herniated disk

Herniated Disk

 

Definition

Disk herniation is a rupture of fibrocartilagenous material (annulus fibrosis) that surrounds the intervertebral disk. This rupture involves the release of the disk's center portion containing a gelatinous substance called the nucleus pulposus. Pressure from the vertebrae above and below may cause the nucleus pulposus to be forced outward, placing pressure on a spinal nerve and causing considerable pain and damage to the nerve. This condition most frequently occurs in the lumbar region and is also commonly called herniated nucleus pulposus, prolapsed disk, ruptured intervertebral disk, or slipped disk.

Description

The spinal column is made up of 26 vertebrae that are joined together and permit forward and backward bending, side bending, and rotation of the spine. Five distinct regions comprise the spinal column, including the cervical (neck) region, thoracic (chest) region, lumbar (low back) region, sacral and coccygeal (tail-bone) region. The cervical region consists of seven vertebrae, the thoracic region includes 12 vertebrae, and the lumbar region contains five vertebrae. The sacrum is composed of five fused vertebrae, which are connected to four fused vertebrae forming the coccyx. Intervertebral disks lie between each adjacent vertebra.

Each disk is composed of a gelatinous material in the center, called the nucleus pulposus, surrounded by rings of a fiberous tissue (annulus fibrosus). In disk herniation, an intervertebral disk's central portion herniates or slips through the surrounding annulus fibrosus into the spinal canal, putting pressure on a nerve root. Disk herniation most commonly affects the lumbar region between the fifth lumbar vertebra and the first sacral vertebra. However, disk herniation can also occur in the cervical spine. The incidence of cervical disk herniation is most common between the fifth and sixth cervical vertebrae. The second most common area for cervical disk herniation occurs between the sixth and seventh cervical vertebrae. Disk herniation is less common in the thoracic region.

Predisposing factors associated with disk herniation include age, gender, and work environment. The peak age for occurrence of disk herniation is between 20-45 years of age. Studies have shown that males are more commonly affected than females in lumbar disk herniation by a 3:2 ratio. Prolonged exposure to a bent-forward work posture is correlated with an increased incidence of disk herniation.

There are four classifications of disk pathology:

• 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

Any direct, forceful, and vertical pressure on the lumbar disks can cause the disk to push its fluid contents into the vertebral body. Herniated nucleus pulposus may occur suddenly from lifting, twisting, or direct injury, or it can occur gradually from degenerative changes with episodes of intensifying symptoms. The annulus may also become weakened over time, allowing stretching or tearing and leading to a disk herniation. Depending on the location of the herniation, the herniated material can also press directly on nerve roots or on the spinal cord, causing a shock-like pain (sciatica) down the legs, weakness, numbness, or problems with bowels, bladder, or sexual function.

Diagnosis

Several radiographic tests are useful for confirming a diagnosis of disk herniation and locating the source of pain. These tests also help the surgeon indicate the extent of the surgery needed to fully decompress the nerve. X rays show structural changes of the lumbar spine. Myelography is a special x ray of the spine in which a dye or air is injected into the patient's spinal canal. The patient lies strapped to a table as the table tilts in various directions and spot x rays are taken. X rays showing a narrowed dye column in the intervertebral disk area indicate possible disk herniation.

Computed tomography scan (CT or CAT scans) exhibit the details of pathology necessary to obtain consistently good surgical results. Magnetic resonance imaging (MRI) analysis of the disks can accurately detect the early stages of disk aging and degeneration. Electomyograms (EMGs) measure the electrical activity of the muscle contractions and possibly show evidence of nerve damage. An EMG is a powerful tool for assessing muscle fatigue associated with muscle impairment with low back pain.

Treatment

Drugs

Unless serious neurologic symptoms occur, herniated disks can initially be treated with pain medication and up to 48 hours of bed rest. There is no proven benefit from resting more than 48 hours. Patients are then encouraged to gradually increase their activity. Pain medications, including antiinflammatories, muscle relaxers, or in severe cases, narcotics, may be continued if needed.

Epidural steroid injections have been used to decrease pain by injecting an antiinflammatory drug,

A herniated disk refers to the rupture of fibrocartilagenous material, called the annulus fibrosis, that surrounds the intervertebral disk. When this occurs, pressure from the vertebrae above and below may force the disk's center portion, a gel-like substance, outward, placing additional pressure on the spinal nerve and causing pain and damage to the nerve.

(Illustration by Electronic Illustrators Group.)

usually a corticosteroid, around the nerve root to reduce inflammation and edema (swelling). This partly relieves the pressure on the nerve root as well as resolves the inflammation.

