Herniated Disc

The term “herniated disc” describes the condition when the intervertebral disc is injured, and its contents are bulging or protruding into the spinal canal. Herniated disc can also be referred to “slipped disc,” “ruptured disc,” “bulging disc,” “disc protrusion” and “extruded disc.” Studies have shown that a great number of patients with back pain have sustained a disc injury, especially if the patient has accompanying radiating leg pain (sciatica).

How is it diagnosed?

The diagnosis of a herniated disc is straightforward in most patients. However, it can be complicated when the symptoms or physical findings are atypical. Some patients will complain of isolated hip pain or knee pain and be evaluated and treated for this rather than a back problem. It’s important to get a thorough history and clinical examination prior to getting a diagnosis so you’re not misdiagnosed. Imaging studies and occasionally laboratory tests must be used to clarify the diagnosis.

How is it treated?
Overall, nearly 99 percent of patients with a spinal disorder do not require surgical treatment and improve with conservative treatment. At the Keck Medical Center of USC, patients and health care providers have access to a host of non-surgical treatments that best fit a patient’s lifestyle.

1. Medications

Neck and back problems are the second most common reason patients seek medical attention. Fortunately, the vast majority of patients recover with or without medical treatment. However, patients who develop acute, sudden neck or back pain may suffer significantly until it resolves, which may be days or even weeks. Chronic spinal conditions may take months or years to settle down on their own. Therefore, most physicians recommend the use of medications to help relieve spinal pain and speed up the recovery process.

Specific oral (taken by mouth) medications listed below generally allow patients with spinal pain to improve, and improve more rapidly, as well as reduce inflammation and the likelihood of a recurrence of symptoms.

Medications often prescribed include:

• Anti-inflammatories (NSAIDS)
• Acetaminophen
• Muscle relaxants
• Narcotics
• Corticosteroids
• Anticonvulsants

Anti-inflammatories (NSAIDS)

Because spinal disorders often generate pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed pain-relief medications for mechanical neck and back pain worldwide and are very effective. NSAIDs include ibuprofen and naproxen and are available over-the-counter without a physician prescription. Stronger NSAIDs such as ketorolac or indomethacin are also available by prescription. NSAID medications work by reducing the inflammation and swelling, which typically reduces the pain as well. NSAIDS should not be used by patients with severe kidney disease.

Acetaminophen

Acetaminophen (Tylenol) is a common, over-the-counter medicine that favorably decreases pain in many patients with spinal pain. Acetaminophen should not be used by patients with severe liver dysfunction.

Muscle relaxants

Muscle relaxants are another category of medicine, which are routinely prescribed for spinal disorders. These medications work by decreasing muscle spasms, which can promote pain and inflammation.

Narcotics (opioids)

These are controlled, prescription medications that are used specifically for pain. Narcotic medications, such as Tylenol with codeine or Tylenol with oxycodone, are mainstays for the short-term treatment of severe neck or back pain, but should be used sparingly for patients with chronic spinal pain.

Corticosteroids

Corticosteroids such as methylprednisolone or prednisone are appropriate for patients with significant radicular nerve pain, such as sciatica from a disc herniation. However, patients with diabetes should be carefully followed because steroid medicines can disturb sugar metabolism.

Anticonvulsants

This type of medication, which can stabilize nerve membranes and decrease nerve inflammation, are frequently effective for patients with significant nerve pain unrelieved with other medicines or treatments.

2. Physical Therapy

Physical therapy can aid in achieving and maintaining optimal health of a patient’s spine and alleviating pain. Overall, the goal of physical therapy is to identify and teach patients efficient management strategies to improve spine-related problems with an emphasis on decreasing current pain symptoms, improving strength and function and minimizing recurrence of symptoms. Physical therapy, with or without other conservative treatments, can often cure spinal pain, as evidenced by the fact that fewer than one percent of patients with neck or back problems ultimately go on to have a spinal surgery.

The USC physical therapy group provides top-level conservative treatment with a primary focus on spinal stabilization to improve the strength, endurance, balance and control of abdominal, trunk and back muscle groups. Patients are issued a program booklet and personally instructed by the therapist on strengthening exercises. As patients strengthen their core and back muscles and improve their flexibility, more of the joint-loading forces of the spine are stabilized by the muscles, and there is less strain on the injured disc and ligaments, which generally leads to less inflammation and pain.

3. Steroid Injections

Steroid injections are a commonly prescribed treatment for numerous orthopaedic ailments, including many spinal disorders. When oral medications or physical therapy fail to improve a patient’s spinal condition and a patient has severe incapacitating pain, spinal injections can be a very effective treatment option. Depending on the type and location of the spinal problem, a small dose of steroid medicine can be injected under X-ray guidance into the right spot, often immediately alleviating pain and inflammation.

The type of steroid injection varies, depending on the specific spinal disorder being treated. Types of steroid injections of the spine include:

• Epidural Steroid Injection (ESI)
• Translaminar ESI
• Transforaminal ESI
• Caudal ESI
• Facet joint injections
• Nerve root blocks
• Sacroiliac joint injections (lower back)
• Coccyx injections (pelvis and tailbone)

4. Surgical Procedures

Microdiscectomy

What is it?

Microdiscectomy, also called Microlumbar Discectomy (MLD), is is a very common, if not the most common, surgery performed by spine surgeons. The operation consists of removing the herniated or protruding portion of the disc that is compressing the nerve. This microscopic surgical approach uses a small, minimally-invasive, poke-hole incision to remove the herniated disc allowing for a more rapid recovery.

Who should have it?

Microdiscectomy is recommended for patients with a painful herniated disc in the lower back.

Post-Operative Care

• In-patient physical and occupational therapy during the first one to two days after surgery
• Avoid bending at the waist, lifting (more than 5 pounds) and twisting in the first two to four weeks after surgery
• Avoid sitting in the same position for more than 45 to 60 minutes in the first few weeks after surgery. After sitting for 45 to 60 minutes, get up and stretch or walk for a little while
• If necessary, use of a small, soft lumbar corset to provide additional lower back support .

Microlaminectomy

What is it?

Microlaminectomy is performed to remove large, arthritic bone spurs that compress the spinal nerves. This microscopic minimally invasive surgery is used, rather than a lumbar laminectomy, which involves a large surgical incision and exposure. A microlaminectomy results in a more rapid recovery and may provide an improved long-term outcome because there is less muscle and tissue damage.

Who should have it?

Microlaminectomy is performed for patients with symptomatic, painful lumbar spinal narrowing (stenosis).

Post-Operative Care

• In-patient physical and occupational therapy during the first one to two days after surgery
• No bending at the waist, lifting (more than five pounds) and twisting in the first two to four weeks after surgery to avoid a strain injury
• Gradual bending, twisting and lifting after one to two weeks as the pain subsides and back muscles get stronger
• If necessary, use of a small, soft lumbar corset to provide additional lower back support in the first two weeks after surgery