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Category: Orthopedics
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createdon: 16 Jun 2023
updatedon: 16 Jun 2023

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Author: Khoa Tran
Published Jun 16, 2023
Updated Jun 16, 2023

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Herniated Disc

Etymology and Pronunciation

herniated (her-nee-ey-tid)
hernia - Latin for "a rupture"

History of Herniated Disc

The ancient Egyptians and Greeks also recognized a connection between spinal disorders and lower extremity symptoms. Hippocrates, a prominent figure in ancient Greek medicine, observed the correlation between an altered posture to relieve pain, and claudication. Hippocrates prescribed rest, massage, heat, dietary adjustments, and even music for treatment.

By the fourth century, Caelius Aurelianus presented illustrations depicting the spinal column and intervertebral disc spaces. Treatment options included bed rest, massage, heat therapy, and passive range of motion exercises. In severe cases with muscle wasting, interventions such as leeches, hot coals, skin hooks, and blood-letting were employed.

In the early 1700s, our knowledge about the clinical entity known as lumbar disc herniation (LDH) began to emerge. However, references to sciatica, a common symptom of LDH, can be traced back to ancient times. The first surgeries to address spinal "enchondromas," likely herniated discs, were performed in the early 1900s. It wasn't until the 1930s that modern discectomy surgery, as we know it today, was introduced by Mixter and Barr.

It was in the seventh century when Paulus of Aegina first mentioned the possibility of spine surgery, although his focus was primarily on spine trauma. He described sciatica as pain radiating from the buttock and groin to the knee and, in some cases, extending to the foot. Conservative approaches were favored initially, but for chronic cases, cauterization of the hip in multiple places was recommended to prevent dislocation.

In 1911, Goldthwait and Osgood proposed that a protruding disc could be the cause of lower extremity paresis. Based on this understanding, Harvey Cushing performed a surgery that successfully resolved the patient's cauda equina syndrome. Interestingly, Cushing's surgery turned out to be a negative exploration, as Goldthwait suggested that the disc had "slipped back into place."

During the 1920s, German pathologist Christian Georg Schmorl studied thousands of spines and identified herniations of disc material into the vertebral body and spinal canal. While these findings didn't initially carry clinical significance, the term "disc herniation" gained popularity in parts of Europe influenced by German literature. In English-speaking countries, alternative terms such as disc collapse, retropulsion, and rupture became more commonly used.

In 1929, American neurosurgeon Walter Dandy reported two cases of lumbar surgery for back and leg pain. During the surgeries, loose cartilaginous fragments were discovered in the epidural space. Dandy attributed this process to osteochondritis dissecans resulting from trauma, with the fragments acting as sequestra. A. G. Smith is also credited with performing the first discectomy procedure in the United States.

In 1930, at the Surgical Academy of Paris, Alajouanine and Petit-Dutaillis presented a case involving sciatica associated with an intraspinal lesion at L5-S1. They suggested that the lesion, previously believed to be a tumor, was actually a herniation of the nucleus pulposus.

In 1932, neurosurgeon Mixter and orthopedic surgeon Barr performed the first surgery with a preoperative diagnosis of "ruptured intervertebral disc". The surgery involved an L2 to S1 laminectomy on a 28-year-old patient who displayed classic signs of nerve root compression. A 1-cm mass was removed, resulting in complete resolution of the patient's radicular symptoms. This case, along with comparisons between disc tissue and samples from other specimens, led Barr and pathologist Charles S. Kubik to conclude that there was no difference between them.

In 1934, Mixter and Barr presented a correlation between disc prolapse and the clinical syndromes associated with nerve and cord compression. They advocated for a surgical approach, gaining traction in the medical community with the diagnosis of a "ruptured" disc. Mixter promoted the use of a pituitary rongeur to access the disc space. Barr later reported a larger series of 35 patients and was one of the first to identify preexisting degeneration as a contributing factor in disc herniations. There is some debate regarding the contributions of Dandy, Mixter

By the 1940s, the term "herniation of the nucleus pulposis" gained favor and continues to be used today, although it inadequately describes the histology of the displaced elements, especially in older patients with degenerated discs. Alternative terms such as disc prolapse and intervertebral disc herniation are also commonly used.

In the early 1970s, surgery was commonly offered to patients even in the very early stages of acute symptoms. However, by the 1980s, the favorable natural history of most patients with lumbar disc herniation (LDH) started to gain recognition. Seminal papers by Weber and Hakelius compared long-term outcomes between surgically and nonsurgically managed patients. Weber's study showed that after 10 years, 60% of both groups were free of pain, with earlier relief seen in the surgical group. Hakelius' study, which involved 583 patients, found no differences between the surgical and nonsurgical groups at 6 months. However, operatively treated patients experienced fewer episodes of low back pain, sciatica, and missed work at 7 years.

Following Weber's studies, a 4- to 8-week trial of "conservative care" before considering surgery became the typical recommendation. Conservative care included various nonoperative approaches such as bedrest, medications, physical therapy, injections, and lumbar traction. Spinal traction, used since the Middle Ages, aimed to correct the "curvature" associated with radiculopathy and later theorized to promote regression of the herniated disc or improve disc nutrition or radicular blood flow. 

In the 1990s, histopathologic and immunochemical studies revealed that in migrated or extruded disc herniations, the displaced disc material could undergo phagocytosis by macrophages in the epidural tissue or arriving from epidural veins.

While early studies emphasized the role of trauma in LDH, research in the 1980s and 1990s increasingly identified a strong genetic susceptibility to both disc herniation and degeneration. Although fully protective strategies remain elusive, our understanding of the pathophysiology and genetics of disc herniation has improved.

