Conquer Back and Neck Pain - Walk It Off! (15 page)

To further illustrate when you should have surgery for a herniated disc, I will relate the story of four pregnant patients who developed symptoms of progressive nerve damage from herniated discs and were operated upon. They all had relief of pain, recovered normal function, and had normal babies.

One of the women had severe pain, significant loss of strength in her legs, and difficulty passing urine (cauda equina syndrome) because of a herniated disc in her low back — and she was eight months pregnant. We were afraid that the strain of labor would make the disc herniate more and cause permanent paralysis. Her obstetrician delivered her normal baby by cesarean section after which, under the same anesthesia, I performed a disc excision. She was able to walk normally the same day of surgery and recovered all of her normal nerve function.

Another of the four patients had cauda equina syndrome from a massive disc herniation in her low back, and she was five months pregnant! We performed a disc excision and she delivered a normal baby at term. Five years later she and her daughter were featured on a poster for the American Academy of Orthopaedic Surgeons. They took my wife and me out to dinner to celebrate the 10th anniversary of her surgery.

The other two patients had similar stories and outcomes. Both had weakness in major muscles of their legs and loss of sensation from herniated discs in their backs. Both patients had complete recovery of nerve function, relief of pain, and delivered normal babies at term. The point is that if you need surgery for a herniated disc, you need it! And the results can be excellent even if you are pregnant.

This American Academy of Orthopaedic Surgeons Poster features a patient of the author’s who had cauda equina syndrome from a massive disc herniation during pregnancy. It was successfully treated with surgery.

Another myth is that disc herniation is the result of trauma. The truth is that normal discs do not herniate. In fact, the discs are so tough that the adjacent vertebrae will break as the result of a fall but the nearby discs will not rupture. There must be some deterioration in the disc (degeneration) for the disc to displace or herniate from the normal position between the vertebrae. Simply bending over is all it takes to herniate a degenerated disc when it is ready to fail, much like the potential for a rotting tree to blow over in a mild windstorm (the straw that broke the camel’s back analogy). That is why it is so confusing for people who suffer from a painful disc herniation. They often cannot remember what brought on the pain!

Unlike in adults, trauma
can
cause normal discs to herniate in growing children. Children under the age of 16 have a growth plate on their vertebrae at the point where the strongest attachment of the disc to the vertebrae occurs. A separation of this growth plate can occur as the result of trauma, causing the disc to herniate even though it is perfectly normal otherwise. The youngest patient I ever operated upon for a disc herniation, a 12-year-old, had such an injury to a normal disc as the result of a fall from a jungle gym. Back pain in children, be it from injury or otherwise, should be considered serious and requires medical attention.

Some people have a strong genetic disposition to disc herniation. One of my 25-year-old orthopaedic residents was assisting me in surgery when he experienced a sudden onset of pain shooting down his leg from his back. “It’s happened again!” he said. “I have another herniated disc.” And sure enough he did, at the L5-S1. At the age of 16 he had undergone a disc excision for a herniated disc at the L3-4 level in his low back. At the age of 21 he had surgery for a L4-5 disc herniation. I removed his L5-S1 disc herniation and he returned to work within a week of surgery. He subsequently became an accomplished surgeon. He was in excellent physical condition when I operated on him, and remains that way, swimming a mile a day to stay in shape. He has a busy practice and a good quality of life despite a strong genetic predisposition to herniate discs.

Most herniated discs produce pain in one leg or one arm. Less commonly a disc will cause only back pain or pain in both legs and both arms. The pain associated with a disc herniation usually radiates from the back down the leg, the neck down the arm, or from the back of the chest to the front along the ribs, depending on the site of the herniation. The pain is described as any combination of the following sensations: burning, numbness, pins and needles, aching, and stabbing. Most people describe attacks of neck or back pain leading up to the pain that radiates into the arm or leg. The pain may be associated with loss of sensation and/or weakness of handgrip from a disc herniation in the neck and an inability to lift the foot (foot drop) from a disc herniation in the low back.

I always have my patients fill out a pain drawing so that I can immediately tell the location and characteristics of the pain. When I first see a patient’s self-generated pain drawing, I not only can tell that they have a herniated disc, but I can also tell you which nerve it is pressing on. For example, a patient with an L5-S1 disc herniation in the low back pressing on the first sacral nerve root will place symbols depicting pain down the back of the thigh, lower leg, and into the bottom and side of the foot. The symbols on the pain drawing may designate any combination of abnormal sensations such as stabbing pain, burning, numbness, tingling, and aching.

