Prognosis for bulging lumbar disc
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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The vertebral disc is a complex structure that provides two principal functions: it connects two vertebra (while permitting some motion) and provides shock absorbtion.
The disc is located between two vertebra and looks like a solid “doughnut” made of multiple outer fibrous layers (called the 'annulus' which means "ring"). Inside the center is a jelly-like substance (called the 'nucleus pulposus').
With age, the intervertebral disc loses water and becomes dried out. When this happens, the disc compresses. This leads to deterioration of the outer ring allowing the nucleus to bulge out. This is called a bulging disc.
A ruptured disc means that an excessive load has been applied to the disc resulting in the rupture of the layers of the annulus. The consequence is a leakage of the central "jelly" out beyond the boundaries of the annulus. As a consequence, the two vertebrae are no longer bound together and a combination of instability and nerve irritation leads to severe pain.
With severe bulging or rupture there is inflammation of affected nerve roots which cause pain down the leg. This is called "sciatica." The compression of the nerve may lead to weakness in the leg or foot.
The initial treatment for a bulging or herniated disc is usually conservative. This begins with rest, maintainence of a comfortable posture, and restricted activity for a few days to several weeks. This allows the nerve inflammation to subside.
A herniated disc is frequently aided by non-steroidal anti-inflammatory medications such as Motrin, Naprosyn, Lodine, Celebrex, or Advil. An epidural steroid injection may be performed utilizing ultrasound or fluoroscopic guidance.
Physical therapy may be beneficial. These modalities may include traction, ultrasound, electrical muscle stimulation, etc., to relax the muscles which are in spasm and reduces inflammation from the compressed nerve. Pain medication and muscle relaxing medications may also be beneficial.
If these conservative treatments are not successful and the disc is herniated and the pain is still severe or a neurologic deficit progresses, then surgery is necessary. Surgery may be performed via a percutaneous discectomy if the disc herniation is small.
If the herniation is large, or there is a "free floating fragment", then a microlaminotomy with disc excision is necessary. A micro-laminotomy requires one to two days of hospitalization after the surgery. The sciatic pain should go away immediately after surgery.
A person who has sustained one disc herniation is at increased risk for experiencing another. There is an approximate 5% rate of recurrent disc herniation at the same level, and a lesser incidence of new disc herniation at another level. Factors involved may be weight,level of physical conditioning, work or behavioral habits.
The majority of disc herniations (90%) do not require surgery, and will resolve with conservative, nonoperative treatment, without significant long-term consequences. Unfortunately, approximately 5% of patients with herniated, degenerated discs will go on to experience severe and incapacitating low back pain which affects their activities of daily living. When this occurs, the prognosis is poor, regardless of age.
After a successful laminotomy and discectomy, 80-85% of patients do well and are able to return to their normal job in about six weeks. There may be residual patches of numbness in the involved leg which, fortunately, are not disabling. Exacerbations of less severe pain may develop on an infrequent basis.
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