Studies in the 1980s and 1990s began to shed light on the mechanisms of pain generation from disc herniations. These mechanisms include the variable impact of mechanical pressure on the nerve roots and dorsal root ganglia, their blood supply, and their nutritional transport systems. Prior to 1947, the lumbar disc was considered a nerve-free and painless structure. However, Inman and Saunders' discovery of pain fibers in the annulus that year challenged this belief.

In the early 20th century, advancements in imaging technology allowed for better visualization of the spinal column. In 1929, a technique called myelography was developed, which involved injecting a dye into the spinal canal and taking X-rays to see if the dye leaked out of the spinal canal. This technique was helpful in diagnosing herniated discs.

Further advancements in imaging technology in the latter half of the 20th century, including computed tomography (CT) and magnetic resonance imaging (MRI), have enabled even more accurate diagnosis of herniated discs. CT scans use X-rays and computer technology to produce detailed images of the spinal column, while MRI uses strong magnets and radio waves to create highly detailed images of the spine and surrounding structures.

Modern Understanding of Herniated Disc

A herniated disc is a condition that affects the spine. The spine is made up of a series of bones called vertebrae, and each of these bones has a soft, cushiony disc between them. A herniated disc occurs when the soft, inner part of the disc pushes out through the tough outer layer.

When a disc herniates, it can put pressure on nearby nerves. This pressure can cause pain, tingling, numbness, or weakness in the body. Symptoms can vary depending on which part of the spine is affected.

A herniated disc can occur in the neck, upper back, or lower back. It is more common in the lower back because this area of the spine supports most of the body's weight.

There are several factors that can increase your risk of developing a herniated disc. These include age, genetics, obesity, and poor posture. However, anyone can develop a herniated disc, even if they have no known risk factors.

Causes of Herniated Disc

A herniated disc, also known as a slipped or ruptured disc, occurs when the soft center of a spinal disc protrudes through a tear in the tough outer layer. This condition can be caused by a variety of factors including:

- Age: As we age, the discs in our spine lose elasticity, making them more susceptible to herniation.
- Injury: Trauma to the spine, such as from a car accident or sports injury, can cause a disc to herniate.
- Repetitive stress: Performing the same motions repeatedly, such as heavy lifting, twisting, or bending, can cause the disc to wear down and eventually herniate.
- Obesity: Being overweight puts extra pressure on the spine, which can lead to herniated discs.
- Genetics: Some people are born with a predisposition to herniated discs due to genetic factors.

It's important to note that not all herniated discs cause symptoms, and some may be asymptomatic. If you are experiencing pain or other symptoms, it's important to see a healthcare provider for proper diagnosis and treatment.

Treatments for Herniated Disc

- Pain medications: Over-the-counter pain relievers such as acetaminophen, ibuprofen, and naproxen can help relieve pain caused by a herniated disc. Prescription-strength painkillers may be required in severe cases.
- Physical therapy: Physical therapy is often recommended to help reduce pain and improve mobility. A physical therapist may create an exercise program that aims to strengthen the muscles supporting the spine and improve flexibility.
- Injections: Corticosteroid injections can help reduce inflammation and relieve pain in some cases.
- Surgery: Surgery may be recommended in severe cases where other treatments have not provided relief. The most common surgical procedure for a herniated disc is a discectomy, which involves removing the portion of the herniated disc that is pressing on the nerves.

Lifestyle Changes

- Exercise regularly: Engage in low-impact exercises that strengthen the back and core muscles, such as walking, swimming, or cycling. Avoid high-impact activities that can worsen the condition.
- Maintain good posture: Practice proper posture while sitting, standing, and lifting heavy objects. Use ergonomic chairs and supportive pillows to provide adequate lumbar support.
- Lift objects correctly: When lifting heavy objects, bend your knees and use your leg muscles rather than straining your back. Hold the object close to your body and avoid twisting movements.
- Weight management: Maintain a healthy weight to reduce stress on the spine and decrease pressure on the herniated disc.
- Quit smoking: Smoking can impair blood circulation and hinder the healing process. Quitting smoking can improve overall health and aid in recovery.
- Modify daily activities: Avoid prolonged sitting or standing and take regular breaks to stretch and move around. Use proper body mechanics during activities such as bending, reaching, or lifting.
- Use proper body mechanics during sleep: Choose a supportive mattress and pillow that promote proper spinal alignment while sleeping. Side sleeping with a pillow between the knees or back sleeping with a pillow under the knees may help.
- Physical therapy: Engage in prescribed physical therapy exercises that aim to strengthen the surrounding muscles, improve flexibility, and alleviate pain.
- Practice stress management: Chronic stress can exacerbate pain. Incorporate stress management techniques such as meditation, deep breathing exercises, yoga, or engaging in hobbies to relax and reduce tension.
- Avoid repetitive activities: Minimize repetitive motions or activities that strain the spine, such as heavy lifting, prolonged sitting, or activities that involve twisting or bending.

Remember, it's essential to consult with a healthcare professional or physical therapist to determine the most appropriate lifestyle changes for your specific condition and to receive personalized guidance.

Symptoms

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Radiating pain or numbness that travels down one or both legs or arms
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Difficulty standing, sitting, or walking for prolonged periods
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Pain in the affected area, such as the neck or lower back
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Weakness, cramping, or numbness in the legs
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Pain in lower back, legs, or arms
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Back pain
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Muscle spasms
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Muscle Weakness

Confirmation Tests

- CT scan
- MRI
- X-rays

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