Mark W. McFarland, DO
The spinal disc is a marvel of nature – a cushion between our vertebrae to absorb the shocks and traumas of everyday life, a tough ligament that helps create stability for the spinal bones and a joint which allows for some spinal mobility. There are 23 discs in the spine, six in the cervical (neck) region, twelve in the thoracic (middle) region and five in the lower or lumbar region. These incredible shock-absorbers are living tissue that change with age, wear and tear or injury. In this article, I’ll discuss spinal discs and the commonly seen problems associated with them.
First, a quick anatomy lesson, where I will ask you to envision a jelly doughnut. Everyone knows that the outside of the jelly doughnut is a type of round container for the inside of the doughnut, which is jelly. A spinal disc is quite similar in structure. The stronger, outside of the disc is called the annulus (the cooked dough of the doughnut) and the jelly part or inside of the doughnut is called the nucleus pulposis (NP). The NP is a protein rich, gel-like substance that contains fibers of cartilage.
Now what happens when the jelly doughnut is squished? The filling comes out, either a little, a lot or totally. Usually, we just lick the jelly off our fingers and the problem is solved. But when this happens to a spinal disc, through injury or simple wear and tear with age, the contents can bulge or completely herniate and rupture, pressing on spinal nerves or the spinal cord, causing pain, numbness and even dysfunction. The fix for this problem is a bit more complex than that of a squished jelly donut. Also, if your jelly doughnut becomes stale (who can imagine resisting it long enough for that to happen?), the jelly inside will dry out and become stiff, flat and hard. The same can happen to the inside of a disc. Unfortunately, by adulthood, the disc has almost no blood supply, but is nourished by an exchange of nutrient rich fluid, the supply of which decreases with age and wear and tear. We call that desiccation, often used interchangeably with degeneration.
Ever notice how we tend to shorten as we get older? That can come from fallen arches, but it most commonly happens because our spinal discs dehydrate and lose volume and height as they dry out or desiccate. By the age of forty, 60% of persons who have an MRI of their spine will show at least some level of degeneration in their spinal discs, although that doesn’t directly correlate to pain. It’s just a part of the aging process. But for some folks, the annulus (outside of the disc) can start to crack and form fissures, allowing what’s left of the nucleus pulposis to seep out and put pressure on the spinal nerves, resulting in pain.
As a fellowship-trained spine specialist, I regularly see people who complain of pain, numbness or tingling in their limbs, neck and back. When there is a problem with the spinal discs in the neck, the patient will often complain of pain, tingling or numbness in their shoulder, arm or fingers. They may also have weakness. The same holds true for problems with discs in the lumbar region, but the symptoms will be felt in the buttocks, legs and feet. I order x-rays to see if there are any bony issues in the spine, such as bone spurs. An x-ray will also alert me to loss of disc height, which signals disc degeneration. However, an x-ray will not allow me to visualize a disc herniation. Often, patients are quite surprised when I diagnose them with a spinal disc problem.
We start treatment conservatively, with oral steroids and OTC NSAIDS to reduce inflammation and pain. Physical Therapy is often prescribed to help relieve the physical pressure being placed on the nerve or spinal cord. If after several weeks the patient is not feeling better, I’ll order an MRI to find out more definitively what may be causing the problem. The MRI will allow me to see if the nucleus pulposis has left its casing in the annulus and is pressing on a nerve or the spinal cord.
If there is a bulging or herniated disc, I’ll recommend an epidural steroid injection to deliver the steroid medication directly to the spinal nerve that is being inflamed by the protruding disc material. Oftentimes, this injection does the trick and provides effective pain relief for months or even years. Many patients of mine are on a maintenance schedule of epidural steroid injections which controls their pain and helps them to avoid surgery.
If the epidural steroid injection doesn’t work, I may next recommend the use of Stem Cell Therapy. Not everyone is a candidate for this therapy, but my patients have seen great results and effective pain relief when stem cells are used. As insurance doesn’t cover the cost of the stem cells, this may be a consideration when considering the available treatment options. Get an idea of Stem Cell Therapy costs here.
Surgery is the last treatment option we consider. Some patients who have herniations, but otherwise healthy discs, can have a microdiscectomy, a minimally-invasive outpatient surgical procedure where I remove only the protruding part of the disc that is pressing on the nerve. When patients have disc degeneration AND a herniation, the protruding disc material must be removed off of the nerve or spinal cord. In addition, due to the degeneration, the disc is unstable and will have to be fused in order to provide stability to the spine. Most fusions are also minimally-invasive outpatient procedures that allow the patient to go home to recover the same day as surgery.
Recovery times vary according to the size of the surgery, the patient’s general condition and other factors. I typically send in-home nursing staff and Physical Therapy to the patient’s home to ensure that all is going well medically and that they are actively participating in their own recovery. Any post-surgical pain is usually well-controllable and decreases with recovery time. I normally prescribe my patients a supportive brace that should be worn while the patient is up and around. Some fusion patients may require a bone growth stimulator to be worn for several hours a day. This device supplies a gentle electric current to the bone, inspiring growth and full fusion. Usually, patients will be able to return to office work in 2-6 weeks and most activities in three months. I consider surgery to be a success when my patients tell me that they have returned to the lifestyle they once enjoyed BEFORE their disc problem occurred.