>
</ul>

[1] Dydyk AM, Ngnitewe Massa R, Mesfin FB. Disc Herniation. [Updated 2022 Jan 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[2] Iqbal W, Ahmad N, Mirza T, Waheed A, Butt AW. Comparison of electromyography/nerve conduction studies and magnetic resonance imaging in diagnosis of lumbosacral radiculopathy. Pakistan Armed Forces Med J. 2011;(2):79.

[3] Herniated disk: What it is, diagnosis, treatment & outlook. Cleveland Clinic.

[4] Bonetti M, Lauritano D, Ottaviani GM, Fontana A, Zambello A, Della Gatta L, et al. Oxygen--Ozone Therapy Associated with Alpha Lipoic Acid Plus Palmitoylethanolamide and Myrrh versus Ozone Therapy in the Combined Treatment of Sciatic Pain Due to Herniated Discs: Observational Study on 318 Patients. Int J Environ Res Public Health. 2022;19(9):571