What is a slipped disc?

Injury or weakness can cause the inner jelly like portion of the disk to protrude through the outer ring. This is known as a slipped or herniated disk. This causes pain and discomfort. If the slipped disk compresses one of your spinal nerves, you may also experience tingling, numbness and pain along the affected nerve. As the lumbar spine (lower back) carries most of the body weight, it tends to “slip” more than higher levels.

What is the anatomy of disc herniation / herniated disc/ slip disc /sciatica?

Human Spine is made of up 33 bones (vertebrae) that are cushioned by discs.These vertebrae are divided by region: neck (cervical spine), mid-back (thoracic spine), and low back (lumbar spine). At the lower end of your spine, you also have the sacrum and the coccyx, which is commonly called your tailbone. Discs are present between these bones. The disks protect the bones by absorbing the shocks from daily activities like walking, lifting, and twisting. Each disk has two parts—a soft, gelatinous inner portion (nucleus pulposus) and a tough outer ring(annulus fibrosis) . Together, the vertebrae and discs form a tunnel through which the spinal cords and nerve pass.

What are the causes of slip disc?

The aetiology/cause of slip disc is multifactorial, there is no evidence to prove/disprove the quantitative effect of one or other. The risk factors for slip disc can be:

•Ageing : as a part of the normal age related degenerative process.
•Life style: Stress and emotional tension, poor posture -standing for long periods of time or sitting incorrectly—can cause slip disc , heavy physical work, lifting or forceful movement, bending, or awkward positions can really hurt your back.
•Injuries and Accidents : Injury to muscle , ligaments , or soft tissue can lead to slip disc .Fracture in spinal bone in a fall or a car accident also is a common cause. If you have osteoporosis, a condition that weakens your bones, you’re much more prone to fracturing a bone.
• Obesity :Being overweight puts pressure and stress on the back, especially the low back. Carrying excess weight aggravates other health conditions such as osteoporosis (weak bones), osteoarthritis (joint pain), rheumatoid arthritis (an autoimmune disease), degenerative disc disease (described above in the aging section), spinal stenosis, and spondylolisthesis.

What are the symptoms of Herniated disc OR Slip Disc ?

Symptoms of a slipped disk include:

Sciatica – Pain in buttock radiating to leg
• pain and numbness, most commonly on one side of the body
• pain that extends to your arms and/or legs
• pain that worsens at night
• pain that worsens after standing or sitting
• pain when walking short distances
• unexplained muscle weakness
• tingling, aching, or burning sensations in the affected area
• sciatica— a sharp shooting pain that can extend from the buttock into the leg and sometimes into the foot.
• muscle spasm, locked back , low slip disc , stiffness in back , morning stiffness.
• Although rare, herniated discs can cause you to lose bowel or bladder control known as cauda equina syndrome and one should seek medical advice as prognosis deteriorates with time. one can know whether this is happening to him or not if he has urgency /frequency of urination or loss of control over urination

When do i need to have a physician opinion ?

Patients with progressive symptoms in leg / back need a specialist opinion to diagnose and treat the problem.

Symptoms which need specialist attention (RED FLAGS)are:

1. Persistent leg pain
2. Numbness in leg
3. Weakness in leg
4. Difficulty in walking
5. Claudication
6. Low slip disc / neck pain more than 3 weeks
7. Unable to control urine / motion
8. Bladder incontinence

Symptoms like bowel and bladder urinary incontinence shall seek urgent / emergency opinion /management by the spine specialist

Which tests will be needed to confirm the diagnosis?

Imaging studies / investigations help to arrive a diagnosis of slip disc / herniated disc and include :

• X-rays
• CT scans
• MRI scans
• Discograms, which are rarely utilized

What are the treatment options for slip disc ?

There are different options to treat slip disc depending on the severity and duration of symptoms . They may comprise of one or many :

1. Drugs & Medications
2. Physical Therapy
3. Spinal Bracing
4. Spinal Injections
5. Spine surgery
6. Physiotherapy

Drugs, Medications, to Relieve Slip disc :

Medication alone is not the ultimate solution to your back pain, however during emergency or during severe pain these medicines may help you curb the suffering.

Acetaminophen :
Your doctor may call this an analgesic, but most of us refer to acetaminophen medications as painkillers. They don’t help reduce inflammation, though.

NSAIDs (non-steroidal anti-inflammatory drugs) :
These will help reduce swelling (or inflammation) while relieving your pain; that’s how NSAIDs differ from acetaminophen. If an over-the-counter NSAID is an option for you, you have plenty to choose from. You can use ibuprofen, aspirin; however seek medical advice before you take any medicine.

Muscle Relaxants :
If you have chronic slip disc caused by muscle spasms, you may need a muscle relaxant, which will help stop the spasms

Anti-depressants :
As surprising as it may seem, anti-depressants can be effective drugs for treating pain because they block pain messages on their way to the brain. They can also help increase your body’s production of endorphins, a natural pain killer.

Opioids :
In the most extreme cases, and only under careful supervision, you doctor may also prescribe an opioid, such as morphine or codeine.

Medication Warning :
As with all medications, you must follow your doctor’s advice precisely. Never mix over-the-counter and prescribed drugs without consulting your doctor.

