Treatment

Conservative treatment — mainly avoiding painful positions and following a planned exercise and pain-medication regimen — relieves symptoms in nine out of 10 people with a herniated disk. Within a couple of months of starting this treatment, you should be back to normal. Imaging studies show that the protruding or displaced portion of the disk shrinks over time, corresponding to the improvement in symptoms. Depending on your symptoms, your doctor may recommend:

• Modified activity. Take it easy when you have severe back pain. Try to stay away from activities that aggravate your symptoms, such as improper reaching, bending and lifting, using a rowing machine, and prolonged sitting.However, remember that the spine and disks rely on motion and use for their nutrition. Intermittent activity to maintain fitness and minimize stiffness is very important, so physical therapy and exercises to increase flexibility and strength may be prescribed. A herniated disk isn't a fragile spine problem, and physical activity shouldn't be avoided altogether. In fact, staying at work is best, even if you need to reduce your workload or assume lighter duties. No two people have quite the same levels of discomfort with different activities. That's why you should work with your doctor or a physical therapist to find the right combination of rest and activity. Over several weeks, your activity level can gradually increase until you're comfortable with everyday tasks.
• Physical therapy. A physical therapist can apply heat, ice, traction, ultrasound and electrical stimulation for pain relief. Physical therapists can also show you positions and exercises designed to minimize the pain of a herniated disk. As the pain improves, physical therapy can advance you to a rehabilitation program of core strength and stability to maximize your back health and help protect against future injury.
• Heat or cold. Initially, cold packs can be used to relieve pain and inflammation. After a few days, you may switch to gentle heat to give relief and comfort.
• Pain medication. If your pain is mild to moderate, your doctor may tell you to take an analgesic medication, such as aspirin, ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or naproxen (Aleve, others). Muscle relaxants such as diazepam (Valium) or cyclobenzaprine (Flexeril) may be prescribed for a few days if you have back or limb spasms.If your pain doesn't improve with these medications, your doctor may prescribe narcotics, such as codeine or a hydrocodone-acetaminophen combination (Lortab, Vicodin) for a short time. Recently, neuropathic pain medications or "nerve pain" pills, such as gabapentin (Neurontin, others) also have been prescribed for this type of pain. Alternatively, inflammation-suppressing corticosteroids may be prescribed orally or given by injection directly into the area around the spinal nerves.

• Bed rest. Constant, severe back pain from a herniated disk sometimes requires one or two days in bed on a firm surface or mattress. Strict bed rest for longer than a day or two, however, can inhibit recovery by causing loss of muscle tone.
• Time. Herniated disk symptoms generally take four to six weeks to significantly improve. If your symptoms have not resolved after six weeks, more aggressive therapies may be effective and prevent you from needing surgery.

Surgery
About 10 percent of people with herniated disks eventually need surgery. You may be a good candidate for surgery if conservative treatment fails to improve your symptoms after four to six weeks. Surgery also may be considered if a disk fragment lodges in the spinal canal, pressing on a nerve, or if you're having trouble standing or walking.

The most common surgery for a herniated disk is a microdiskectomy. This procedure has the best success rate among healthy people with single disk herniations.

Microdiskectomy is related to standard or open diskectomy, a spinal surgery that involves cutting away some of the spinal bones (vertebrae) to access the herniated disks and compressed nerve roots. In microdiskectomy, surgeons use a surgical microscope or magnifying lens to allow smaller incisions in the skin, muscles and bone overlying a herniated disk. Smaller incisions and less disruption to surrounding tissue lessen pain and shorten recovery time. During a microdiskectomy:

• You're placed under general anesthesia, which means you won't be conscious during the surgery. In some cases, though, microdiskectomy is possible without general anesthesia, using injections that cause temporary numbness (local anesthesia) in the back.
• The surgeon makes a small incision over the herniation and moves the back muscles away from the spine as much as possible. Small amounts of bone and ligaments may be removed to gain access to the herniated disk and nerve root.
• Small instruments are used to remove the herniated portion of the disk and other disk tissue and fragments, relieving pressure on the nerve.
• The incision is closed with stitches or staples.
• Some people go home the same day, while others stay in the hospital for one to two days after surgery.
• Most people make a full recovery and return to work within two to six weeks.

2006-12-20

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