Disc Herniation/Annular Tear

What is it?

Herniated discs can lead to a sudden onset of pain in the neck, back and/or radicular pain in the arms or legs.

The discs are compressible structures and change shape in response to movement and pressure.

In fact, normal sitting for more than 40 minutes causes bulging in normal lumbar discs. Excessive movement or pressure in the disc can cause a tear or herniation.

Tears occur in the annulus, which is the outer fibrous layer, and allows the inner fluid of the disc (nucleus pulposus) to force its way out of the tear.

Disc herniations are classified as bulges (wide herniations), protrusions (narrow herniations), and extrusions (protrusion with migration of disc contents).

There is often confusion due to the wide range of terms used to describe spinal disc problems, including a ruptured disc, torn disc, slipped disc, collapsed disc, disc protrusion, disc disease, and dark disc.

All of these terms are considered features of a herniated disc, but do not indicate how much pain is likely to occur.

What causes it?

Herniated discs are quite common.

The causes of disc herniations include mechanical and genetic factors.

A disc herniation can occur in any part of the spine, but is most common in the low back (lumbar).

Disc herniations are more common in middle age, as normal aging causes the disc to become less pliable.

Trauma, bending and lifting activities, and especially prolonged sitting can cause excessive pressure on the disc.

In fact, being inactive and sedentary puts your back at increased risk for disc degeneration.

Scientific studies also show that a major risk for disc herniation has to do with our genetics. So, it is important to pay attention to our family history as well.

What are other side effects, and anatomic structures, affected?

All types of herniation have the potential to cause inflammation of the spinal nerves, and at times in the cervical and thoracic spine, and the spinal cord ultimately causing pain.

However, most herniated discs are not inherently painful. In fact, most bulging discs cause no symptoms at all.

How is it diagnosed?

Herniated disc and associated radicular pain are typically diagnosed by careful history and physical examination.

X-ray may be helpful but is not always necessary.

MRI is generally not necessary unless the symptoms are not responding to usual treatments. MRI is considered the gold standard to evaluate for herniated discs, and to determine if injections or surgery are indicated.

Occasionally, a CT scan or other imaging modalities may be helpful.

What are the treatment options?

Nonsurgical treatment is the first step for herniated discs and associated radicular pain unless there are significant neurologic symptoms. Initial treatment is aimed at decreasing pain and neurologic symptoms.

As long as there is no evidence of severe or worsening nerve damage, most patients with herniated discs do not require surgery.

Treatment typically involves physical therapy, activity modifications and tailored medication management.
If these usual measures are not adequate, epidural steroid injections may be a good treatment option to treat the radicular pain.

Surgery is an option for those who continue to have painful nerve symptoms or have persistent or progressing weakness or numbness.

• Activity modification: For very acute pain, a temporary decrease in activity without too much restriction may be indicated. However, it is recommended to remain as active as possible, and bed rest for more than a few days has been shown to make disc conditions worse.
• Physical therapy: There are many different types of physical therapy. Our team will decide which approach is best for you. In general an active approach in which you are given exercises and stretches is recommended. There is no way to predict how many sessions you will need. However, you should feel that there is clear progress within a few visits and many people only need 6 to 8 visits.
• Manual medicine: At times, there are restricted areas in your body that either lead to pain or cause increased strain in another region. There are numerous techniques employed in manual medicine, and the treatment choice is individualized for the patient. Our team will guide your treatment for your specific needs. It is difficult to predict how many sessions are necessary, but there should be clear progress within a few visits. 
• Medications: Analgesic medications such as acetaminophen or an anti-inflammatory such as ibuprofen can be helpful temporarily. Our team will tailor your medications to help you stay active. This may include prescription anti-inflammatories, medications that target nerve pain and muscle relaxers. For very acute and severe pain, narcotics may be used for a short period.
• Injections: Epidural steroid injections can be quite effective for radicular pain. There are several different approaches and a few different types of steroid medication. The specific type of injection is individualized after careful history and physical, and personal review of the imaging. There is no need for a routine “series” of injections. Your response to the injection will be monitored and further treatment will be recommended depending on your personal results. Injections are typically part of a comprehensive treatment plan.

Surgical (injection/minimally invasive/surgical) – spine surgery for herniated discs is indicated if one has not responded to other treatments or if there is progression of neurologic symptoms such as weakness or numbness.

The exact type of surgery will depend on multiple factors, though most are done with minimally invasive techniques to provide patients with the quickest recovery and minimize post-surgical pain.