Physical therapy

Physical therapists are skilled in treating acute back pain caused by the disk herniation. The physical therapist can provide noninvasive therapies, such as ultrasound or diathermy to project heat deep into the tissues of the back or administer manual therapy, if mobility of the spine is impaired. They may help improve posture and develop an exercise program for recovery and long-term protection. Appropriate exercise can help take pressure off inflamed nerve structures, while improving overall posture and flexibility. Traction can be used to try to decrease pressure on the disk. A lumbar support can be helpful for a herniated disk at this level as a temporary measure to reduce pain and improve posture.

Surgery

Surgery is often appropriate for conditions that do not improve with the usual treatment. In this event, a strong, flexible spine is important for a quick recovery after surgery. There are several surgical approaches to treating a herniated disk, including the classic discectomy, microdiscectomy, or percutanteous discectomy. The basic differences among these procedures are the size of the incision, how the disk is reached surgically, and how much of the disk is removed.

Discectomy is the surgical removal of the portion of the disk that is putting pressure on a nerve causing the back pain. In the classic disectomy, the surgeon first enters through the skin and then removes a bony portion of the vertebra called the lamina, hence the term laminectomy. The surgeon removes the disk material that is pressing on a nerve. Rarely is the entire lamina or disk entirely removed. Often, only one side is removed and the surgical procedure is termed hemi-laminectomy.

In microdiscectomy, through the use of an operating microscope, the surgeon removes the offending bone or disk tissue until the nerve is free from compression or stretch. This procedure is possible using local anesthesia. Microsurgery techniques vary and have several advantages over the standard discectomy, such as a smaller incision, less trauma to the musculature and nerves, and easier identification of structures by viewing into the disk space through microscope magnification.

Percutaneous disk excision is performed on an outpatient basis, is less expensive than other surgical procedures, and does not require a general anesthesia. The purpose of percutaneous disk excision is to reduce the volume of the affected disk indirectly by partial removal of the nucleus pulposus, leaving all the structures important to stability practically unaffected. In this procedure, large incisions are avoided by inserting devices that have cutting and suction capability. Suction is applied and the disk is sliced and aspirated.

Arthroscopic microdiscectomy is similar to percutaneous discectomy, however it incorporates modified arthroscopic instruments, including scopes and suction devices. A suction irrigation of saline solution is established through two entry sites. A video discoscope is introduced from one site and the deflecting instruments from the opposite side. In this way, the surgeon is able to search and extract the nuclear fragments under direct visualization.

Laser disk decompression is performed using similar means as percutaneous excision and arthroscopic microdiscectomy, however laser energy is used to remove the disk tissue. Here, laser energy is percutanteously introduced through a needle to vaporize a small volume of nucleus pulposus, thereby dropping the pressure of the disk and decompressing the involved neural tissues. One disadvantage of this procedure is the high initial cost of the laser equipment. It is important to realize that only a very small percentage of people with herniated lumbar disks go on to require surgery. Further, surgery should be followed by appropriate rehabilitation to decrease the chance of reinjury.

Chemonucleolysis

Chemonucleolysis is an alternative to surgical excision. Chymopapain, a purified enzyme derived from the papaya plant, is injected percutaneously into the disk space to reduce the size of the herniated disks. It hydrolyses proteins, thereby decreasing water-binding capacity, when injected into the nucleus pulposus inner disk material. The reduction in size of the disk relieves pressure on the nerve root.

Spinal fusion

Spinal fusion is the process by which bone grafts harvested from the iliac crest (thick border of the ilium located on the pelvis) are placed between the intervertebral bodies after the disk material is removed. This approach is used when there is a need to reestablish the normal bony relationship between the vertebrae. A total discectomy may be needed in some cases because lumbar spinal fusion can help prevent recurrent lumbar disk herniation at a particular level.

Alternative treatment

Acupuncture involves the use of fine needles inserted along the pathway of the pain to move energy locally and relieve the pain. An acupuncturist determines the location of the nerves affected by the herniated disk and positions the needles appropriately. Massage therapists may also provide short-term relief from a herniated disk. Following manual examination and x-ray diagnosis, chiropractic treatment usually includes manipulation to correct muscle and joint malfunctions, while care is taken not to place an additional strain on the injured disk. If a full trial of conservative therapy fails, or if neurologic problems (weakness, bowel or bladder problems, and sensory loss) develop, the next step is usually evaluation by an orthopedic surgeon.

Key terms

Annulus fibrosis — The outer portion of the intervertebral disk made primarily of fibrocartilage rings.

Epidural space — The space immediately surrounding the outermost membrane of the spinal cord.

Excision — The process of excising, removing, or amputating.

Fibrocartilage — Cartilage that consists of dense fibers.

Nucleus pulposus — The center portion of the intervertebral disk that is made up of a gelatinous substance.

Percutaneous — Performed through the skin.

