As people age, certain injuries become more common than others. In addition to heart disease and cancer, elderly individuals can develop bulging discs (also called a herniated disc) at a higher rate than their younger counterparts. The vertebral discs are used to provide a cushion between the bony vertebrae that protect the spinal cord. A herniated disc occurs when the liquid portion of the disc (called the nucleus pulposus) breaks through the fibrous disc that encloses it (called the annulus fibrosis). When this liquid starts to leak out of the disc, this leads to a loss of the cushion that is vital for the comfort of the spinal cord. In addition, this liquid can leak over the nerves that branch out from the spinal cord, leading to a significant amount of pain. For this reason, it is important for patients everywhere to understand the basics of a bulging disc.Incidence: How Common are Herniated Discs?
Many people want to know how common a herniated disc is in the general population. A study published in BMJ Clinical Evidence in 2009 revealed that herniated discs are relatively common but are most common between the ages of 30 and 50 with males being affected twice as often as females. Without a doubt, the most common spinal region to be impacted by a herniated disc is the lumbar region, with the L3-L4 discs and the L4-L5 discs being the most commonly herniated discs. Because of their commonality, there is a substantial amount of information in the medical literature that has led to improved treatment options and symptom relief for patients everywhere.Mechanism of Injury: How Does a Herniated Disc Develop?
There is a substantial amount of research being done in the area of bulging discs; however, patients who spend a lot of time with their lumbar region flexed have a higher chance of a herniated a spinal disc. This is because the lumbar region is the most common region for people to experience a herniated disc and that flexing the spinal region places stress on these discs. For example, patients who spent a significant amount of time flying a plane or driving a car have their lumbar region flexed the entire time that they are sitting in that chair. Therefore, these occupations are at a higher risk of suffering a herniated lumbar disc than other occupations.Physical Exam: The Signs of This Injury
After the physician collects a history of the injury, the physician will perform a detailed physical exam to determine whether or not a herniated disc is present. There are a few areas that the physician will examine.
- Motor and Sensory Function: Because this is a potential spinal cord injury, the physician is going to examine the various parts of the body to ensure that there isn’t any serious nerve damage. The physician will assess the patient’s muscle groups to make sure that all of the muscle groups are intact. The physician will palpate the patient in various locations of their body to make sure that their sensory function is preserved.
- The Leg Raise Test: This is an important test to diagnose a herniated disc. The physician will ask the patient to lie down on the exam table. Then, the physician will raise the patient’s legs one at a time. If the bulging disc is present in the lumbar region, the patient’s pain should worsen on this leg raise test. Therefore, a positive test will go a long way to diagnosing a herniated disc.
- Range of Motion: If any of the nerves have been damaged, the patient should lose some of their range of motion due to the pain. Therefore, the physician will assess the range of motion at every joint. If any of the joints have been compromised, patients likely will have lost some of the range of motion. The physician will look for this on these tests.
- Vital Signs Will Not Be Neglected: Vital signs are called vital signs for a reason. If the patient’s heart rate and breathing are elevated, it could be sign of a serious complication called cauda equina syndrome. If this syndrome is present, it constitutes an emergency that merits immediate attention.
If the physician suspects that the patient has suffered a bulging disc, they will start with a history and physical exam. If the findings support a herniated disc, the physician will order some imaging studies to confirm the injury. Without a doubt, the most accurate study for diagnosing a herniated disc is an MRI. The spinal cord is a narrow structure with an immense amount of detail that can only be accurately visualized on an MRI. An MRI is beneficial for a patient because, while it does take a while to complete, it also doesn’t require any radiation to produce its image, keeping patients safe. On an MRI, a physician will be able to clearly and accurately diagnose a herniated disc. The physician will also be able to determine if any of the surrounding structures have been compromised. Most importantly, the MRI will provide the surgeon with a roadmap that they can use to repair the herniated disc if surgery is required.Treatment Options for a Herniated Disc
Many people would be surprised to learn that the initial management of a bulging disc is actually conservative in nature. While a herniated disc sounds like a severe injury, a significant number of people can be managed with medical management alone.
- High-Dose Over the Counter Medications: If the physician suspects that a patient has a herniated disc, they will start by prescribing high-dose ibuprofen or Tylenol. While ibuprofen is the first line medication, some elderly patients may have underlying kidney disease due to high blood pressure or diabetes. For these patients, ibuprofen is not the first-line treatment and the physician may prescribe Tylenol instead. Patients will be prescribed either high-dose ibuprofen or high-dose Tylenol and asked to return to the physician in around six to eight weeks. If the patient has improved, then their bulging disc has been successfully managed with over the counter medications. If the symptoms persist, the physician will increase the strength of the medications.
