A single copy of this article may be reprinted for personal, noncommercial use only.
Herniated diskBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/herniated-disk/DS00893
CLICK TO ENLARGE
A herniated disk refers to a problem with one of the rubbery cushions (disks) between the individual bones (vertebrae) that stack up to make your spine.
A spinal disk is a little like a jelly donut, with a softer center encased within a tougher exterior. Sometimes called a slipped disk or a ruptured disk, a herniated disk occurs when some of the softer "jelly" pushes out through a crack in the tougher exterior.
A herniated disk can irritate nearby nerves and result in pain, numbness or weakness in an arm or leg. On the other hand, many people experience no symptoms from a herniated disk. Most people who have a herniated disk don't need surgery to correct the problem.
You can have a herniated disk without knowing it — herniated disks sometimes show up on spinal images of people who have no symptoms of a disk problem. But some herniated disks can be painful. The location of your symptoms may vary, depending on where the herniated disk is located along your spine. Most herniated disks occur in your lower back (lumbar spine), although they can also occur in your neck (cervical spine).
The most common signs and symptoms of a herniated disk are:
- Arm or leg pain. If your herniated disk is in your lower back, you'll typically feel the most intense pain in your buttocks, thigh and leg below the knee. It may also involve part of the foot. If your herniated disk is in your neck, the pain will typically be most intense in the shoulder and arm. This pain may shoot into your arm or leg when you cough, sneeze or move your spine into certain positions.
- Numbness or tingling. People who have a herniated disk often experience numbness or tingling in the body part served by the affected nerves.
- Weakness. Muscles served by the affected nerves tend to weaken. This may cause you to stumble, or impair your ability to lift or hold items.
When to see a doctor
Seek medical attention if your neck or back pain travels down your arm or leg, or if it's accompanied by numbness, tingling or weakness.
Disk herniation is most often the result of a gradual, aging-related wear and tear called disk degeneration. As you age, your spinal disks lose some of their water content. That makes them less flexible and more prone to tearing or rupturing with even a minor strain or twist.
Most people can't pinpoint the exact cause of their herniated disk. Sometimes, using your back muscles instead of your leg and thigh muscles to lift large, heavy objects can lead to a herniated disk, as can twisting and turning while lifting. Rarely, a traumatic event such as a fall or a blow to the back can cause a herniated disk.
Factors that increase your risk of a herniated disk may include:
- Age. Herniated disks are most common in middle age, especially between 35 and 45, due to aging-related degeneration of the disks.
- Weight. Excess body weight causes extra stress on the disks in your lower back.
- Occupation. People with physically demanding jobs have a greater risk of back problems. Repetitive lifting, pulling, pushing, bending sideways and twisting also may increase your risk of a herniated disk.
Your spinal cord doesn't extend into the lower portion of your spinal canal. Just below your waist, the spinal cord separates into a group of long nerve roots (cauda equina) that resemble a horse's tail. Rarely, disk herniation can compress the entire cauda equina. Emergency surgery may be required to avoid permanent weakness or paralysis.
Seek emergency medical attention if you have:
- Worsening symptoms. Pain, numbness or weakness may increase to the point that you can't perform your usual daily activities.
- Bladder or bowel dysfunction. People who have the cauda equina syndrome may become incontinent or have difficulty urinating even with a full bladder.
- Saddle anesthesia. This progressive loss of sensation affects the areas that would touch a saddle — the inner thighs, back of legs and the area around the rectum.
Preparing for your appointment
You're likely to initially bring your symptoms to the attention of your family doctor. He or she may refer you to a doctor specializing in physical medicine and rehabilitation, orthopedic surgery, neurology or neurosurgery.
What you can do
Before your appointment, write a list that answers the following questions:
- When did you first begin experiencing symptoms?
- Were you lifting, pushing or pulling anything at the time you first felt symptoms? Were you twisting your back?
- Has the pain kept you from participating in activities you wanted to do?
- Do you have any pain that travels into your arms or legs?
- Do you feel any weakness or numbness in your arms or legs?
- Have you noticed any changes in your bowel or bladder habits?