Prognosis

Only 5-10% of patients with unrelenting sciatica and neurological involvement, leading to chronic pain of the lumbar spine, need to have a surgical procedure performed. This strongly suggests that many patients with herniated disks at the lumbar level respond well to conservative treatment. For those patients who do require surgery for lumbar disk herniation, the reviewed procedures of nerve root decompression caused by disk herniation is favorable. Results of studies varied from 60-90% success rates. Disk surgery has progressively evolved in the direction of decreasing invasiveness. Each surgical procedure is not without possible complications, which can lead to chronic low back pain and restricted lifestyle.

Prevention

Proper exercises to strengthen the lower back and abdominal muscles are key in preventing excess stress and compressive forces on lumbar disks. Good posture will help prevent problems on cervical, thoracic, and lumbar disks. A good flexibility program is critical for prevention of muscle and spasm that can cause an increase in compressive forces on disks at any level. Proper lifting of heavy objects is important for all muscles and levels of the individual disks. Good posture in sitting, standing, and lying down is helpful for the spine. Losing weight, if needed, can prevent weakness and unnecessary stress on the disks caused by obesity. Choosing proper footwear may also be helpful to reduce the impact forces to the lumbar disks while walking on hard surfaces. Wearing special back support devices may be helpful if heavy lifting is required with combinations of twisting.

Resources

Other

"Back Pain." Healthtouch Online Page. http://www.healthtouch.com.

herniated disk

 [her´ne-āt″ed]

protrusion of all or part of the nucleus pulposus through the weakened or torn outer ring (anulus fibrosus) of an intervertebral disk; it occurs most often in the lower back and occasionally in the neck or upper portion of the spinal column. Called also disk herniation, herniation of intervertebral disk or of nucleus pulposus, ruptured disk, and, popularly, “slipped disk.”

Causes and Symptoms. Between each pair of vertebrae lies a pad of cartilage and fiber (the anulus fibrosus) that encloses a soft, mucoid central portion (the nucleus pulposus). The pads act as cushions between the vertebrae, absorbing ordinary shocks and strains, and shifting position to accommodate various movements of the spine. If the nucleus pulposus herniates through a weakened outer ring, it can impinge on spinal nerve roots as they exit from the spinal canal, or on the spinal cord itself, causing severe pain. Herniation may be caused by injury or by sudden straining with the spine in an unnatural position. It may also come on gradually as a result of a progressive deterioration of the disks.

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.

Diagnosis and Treatment. Careful examination is necessary to distinguish this condition from other disturbances of the spine. This may include laboratory tests, x-ray examinations, myelography, magnetic resonance imaging (MRI), and CT scans. The x-rays or MRI may reveal pathologic changes in the spine and narrowing of the space between the vertebrae.

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.

Patient Care. The patient receiving conservative treatment for a herniated disk must always have the spine in good alignment so as to avoid pressure on the adjacent nerves. In addition to using a firm mattress and bed boards, the patient should be instructed in the proper method of turning himself or herself by “log-rolling.” To accomplish this the patient crosses arms over chest, flexes the knee opposite the side being turned onto, and then rolls over “in one piece,” being sure that the spine is not bent forward or twisted. Training in good posture and body mechanics, especially during lifting or stooping, are important in preventing recurrence of acute episodes.

Transverse section showing normal intervertebral disk and ruptured intervertebral disk with herniation of the nucleus pulposus (herniated disk).

herniated disk

n.

The protrusion of a degenerated or fragmented intervertebral disk into the intervertebral foramen, compressing the nerve root.

herniated disk

Herniated 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

Herniation disk types, used for MRI exams

Bulge–circumferential symmetric extension of the disk beyond interspace

Protrusion–focal or asymmetric extension of the disk beyond interspace

Extrusion–more extreme extension of the disk beyond interspace Note: Bulges and protrusions on MRI examination are common findings in normal subjects, and appear to be coincidental findings–NEJM 1994; 331:69oa  

Herniated Disk

DRG Category:	490
Mean LOS:	4.5 days
Description:	SURGICAL: Back and Neck Procedures Except Spinal Fusion With CC or Major CC or Disc Device/Neurostim
DRG Category:	552
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.

Causes

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.

Genetic considerations

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.

Assessment

History

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.

Physical examination

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.

Psychosocial

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.

Diagnostic highlights

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

Diagnosis

Pain (acute) related to inflammation and compression

Outcomes

Comfort level; Pain control behavior; Pain level; Symptom severity

Interventions

Analgesic administration; Anxiety reduction; Environmental management: Comfort; Pain management; Medication management

Planning and implementation

Collaborative

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.

Pharmacologic highlights

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.

Independent

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.

Documentation guidelines

• 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?

A. It's possible that you have a nerve impingement from a disc herniation, but not necessarily so. What you need to know is that even if you have a herniated disc, the question is what would the recommended treatment be?
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!