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- A protrusion may occur where a disk bulges without rupturing the annulus fibrosis.
- The disk may prolapse where the nucleus pulposus migrates to the outermost fibers of the annulus fibrosis.
- There may be a disk extrusion, which is the case if the annulus fibrosis perforates and material of the nucleus moves into the epidural space.
- The sequestrated disk may occur as fragments from the annulus fibrosis and nucleus pulposus are outside the disk proper.
Causes and symptoms
Symptoms depend upon the location and the extent to which the disk material has been pushed out. Most cases involve the disks between the fourth and fifth lumbar vertebrae or between the fifth lumbar vertebra and the sacrum. There is severe pain in the lower back and difficulty in walking. The sciatic nerve, which originates in the lower part of the spinal cord, is affected, with resulting pain at the back of the thigh and lower leg. A cough, sneeze, or strain will send the pain along the course of the sciatic nerve to the calf or ankle. When the disks of the cervical vertebrae are affected, severe pain in the back of the neck radiates down the arms to the fingers. Neck movements are restricted, and any neck motion, such as coughing, sneezing, or straining, will accentuate the pain.
Treatment varies according to the seriousness of the condition. Conservative treatment for a herniated disk in the lower back consists of bed rest with leg- and back-strengthening exercises, as well as muscle relaxants and analgesics to relieve pain. Pelvic traction may be applied. In chronic cases the wearing of a surgical support may be helpful. Care must be taken to avoid aggravating the condition by excessive physical effort. Herniated disks in the neck are treated in a similar manner with bed rest, analgesics, anti-inflammatory agents, and traction. A collar may be worn to immobilize the neck when the patient is out of bed. If the response to these measures is inadequate or if the condition becomes disabling, surgery may be necessary to relieve the pressure on the injured disk. microdiskectomy is a newer surgical technique that is minimally invasive. Another treatment is chemonucleolysis, in which an enzyme that causes shrinkage in the size of the disk is injected into the herniated nucleus pulposus.
herniated diskHerniated intervertebral disk, herniated nucleus pulposus, prolapsed intervertebral disk, slipped disk Neurology The herniation of an intervertebral disk, most commonly, lumbar; the term herniation in this context describes a spectrum of disk defects
|Mean LOS:||4.5 days|
|Description:||SURGICAL: Back and Neck Procedures Except Spinal Fusion With CC or Major CC or Disc Device/Neurostim|
|Mean LOS:||3.9 days|
|Description:||MEDICAL: Medical Back Problems Without Major CC|
The intervertebral disk is a complex structure situated between vertebrae; it provides additional structural support to the spinal column and cushions the vertebrae. The outer layer of the disk contains numerous concentric rings of tough, fibrous connective tissue called the annulus fibrosus. The central portion of the disk consists of a softer, spongier material called the nucleus pulposus. If the annulus fibrosus weakens or tears, then the nucleus pulposus may “slip” or herniate outward, creating the condition known as a “slipped disk,” or more precisely, herniated nucleus pulposus. When the disk material herniates, it can compress the spinal cord or the nerve roots that come from the spinal cord. Of herniations, 90% usually occur in the lumbar and lumbosacral regions, 8% occur in the cervical area, and 1% to 2% occur in the thoracic area. The disk between the fifth and the sixth cervical vertebrae is involved most frequently.
Disk herniation is often seen in individuals who have had previous episodes of back problems; however, a herniation may occur without such a history. Repeated episodes are thought to weaken the annulus fibrosus. Heavy physical labor, including repetitive bending, twisting, and lifting, is a risk factor for herniated disk, especially if combined with weak abdominal and back muscles or poor body mechanics. Advancing age produces desiccations of the disk and friability of the annulus, which can increase the likelihood of injury.
While disk herniations are the result of trauma, various genetic factors may increase a person’s susceptibility to injury. Twin studies have supported the contribution of genetic factors to back and neck pain reporting in women. Associated factors include both genetic determinants of structural disk degeneration and genetic determinants of psychological distress.
Gender, ethnic/racial, and life span considerations
Disk herniations most often occur in adults, with a mean age at surgery of 40. Men are affected more often than women, and the highest incidence is in men ages 30 to 60. There are no known racial and ethnic considerations.