- Does coughing, sneezing or straining for a bowel movement worsen your leg pain?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
- Is the pain interfering with sleep or work?
- What medications or supplements do you take?
What to expect from your doctor
During the physical exam, your doctor may ask you to lie flat so that he or she can move your legs into various positions to help determine the cause of your pain. Your doctor may also perform a neurological exam, to check your:
- Muscle strength
- Walking ability
- Ability to feel light touches, pinpricks or vibration
Tests and diagnosis
CLICK TO ENLARGE
|MRI of herniated disk|
In most cases of herniated disk, a physical exam and a medical history are all that's needed to make a diagnosis. If your doctor suspects another condition or needs to see which nerves are affected, he or she may order one or more of the following tests.
- X-rays. Plain X-rays don't detect herniated disks, but they may be performed to rule out other causes of back pain, such as an infection, tumor, spinal alignment issues or a broken bone.
- Computerized tomography (CT scan). A CT scanner takes a series of X-rays from many different directions and then combines them to create cross-sectional images of your spinal column and the structures around it.
- Magnetic resonance imaging (MRI). Radio waves and a strong magnetic field are used to create images of your body's internal structures. This test can be used to confirm the location of the herniated disk and to see which nerves are affected.
- Myelogram. A dye is injected into the spinal fluid, and then X-rays are taken. This test can show pressure on your spinal cord or nerves due to multiple herniated disks or other conditions.
Electromyograms and nerve conduction studies measure how well electrical impulses are moving along nerve tissue. This can help pinpoint the location of the nerve damage.
Treatments and drugs
Conservative treatment — mainly avoiding painful positions and following a planned exercise and pain-medication regimen — relieves symptoms in nine out of 10 people with a herniated disk. Many people get better in a month or two with conservative treatment. Imaging studies show that the protruding or displaced portion of the disk shrinks over time, corresponding to the improvement in symptoms.
- Over-the-counter pain medications. If your pain is mild to moderate, your doctor may tell you to take an over-the-counter pain medication, such as ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or naproxen (Aleve, others). Many of these drugs carry a risk of gastrointestinal bleeding, and large doses of acetaminophen may damage the liver.
- Narcotics. If your pain doesn't improve with over-the-counter medications, your doctor may prescribe narcotics, such as codeine or a hydrocodone-acetaminophen combination (Vicodin, Lortab, others), for a short time. Sedation, nausea, confusion and constipation are possible side effects from these drugs. Decrease or eliminate your Tylenol use if these combination medications are prescribed.
- Nerve pain medications. Drugs such as gabapentin (Neurontin), pregabalin (Lyrica), duloxetine (Cymbalta), tramadol (Ultram, Ryzolt) and amitriptyline often help relieve nerve-damage pain. Because these drugs have a milder set of side effects than do narcotic medications, they're increasingly being used as first-line prescription medications for people who have herniated disks.
- Muscle relaxers. Muscle relaxants such as diazepam (Valium) or cyclobenzaprine (Flexeril, Amrix) also may be prescribed if you have back or limb spasms. Sedation and dizziness are common side effects of these medications.
- Cortisone injections. Inflammation-suppressing corticosteroids may be given by injection directly into the area around the spinal nerves, using spinal imaging to more safely guide the needle.
Physical therapists can show you positions and exercises designed to minimize the pain of a herniated disk. As the pain improves, physical therapy can advance you to a rehabilitation program of core strength and stability to maximize your back health and help protect against future injury.
A physical therapist may also recommend:
- Heat or ice
- Electrical stimulation
- Short-term bracing for the neck or lower back
A very small number of people with herniated disks eventually need surgery. Your doctor may suggest surgery if:
- Conservative treatment fails to improve your symptoms after six weeks
- A disk fragment lodges in your spinal canal, pressing on a nerve and resulting in progressive weakness
- You're having significant trouble performing basic activities such as standing or walking
In many cases, surgeons can remove just the protruding portion of the disk. Rarely, however, the entire disk must be removed. In these cases, the vertebrae may need to be fused together with metal hardware to provide spinal stability. Or your surgeon may suggest the implantation of an artificial disk.
