Spinal disc herniation
The herniated disc (Latin prolapsus nuclei pulposi, Discushernie, prolapsed disc, herniated disc also, BSP ) is a disease of the spine, where parts of the intervertebral disc into the spinal canal - the room in which the spinal cord is - step forward. In contrast to the disc protrusion ( bulging ) at the prolapse of the fiber annulus of the intervertebral disc ( annulus fibrosus ) is torn completely or partially, while the posterior longitudinal ligament ( posterior longitudinal ligament ) may remain intact (so-called subligamentous herniated disc ).
The cause is often overloaded with pre-damage of the intervertebral discs, but a herniated disc can occur even without external cause. Symptoms of herniated disc are strong, often radiating into the extremities pain, often with a feeling of numbness in the area supplied by the pinched nerve root, sometimes paralysis. Treatment is usually conservative possible serious incidents must be treated surgically.
The fact that a herniated disc is the cause of nerve root compression, was first published in 1934 by the neurosurgeon William Jason Mixter ( 1880-1958 ) and the orthopedic surgeon Joseph Seaton Barr ( 1901-1963 ) described that for the first time suggested a laminectomy as surgical treatment.
- 5.1 Surgical treatment
Causes
Intervertebral discs are bradytrophic tissue, that is, they are not powered directly from the bloodstream out with nutrients but by diffusion. This play semipermeable membranes which separate the cartilaginous rings of each other, the decisive role. These membranes by shearing forces can tear, thereby losing their function and the disc in addition to the nucleus pulposus of the intervertebral disc ( nucleus pulposus ), dry (black disc lesion ). When it comes to a herniated disc, the nucleus pulposus is practically no longer exists in its original form. So the herniated disc occurs most often on the bottom of a long-term pre-damage of the intervertebral disc. The nucleus pulposus (about 80 % water) is in the healthy disc from a jelly-like, cell- poor tissue and accepts load together with the cartilage rings and the membranes of the function of a hydraulic ball ( " water cushion "). The vertebral bodies and intervertebral discs in front, allow, together with the small vertebral joints back ( " facet joints " ), the high mobility of the entire spine and its high stability.
The human spine has 23 discs. Between the first vertebra ( atlas lat. ) - counted from the top - and the second vertebra (axis ) no disc is formed. Thus the head in pitch (Atlas) and turning ( Axis ) is given the necessary freedom of movement. In addition, focus there essential nerves and the blood supply to the head.
There are several causes of a herniated disc: lying genetic weaknesses, one-sided loads or a weakness of the paraspinal, that is beside the vertebrae, muscles. The only accident or injury-related damage to the intervertebral disc has not yet been proven as the cause - the contradictory arguments are of professional associations and social courts rarely recognized. Healthy intervertebral disc tissue is according to common opinion, if any, to tear with a piece of bone composed of the vertebral bodies. Often a herniated disc occurs during pregnancy. Another cause, which favors the prolapse of intervertebral discs, is the upright carriage of man. There are many old people of over 90 years who have never had complaints on the spine or the discs in their busy lives. In contrast, there are children who had already suffered a herniated disc.
Possible reasons for the rapid increase of herniated discs at the present time are lack of exercise and poor posture, especially for office work. In some studies, an increased risk for obesity could be detected by body mass index compared with disc disease. In a Finnish study showed a 2- fold increased risk of hospitalization for intervertebral disc disease even with a BMI > 27.5 kg / m².
Furthermore, a study revealed that in the disc tissue from ( operated ) patients often viruses of the herpes class were detectable with incident compared to a control group. Reactivation of surviving in the disc tissue virus (cause: a herpes infection in childhood, in which the spinal discs still have blood vessels), which then contribute to the degeneration of the tissue is suspected.
The average age at diagnosis is 40 years, which are most commonly affected vertebrae in the lumbar region. Less commonly affected are the cervical vertebrae and very rarely the thoracic vertebrae. The ratio is about 100 to 10 to 1
Recent reports suggest that the severe pain may not go back for pinched nerve, but to an immune response and inflammation.
Symptoms
Many disc herniations are asymptomatic and require no treatment. In older healthy patients herniated discs are detected as an incidental finding, for example, in about 60 % of cases. It is therefore important to determine, prior to therapy, whether it is possible the patient's complaints explained by the affected intervertebral disc.
Typically, herniated discs causing back pain ( lumbago ) with or without radiation to the legs ( sciatica) or in the arms ( brachialgia ). Depending on the severity of the symptoms it can also lead to a numbness or a muscle failure in the supply area of the pinched nerve root.
A herniated disc can lead to a positive Lasègue sign and Kernig's sign. In extreme cases it can lead to a cross-section syndrome, characterized, for example, a chair and / or urinary incontinence, as well as a saddle anesthesia occur.
Red Flags
Red flags are clues that point to an urgent need for action.
Red flag symptoms, according to the AWMF guideline are:
- Current accident
- Known osteoporosis with minor trauma
- Tumor history
- Infection
- Weight loss
- Fever
- Increased pain at night
- Progressive nerve deficits
- Easing pain with a significant paresis
- Cauda equina syndrome
- Voiding dysfunction (typically urinary retention, overflow incontinence, incontinence if applicable )
Diagnostics
A herniated disc can be diagnosed by MRI. As an alternative method, a herniated disc can also be detected by CT.
