Slipped Disc (Herniated Disc)

Treatment at home will likely include the application of hot or cold packs, limited activity (although strict bed rest is not generally advised), and over-the-counter pain relievers.

What You Should Know About Slipped Discs

• Discs are protective shock-absorbing pads between the bones of the spine (vertebrae). The cushion-like discs between the vertebrae of the spine are also referred to as intervertebral discs. Although they do not actually "slip," a disc may bulge, split, or rupture. This can cause the disc cartilage and nearby tissue to fail (herniate), allowing the central gel portion of the disc to escape into the surrounding tissue. This protruding, jelly-like substance can place pressure on the spinal cord or on an adjacent nerve to cause symptoms of pain, numbness, or weakness either around the damaged herniated disc or anywhere along the area supplied by that nerve.
• Seek medical care for any back or neck pain that limits activity, last for a few days, is accompanied by chest pain, abdominal pain, fever, loss of bladder control, numbness, or weakness.
• Treatment may incorporate the use of ice packs, physical therapy, massage, exercise, and sometimes surgical repair.

Many people experience no symptoms from a herniated disc, and the majority of people who have herniated discs do not need surgery.

The layman's term slipped disc is, therefore, a misnomer and actually refers to a condition whereby portions of an abnormal, injured, or degenerated disc have protruded against adjacent nerve tissues. This condition is also known as a slipped disk, herniated disc, ruptured disc, or prolapsed disc. The most frequently affected area is in the low back, but any disc can rupture and become herniated, including those in the neck. The spinal nerves and spinal cord are vulnerable to disc herniation in the neck, middle back, and low back.

Cross-section (side view picture) of herniated disc between L4 and L5 (the fourth and fifth lumbar vertebrae)

Cross-section (vertical) of lumbar disc herniation into the spinal canal

Causes and risk factors of a slipped disc include:

• Aging with associated degeneration and loss of elasticity of the discs and supporting structures
• Injury from improper lifting, especially if accompanied by twisting or turning
• Excessive strain associated with physical activities
• Sudden forceful acute trauma, which is an uncommon cause

The nerves of the body exit the spine at each spinal level in the low back, mid back, and neck. A herniated disc can produce symptoms anywhere along the course of that nerve, though the injury and irritation of the nerve are at the spine itself. (This is known as referred pain, as the pain is "referred" from the source of the problem in the spine to the area supplied by the affected nerve.) A slipped disc can produce varying degrees of pain in the back or neck along with numbness or weakness in the corresponding organs, arms, or legs as follows:

• For slipped discs in the neck: Neck symptoms and other associated symptoms include numbness, tingling, weakness, or pain in the shoulder, neck, arm, or hand. Symptoms of a herniated disc in the neck often increase or decrease with neck motion.
• For slipped discs in the lower back, back symptoms include
  • Pain down the back of each leg from the buttocks to the knee or beyond (this is called sciatica, as it affects the sciatic nerve)
  • Numbness, tingling, weakness, or pain in the buttocks, back, legs, or feet or all of these as in sciatica
  • Numbness and tingling around the anus or genitals
  • Pain with movement, straining, coughing, or doing leg raises
  • Difficulty controlling bowel movements or bladder function

You should consult with your doctor for the following:

• Neck or back pain significant enough to limit activity
• Back pain that lasts more than a few daysli>
• Neck or back pain associated with numbness or weakness
• Loss of bladder or bowel control
• Fever
• Abdominal or chest pain

Your doctor may suggest an urgent office evaluation or may advise you to go to the hospital's emergency department.

Any injury that may indicate more significant back or neck problems, such as a fall from a height or a direct blow to the spine, should be evaluated at the hospital's emergency department. Consider calling 911 for an ambulance. Medical teams can immobilize the spine and protect against further damage.

You should also seek emergency evaluation if the pain or symptoms are:

• Severe enough to prevent you from walking
• Associated with severe numbness or weakness of any extremity
• Associated with loss of bowel or bladder control
• Associated with symptoms not readily explained by the spine problem (such as fever, abdominal pain, or chest pain)

The doctor will take a complete medical history and perform a thorough physical examination with special emphasis on the neurologic examination.

