Prolapsed Disc (Slipped Disc)

There are altogether 23 discs in our entire spine, and they are located in between the bones or vertebrae of the spine. They function as shock absorbers and at the same time allowing some flexibility at the spine.

The normal healthy disc consists of a central gel-like nucleus pulposus surrounded by a ring-like structure or annulus fibrosus. When the disc becomes damaged due to major injury, or more commonly due to repeated “wear and tear” processes in our daily activities, the central gel like nucleus pulposus is no longer able to “hold on” to the water content which provides the cushioning effect of the spine.

At the same time, the outer ring like annulus fibrosus starts to exhibit signs of tears. These processes allow the disc material to protrude out of their normal boundaries, coming into close contact with the nerves that are running through the spinal column.

Herniated disc in spinal cord description

I. Prolapsed Disc in the Neck (Cervical Spine)

Symptoms

Prolapsed Disc in the Neck
Pain radiating from the neck to the arm. One or both arms may be involved, depending on the degree of disc prolapse.
There may be accompanying pins and needles, numbness, or weakness of the arm(s).
The pain is usually exacerbated by sitting and certain positions of the head. Usually, keeping the painful arm elevated above the head may relieve the pain.
Occasionally, the prolapsed disc in the neck not only affects the nerves to the arms, but also the legs. In this case, there may be pins and needles, numbness, or weakness of the arms as well as the legs.
There may also be loss of dexterity of the hands, for example, difficulty using chopsticks and picking up coins.
There may be an electric feeling running down the torso and legs when bending.

To confirm the presence of prolapsed disc and to ascertain the severity of the prolapsed disc, an MRI scan of the neck or cervical spine may be done (Figure 1). At the same time, bending x-rays of the neck may be needed to look for any mis-alignment of the cervical spine.

MRI scan of the Cervical Spine
MRI scan of the neck

Figure 1

Treatments

(1) Conservative

Medicine, lifestyle modification, physiotherapy and/or acupuncture treatment

(2) Spinal Injections

Spinal injections may be considered if one does not improve significantly with conservative treatment, and yet not debilitating enough to require formal surgery. Spinal injections are done as a day case where patients can admit and discharge on the same day. Such a procedure is performed under sedation. These injections are done under the guidance of a CT scanner machine to allow the Doctor to place his needles accurately at the location where he thinks the nerve is being affected. This is also known as a nerve block. In addition, the Doctor may also perform radiofrequency ablation of the affected disc, thereby reducing the amount of protrusion so that the irritation to the nerve(s) will be reduced.

(3) Surgery

Surgery may be recommended if the patient does not improve with the above-mentioned treatments, or the initial presentation warrants surgery (for example cervical myelopathy). The surgery entails removing the disc that is compressing the nerve(s), allowing recovery of the nerve(s). Such surgery is usually performed from the front of the neck. Following the removal of the disc, reconstruction of the disc will be undertaken. The reconstruction options will be either:

(i) cervical disc replacement where an artificial disc prosthesis is inserted.

(ii) cervical fusion is done using a cage filled with allograft/bone material; usually obtained from the bone bank to avoid harvesting bone from the patient’s hip. The cage can be further stabilized with a titanium plate and screws in front providing immediate stability.

An x-ray of a cervical disc replacement

Cervical Disc Replacement

Cervical Fusion

Cervical Fusion

Postoperative Care

After surgery, the patient will start walking the next day with a soft collar around the neck, with the help of the physiotherapist.
Patient will usually stay in the hospital for 2 nights
By the time a patient leaves the hospital, he/she will be pretty much independent in getting in and out of the bed, walking, and using the bathroom.
The dressing will be changed to a waterproof dressing so that the patient can shower at home.
There will be weekly change of dressing, and by the 2nd week, the wound should be able to be exposed.
After the dressing is removed, the Doctor will refer the patient for postoperative neck physiotherapy.

II. Prolapsed Disc in the Low Back (Lumbar Spine)

Symptoms

Pain radiating from the low back to the buttock and leg. One or both legs may be involved, depending on the degree of disc prolapse.
There may be accompanying pins and needles, numbness, or weakness of the leg(s).
The pain is usually exacerbated by sitting, bending, lifting, and twisting activities. Standing or lying down may relieve the pain.
In rare instances, there may be loss of control of the bladder and/or bowel.

To confirm the presence of prolapsed disc, and to ascertain the severity of the prolapsed disc, an MRI scan of the low back or lumbar spine may be done (Figure 1). At the same time, bending x rays of the low back may be needed to look for any mis-alignment of the lumbar spine.

MRI scan of low back (lumbar) spine
a right-sided prolapsed disc on a cross-sectional MRI view of the low back

Figure 1 shows a right sided prolapsed disc on a cross sectional MRI view of the low back.

Treatments

(1) Conservative

Medicine, lifestyle modification, physiotherapy and/or acupuncture treatment

(2) Spinal Injections

Spinal injections may be considered if one does not improve significantly with conservative treatment, and yet not debilitating enough to require formal surgery.Spinal injections are done as a day case where patients can admit and discharge on the same day. Such a procedure is performed under sedation. These injections are done under the guidance of a mobile x-ray machine to allow the Doctor to place his needles accurately at the location where he thinks the nerve is being affected. This is also known as a nerve block. In addition, the Doctor may also perform radiofrequency ablation of the affected disc, thereby reducing the amount of protrusion so that the irritation to the nerve(s) will be reduced.

(3) Surgery

Surgery may be recommended if the patient does not improve with the above-mentioned treatment, or the initial presentation warrants surgery (for example, significant weakness and/or numbness of the leg or bladder incontinence). The surgery entails removing the disc that is compressing the nerve(s), allowing recovery of the nerve(s). The surgery is routinely performed nowadays in a minimally invasive manner, using small metal tubes that also function as retractors keeping the soft tissues away from the surgical area. The tubes are “docked” at the area where the prolapsed disc is, and this is done under the guidance of the x-rays (see Figure 2). A microscope is used throughout the surgery, allowing the Doctor to see the nerve(s) and prolapsed disc clearly. The affected disc will then be removed using micro instruments.

Minimally invasive surgery uses small metal tubes for the prolapsed disc treatment.

Figure 2

Postoperative Care

After surgery, the patient will start walking the next day with a corset around the low back, with the help of the physiotherapist.
Patient will usually stay in the hospital for 2 nights
By the time a patient leaves the hospital, he/she will be pretty much independent in getting in and out of the bed, walking, and using the bathroom.
The dressing will be changed to a waterproof dressing so that the patient can shower at home.
There will be weekly change of dressing, and by the 2nd to 3rd week, the wound should be able to be exposed.
After the dressing is removed, the Doctor will refer the patient for postoperative back physiotherapy.

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