Herniated Disks and the Options for Recovery - Essay Example

Herniated disks and the options for recovery An inter-vertebral disc is constructed of a strong fibrous material, much the same as the tissue on the breast bone of a chicken and is located between every two bones of the spinal column cushioning the movement of the spine. Pieces of the fibrous tissue push backward into the spinal canal if the disc breaks down occasionally pressing against nerves or the spinal cord which causes pain, numbness, or weakness in the legs or arms. A herniated disc can cause discomfort in many ways. Most usually it inflames a nerve from pressure by the piece of the disc rubbing against it. If the herniated disc is located in the low back area, the pain often seems to be roaming down the leg as the patient feels the pain in the area where the nerve winds up and not in the area where it’s really being aggravated. The nerve that is rubbed by the piece of disk becomes irritated and inflamed. Cortisone decreases inflammation and when positioned around the irritated nerve can ease pain. In the neck, herniated discs, or bone spurs, place pressure on the spinal cord resulting in progressive hardships while walking (DeLong, 2003). The location and size of the herniated disk determines the severity of the pain. Pain may extend over the buttocks, down the back of one thigh or may be in one or both legs and cause the patient to experience numbness or weakness in the legs or feet. Bowel or bladder changes can also occur in acute cases. Patients are not able to soothe the pain even when lying down and experience unexpected twinges in the neck that cannot be adjusted without severe pain. This causes numbness in one or both arms (Scholten, 2005). There are many types of treatment options for herniated disk problems including surgery as well as less evasive techniques. Most patients who suffer symptoms generating from a herniated disc recuperate without surgery if they are involved in a program of conservative care. Effectual conservative care includes physical therapies and medications and can also include chiropractic treatments although this treatment is as yet controversial. As mentioned, cortisone can be positioned directly inside the spinal canal or nerve channel soothing the nerves by relieving inflammation. It’s widely recommended by physicians to attempt a conservative program before opting for surgery (DeLong, 2003). Conservative care options include but are not limited to physical therapies such as moderate stretching exercises to help relieve pressure on the nerve; ice and heat therapy; chiropractic manipulation of the vertebrae; narcotics; steroids; epidural injections to decrease inflammation and non-steroidal anti-inflammatory drugs such as naproxen and ibuprofen. Chiropractic treatment is founded on the reasoning that restricted movement in the spine results in pain. Chiropractors utilize spinal adjustments or manipulation to treat restricted spinal movements, the objective being to re-establish normal spinal movement thereby improving function and lessen pain. “Some studies have shown that some types of spinal manipulation can relieve symptoms in people with a herniated disk. However, the practice remains controversial and many medical doctors don’t recommend chiropractic care to treat herniated disk” (Shelerud, 2005). Muscle relaxants may be used to decrease muscle spasms and depending on the level of pain, various kinds of analgesic medications may be prescribed. If medicine isn’t proving effective, steroids may be injected into the affected area around the disk and nerve in an effort to reduce inflammation and the pain associated with it. An epidural steroid injection, about a 15 minute procedure, puts this strong anti-inflammatory drug around spinal nerves. Many patients experience long-lasting relief of symptoms within a few weeks following this treatment. Side-effects from epidural steroid injections, though rare, include infection and bleeding, but both are very unusual occurrences, less than one half of one percent. Dural Tears can also occur which are caused by piercing the sac around the spinal nerves with the needle but this only results in a headache. Diabetics should be careful to monitor their blood sugar following steroid injections (Cluett, 2006). For severe pain resulting from a herniated disk, bed rest for a couple of days is usually recommended. The patient should lie on a firm mattress with the knees and hips partially bent and lower legs elevated on pillows. Massage is commonly utilized and is an effective treatment for back discomfort. Neck and back massage and physical therapy can help relax muscles, decrease pain and increase strength and mobility. Research has shown that massage provides temporary relief from chronic low back pain, but its usage may not be sufficient to relieve chronic pain and the treatment is seldom a long-term solution. Massage helps to extend soft tissues which restores muscle length and allow the patient to resume a number of normal activities. Massage therapy is generally safe and doesn’t produce undesirable side effects but this is not a proven treatment. Massage therapy, however, is not