• This history will include questions about other illnesses, prior spine problems, arthritis, injuries, duration and type of symptoms, and response to treatments. The examination includes a spine examination, testing of basic nerve functions, an abdominal examination, and a general screening.
• Often no diagnostic tests are needed for adequate treatment. In certain situations, imaging studies or laboratory tests of blood and urine may provide your doctor further information necessary to establish a diagnosis. If needed at all, they may not be necessary immediately for a diagnosis. Sometimes they are ordered later if basic treatments fail to improve your condition.
• Imaging studies may include the following:
  • Plain X-rays (and even computerized axial tomography, CAT scans) cannot depict a prolapsed disc and can only identify bony abnormalities. These X-rays are best used to evaluate back pain that is from causes other than a prolapsed disc, such as bony displacement, tumor, or broken bone. Most young or middle-aged people without a history to suggest trauma or suspicion of a tumor are best served without the expense and radiation associated with obtaining these X-rays. In most cases, the bones seen on X-ray are normal.
  • More specialized tests include magnetic resonance imaging (MRI) or myelogram (which involves injecting a contrast dye into the spinal column). These are ideal for diagnosing a deformed disc and how a specific nerve is affected. In the absence of signs or symptoms suggesting severe nerve damage, however, these studies are very rarely necessary early in the course of the evaluation. This is because of the fact that the findings rarely affect initial treatment decisions. Your doctor may obtain these tests after a course of treatment fails to provide you relief over a period of 4 to 6 weeks.
  • A bone scan can detect infection, healing fractures, or tumors. This test is rarely ordered as part of an emergency evaluation but may be part of a further evaluation to find the cause of your symptoms.

A minor slipped disc can be handled at home in consultation with your doctor, and many nonsurgical treatment options are available. Treatment at home will likely include application of hot or cold packs, limited activity (although strict bed rest is not generally advised), and over-the-counter pain relievers such as acetaminophen (Tylenol), naproxen (Aleve), and ibuprofen (Advil, Motrin). As your condition improves, medical professionals may suggest specific neck or back stretching or strengthening exercises.

Physician specialties that evaluate and treat slipped discs range from generalists to subspecialists. These specialties include general medicine, family medicine, internal medicine, gynecology, orthopedics, neurosurgery, rheumatology, pain management, and physiatry.

Other health care providers for low back pain include physical therapists, chiropractors, massage therapists, psychologists, and acupuncturists.

Treatment for a slipped disc often involves rest or limited activity for several days followed by a gradual increase in activity over the next few weeks. Strict bed rest is generally not advised because people with back pain have been shown to recover more quickly with normal activity while lifting, bending, and straining are limited.

Apply ice or cold packs early after an injury and switch to heat later. Heat may be used early if the pain and symptoms are not caused by a sudden injury.

Physical therapy, exercise, and massage can be helpful if indicated (always check with your doctor before resuming any stressful activity). Physical therapy can also be used to guide gradual activity and exercise after surgical repair of disc herniation.

• Anti-inflammatory medications, such as ibuprofen (Motrin) and others, may be recommended. These can generally be safely taken with acetaminophen (Tylenol) as home remedies for a slipped disc.
• Medicines to relax the surrounding muscle tightness and spasms are sometimes used (cyclobenzaprine, [Flexeril], or diazepam [Valium]).
• A short course of a medical steroid (corticosteroids, similar to cortisone), such as prednisone, prednisolone, and methylprednisolone (Medrol), also may be used.
• Injections of cortisone (Depo-Medrol, Kenalog) can help suppress the inflammation and therefore the associated pain.
• Narcotic medication is sometimes added for a short period of time for pain relief.
• Sometimes, drugs that treat "nerve pain" such as gabapentin (Neurontin), pregabalin (Lyrica), or tramadol (Ultram) can help relieve the pain.

If the medical measures are not successful within a reasonable time (6 weeks or more), and the tests confirm a herniated disc as the source of symptoms, a patient may need surgical repair. Except in extreme situations or in those who have a high potential for permanent nerve damage, surgery is not considered early. Neck surgery and back surgery are serious procedures and are considered under specific situations where unrelenting pain and risk of permanent damage to nerve tissue exists. Frequently, time and basic spine care resolve most slipped disc symptoms without the need for operation.

Several surgical options exist ranging from microdiscectomy to open surgical operations. Appropriate options of treatment must be individualized and depend on many underlying conditions, as well as the current nature of the spine. Your doctor will refer you to a spine surgical specialist (an orthopedic or neurosurgeon) to discuss which option is best for you and what the likelihood of success will be.

Follow your instructions carefully and do not overexert yourself too soon. Your initial treatment plan may need to be extended or modified based on your response.

• Regular exercise can improve the overall strength and tone of the supporting muscles and structures. Low back exercises are particularly important to prevent recurrent back injury.
• Use proper techniques while performing strenuous exercise and strenuous work, including lifting. Lifting should be done with the legs performing the work, not the back. The worst possible combination of activities for your spine is heavy lifting while bending and twisting simultaneously.
• Use of a spine brace during heavy lifting may be advised. Its proper use is to keep your back straight and encourage proper lifting technique. It should not be used as a substitute for proper technique or to encourage you to exceed safe lifting limits.
• If the patient is overweight, losing weight can help decrease the back pain.

The vast majority of disc problems improve without any surgical intervention. Most people are able to return to normal function (with emphasis on protecting the spine from recurrent or new injury) within a short time. It is not unusual for similar symptoms to return in the future, however. Therefore, long-term maintenance exercise regimens are recommended for prevention of reinjuring a slipped disc.