INTERVERTEBRAL DISC HERNIATION

What is intervertebral disc herniation (intervertebral disc hernia, herniated disc, prolapsed disc, ruptured disc, slipped disc)?

The intervertebral disc is the material located between the vertebral bodies and consists of the core nucleus and the surrounding fibrous ring. The intervertebral disc acts as a dynamic shock absorber of the spine – “amortisseur”.

Intervertebral disc herniation (intervertebral disc hernia, herniated disc, prolapsed disc, ruptured disc, slipped disc).

Intervertebral disc herniation (intervertebral disc hernia, herniated disc, prolapsed disc, ruptured disc, slipped disc) is a most common spinal cord disease due to intervertebral disc damage and which, depending on its location in the spine, can cause:

Back pain and Sciatica (pain in the legs) if it is located in the lumbar spine.
Neck pain with or without radiculitis / radiculopathy (pain or numbness or palsy) in the upper limbs if it is located in the cervical spine, or in chronic cases myelopathy and findings from the long tracts with instability, gait disturbances or balance, muscle atrophy and weakness.
Thoracic pain (chest pain, burning sensation and numbness of the lower limbs or thoracic and abdominal wall with or without neurological disorders-myelopathy (difficulty walking, hypoaesthesia, urination or defecation disorders, spasticity, etc.) if it is located in the thoracic part of the spine.

Some basics of terminology.

Lumbar pain: is a symptom of any pain in the lumbar spine (pain in the waist), regardless of the cause of it.
Lumbago: The word lumbago is French and means “back pain,” but it was introduced in both English and Greek. Lumbar pain (or lumbago) is not a disease but a symptom of an existing illness.
Sciatica: Sciatica or lumbo-sacral syndrome is a set of symptoms involving pain along the sciatic nerve, with associated sensory disturbances. Sciatica can follow a long path, from the waist, to the buttock, thigh, knee, leg and sometimes to the ankle and toes, rarely in the perineum and the genitals. Depending on which root of the sciatic nerve is irritated, the symptoms are different. Sciatica usually coexists with back pain, but not always, and has pain features that may change position, with or without a feeling of “burning” or feeling cold on the leg with “tingling” or “stitching” on the skin of the thigh, calf and leg.
Discopathy: By this term we mean “degenerated disc disease” in all its forms and stages. This term does not include intervertebral disc lesions caused by microbes, in which case we have inflammations of the discs or by tumors of the area of the spine.

Intervertebral disc herniation (intervertebral disc hernia, herniated disc, prolapsed disc, ruptured disc, slipped disc) – Aetiology.

The cause accounting for the creation of a disc is the degeneration of the disc that almost always precedes. The nucleus pulposus loses its hydrophilic property and ceases to function as a “shock absorber”. At the same time, the annulus fibrosus ring gradually loses its elasticity and exhibits cracks, especially in its lateral and posterior parts, which have smaller thickness. In addition to this, the structure of the Posterior longitudinal Ligament contributes because it is strong centrally and weak peripherally. Previously, the herniated intervertebral disc was attributed to injury of it. Today, the condition belongs to degenerative diseases, but nevertheless, the term “Traumatic Hernia” exists, as long as there is a definite injury.

Generally however, the intervertebral disc herniation (intervertebral disc hernia, herniated disc, prolapsed disc, ruptured disc, slipped disc) appears to be due to multiple causes such as:

hereditary predisposition,
gene predisposition
age
chronic stress with weight lifting
chronic standing position
Chronic bended position when working
Injuries
the different structure and mobility (Biomechanics) of vertebrae and discs
smoking due to blood vessel vasoconstriction of the disc

Based on the magnetic tomography imaging (MRI), for the classification of the stages of a hernia, we have the following stages:

Stage I: Disc Protrusion, Bulging,
Stage II: Disc Prolapse, Prolapsed disc, or Slipped disc)
Stage III: Disc Extrusion, Extruded disc.
Stage IV: Exposure to Descendent Disc (Resurgent Disc)
Stage V: Wrinkled Disc – Narrowed disc, Black Disc
Stage VI: Totaly Degenerated Disc

Intervertebral disc herniation (intervertebral disc hernia, herniated disc, prolapsed disc, ruptured disc, slipped disc) - Frequency and Location.

As statistically observed, the incidence of intervertebral disc herniation is not the same in all areas of the spine.

The majority of cases occur in the lumbar spine (95% in Lumbar 4-5 or Lumbar 5 and Sacral 1).

The second most frequent location is the cervical spine C5 – C6 and C6 – C7.

Pain in the thoracic spine is only 0.25% – 0.75% of the total.

Especially in the lumbar region the greatest number of hernias occurs in:

L4 – L5 (50%)
L5 – S1 (30%)

Intervertebral disc herniation (intervertebral disc hernia, herniated disc, prolapsed disc, ruptured disc, slipped disc)

Diagnostic approach:

Simple X-Rays
CT Scan
MRI
EMG

Intervertebral disc herniation (intervertebral disc hernia, herniated disc, prolapsed disc, ruptured disc, slipped disc) - Conservative Treatment

Conservative treatment

Conservative treatment includes analgesics, anti-inflammatory and physiotherapy. After the end of the acute phase, exercises that strengthen the abdominal and back muscles in order to improve the general condition of the patient are a fundamental part of the conservative treatment.

Surgical Intervention

Nowadays, with the aid of paraclinical examinations, the percentages of asymptomatic intervertebral disc warts are particularly elevated, thus it is imperative to have a high correlation between clinical symptomatology, neurological signs and imaging findings to indicate surgical procedure.

Absolute indications of surgical treatment are:

The presence of a worsening neurological deficit,
Cauda equina syndrome or
Paraparesis

A sign of this is persistent pain with or without mild sensory-motor disorders exceeding the period of three months and after the exhaustion of all conservative methods of treatment.

The surgical techniques applied are microdiscectomy, endoscopic discectomy and transdermal discectomy, intradermal discectomy, percutaneous discectomy / discoplasty.