Lifestyle and home remedies
- Take pain relievers. Over-the-counter medications — such as ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or naproxen (Aleve, others) — may help reduce the pain associated with a herniated disk.
- Use heat or cold. Initially, cold packs can be used to relieve pain and inflammation. After a few days, you may switch to gentle heat to give relief and comfort.
- Avoid too much bedrest. Too much bedrest can lead to stiff joints and weak muscles — which can complicate your recovery. Instead, rest in a position of comfort for 30 minutes, and then go for a short walk or do some work. Try to avoid activities that worsen your pain during the healing process.
Coping and support
Pain affects more than just your physical well-being. If you have to deal with recurring herniated disks or other back problems, your psychological and emotional health also are vulnerable. These tips may help you cope with pain related to a herniated disk:
- Acknowledge the pain. Some people try to pretend their chronic pain doesn't exist. In the process, they may actually make it worse. You may have more success in coping if you affirm that your pain isn't imaginary and make necessary adjustments to accommodate it.
- Manage stress. Stress magnifies pain. Try doing deep-breathing exercises and practicing other relaxation techniques when your stress level begins to rise.
- Identify pain triggers. Certain activities or behaviors may worsen your pain. If you identify these triggers, you can avoid or limit them.
- See a counselor. Talking with a mental health counselor helps you recognize and rethink unrealistic expectations and beliefs about yourself. Even if you can't change your chronic pain, you can change the way you feel about it.
To help prevent a herniated disk:
- Exercise. Core-muscle strengthening helps stabilize and support the spine. Check with your doctor before resuming high-impact activities such as jogging or tennis.
- Maintain good posture. Good posture reduces the pressure on your spine and disks. Keep your back straight and aligned, particularly when sitting for longer periods. Lift heavy objects properly, making your legs — not your back — do most of the work.
- Maintain a healthy weight. Excess weight puts more pressure on the spine and disks, making them more susceptible to herniation.
- Chad DA. Disorders of nerve roots and plexuses. In: Bradley WG, et al. Neurology in Clinical Practice. 5th ed. Philadelphia, Pa.: Butterworth Heinemann Elsevier; 2008. http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-0-7506-7525-3..50117-5&isbn=978-0-7506-7525-3&sid=1063623544&type=bookPage§ionEid=4-u1.0-B978-0-7506-7525-3..50117-5--cesec12&uniqId=221226396-3#4-u1.0-B978-0-7506-7525-3..50117-5--cesec12. Accessed Oct. 5, 2010.
- Herniated disk. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=A00334. Accessed Oct. 5, 2010.
- Herniated disc. American Association of Neurological Surgeons. http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/Herniated%20Disc.aspx. Accessed Oct. 5, 2010.
- Herniated lumbar disc. North American Spine Society. http://www.spine.org/Documents/herniated_lumbar_disc_2006.pdf. Accessed Oct. 6, 2010.
- Herniated cervical disc. North American Spine Society. http://www.spine.org/Documents/herniated_cervical_disc_2006.pdf. Accessed Oct. 6, 2010.
- JAMA patient page: Herniated lumbar disks. Journal of the American Medical Association. 2006;296:2512.
- Cauda equina syndrome. American Association of Neurological Surgeons. http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/Cauda%20Equina%20Syndrome.aspx. Accessed Oct. 6, 2010.
- Neurological diagnostic tests and procedures. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/misc/diagnostic_tests.htm. Accessed Oct. 6, 2010.
- Chou R, et al. Diagnosis ad treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine. 2007;147:478.
- Robinson J, et al. Treatment of cervical radiculopathy. http://www.uptodate.com/home/index.html. Accessed Oct. 7, 2010.
- Levin K, et al. Lumbosacral radiculopathy: Prognosis and treatment. http://www.uptodate.com/home/index.html. Accessed Oct. 7, 2010.
- Dworkin RH, et al. Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain. 2007;132:237.
- Shelerud RA (expert opinion). Mayo Clinic, Rochester, Minn. Oct. 13, 2010.