Are steroids given for degenerated disc problems?

Steroids applied locally by injection can be very helpful if properly given to selected patients and generally post few dangers. These injections should be given by an experienced pain specialist or radiologist. They may be most effective in the setting of spinal stenosis or nerve root irritation due to disc degeneration. Steroids given orally in the form of pills (such as Prednisone ) may have significant side affects on various organ systems including the bones (osteoporosis, avascular necrosis…) that can exceed the potential medical benefits. One must realize that a mildly bulging, or "dried out" disc is rarely a severe problem. Disc changes are a normal part of aging in the spine. When discs are found to lose water content, it means they are losing some of their ability to act as a shock absorber and the function of properly binding the vertebrae. This can lead to a very subtle instability that may be responsible for pain in some people. If the pain is not severe when a person is in bed or at rest but becomes severe with walking, moving about or prolonged sitting, then there is most likely a mechanical component to the pain. In that case it may be very beneficial to work on stabilizing the spine by developing the muscular supports. Steroid injections may not be the best approach in such cases. Good results can be achieved with a combination of bracing and upper extremity exercises. Locally injected steroids into the facet joints of the spine may offer temporary anti-inflammatory action that can offer some pain relief. However, the primary focus of treatment in most cases is directed towards a guided exercise program.

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When does one consider surgery for a herniated disc in the cervical spine ?

The spinal canal which contains the spinal cord has only limited space available within the limits of the bones and ligaments of the cervical spine. When a disc bulges inside the canal and leads to a large herniation then a compression of nerves or spinal cord can develop which leads to abnormal function of the nerves or pain. In many cases the herniated disc may shrink, or the nerves become "adjusted" to the herniation and the symptoms may resolve with time. When symptoms are severe or do not improve with time, then surgery may be necessary. Surgical treatment usually involves a decompression performed by an anterior disc removal followed by interbody fusion (fusion means causing two vertebrae to grow together into a solid block by inserting a bone graft at the place where the disc was removed). In some cases a decompression can be accomplished by a posterior laminectomy and disc resection without fusion.

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What is a ruptured disc?

The disc is a complex structure that carries two principal functions: bind two vertebra solidly together (while permitting some motion) and providing a shock absorbing function. The disc is located between two vertebra and looks like a very solid ligament made of multiple outer fibrous layers (called the 'annulus' which means "ring") while containing a jelly-like substance in the middle (called the 'nucleus').

A ruptured disc means that an unusual and excessive load was applied (usual by high velocity) on a disc resulting in the rupture of all or most of the layers of the annulus. The consequence is a disruption of the binding ligament and leakage of the jelly (nucleus pulposus) out of the boundaries of the annulus. As a consequence the two vertebrae connected by the disc which suffered the injury are no longer smoothly bound together and a combination of instability and nerve irritation can lead to severe back pain which does not respond to conservative treatment. When conservative treatment fails, the appropriate treatment for this condition is not a laminectomy with discectomy (even when there is an image which may suggest a herniated disc) but rather a stabilization by interboby fusion.

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What is the difference between a slipped, herniated and bulging disc?

The word "slipped " means that a disc has lost its integrity and that a portion of the disc has passed beyond the normal anatomical boundaries. A herniated disc is the same thing as a 'slipped disc'. When a disc fragment bulges beyond its normal position nerve irritation may occur which is often call a "pinched nerve" or sciatica. Symptoms of leg or foot pain and numbness, tingling or shooting electrical type feelings may occur. Varying degrees of disc herniation may occur ranging from " bulge" (which is usually not serious) to "large herniation" or "extrusion".

It is often not clear what causes a disc to herniate. The application of unusual loads may compress the disc in such a way that part of the jelly (nucleus) gets out of the boundaries of the annulus and is partially or totally extruded backward, where the ligaments are weakest. The disc fragments may get stuck in the spinal canal. The canal can not expand and the presence of the disc fragment takes up the space of the nerves thus leading to compression of one or several nerve roots. This leads to pain following the nerve root distribution and can go to the hip, the knee, the calf or the ankle and the foot. Any disc herniation requires a complete evaluation by a spine specialist. If there are no severe neurological symptoms (weakness, abnormal reflex…) conservative management is likely to be successful. Surgical treatment is only considered in rare cases of intractable excruciating pain, which does not improve, and/or severe neurological symptoms.

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When does a herniated disc require surgery?

It is rare that a herniated disc must be removed surgically. In most instances of disc herniation symptoms gradually resolve without surgical treatment. In the few cases of severe persistent symptoms and progressive neurologic impairment, an operation may be required. One of the few reasons for an immediate removal of a disc is when the disc compresses the nerves which are responsible for bladder and bowel control (cauda equina syndrome). Any loss of bladder control or changes in bowel or bladder habits should be evaluated immediately by a specialist.

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What are the results for disc surgery?

In those few patients who require surgery for a herniated or extruded intervertebral disc, the results of surgery are very good. The results in various studies are variable but over 90% of patients can be expected to get relief from their symptoms. It is essential to have proper pre-operative evaluation by a spine surgeon, which includes an MRI and occasionally a CT-myelogram. Careful selection of patients who truly require surgery is essential.

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