A herniated disc in the low back may cause you to lean over like the Tower of Pisa and to have a painful limp. A disc in the neck can cause you to stumble and trip and lose your balance (my aunt’s symptoms). A disc in the low back can cause inability to urinate or constipation. If you experience gait disturbance or change in bowel and bladder function associated with spine pain, notify your doctor immediately. If your pain lasts for more than a few days, interferes with your sleep, or requires that you take pain medication, you need to see your doctor to determine what is wrong.

To diagnose a disc herniation, your doctor will listen to you describe your symptoms and then perform a physical examination. Your doctor will have you walk on your toes and on your heels to check your strength and coordination; look at your spine to see if it is straight or leaning to one side and have you bend forward as far as the pain allows to determine if you have muscle spasm; check to see if you have lost any reflexes or if you have abnormal reflexes (I discovered abnormal reflexes when I examined my aunt, which told me she had something seriously wrong); determine if you have lost any sensation or muscle strength; and check to see that you have good circulation in your legs, arms, and neck.

This patient-generated pain drawing depicts typical left sciatic leg pain from a herniated disc between the 5
^th
lumbar vertebra and the sacrum (L5-S1 HNP).

There are a few maneuvers that will stretch the nerve over a disc herniation and reproduce the pain that you have to confirm that diagnosis. One test that is specific for detecting a disc herniation in the low back is the so-called straight-leg-raising test. While you are lying on your back facing up, the doctor slowly raises the painful leg while keeping your knee straight. The degree of elevation of the leg from the table and the degree of reproduction of the pain radiating down your leg is an indication of how much the disc is pressing on the nerve in your back. I could only lift my neighbor’s painful leg a few degrees before he screamed from the pain all the way from his back, down the leg, and to his foot. Even more ominous was that when I lifted his opposite leg, the pain was reproduced in his painful leg; this is called the crossed-straight-leg-raising test. The tests told me that the disc had squeezed completely into the spinal canal and that is exactly where I found it at surgery.

Warning
: If you are having severe pain in your arm or leg, do not have someone other than a doctor try these tests on you, because it may make the pain even worse! When the doctor goes to perform the tests, tell her or him to go slowly and stop as soon as you feel the pain get worse. When I was a resident in training I unknowingly lifted a colleague’s leg too fast and too far, which exacerbated his leg pain so much that he could not sleep that night. The test did confirm my suspicion that he had a herniated disc in his low back, but he wouldn’t talk to me after that, and he insisted that someone else take care of him.

There are two other variations of the nerve-root-tension test. The first is the femoral-stretch test (see the illustration on this page), in which you lie face down and the doctor bends your knee. If you experience pain in the front of your thigh, it may mean that you have a disc herniation in the upper part of your low back (the L2-3, L3-4, or L4-5 disc). The second variation is the straight-arm-raising test where the doctor raises your arm sideways and backward. Reproduction of arm pain with this maneuver may mean that you have a disc herniation in you neck (most common levels are C5-6 and C6-7).

After hearing your story and examining you, the most accurate, safest, least painful, and most cost-effective test your doctor can order to confirm the diagnosis of a disc herniation is an MRI scan. The MRI scan has replaced the myelogram and CAT scan for diagnosis of herniated discs and most other spinal disorders. For this reason I will describe what this test is, how it works, how it is performed and what it shows.

When I started in practice, we would confirm the diagnosis of a disc herniation by performing a myelogram, a painful procedure that involved inserting a needle into the spinal canal, injecting a painful oily dye, and taking numerous x-rays. The disc would appear as an indentation on the dye column. The test was painful, required hospitalization and x-ray exposure, and could be dangerous. Later the CAT scan, a three-dimensional x-ray, was developed. It could detect a herniated disc without performing a myelogram, but the patient was still exposed to x-rays, and the pictures from a CAT scan were not very clear. Then new water-soluble myelogram dyes were developed that weren’t as painful or potentially harmful as the older oil-based dyes, and they could be used with the CAT scans to make them more accurate. This method is still used to diagnose spinal conditions in patients who cannot have an MRI scan, such as those with metal implants near the spine and people with heart pacemakers.

In the early 1980s the MRI scan was developed for diagnosis. This procedure was a dramatic development in all of medicine but was especially beneficial for the diagnosis of painful spinal disorders. It is a painless procedure, safe — even during pregnancy (no x-ray exposure) — and extremely accurate. MRI scans are the only way to determine exactly where and how far the disc has herniated into the spinal canal (see MRI scan this page). The picture of the spine produced by an MRI is so accurate that it can provide the surgeon with an exact map as to where to find a herniated disc fragment in the spinal canal.