Physical Therapy to Relieve Slip disc :

(A) Passive Therapy
i. Massage
ii. Heat Therapy /Cold /Ice Packs
iii. Local Ointments application
v. Traction

(B) Active Therapy – exercises
1. Endurance exercises
2. Strengthening exercises for back and abdominal muscles
3. Core stability Exercises

Passive Treatments :

• Deep Tissue Massage :Deep tissue massage relieves deep muscle tension and spasms, which develop to prevent muscle motion at the affected area.

• Hot and Cold Therapy :Both hot and cold therapies offer their own set of benefits, and your physical therapist may alternate between them to get the best results. This reduces inflammation, muscle spasms and pain.

• TENS (transcutaneous electrical nerve stimulation) : Uses electrical current to stimulate your muscles and reduces muscle spasms and is generally believed to trigger the release of endorphins, which are your body’s natural pain killers.

• Traction :Reduce the effects of gravity on the spine. the intent is to reduce the disc herniation and is usually performed in the cervical or lumbar spine.

Active Treatments :Help to reduce recurrent pain but will also benefit your overall health.

Core stability :Many people don’t realize how important a strong core is to their spinal health. Your core (abdominal) muscles help your back muscles support your spine. When your core muscles are weak, it puts extra pressure on your back muscles. Your physical therapist may teach you core stabilizing exercises to strengthen your back.

Flexibility :Learning proper stretching and flexibility techniques will prepare you for aerobic and strength exercises. Flexibility helps your body move easier by warding off stiffness.

Muscle strengthening :Strong muscles are a great support system for your spine and better handle pain.

Spinal Injections : (A) Injection techniques
• Root Block Injection
• Epidural Injection
• Caudal Block Injection
• Facet Block Injection

Epidural Steroid Injection : An epidural steroid injection sends steroids—which are very strong anti-inflammatories—right to the nerve root that’s inflamed. This is a pain management therapy, so it’s best to have a well-trained pain management specialist do the injection. You’ll probably need 2-3 injections; generally, you shouldn’t have more than that because of the potential side effects of the steroids.

Spinal Bracing :
Spinal bracing is often advised for pain relief in patients with

1. back pain
2. neck pain
3. slip disc
4. stenosis
5. spondylolisthesis
6. Scoliosis
7. kyphosis
8. Spinal Trauma
9. Herniated Disc
10. Spinal tuberculosis with pain

Spinal bracing utilises these primary objectives:

• Controlling back pain by limiting motion and unloading discs, vertebrae and other spinal structures by compressing the abdomen.
• Stabilising weak or injured structures by immobilising the spine.
• Providing three-point force systems to provide correction or prevent progression of a deformity.

Different type of braces are classified based on the rigidity and are – Flexible, Rigid or Semi-rigid.

Flexible orthoses or corsets are prescribed for relief of low back pain associated with degenerative disc disorders, trauma, or postural deformities. Rigid stays and inserts can be added to restrict motion and act as a postural reminder.

Rigid orthoses are commonly custom fabricated and provide the most support to the area being treated. A body jacket or TLSO controls motion in all planes.A two piece front and back design is commonly used post operatively for ease of application while a front or back opening single piece design is commonly utilised when treating scoliosis.

Different types are :
• Corset braces
• Hyperextension braces
• Moulded jackets
• Neck braces
• Rigid braces
• Sacroiliac and lumbosacral belts
• Trochanteric belts
• Thoracolumbosacral orthoses (TLSO)

Long time usage of corsets / belts can lead to muscular atrophy due to disuse.
Please consult your specialist before using a corset/ belt for your spinal problem.

Surgery for Slip disc :
Only 5% of people need surgery to treat back problems. Your pain may be severe, but most sprains and strains do not require surgery. Surgery is reserved for the most severe cases of slip disc (spinal cord impingement, structural deformity, severe cases of spinal stenosis)

Surgery- Surgery is often required for patients whose symptoms are worsening over 2-3 weeks, and patients are not responding to conservative treatment. Emergency surgery is required for patients who have lost bowel / bladder control – Cauda Equina syndrome.

The options of surgery are
• Decompression
• Spinal Fusion
• Disc replacement surgery

The spine surgery advised for Slip disc can be performed in many different ways. The success rates of surgery in slip disc/ herniated disc / sciatica is 99 % and with invention of modern technology and minimal invasive surgery techniques it nears 100 %. Spine surgery can be performed in different manners;-

• Conventional Open surgery
• Minimal Invasive Spine surgery – Key hole spine surgery
• Endoscopic Spine Surgery
• Microscopic spine surgery
• Micro endoscopic spine surgery

Decompression includes

•Facetectomy :A procedure that removes a part of the facet (a bony structure in the spinal canal) to increase the space.

•Foraminotomy :A procedure that removes the bony compression over foramina (the area where the nerve roots exit the spine) to increase the size of the nerve pathway.

Laminoplasty :A procedure make more room for the spinal canal.

•Laminotomy :A procedure that removes only a small portion of the lamina (a part of the vertebra) to relieve pressure on the nerve roots

• Micro-discectomy :A procedure that removes a disc through a very small incision using a microscope.

Laminectomy :A procedure for treating spinal stenosis by relieving pressure on the spinal cord.

Spinal Fusion: The surgery intends to stabilise a unstable segment responsible for pain , this may involve putting some screws in your spine to increase stability.

Various options of doing spinal fusion are PLF /PLIF/TLIF/ ALIF/XLIF