Nsg6001 - Treatment and Management of Disc Herniation

Treatment and Management of Disc Herniation

Kellie Wilhelm

South University

NSG6001

Pathophysiology of Disc Herniation

        The bones of the spine or vertebral column are composed of alternating vertebrae and intervertebral discs that support spinal ligaments and muscles (Rawls & Fisher, 2010). These round and flat discs serve to cushion vertebra in the spinal column and absorb weight and movement. This absorption allows bending, reaching and lifting. When the nucleus of the disc becomes displaced out of the annulus into the spinal canal, or moves out of place, it is referred to as “herniated”. The disc may also rupture from strenuous activity or injury. This can also result due to loss of fluid or elasticity in the intervertebral discs leading to deterioration of the nucleus and consequently, a bulging disc. The dysfunctional nature of the intervertebral disc can related to the effects of aging, degenerative disorders like osteoarthritis or ankylosing spondylitis, or trauma like lifting, slipping or falling (Grossman & Porth, 2014).

        The regions of the cervical and lumbar areas of the spine are the most flexible and are most often the site of the disc herniation. The majority of weight and bending occur in the lumbar region, taking the most pressure and stress. The severity of stress is assorted based on positioning (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013). This is usually seen in the L4- L5 to S1 regions (Grossman & Porth, 2014). Disc herniation in the lumbar region is particularly complicated due to the nerve fibers of the cauda equine that are involved. Although these nerve fibers have the capacity to regenerate, recovery can take weeks or months.

Signs and Symptoms of a Disc Herniation

        Manifestations of disc herniation are greatly dependent on the location and magnitude of damage. When the disc herniation is pressing on a nerve fiber, symptoms experienced are pain, numbness, tingling and/or weakness to the side of the body to which the nerve fiber travels (Marieb, 2009). These symptoms may be acute or chronic in nature with intermittent episodes of symptoms.

        Disc herniation of the lumbar spine may result in sciatica. This occurs when there is pressure on one or several nerve fibers that connect to the sciatic nerve to cause symptoms of pain, burning, numbness or tingling from the buttocks into the leg and foot of the effected side. Symptoms can be exaggerated with positions of sitting and standing or movements like walking. Leg and foot pain is accompanied by lower back pain and is often referred to as radiculopathy. Other symptoms may include spasms of the back muscles, decreased reflexes at the knee or ankle or changes in bladder or bowel function. These may resemble or mimic other medical problems making the diagnosis more difficult. A thorough history and physical is necessary along with recent trauma, cancer, lumbar puncture, concurrent infection or chronic use of high-dose corticosteroids (Buttaro, et al., (2013).

        While disc herniation of the lumbar spine causes lower back pain and extremity discomfort, herniation of the cervical spine or neck region includes sharp pain in the neck and between the shoulder blades or scapulae. Pain, numbness and tingling can be experienced radiating down one or both upper extremities and can be exaggerated by certain positions or movements of the neck.

        In the assigned case study, the patient subjectively reports worsening lower back pain, numbness and tingling to the right lower extremity. His objective assessment demonstrates decreased strength with resistant extension in the right lower extremity and complains of pain in the posterior thigh. Sensation is decreased in the right lower extremity along L5:S1 and assessment is noted to have positive straight leg raise to right side at 20 degrees.

Trajectory of Disease Progression

        There are three stages to degenerative disc disease studied by William H. Kirkaldy-Willis. The first stage is the injury leading to acute back pain and physical dysfunction. The second stage is the unstable vertebral segment that causes intermittent back pain. As the body is able to re-stabilize and restore itself and the vertebral segment, fewer episodes of back pain are experienced. This process of reparative influence is slow (Ullrich, 2013). In the assigned case study, the patient presents to the clinician in the second stage of the degenerative cascade.

Diagnostic Testing of Disc Herniation

        To diagnose disc herniation, as aforementioned, a history, symptom list, physical examination, and diagnostic tests are reviewed. A radiography, type of electromagnetic radiation, is completed to show the structures of the vertebrae and joints in search of potential pain-causing culprits like tumors, infections and/or fractures. A computed tomography (CT) scan is completed to illustrate the shape of the spinal canal, its contents and the structures outlying it. A magnetic resonance imaging (MRI) test is completed to illustrate a three-dimensional (3-D) image of the body structures like the spinal cord, nerve roots and any enlargement, degeneration and/or tumors. A myleogram is a radiograph that uses an injected contrast into the cerebrospinal fluid spaces to illustrate pressure on the spinal cord or nerves due to herniated discs, bone spurs and/or tumors. Finally, an electromyogram and nerve conduction study (EMG/NCS) measures electrical impulses along the nerve root, peripheral nerves and muscle tissue. This test can illustrate ongoing nerve damage, process of nerve healing and/or nerve compression (American Association of Neurological Surgeons, 2014).

        In the assigned case study, a plain film radiography is completed and illustrates a degeneration to L5:S1 height with mild degeneration changes to the lumbar vertebrae.

Treatment Options for Disc Herniation

        Treatment for disc herniation is initially conservative and non-surgical, however, in cases of severe herniated and degenerated discs, symptoms may become life altering requiring surgical interventions. A very small percentage of people experience this incapacitating pain (AANS, 2014). Pharmacological treatment consists of non-steriodal anti-inflammatory drugs (NSAIDs) for mild to moderate pain, however in severe cases, narcotics and muscle relaxants can be prescribed. Another pharmacological option would be an epidural steroid injection into the area of disc herniation under a radiography-guided procedure by the clinician. The second non-surgical form of treatment is the recommendation of physical therapy. The therapist will introduce techniques of stretching exercises, pelvic traction, ice and heat therapy, ultrasound and electrical muscle stimulation (AANS, 2014).