Ruptured Disc

By Tarun Jolly, MD, Ryan Cooper

An estimated 65-80% of individuals can be expected to experience some type of back pain during their lives, with up to 28% of the population experiencing back pain that is disabling1. Some 2% of all low back pain cases will be due to a condition known as a herniated inter-vertebral disc2. The inter-vertebral discs have three major functions:

  1. they connect individual vertebrae to one another,
  2. they provide for movement between vertebrae, and
  3. they absorb weight, or ‘load’, placed on the spine4.

The discs are composed of a thick fibered outer layer of annulus fibrosus containing a soft, jelly-like layer of nucleus pulposus. Herniated discs are the result of an annular tear, which allows the nucleus to leak through2.

When a tear or herniation is specifically the result of a single, traumatic event, the injury is termed a ruptured disc3. Care must be taken to differentiate the term “rupture” from herniation or annular tearing; herniation via tearing has a variety of causes, such as slow injury or degeneration with age. Rupture, however, specifically suggests a traumatic cause. This trauma causes tears or breaks in the fibers of the annulus which break apart or burst this outer layer allowing the nucleus to leave the disc and spread beyond the borders of its joint, or disc space3.

Although some individuals may be asymptomatic without even realizing that a disc has ruptured, many others will experience pain when ejected disc material compresses nearby nerve roots. Compression of nerve roots is termed a radiculopathy4. Radiculopathies can cause mild to severe pain in the back, neck, lower and upper extremities, as well numbness and/or weakness in affected areas. The lumbar spine, or the lower back, is the most common location of a disc rupture leading to a radiculopathy and causing pain in the lower back and leg5. Pain associated with a ruptured disc can be very diverse, ranging from a dull ache to a stabbing or pulsing sensation. In some cases a radiculopathy can also cause bowel and/or bladder incontinence which may be the sign of a more serious condition known as Cauda Equina syndrome; a true surgical emergency6.

Diagnosis of a disk rupture is made by a doctor through a comprehensive history, physical exam, and neurological exam with supplemental imaging. A definitive diagnosis requires both symptoms consistent with disc herniation (the radiculopathy) and visualization of the herniation by imaging. Conservative treatment is generally prescribed before diagnostic imaging studies are ordered, however, as pain generally does not persist beyond a few weeks7.

The standard for visualizing a ruptured disc is magnetic resonance imaging (MRI) – which is designed to image soft tissue, such as displaced nucleus pulposus and nerve root compression8. Other diagnostic techniques include9:

  • Computed tomography (CT) to be used when MRI isn’t available or possible due to installed metal medical devices
  • X-Ray imaging to rule out other possible causes of pain, such as a tumor or fracture before an MRI is performed
  • Discography to image discs with CT/MRI after contrast has been injected, providing better visualization
  • Nerve conduction tests can be done when isolating affected nerve roots is difficult

A treatment regimen begins with conservative measures, since the majority of cases resolve on their own in under a month6. Below are examples of conservative treatments10, 11.

  • The first choice therapy for long-term management of pain and swelling are over-the-counter anti-inflammatory/pain relief medications such as aspirin, ibuprofen (Advil™) or naproxen (Aleve™)
  • Narcotics/opioids can be prescribed short-term to patients experiencing more severe pain
  • Steroid injections are beneficial in reducing inflammation for longer periods of time
  • Physical therapy may be beneficial in helping strengthen affected muscles and joints thereby improving stability and reducing pain. Traction, a physical therapy technique designed to spread the vertebrae apart and expand inter-vertebral spaces can relieve compression as well
  • Some benefit can come from simply avoiding aggravating physical activity and/or temporary immobilization until symptoms resolve

Surgery may be indicated when conservative treatment fails and pain persists5, 7. The following are selected procedures currently employed by pain management specialists7, 12.

  • With annuloplasty, electro-thermal devices can be implanted to specific areas of the disc to apply temperature changes and decompress the disc
  • Percutaneous/endoscopic disc decompression uses lasers, radio waves, suction and other manual methods through small incisions to decompress the disc
  • Surgical intervention is generally done via open- or micro-discectomy to remove part of the damaged disc and alleviate pressure and pain. Fusion of adjacent vertebral bones is sometimes recommended to prevent recurrent ruptures

New techniques in lower back surgery are currently under investigation as well7. Louisiana Pain Specialists are trained to help patients determine the best, individualized treatment for low back pain. Patients must take time after treatment before resuming any strenuous activities to prevent recurrence5.

It’s always better to prevent injury before it happens. As a ruptured disc is typically the result of a traumatic injury, they can often be avoided by practicing proper safety habits when working, exercising or recreating. It’s a good idea to maintain strong, flexible muscles and practice good posture and proper lifting techniques5.

References

  1. Manchikanti, L. (2000). Epidemiology of Low Back Pain. Pain Physician. Vol 3(2): p. 167-192.
  2. Deyo, R.A.; et al. (1992). What can the history and physical examination tell us about low back pain? JAMA. Vol 268(6): p. 760-5.
  3. Fardon, D.; Milette, P. (2001). Nomenclature and Classification of Lumbar Disc Pathology: Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine. Vol 26, E93-E113.
  4. Hsu, P.; et al. (2011). Lumbosacral radiculopathy: Pathophysiology, clinical features and diagnosis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
  5. Nidus Information Services. (2010). Herniated Disk. Patient Handouts page. MD Consult Web site, Core Collection. Retrieved from www.mdconsult.com.ezproxy2.library.arizona.edu/das/patient/body
  6. Wheeler, S.; et al. (2010). Approach to the diagnosis and evaluation of low back pain in adults. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
  7. North American Spine Society. (2009). Lumbar (open) Microscopic Discectomy. Patient Handouts page. Retrieved from www.knowyourback.org/Pages/Treatments/SurgicalOptions/LumbarDiscectomy
  8. Deen, H.G., Jr. (1996). Diagnosis and management of lumbar disk disease. Mayo Clin Proc. Vol 71(3): p. 283-7.
  9. Milette, P. (1997). The Proper Terminology for Reporting Lumbar Intervertebral Disc Disorders. American Journal of Neuroradiology. Vol 18, 1859-1866.
  10. Robinson, J.; Kothari, M. (2010). Treatment of cervical radiculopathy. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
  11. Chou, R. (2010). Subacute and chronic low back pain: pharmacologic and noninterventional treatment. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
  12. Raj, P. (2008). Intervertebral Disc: Anatomy-Physiology-Pathophysiology-Treatment. Pain Practice. Vol 8, 18-44.