completely without risk to the patient. “Massage isn’t recommended for patients with osteoporosis, deep vein thrombosis, skin infections or open wounds, or arthritis in the area to be massaged” (Shelerud, 2005). Following the severe phase of the ailment, there are particular exercises that can aid the recuperation phase and preclude recurrences. Hot or cold packs can also help lessen pain and muscle spasms. For herniated disks located in the neck region, weights and pulleys may be used to relieve pressure and restrict the patient from undue movement. A neck collar or brace may also be used to relieve muscle spasms for a herniated disk of the neck. Acupuncture is not a commonly utilized treatment for herniated disks. Though this procedure may relieve back pain, scientific studies aren’t conclusive regarding acupuncture. The patient may experience relief from pain resulting from the release of endorphins, the body’s natural painkillers, but how acupuncture accomplishes this is largely unknown. Possibly, it may control pain by blocking in the central nervous system from the sensation of the needle in the skin and may alter the brain’s chemistry in a way that affects the involuntary body functions (Shelerud, 2005). The objective of surgery for a herniated disk is to remove about 5 to 10 percent of the disk, the part that is encroaching on the nerve. The most common type of surgery is microsurgical discectomy. “In the last 10 to 15 years the microdiscectomy surgery has been modified to allow for a relatively small incision and less soft tissue dissection, which provides for significantly less postoperative discomfort and quicker healing” (Ullrich, 2000). Microsurgical Discectomy is an ‘open’ operation because the doctor must make a minor incision to reach the herniated disc. The surgeon can observe the disc fragments directly in an ‘open’ operation so this is by and large a more reliable procedure than the ‘closed’ operations. After moving the muscles back, the surgeon removes a fragment of bone so as to observe the spinal canal. The affected nerve is then moved to get to and remove the piece of disc that has pushed into the spinal canal. Loose disc material is then removed so as to decrease the likelihood that it could again work its way out into the spinal canal at a later date (DeLong, 2003). Following surgery, the patient can be expected to be released from the hospital that same day. The day following surgery, the patient will begin an undemanding exercise ritual then after about one week begin working with a physical therapist in an extended therapeutic program training in general conditioning. If the patient is under chiropractic care, they may return for treatments after about a week following surgery though they should avoid lower back adjustments for at least six months. The general conditioning program should begin within a week following surgery. The patient should begin walking for 20 to 30 minutes per day progressing to a swimming curriculum and/or relaxed cycling. Two or three months should pass before attempting more energetic sporting activities such as running or playing tennis. Generally speaking, if there are no complications, the patient should be able to resume normal activities four to six weeks following surgery although heavy physical types of employment should still be avoided. The patient should wait three or four months before returning to a job that requires heavy lifting. Laser, Percutaneous and Arthroscopic Discectomy are examples of ‘closed’ operations as the surgeon does not make a full incision in order to be able to operate on the disc. Closed operations are useful if the disc that is generating pressure on the nerves hasn’t yet broken through the back of the disc. These procedures are only minimally invasive, much the same as arthroscopic knee surgery and offer a brief hospitalization period and relatively quick rehabilitation. These are safer techniques for the patient and easier for the surgeon to execute. The center portion of the herniated disc is detached with the instruments or with the laser. Rather than viewing the operation through arthroscopy, the surgeon sees into the disc by means of fluoroscopy during a Laser or Percutaneous Discectomy. With all of these procedures, however, “the surgeon can’t be sure that he or she has been able to remove pieces of the disc which have become stuck in the spinal canal. To do this reliably, the surgeon needs to be able to see directly into the spinal canal” (DeLong, 2003). The ideal age range of patients for these closed operating procedures is 15 to 50. It is neither indicated “for large herniation inside the spinal canal and probably it is not for those patients with a history of symptoms lasting over two years because nucleus pulposus becomes dry, and the decompression will not be effective” (Rezaian & Ghista, 1995). In percutaneous discectomy, the surgeon utilizes fluoroscopy (continuous X-ray monitoring). During fluoroscopy, X-rays are directed at the spine which transmits a picture of the procedure displayed on a monitor. The surgeon inserts instruments into a small incision in the patient’s back to remove the necessary parts of the