Herniated nucleus pulposus (slipped disk)

Alternative names:

cervical radiculopathy; herniated intervertebral disk; lumbar radiculopathy; prolapsed intervertebral disk; radiculopathy; ruptured disk; slipped disk

Treatment:

Conservative treatment is usually initiated unless neurological impairment is present. Several weeks of bed rest on a firm mattress and medications to relieve pain and reduce inflammation may be all the treatment that is necessary for recovery. Surgery may be indicated for people who fail to respond to bed rest and medications.

MEDICATIONS:

• NSAID

Nonsteroidal anti-inflammatory medications (NSAID) such as ibuprofen or naproxen are usually prescribed to reduce the pain associated with the radiculopathy. Take these medications with food to avoid stomach irritation.

• MUSCLE RELAXANTS:

Muscle relaxants such as cyclobenzaprine (Flexeril) or carisoprodol (Soma) may be prescribed to relieve the discomfort associated with muscle spasms. However, these medications may cause confusion in older people.

• ANALGESICS

Depending on the level of pain, various analgesic medication may be used in the initial period.

SURGERY:
Surgery may be indicated for people who fail to respond to bed rest and medications, or show signs of progressive worsening of symptoms or experience intractable pain. Surgical options include laminectomy, spinal fusion, micro diskectomy and chemonucleolysis.

• LAMINECTOMY:

Laminectomy is performed to remove the protruding disk. This procedure is performed under general anesthesia. The bone that curves around and covers the spinal cord (lamina) and the tissue that is causing pressure on the nerve or spinal cord is removed. The hospital stay is about 7 days. You will be encouraged to walk the first or second day after surgery to reduce the risk of blood clots. Complete recovery takes about 5 weeks. Heavy work is not recommended until several months after surgery.

• SPINAL FUSION:

A spinal fusion may be necessary if instability between vertebrae is present. The surgery stabilizes (fuses) vertebrae together with bone grafts or metal rods. The most common spinal area involved is the lower (lumbar) spine, but upper (cervical) spine involvement can occur. The lumbar vertebrae are repaired through an incision directly over the spine (posterior lumbar approach). The cervical vertebrae are repaired through an incision in the front or side of the neck (anterior cervical approach). You will be hospitalized for several days after surgery. A back brace or cast may be necessary for weeks after the surgery to immobilize the spine until the fusion has occurred.

• MICRO DISKECTOMY:

Micro diskectomy is a procedure used to remove fragments of nucleated disk.

• CHEMONUCLEOLYSIS:

Chemonucleolysis is the injection of an enzyme chymopapain into the herniated disk to dissolve the protruding gelatinous substance. This procedure may be an alternative to laminectomy in certain situations.

DIET:
Constipation is frequently a problem because of the prolonged bed rest and immobility, use of narcotic pain medications, and pain. Increase the intake of high fiber foods, including fresh fruits and vegetables, whole-grains, and beans. Ensure a daily fluid intake of at least 2 to 3 liters of fluids.

BED REST:
Several weeks of bed rest on a firm mattress and medications to relieve pain and reduce may be all the treatment that is necessary for recovery. A gradual progressive increase in the level of activity will be prescribed once the acute pain subsides. Follow your health care providers advice regarding exercise and activity level.

While on bed rest, it is very important to change position frequently and monitor for complications of immobility. See also how to avoid complications of immobility and preventing pressure ulcers.

BRACES OR SUPPORTS:
Back braces or supports are recommended initially after the injury. They are usually worn until muscle support has improved through exercise. Use of back braces have been shown to decrease the amount of time on bed rest. However, it may be necessary to wear the brace for up to 8 weeks.

A soft cervical collar may be prescribed for people with cervical radiculopathy. The collar helps reduce the pain and muscle spasms by limiting neck movements. A rigid neck collar may occasionally be necessary to eliminate weight bearing on the cervical spine in people with severe pain and muscle spasms.

ICE OR MOIST HEAT:
Some people find that ice packs or moist heat to the affected area provides some relief of the pain and muscle spasms associated with the injury.

PHYSICAL THERAPY:
Initially after the injury you may be referred to a physical therapist to receive "sedative physical therapy" which may include application of hot packs, ice massage, neck rotation, relaxation exercises, and occasionally cervical traction to provide decompression of the spinal nerves.

You will also be given instructions on how to perform exercises to strengthen the muscles of the neck (for cervical radiculopathy) and abdomen (for lumbar radiculopathy). Flexion (bending) and extension (straightening) exercises may be prescribed to increase muscle strength and range of motion.

Expectations (prognosis):

Most people will improve with treatment. A small percentage may continue to have chronic back pain even after treatment. It may take several months to a year or more to resume all activities without pain or strain to the back. Certain occupations that involve heavy lifting or back strain may need adjustment to avoid recurrent back injury.

Complications:

• chronic back pain
• permanent loss of movement or sensation in the legs or feet

Calling your health care provider:

Call your health care provider if persistent severe back pain develops, especially if there is any numbness or loss of movement.