- High-Dose Prescription Medications: If the symptoms persist, the physician will increase the strength and dosage of their medical treatment. Most physicians will reach for a medication that is in the same class as ibuprofen called Mobic. This has a similar mechanism of action to ibuprofen only it is stronger. Therefore, some patients who could not control their symptoms with ibuprofen may find relief with Mobic. Along with Mobic, some physicians may elect to add on other medications in an attempt to control the pain that patients feel with a bulging disc.
While many patients will be able to manage their symptoms using either over the counter or prescription medications, some patients may have symptoms that persist despite these medical treatment options. These patients will require surgery for symptom relief.Some Patients will Require Surgery
Physicians will attempt to manage the symptoms of patients with herniated discs with over the counter and prescription medications first. For patients that have symptoms despite these medical treatments, they will require a surgical procedure called a spinal fusion.
- Spinal Fusion and Removal of the Herniated Nucleus Pulposus: A spinal fusion is a procedure that is typically used to treat a bulging disc and is performed by either an orthopedic surgeon or a neurosurgeon. It is used to fuse the two vertebrae surrounding the herniated disc together. This will immobilize the spine at this location and relieve the pain of a herniated disc. When the surgeon opens up the patient’s back, they will see the herniated disc and the liquid that has been released from the disc. The first step in this procedure is to remove the liquid nucleus pulposus that is irritating the nerves that are exiting the spine at that location. The surgeon will use delicate tools to clean out the nucleus pulposus that has been coating the nerves and irritating the spinal nerves.
- Spinal Fusion and Fusing the Vertebrae: After the nucleus pulposus has been removed, the surgeon will need to immobilize the spine at the level of these two vertebrae because the cushion between the two vertebrae was eliminated when the disc herniated. Therefore, the surgeon will apply rods and screws to screw the two vertebrae together. Patients will lose a few degrees of flexibility in their spine because the spinal vertebrae have been fused together. Typically, the screws and rods that are used to fuse the vertebrae together are left in place for life. Almost all patients who require surgery for a herniated disc find relief with this surgical procedure.
It is important for patients to remember that not all patients will require surgery to treat a bulging disc; however, the patients that do require surgery typically have symptom relief with a spinal fusion. In fact, some patients have multiple herniated discs and will have a spinal fusion performed at multiple levels to relieve their symptoms.Complications of a Herniated Disc
Because a herniated disc can cause damage to the spinal cord, there are several complications that can develop as a result of the nucleus pulposus irritating the nerves that exit the spine at that level; however, some complications are worse than others.
- Cauda Equina Syndrome: Without a doubt, the most dangerous complication that can result from a herniated disc is called Cauda Equina Syndrome. This syndrome develops when a large disc, such as a lumbar disc, herniates at one of the lower levels of the spinal cord. When this disc herniates, the liquid and the disc can exit from the spinal cord and compress a region of the spinal cord called the cauda equina. This region of the spinal cord is vulnerable because the lower portion of the spinal cord is not protected in the same way that the upper regions of the spinal cord are. Therefore, a herniated disc can compress this region of the spinal cord and cause emergent symptoms. The cauda equina sends out nerves to the bowel, bladder, and legs. When this region if compressed, the innervation to the bowel and bladder can become damaged, leading to symptoms of incontinence and constipation. Patients may also lose motor and sensory function in their legs. This is a medical emergency that requires an emergent decompression of the cauda equina in order to preserve the nerve function and innervation to the bowel, bladder, and legs.
- Kidney Damage: Many patients receive high-dose ibuprofen as a first-line treatment option for a herniated disc. While ibuprofen is used to relieve inflammation and treat a herniated disc, the amount of ibuprofen that is used to treat a herniated disc does run the risk of damaging the kidneys. Patients will have blood work regularly to monitor their creatinine and ensure that damage isn’t being done to the kidneys. Patients who do suffer kidney damage should look for a decrease in urine output and discolored urine. This could be a sign that the high-dose ibuprofen is damaging the kidneys.
- Complications from Surgery: Patients who require surgery run the risk of typical surgery complications. Notably, these include the risk of infection at the surgical site and possible blood clots from the duration of surgery. Both of these complications are treatable with antibiotics and blood thinners respectively; however, both of these can also become serious if not caught early and patients could wind up spending an extra amount of time in the hospital due to these complications.
It is important for patients to remember that this list represents only a few of the complications that can develop from a herniated disc. Patients should monitor their symptoms closely and contact their doctor if their symptoms change or worsen.Sacramento Personal Injury Lawyer
I’m Ed Smith, a Sacramento Personal Injury Lawyer. If you have suffered a bulging disk in a car crash or other type of accident, please call me at (916) 921-6400 for friendly, free advice.
I am one of the members of the California sector of the Million Dollar Advocates Forum. As a group, we represent some of the top injury lawyers in the United States. All of us have won case verdicts and settlements in excess of 1 Million Dollars.
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Photograph: Personal Injury Lawyer, Edward A. Smith
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