herniated disc. Before surgery, the doctor will confirm that a herniated disc is causing your symptoms by using an imaging study, such as magnetic resonance imaging (MRI) or computed tomography (CT scan) (Cooke & Hayden, 2005). Percutaneous discectomy is performed after the patient has gone through both physical examination and imaging techniques such as CT scan or MRI. This procedure is appropriate if these tests reveal that the disc is bulging but the material inside the disc has not ruptured into the spinal canal. If corrective procedure is not performed, the patient will likely suffer additional nerve damage and the associated discomfort. The patient should seek this type of surgery, if appropriate, no longer than a month after non-surgical procedures have failed. The repercussions of not seeking further treatments such as closed surgery are acute and immobilizing. The resulting serious nerve damage may require open surgery (Deyo & Weinstein, 2001). Though closed herniated disc operations have proven very effective and a preferred method of treatment by both patient and doctor, it does present risks, as do any type of surgery, no matter what level of intrusiveness. There is no guarantee that pressure on the nerve will be lessened or eradicated using percutaneous discectomy because the surgeon cannot see the compressed nerve root during the procedure. If pieces of disc material, which have been pushed out of the disc, are not taken out by this procedure, the patient may not notice any alleviation of pain. Many specialists consider standard, or open percutaneous discectomies to be a better alternative to the closed procedure for these reasons. There are several innovative percutaneous disc procedures that entail the use of small surgical instruments. These instruments include suction devices, cutting tools, and lasers. “The goal of all of these methods is to remove or destroy the central disc (nucleus) in the hope that the disc material that has been pushed outward will be drawn back into the disc. These procedures are not well-researched and are considered experimental” (Cooke & Hayden, 2005). The use of lasers in various domains of medicine has proven to provide unique advantages in the treatment of disc disorders. Laser discectomy, as in other closed procedures is performed on an outpatient basis. The minimally invasive surgery is accomplished with the insertion of a needle into the disc. Disc material is not removed but rather burned away by the laser. Laser discectomy does not cause post-operative pain issues in comparison to other discectomy procedures and many physicians feel that it is not utilized often enough. The objective of laser disc surgery is to eliminate a small piece of the inter-vertebral disc, thereby reducing the pressure it causes to the nerve. “A small amount of tissue is excised from the center or nuclear part of the disc, which is believed to exert an effect on a noncontiguous portion of nucleus that is protruding through the annulus fibrosus and abutting an exiting nerve root” (Patel, 2002). The central space produced by the laser procedure permits the disc protrusion to shift back within the disc because minute change in central disc volume exerts disproportionately sizeable alterations on the disc. While laser surgery has provided great benefits to particular patients, “it has not been shown to be an effective alternative to more traditional lumbar disk surgery techniques” (Ullrich, 2000). Laminectomy is a surgical procedure designed to remove pressure on the spinal cord or nerve root by eradicating parts of the bone that are protruding on the spinal canal and the disk. “The term laminectomy comes from the Latin words lamina (bony roof of the spinal canal) and ectomy (removal)” (Phan, 2005). A laminectomy may be performed in different areas of the spine, neck, mid back, and lower back. Sources of spinal cord or nerve root compression that may be removed during this procedure include a herniated disc, arthritis, ligament build-up, or tumors. “Removing the lamina widens the space of the spinal cord or nerve root and therefore relieves symptoms related to compression and irritation of the spinal cord or nerve root” (Phan, 2005). Indications that this procedure may be warranted include pain, numbness, a burning sensation and weakness in the back and legs. Spinal Fusion is a surgical technique that is rarely performed on patients diagnosed with disk problems for the first time. The procedure fuses parts of the vertebrae together using bone grafts or metal rods. This stops the vertebra from moving and rubbing against each other. The concept of fusion should not be confused with that of welding metal in the construction industry. “Spinal fusion surgery does not weld the vertebrae immediately during surgery. Rather, bone grafts are placed around the spine during surgery. The body then heals the grafts over several months, similar to healing a fracture, which joins, or ‘welds,’ the vertebrae together” (“Spinal Fusion”, 2005). Chemonucleolysis is the process by which an enzyme (chymopapain ) is injected into the herniated disk for the purpose of dissolving the protruding portion. It is the least invasive