LUMBAR HERNIATED DISC:A CASE STUDY REPORT

Submitted to:Mrs. Aida Dapiawen

Submitted by:POSADAS, Kristina Grace

NCI-MWF 10:30-11:30

10 October 2007

Introduction

Too much or too little physical activity is the call of

modern living. Most people’s daily routine would comprise of

either spending the day facing the computer or being

subjected to hard labor. As a result, majority complain of

muscle strains especially on the lower back area. But in

spite of the severity of the pain experienced, the common

notion is that such condition is simply due to muscle

tightness, and that minimal interventions will do the trick.

However this may not always be the case, for there is a

great possibility that a nerve may be pinched or compressed

in a particular area. Such impingement may then lead to

disturbances in nerve function characterized by intense pain

and numbness of the affected part. In this light, this case

study report aims to alert the readers on a more serious

underlying cause of what is though of as a simple back pain—

disc herniation. The public’s familiarity with the disease’s

nature, signs and symptoms, and common management including

preventive measures, is the main objective of this report.

Nonetheless, this case study report is only limited to the

presentation of a single case of lumbar disc herniation (as

there are still other types of such condition); which means

that only one set of patient history (probable cause), signs

and symptoms, and treatment (and in this case, only non-

invasive management) was discussed. Furthermore, the report

was a product of the individual effort and restraints

(including information resources and time allotment) of a

student writer and therefore, highly technical terms were

not elaborated. But then again, with regards to data

collection methods, efficient and effective techniques were

utilized such as the use of internet resources, medical

books and references, and most importantly, a consultation

with the patient herself, as well as her attending

physiatrist.

Nature of the Disease

Your back, or spine, is made up of many parts. Your

backbone, also called your vertebral column, provides

support and protection. It consists of 33 vertebrae (bones).

There are discs between each of the vertebra that act like

pads or shock absorbers. Each disc is made up of a tire-like

outer band called the annulus fibrosus and a gel-like inner

substance called the nucleus pulposus. Together, the

vertebrae and the discs provide a protective tunnel (the

spinal canal) to house the spinal cord and spinal nerves.

These nerves run down the center of the vertebrae and exit

to various parts of the body.

Your back also has muscles, ligaments, tendons, and blood

vessels. Muscles are strands of tissues that act as the

source of power for movement. Ligaments are the strong,

flexible bands of fibrous tissue that link the bones

together, and tendons connect muscles to bones and discs.

Blood vessels provide nourishment. These parts all work

together to help you move about.

A herniated disc most often occurs in the lumbar region (low

back). This is because the lumbar spine carries most of the

body’s weight. Sometimes the herniation can press on a

nerve, causing pain that spreads or radiates to other parts

of the body. The amount of pain associated with a disc

rupture often depends upon the amount of material that

breaks through the annulus fibrosus and whether it

compresses a nerve.

Pain from a herniated disc is often the result of daily wear

and tear on the spine. However, it may also be caused by an

injury. Pain is sometimes the result of pinched nerves that

are crowded by the leaking nucleus pulposus. A herniated

disc can occur slowly over time, taking weeks or months to

reach the point when you feel you must seek medical

attention. Or, pain may occur suddenly from incorrect

lifting or twisting that aggravates a weak disc. If this is

the case, call your doctor right away.

There are four stages to the formation of a herniated disc:

1. Disc Degeneration: During the first stage, the nucleus

pulposus weakens due to chemical changes in the disc

associated with age. At this state no bulging

(herniation) occurs.

2. Prolapse: During prolapse, the form or position of the

disc changes. A slight bulge or protrusion begins to

form, which might begin to crowd the spinal cord.

3. Extrusion: During extrusion, the gel-like nucleus

pulposus breaks through the tire-like wall of the

annulus fibrosus but still remains within the disc.

4. Sequestration: During the last stage, the nucleus

pulposus breaks through the anulus fibrosus and even

moves outside the disc in the spinal canal.