After the examination, a neurological experienced physician should determine whether the ascertained changes may explain the patient's symptoms or whether it is just a random finding.
Differential Diagnosis
- Peripheral arterial disease ( Typically smokers. Complaint increase when walking )
- Spinal stenosis ( Typically increasing discomfort when walking )
- Hüftverschleiß ( Typically, increased pain during rotation in the hip)
- Iliosakralgelenksarthrose ( Typically Pressure Sensitive )
- Facet joint osteoarthritis ( Typically, only local back pain without radiation to the arms or legs)
- Neuroforaminale stenosis (eg Facettengelengsarthrose )
- Postoperative scar tissue
- Bannwarth's syndrome ( disease cases with painful inflammation of peripheral nerves)
Treatment
With preserved mobility is recommended to return as soon as possible to normal activities. A Bed rest is not recommended, since this no treatment effect was detected.
In the absence of mobility an effective drug pain therapy should be performed early.
A hospital admission should be done at Red Flags (see symptoms), outpatient uncontrollable pain and increasing neurological deficits.
Heat therapy, massage with exercise therapy, electro therapy, deep tissue massage can help relieve the symptoms in individual cases. The benefits can, however, prove not scientific in some cases.
Manual medicine ( chiropractic, spinal manipulations ) are contraindicated in radiating pain. In acute non- radiating pain therapy within the first 4-6 weeks can be helpful.
Among the many therapeutic and diagnostic approaches are also the Alexander Technique, Hatha Yoga, the McKenzie approach, the spiral dynamics and acupuncture.
A behavioral therapy is helpful in terms of coping with pain in chronic back pain.
Both conservative treatment (physiotherapy - Chiropractic - stretching devices) as well as the less frequent removal of the pressing on the nerve root disc part by means of an operation can lead to success in terms of the relief of the nerve root. Even so-called minimally invasive surgery and microsurgical procedures such as percutaneous laser disc decompression ( PLDD ), are mentioned in this context. Even more rarely, a stiffening of adjacent vertebral body through which is introduced metal material takes place (spondylosis ).
In patients who suffer from back pain radiating into the leg, chronic complaints, the so-called back exercises can be helpful.
The periradicular therapy ( PRT) is a method in the under CT or X-ray inspection cortisone is injected to the affected nerve root, which should be done at least 2x. In 67 % of cases can thus be achieved with a herniated disc pain relief. In Germany, the investigation in health patients is usually not paid by the statutory health insurance. If necessary. going over the costs if a pain therapist patient transfers to the radiologist.
Surgical treatment
Because of the high complication rate, a strict indication for surgery.
Clear indications for surgery, according to AWMF guideline are:
- Cauda equina syndrome with acute paraparesis in extensive herniated disc or a vertebral fracture.
- Bladder and bowel paralysis
- Increasing or acute encountered severe muscle loss
An operation can be performed as a last attempt, when all non-surgical procedures have been tried and the pain can not be still endure.
Complications are not limited to:
- Frequently postoperative scarring, which can pinch the nerve root or the dural sac, for example.
- Frequently Reprolaps / recurrence
- Z. T. severe infection possibly with abscess formation
- Liquorleckage ( CSF) in violation of the dura, for example, with severe headache
The recurrence rate in the microsurgical OP is> 10%.
Implantation of artificial intervertebral discs for pain therapy (2005 ) critically evaluated.
In 2013 the AOK hospital report has shown that the number of disk operations has doubled between 2005 and 2010.
The SPORT trial ( SPORT = Spine Patient Outcomes Research Trial) came to the conclusion that in persistent sciatica due to a herniated disc surgery, even after 8 years, brings an advantage over conservative treatment. Because of the difficult allocation to the different treatment groups and the summary of a number of different studies to a large study, there is some room for interpretation.
Prevention
Since the so-called " connective tissue " as the primary cause is hereditary, can be a herniated disc only partially prevented by building muscle. The prevention of accidents can not always be achieved. So remains for every individual in any case the possibility of a consistent muscle building in the back with gymnastic exercises or sports, and the avoidance of lifting heavy loads. There are to-learn techniques to cope with heavy loads " back-friendly ", but the avoidance of such actions is not in any profession (eg nursing) possible.
Bodybuilding and fitness training can be problematic because misalignments are there not always recognized in studios with less qualified personnel.
Also worth mentioning are the " orthopedic sports ", swimming, dancing, running (or jogging, Nordic walking ), horse riding and cycling, which enables it to run build muscle, important for vertebral discs changing pressure loads. Whether after a herniated disc sports such as horse riding or running ( on asphalt / cemented surface) as well as cycling in strongly bent position to avoid necessarily, is always dependent on the individual type of damage according to the findings of modern sports medicine.
An important measure for the prevention of a herniated disc is the proper workplace ergonomics. This is in addition to the physical work also for activities that are performed in a sitting position. Nowadays there are many ergonomic solutions for work on the screen at a desk and work, which require long static sitting positions. Since the disc is not supplied by blood vessels, it relies on alternating pressure load to replace the nutrient solution, thus static sitting positions should be avoided.