method used to remedy a herniated disc. “After 37 years of clinical experience, multiple clinical trials, a national multicenter, doubleblind study mandated by the Food and Drug Administration, and heated controversy in the scientific community, the injection of chymopapain to treat herniated discs has (in appropriately selected patients) proven as successful as laminectomy, with fewer complications and the advantage of considerable cost savings” (Nordby & Javid, 2000). Microendoscopic surgery is a relatively new technique currently being studied. It uses a retraction system which allows the surgeon to see the disk by way of a small incision. This is an advantage not before previously realized in closed operative procedures. Because this procedure is comparable to a micro-discectomy, it should carry a similar success rate as lumbar discectomies. The new closed procedure is not an advance in post-operative pain and discomfort however. “Although it is less invasive than an open lumbar discectomy, it has not been shown to decrease the morbidity of surgery over that of a micro-discectomy” (Ullrich, 2000). Herniated disc, pinched nerve and bulging disc are all terms used to describe spinal disc pathology and its associated pain. There is little agreement between health care professionals field as to the exact definition of these terms. Too often, the patient hears their diagnosis referred to in different terms, which leads to confusion regarding the proper treatment options. It’s more advantageous for patients to understand the medical (clinical) diagnosis, which identifies the source of the patient’s symptoms rather than on the precise terminology referring to spinal anatomy. The medical diagnosis centers on determining the source of a patient’s pain and is based on more than just the conclusions from a diagnostic test, such as an MRI scan or CT scan. “The spine care professional arrives at a clinical diagnosis of the cause of the patient’s pain through a combination of findings from a thorough medical history, conducting a complete physical exam, and, if appropriate, conducting one or more diagnostic tests” (Ullrich, 2005). The physician will take the patient’s medical history, conduct a physical exam and have diagnostic tests performed in addition to examining the history of the patient’s symptoms. The main issue of the clinical diagnosis is to ascertain whether the patient is experiencing a pinched nerve or if the disc is generating the discomfort. These two common circumstances generate a dissimilar sort of pain that the doctor will recognize readily. It’s important to accurately diagnose the origination of pain because the kind of pain created by the spinal disc determines the type of therapy utilized. Treatments for varying diagnoses differ significantly. Treating a lumbar herniated disc, for example, will not help the patient if it is actually a muscle strain or other injury rather than a herniated disc that is the reason for the patient’s discomfort. The doctor will perform a thorough physical and diagnostic test of the patient to determine the causes of the back or neck problems that the patient is experiencing then outline the proper course of medical action. The tests give a detailed view of the problem such as the location of the herniated disc and encroached upon nerve roots. Afterwards, the doctor will discuss the different options for the patient to consider regarding herniated disk surgery, but whatever method the surgeon utilizes is probably not as important as their comfort level and experience with that particular procedure. References Cluett, Jonathan. (2006). “Epidural Steroid Injection.” About Orthopedics. Retrieved May 2, 2006 from < http://orthopedics.about.com/cs/backpain/a/epiduralsteroid.htm> Cooke, Kerry V. & Hayden, Merrill. (March 18, 2005). “Percutaneous Discectomy for a Herniated Disc.” BC Health Guide. British Columbia Ministry of Health. DeLong, W. Bradford. (2003). “Microsurgical Discectomy.” Spine Doctor [online]. Retrieved May 2, 2006 from < http://www.spine-dr.com/site/surgery/surgery_microsurgery.html> Deyo R. & Weinstein J. (2001). “Low Back Pain.” New England Journal of Medicine. Vol. 344, N. 5, pp. 363–70. Nordby, Eugene J. & Javid, Manucher J. (September 2000). “Continuing Experience with Chemonucleolysis.” The Mount Sinai Journal of Medicine. Vol. 67, N. 4. Patel, Jashvant. (June 10, 2002). “Laser Discectomy.” eMedicine [online]. Retrieved May 2, 2006 from < http://www.emedicine.com/neuro/topic683.htm> Phan, Jackie. (July 2005). “Welcome Sheet: Having a Laminectomy.” California Pacific Medical Center. Sutter Health Network. Rezaian, S.M. & Ghista, D.N. (February 1995). Percutaneous Discectomy: Technique, Indications, and Contraindications – 285 Cases and Results. J Neurol Orthop Med Surg. Vol. 16, pp. 1-6. Scholten, Amy. (2005). “Herniated Disc Symptoms.” Third Age. Boston: EBSCO Publishing. Shelerud, Randy. (September 8, 2005). “Herniated Disk Alternative Therapy.” Mayo Clinic [online]. Retrieved May 2, 2006 from “Spinal Fusion.” (March 3, 2005). North American Spine Society. Ullrich, Peter F. (May 8, 2000). “Surgical Treatments for a Lumbar Herniated Disk.” Spine Health. Read More