Exams & Tests

As you likely know, a herniated disc can cause pain and

interrupt your daily activies. When you visit a spine

specialist, he or she will ask you questions and perform

some exams. This is to try to locate the source of the pain

from the herniation and develop a treatment plan for you—a

way to manage your disc herniation pain and other cervical

and back symptoms and to help you recover overall.

Your doctor will ask about your current symptoms and

remedies you have already tried for your herniated disc.

Typical Herniated Disc Diagnostic Questions

When did the pain start? Where is the pain(cervical,

thoracic or mid-back, or lumbar or low back)?

What activities did you recently do?

What have you done for your herniated disc pain?

Does the disc herniation pain radiate or travel to

other parts of your body?

Does anything reduce the disc pain or make it worse?

Your doctor will conduct a physical exam, observing your

posture, range of motion, and physical condition both

standing and lying down. Movement that causes pain will be

noted. A Laségue test, also known as the Straight-Leg

Raising test, may be done. You will be asked to lie down and

extend your knee with your hip bent. If it produces pain or

makes your pain worse, this may indicate disc herniation.

With disc herniation, you may feel stiff and may have lost

your normal spinal curvature due to muscle spasm. Your

doctor will feel your spine, note its curvature and

alignment, and feel for tightness.

Your spine specialist will also conduct a neurological exam,

which tests your reflexes, muscle strength, other nerve

changes, and pain spread. Radicular pain (inflammation of a

spinal nerve) may increase when pressure is applied directly

to the affected area.

Your spine specialist may order tests to help diagnose your

condition; you may need to visit an imaging center for these

tests. An x-ray can show a narrowed disc space, fracture,

bone spur, or arthritis, which may rule out disc herniation.

A computerized axial tomography scan (a CT or CAT scan) or a

magnetic resonance imaging test (an MRI) both can show soft

tissue of a bulging disc. These tests will show the stage

and location of the disc herniation so you can receive

proper treatment. If your spine specialist suspects you have

nerve damage, he or she may order a test called an

electromyography (an EMG) to measure how quickly your nerves

respond.

To obtain the most accurate diagnosis, your spine specialist

may order additional tests, such as:

Discogram or discography: A sterile procedure in which

dye is injected into one of your vertebral disc and

viewed under special conditions (fluoroscopy). The goal

is to pinpoint which disc(s) may be causing your pain.

Bone scan: This technique creates computer or film

images of bones. A very small amount of radioactive

material is injected into a blood vessel then

throughout the blood stream. It collects in your bones

and can be detected by a scanner. This procedure helps

doctors detect spinal problems such as arthritis, a

fracture, tumor, or infection.

Lab tests: Typically blood is drawn (venipuncture) and

tested to determine if the blood cells are normal or

abnormal. Chemical changes in the blood may indicate a

metabolic disorder which could be contributing to your

back pain.

Treatment Options

1. Non-surgical treatment for degenerative disc disease

The ongoing pain, as well as the frequency and intensity of

the flares, can be mitigated through a number of non-

surgical options. Modifying activities to preclude lifting

of heavy objects and playing sports that require rotating

the back (e.g. golf, basketball or football) can be a good

first step. Other options include:

o Applying heat to stiff muscles or joints to

increase flexibility and range of motion, or using

ice packs to cool down sore muscles or numb the

area where painful flares are concentrated.

o Medications such as non-steroidal anti-

inflammatories (e.g., ibuprofen, naproxen, COX-2

inhibitors) and pain relievers like acetaminophen

(such as Tylenol) help many patients feel good

enough to engage in regular activities. Stronger

prescription medications such as oral steroids,

muscle relaxants or narcotic pain medications may

also be used to manage intense pain episodes on a

short-term basis, and some patients may benefit

from an epidural steroid injection. Not all

medications are right for all patients, and

patients will need to discuss side effects and

possible factors that would preclude taking them

with their physician.