Global health considerations
No data are available.
Establish a history of back pain, including a description of the location and intensity of the pain. Often, the symptoms are of a gradually progressing nature over a period of days to weeks. The development and distribution of extremity pain help determine the level of the involved disk. Ask about weakness in the extremities, altered sensation, or muscle spasms; ask if pain intensifies during Valsalva’s maneuver, coughing, sneezing, or bending. Establish a history of sensory and motor loss in the area that has been innervated by the compressed spinal nerve root.
The most common symptoms is back pain exacerbated by activity. Document any gait abnormalities, such as a limp. Test the patient’s deep tendon reflexes in the upper and lower extremities. Perform a sensory evaluation of the patient’s sharp-dull and fine-touch discrimination. Motor strength testing of the involved extremities is also important, again to determine the extent of injury to the spinal cord or nerve roots. Perform range-of-motion studies of either the cervical, the thoracic, or the lumbar regions. Conduct stretch tests for nerve root irritation, including the straight leg-raise test; if the sciatic nerve is irritated, there will be pain in the involved leg. Braggart’s test, passive stretching of the foot in dorsiflexion, is positive if it elicits pain along the sciatic nerve distribution. The “bow string” sign is performed with the patient sitting and the knees flexed just beyond a 90-degree angle and the body bent slightly forward to increase the stretch on the sciatic nerve. A positive response occurs when gentle pressure with the examiner’s finger into the popliteal space further stretches the sciatic nerve, producing more pain. Check the patient’s peripheral vascular status, including peripheral pulses and skin temperatures, to rule out ischemic disease, another possible cause of leg pain and numbness.
The individual may be unexpectedly debilitated. The assessment should include an evaluation of the patient’s ability to deal with unexpected changes in lifestyle, roles, and income. Along with severe pain, an employed person may be facing a prolonged period of disability and reduced income.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Magnetic resonance imaging is the diagnostic test of choice; computed tomography scan||Normal bony skeleton and soft tissue||Changes in spinal structure and alignment, deterioration or herniation of soft tissues||Indicates the extent of bony and soft tissue injury and deterioration|
|X-rays||Normal bony skeleton||Changes in spinal structure and alignment||Indicate the extent of bony injury|
Other Tests: Myelography, electromyography
Primary nursing diagnosis
DiagnosisPain (acute) related to inflammation and compression
OutcomesComfort level; Pain control behavior; Pain level; Symptom severity
InterventionsAnalgesic administration; Anxiety reduction; Environmental management: Comfort; Pain management; Medication management
Planning and implementation
medical.Pharmacologic measures are often used to manage symptoms. Physical therapy includes various passive modalities of treatment, such as heat, ice, massage, ultrasound, and electrogalvanic stimulation, often directed by a physical therapist, and exercises to stretch and strengthen the spine and supporting musculature. Spinal adjustments performed by osteopathic or chiropractic physicians can also relieve symptoms. Chemonucleolysis may be used by injecting the enzyme chymopapain into the nucleus pulposus. Ask if the patient is allergic to meat tenderizers, because such an allergy contraindicates the use of chymopapain in the procedure.
surgical.When the medical and pharmacologic treatments are not successful or if the symptoms become debilitating, then surgery is considered. Surgery involves removal of the disk using a microscope. A microdiscectomy removes fragments of the nucleus pulposus. More common is a laminectomy, which removes the protruding disk and a portion of the lamina. A spinal fusion of the bony tissues may be performed if there is evidence that the disk herniation is accompanied by instability of the surrounding tissues. Surgical treatment is usually successful but may involve a prolonged recovery time, especially with more involved procedures.
