Lumbar Disc Problems Summary The lumbar region of the human spine is a location that is very susceptible to injury and trauma. A majority of the population experience back pain at some time during their life, and although in most cases the pain subsides after a time of rest, there is an enormous need for treatment of this malady. The various types of treatment for lumbar disc herniations include a more conservative method of rest, physical therapy, and anti-inflammatory or non-steroidal drugs. A more extreme condition would require surgery to try to alleviate the symptoms. The older, more traditional surgery is a posterior laminotomy, however, newer less invasive microscopic and endoscopic surgeries been implemented to increase success and recovery time as well.
Although most of these operations are performed on the posterior, anterior surgeries are also performed, depending upon the nature of the injury. While these surgeries partially remove disc material affecting the spinal cord, another type of surgery is used to remove the disc entirely and replace it with prosthetics. Still, there are alternative treatments including chiropractic care, acupuncture, and physical therapy that are increasing in popularity. Due to the sensitivity and vulnerability of the spinal cord, the diagnosis and treatments have a moderate risk of failure, and force a patient to explore numerous options to relieve pain. Introduction The vertebral column is composed of seven cervical, twelve thoracic, five lumbar, five sacral, and four coccygeal vertebrae.
The lumbar vertebrae are numbered from one through five starting with the highest vertebrae, and preceded by the letter L. (i.e. the lowest vertebral body will be represented as L-5) Between the vertebrae of the cervical, thoracic, and lumbar regions are invertebral discs that serve as shock absorbers that allow the everyday movements of the spine. Discs themselves are represented by naming both of their adjacent vertebral bodies (i.e. a lumbar disc is can be identified as L-4 L-5 or L-4,5). The discs are made up of an outer ring of more dense material called the annulus fibrosus. The annulus fibrosus helps to contain the inner gelatinous material called the nucleus pulposes. Upon a stressful movement of the spine, the nucleus pulposes may rupture through the annulus fibrosus posteriorly toward the spinal cord. Pressure upon the spinal cord, which is the origin of nerves throughout the body, can irritate the nerves exiting through lateral spaces between adjacent vertebrae called the invertebral foramen. These nerves travel to the lower extremities cause a dull ache and sometimes numbness or loss of strength. The nerve most commonly affected by a disc herniation is the sciatic nerve.
The sciatic nerve originates between the third sacral(S-3), and fourth lumbar(L-5) vertebrae, is formed in the pelvis and exits through the greater sciatic foramen towards the gluteal region. It then travels laterally underneath the piriformis muscle towards the pudendal nerve, then divides travels anteriorly down the leg until it divides near the knee into the politeal and tibial nerves(Shanahan, 1997). A term herniated disc is used synonymously with ruptured or prolapsed discs. They describe a protrusion of the nucleous propulsus through the annulus fibrosus upon the spinal cord. Commonly herd terms such as a slipped or a bulging disc refer to the disc being close to herniation, but still remaining intact.
In this case, the nucleus propulsus is contained, however, the contortion can still lead to decreased foraminal space, and sciatic nerve irritation. The symptoms for bulging or slipped discs are similar to those for a herniated disc, but are usually milder and less intense, thus requiring more conservative treatments(Shanahan, 1997). An estimated eighty percent of the population suffers at least one episode of back pain in their life, and in as many as fifty percent of the cases, the problem will recur within the next three years (DiNubile, 1997). The purpose of this paper is to discuss lumbar disc problems that afflict a large portion of the population, and discern between the numerous treatment options available to a patient. It will discuss the wide range of these interventions and attempt to provide a clear view of the success and appropriate applications of the treatments. Discussion The cause of a disc rupture can be traced to many events such as a single squat exercise by weight lifter, or the repetitive stressful jumping of a basketball player, or even a violent sneeze.
The patient would normally become concerned upon recognizing a dull ache in their gluteal or hamstring muscles. More severe cases would include the pain to continue laterally from the knee to foot, and possibly a loss of strength in these areas. Someone uneducated in the nature of the sciatic nerve would not associate the leg pain with a back problem and would most likely take a few days to rest hoping that the pain would subside. If the persistent dull ache were to continue, the patient would be inclined to seek professional help. Traditionally, an orthopaedist who diagnosed a patient with sciatica caused by a prolapsed disc, would prescribe bed rest for two weeks with the aid of narcotic drugs to alleviate pain, and leave surgery as the last option.