o An exercise program is essential to relieving the

pain of lumbar degenerative disc disease and

should have several components, including:

Hamstring stretching, since tightness in

these muscles can increase the stress on the

back and the pain caused by a degenerative

disc

A strengthening exercise program, such as

Dynamic Lumbar Stabilization exercises, where

patients are taught to find their ‘natural

spine’, the position in which they feel most

comfortable, and to maintain that position

Low-impact aerobic conditioning (such as

walking, swimming, biking) to ensure adequate

flow of nutrients and blood to spine

structures, and relieve pressure on the discs

o Chiropractic manipulation can relieve low back

pain by taking pressure off sensitive nerves or

tissue, increasing range of motion, restoring

blood flow, reducing muscle tension, and, like

more active exercise, promoting the release of

endorphins within the body to act as natural

painkillers

o Epidural steroid injections can provide low back

pain relief by delivering medication directly to

the painful area to decrease inflammation

2. Surgery

Patients unable to function because of the pain, or who

are frustrated with their activity limitations, may

consider lumbar spinal fusion surgery. Fusion surgery

works because it stops the motion at a painful motion

segment. A one-level fusion at the L5-S1 segment does not

significantly change the mechanics in the back and is the

most common form of fusion, as this is the most likely

level to break down for degenerative disc disease. Fusion

of the L4-L5 level does remove some of the normal motion

of the spine as this is a major motion segment (as

opposed to L5-S1 which has really limited motion) Multi-

level fusions are more problematic. A two-level fusion

may be considered for patients with severe, disabling

pain, but three-level fusions are not recommended because

back movement is too diminished and altering the muscle

composition can in and of itself cause pain (this has

been termed fusion disease).

HISTORY OF PATIENT

Mrs. T.P. is a forty year old woman. She is a full-time

mother to two children and does most of the household

chores. Her present condition started when she fell from

their water tank, approximately 5 feet in height, with her

buttocks hitting the ground in September 2005. The incident

left her with nothing but a slight abrasion on her right leg

and a minimal amount of pain on her buttock area. She

considered the fall as a trivial matter and did not seek any

medical attention but instead, continued with her usual

tasks and even got through the holidays of that year. It was

only in January 2006 that Mrs. T.P. started to complain of

left low back pain which radiates towards her left leg and

foot. She applied hot packs on the affected areas, and took

some pain medications such as Biogesic™ and Advil™ for one

week; however all these measures were to no avail for the

pain seemed to increase its severity each day even to the

extent that she could barely move her trunk and lower

extremities. The following week, Mrs. T.P. decided to refer

her case to a physiatrist.

PHYSICAL EXAMINATION

Initial observations noted by the physiatrist were the

following:

a. Splinting (or the body is shifted towards the

unaffected area) to the right side

b. Grade 3 tenderness (intolerable pain on area when

palpated or pressed) with moderate muscle spasm (or

sudden/involuntary contractions) of whole left

paralumbar (near or beside the lower back area)

c. Moderate muscle spasm of right paralumbar

d. Pain on lumbosacral (lower back area to upper

buttocks) upon trunkal flexion-extension (forward and

backward bending of torso) and lateral flexion (side

bending of torso)

e. Grade 3 (intolerable pain) deep vertebral tenderness

on L5 (lumbar 5)

f. Difficulty in bed mobility especially in turning

g. No inguinal tenderness

h. Deep tenderness on left iliopsoas (a muscle on the

lower abdominals; prime mover of the thigh)

i. Positive left sciatic nerve exit tenderness

j. Irritable left glutei (buttocks muscle; prime mover of

the thighs) and left piriformis (rotator of the thigh

and hip joint)

k. Positive straight leg raising test on the left at 40

degrees

l. Neurological Findings:

1. Sensory

80-90% on left L5

100% on right and left L4 and S1, and right

L5

2. Motor

4/5 on right and left L4 and L5

0/5 on left and right S1

m. Negative for ankle clonus (involuntary beating of the

foot when flexed backward)