Postoperatively, enforce bedrest and monitor dressings for excessive drainage. Position the patient depending on the type of surgery performed. Teach the patient who has undergone spinal fusion how to wear a brace. Teach the patient proper body mechanics. Encourage the patient to lie down when she or he is tired and to sleep on her or his side, using an extra firm mattress or bed board. Caution the patient to maintain proper weight because obesity can cause lordosis. Ongoing assessments are important if the patient requires surgery. Monitor the patient for signs of weakness, pain, changes in circulation, and numbness in the extremities. Assess the cardiovascular status of the patient’s legs by observing for color, temperature, and motion. Assess the degree of pain in terms of intensity, location, and character.
|Medication or Drug Class||Dosage||Description||Rationale|
|NSAIDs||Varies with drug||Ibuprofen (Ibuprin, Advil, Motrin); ketoprofen (Oruvail, Orudis, Actron); flurbiprofen (Ansaid); naproxen (Anaprox, Naprelan, Naprosyn)||Reduce acute inflammation|
|Muscle relaxants||Varies with drug||Cyclobenzaprine hydrochloride (Flexeril)||Relieve muscular irritation|
Other Drugs: Narcotic analgesics such as codeine and meperidine are used to control pain. Nonnarcotics (e.g., propoxyphene [Darvon]) may also be used. Acute inflammation is usually treated with either a corticosteroid or NSAIDs.
Place the patient in a semi-Fowler’s position or in a flat position with a pillow between the patient’s legs for side-lying to help reduce the pain. Instruct the patient to roll to one side when sitting up to minimize pain during position changes. Perform active and passive range-of-motion exercises within the prescribed regimen. Keep a schedule of progress to encourage the patient when he or she becomes discouraged and provide an estimate of when the patient will return to normal functioning. Allow the patient to direct or perform self-care. Provide meticulous skin care.
Evidence-Based Practice and Health Policy
Jacobs, W.C., van Tulder, M., Arts, M., Rubinstein, S.M., van Middelkoop, M., Ostelo, R., …Peul, W.C. (2011). Surgery versus conservative management of sciatica due to a lumbar herniated disc: A systematic review. European Spine Journal, 20(4), 513–22.
- The benefits of surgical management to treat symptoms of a lumbar herniated disk have not been substantiated.
- A review of randomized controlled trials (RCT) revealed only two studies with low risk of bias. Neither of these studies found significant differences in the long-term benefits of surgery.
- Investigators of the first RCT, which included 283 patients, found significant decreases in leg pain among surgical patients when compared with those receiving more conservative care (mean difference of 17.7 between the groups; 95% CI, 12.3 to 23.1). Surgical patients were also 1.97 times more likely to report a faster perceived recovery rate compared to nonsurgical patients (95% CI, 1.72 to 2.22; p < 0.001). However, 95% of all the patients experience satisfactory recovery within 1 year of diagnosis.
- In the other RCT, which included 501 patients, there were no statistically significant differences in outcomes for surgical and nonsurgical patients during the 2-year follow-up period.
- Physical findings: Neural and musculoskeletal system assessments, degree of pain, tolerance to activity; presence of postoperative complications (infection, pain, immobility, poor wound healing)
- Response to physical therapy: Work status of the patient, ability to cope with both immobility and inability to return to work
Discharge and home healthcare guidelines
Teach the patient the mechanics of disk function and how herniation occurs. Instruct the patient in proper body mechanics and advise avoiding high-torsion activities, such as twisting and heavy lifting. Discuss an exercise program with the patient as a maintenance program, following the 6-week physical therapy regimen. Be sure the patient understands any medication prescribed, including dosage, route, action, and side effects. Advise the patient against driving or operating heavy machinery if the medications are likely to impair judgment.
Patient discussion about herniated disk
Q. I have a low back pain that radiates to my leg when i pick up stuff. Is it a disc herniation? I am a 43 years old bank teller. During the past 5 months I've suffered from a low back pain. The pain is not very strong, but it gets much worse while doing physical activity. When i walk or lift heavy things the pain is even stronger, and it radiates to my left leg. Can it be signs for disc herniation?
90% or more of herniated discs resolve without surgical treatment within 6 months. MRI imaging is generally only indicated if one is considering surgery; in other words, your pain and neurological status is such that surgery is clinically indicated. Then, an MRI may be helpful for the surgeon. If surgery is not indicated based on clinical/symptoms, then it probably is unwise to get an MRI. They often show abnormalities that are simply 'red herrings' and often prompt people to proceed with surgery that really is not needed. Beware!