Besides the fact that it is unrealistic to expect a patient to follow this advice to remain in bed, the treatment has been found to be unsuccessful as well as compromising to a possible recovery. The rest and inactivity is believed to decondition the lumbar musculature, and promote chronic pain and increase the chance of future problems. The lack of strength and flexibility can modify spinal mechanics in a way that places greater strain on the lumbar area, thus prolonging pain (DiNubile, 1997). This lack of success with traditional treatments, combined with the common fear of back surgery, has led people to explore the option of alternative medicine. A study done by the American Board of Family Practice showed that twenty eight percent of family practice patients sought some sort of alternative medicine. Back pain was the most common problem for which patients sought alternative care, which shows that patients are unhappy with traditional treatments. One of the most popular forms of modern intervention is chiropractic care.
Chiropractic care involves a manipulation of the spine in order to relieve the symptoms of back and neck injuries. Although there is no accepted scientific methodology that supports chiropractic care, studies show that twenty one percent of chiropractic patients received “some” relief from manipulation (Drivdahl,1998). Another increasingly popular treatment for chronic low back pain is transcutaneous electrical nerve stimulation (TENS). This treatment involves the conduction of electric impulses into the affected area, in attempt to decrease swelling and pain, while increasing range of motion. Evidence shows that TENS does have positive effects on reducing pain and improving functioning of patients. However, the studies show that although ninety five percent of the two hundred and eighty eight patients experienced a decrease in pain, only three percent had relief for more than two hours(Gadsby 1997). Another form of conservative treatment is physical therapy.
Physical therapy includes a wide variety of exercises that attempt to strengthen and mobilize the spine in order to relieve pressure from the discs. Although most would agree that some form of physical activity is preferred over bed rest, the extent and type of excercises performed are not readily agreed upon. The difficulty comes from the sensitivity of each patient and the nature of his injury. For instance, the McKenzie method of therapy incorporates spinal extension exercises that aim to return a bulged or slightly herniated disc into its original space. Since the disc material is herniated posteriorly, usually during a flexion of the spine, a series of extensions will hopefully force the disc to reverse, and free the spinal cord.
This method has shown good results in moderate cases, however it has also produced some negative results as well. While seventy percent of patients using the McKenzie method showed a decrease in leg pain associated with sciatica, three percent found an increase in the radicular pain in their leg, and twenty eight percent did not notice a difference (Drivdahl, 1998). Still, those who experienced an increase in radicular pain, were the patients who initially had more severe conditions to begin with. This concludes that the McKenzie method of physical therapy is a viable option for most cases of sciatica, especially moderate ones. The prescription of anti-inflammatory drugs as a treatment has also gained increased in volume during the past five years.
This is due in part to the apprehension doctors have when prescribing narcotic drugs, for fear of addiction. Thus, most intermediate cases of lumbar disc herniations are given the option to take anti-inflammatory drugs, with the hope that they will continue with their daily life activities. Sciatic pain is can be due in part to a perineural inflammatory response to a disc herniation(Hatori, 1999). The goal of the anti-inflammatory would be to reduce the inflammation, thus relieving pressure on the sciatic nerve. These non steroidal anti-inflammatory drugs (NSAID’s) also have their problems, however.
With most of these drugs, there is a relatively high rate of gastro-intestinal disturbances. For example, a commonly prescribed drug known as indomethacin has been reported to produce gastro intestinal side effects in up to twenty nine percent of it’s users(Hatori, 1999). Despite these problems, new drugs are constantly being introduced to reduce the side effects. A relatively new NSAID named etoldac has shown good results after testing. In a test done with one hundred and eighty one patients suffering from disc herniations fifty four percent showed a “slight” to “marked”, though short lived, improvement, while only one of these patients complained of gastro intestinal side effects(Hatori, 1999). A more invasive procedure with similar goals to the NSAID’s is an epidural injection into the exact locat …