DIAGNOSTIC EXAMINATIONS

a. CT scan results revealed minimal L4-L5, L5-S1 disc

bulge

b. X-ray examination of the cervical (neck) vertebra

revealed spondylosis (fracture with no vertebral slip)

on the left C3-C4 and mild straightening of the

cervical spine

c. X-ray examination revealed increased lumbosacral angle

and left lumbar functional (can be corrected)

scoliosis (s-curvature of the spine)

d. X-ray examination of the foot revealed minimal

calcaneal(heel of foot) osteophytosis (excess bone

growth)

DIAGNOSIS

Tests confirmed left L5-S1 radiculopathies secondary to

herniated nucleus pulposus at L4-L5, and L5-S1.

The high level of tenderness on the left paralumbar area,

pain or difficulty in moving the left thigh and lower

abdominals, decreased sensory and motor functions on the

left lower extremities, and a positive straight leg raising

test proved that there is indeed sciatic nerve root

irritation. The sciatic nerve innervates the whole length of

the lower extremities and therefore, any impairment to its

structure would definitely result to unbearable pain from

the lower back (where the nerve exits) down to the foot

which it innervates. The inflammation of the particular

nerve root as characterized by the radiating pain felt by

the patient is termed as “radiculopathy”. Furthermore, the

disc bulge located at L4-L5 and L5-S1 (as revealed by the x-

ray examination) pointed out the cause of such irritation.

The bulge is indicative of a stage 1 disc herniation in

which the fibrous covering of the vertebral disc is about to

be torn due to a potential leakage of the disc’s gel-like

center (nucleus pulposus). Although there is only a minimal

protuberance of the disc, this still puts a lot of pressure

on the proximal (nearby) nerves and thereby compressing the

nerve, which in turn results in a shooting pain experienced

by the patient.

TREATMENT

Mrs. T.P. was confined in a medical institution. Upon

admission, she was placed in a complete bed rest and

underwent an extensive physical therapy program twice a day

with static and later, dynamic lumbar traction, electrical

stimulation, ultrasound, and manual (“hands-on”) therapy.

The lumbar traction involved placing a wide belt or strap to

the patient’s lower back area, and the strap in turn is

coupled with 30-lb weights on both ends. The set-up,

together with ultrasound, electrical stimulation (as

provided by a Transcutaneous Nerve Stimulation machine), and

the therapy itself help alleviate the pain and muscle

spasms.

Medications prescribed were the following:

Cataflam (50mg)- an anti-inflammatory drug; one tablet

administered every eight hours

Neurontin (600mg)- a pain reliever specifically due to

nerve irritation; one-third tablet administered before

going to bed

Neurobion (1 ampule)- a pain reliever specifically due

to nerve irritation; administered intramuscularly

Lagaflex- a muscle relaxant

After five hospital days, Mrs. T.P. was discharged with

significant improvements. Both her sensory and motor

functions on the left lower extremities were elevated, and

pain and tenderness felt on the area were notably decreased.

She was advised to continue her physical therapy program

daily on an out-patient or homecare basis, and lumbar

traction at home for an hour with 30-lb weights. Several

medications were also prescribed including Cataflam (50 mg;

one tablet daily), Mecovit (one tablet daily), Lagaflex (one

tablet daily after breakfast), and Topamax (25 mg; one

tablet daily). Furthermore, on the recommendation of her

physiatrist, Mrs. T.P. should only be allowed to perform a

limited set of activities for a specific timeframe.

Transitional activities or those involving repetitive

strokes or movements such as sweeping the floor were

restricted. Her positions (sitting, standing) should also be

maintained only for a maximum duration of an hour. Proper

posture and body mechanics (how to sit, stand, and get up

from a lower position), as well as weight loss, were also

stressed as major areas of concern.

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Mcvan, B. (1990). Diseases and disorders handbook. U.S.A.:

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