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Epidural herniated disk: Epidural injections for the treatment of symptomatic lumbar herniated discs

Содержание

Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study


Background:

Epidural steroid injection is a low-risk alternative to surgical intervention in the treatment of lumbar disc herniation. The objective of this study was to determine the efficacy of epidural steroid injection in the treatment of patients with a large, symptomatic lumbar herniated nucleus pulposus who are surgical candidates.


Methods:

One hundred and sixty-nine patients with a large herniation of the lumbar nucleus pulposus (a herniation of >25% of the cross-sectional area of the spinal canal) were followed over a three-year period. One hundred patients who had no improvement after a minimum of six weeks of noninvasive treatment were enrolled in a prospective, non-blinded study and were randomly assigned to receive either epidural steroid injection or discectomy. Evaluation was performed with the use of outcomes scales and neurological examination.


Results:

Patients who had undergone discectomy had the most rapid decrease in symptoms, with 92% to 98% of the patients reporting that the treatment had been successful over the various follow-up periods. Only 42% to 56% of the fifty patients who had undergone the epidural steroid injection reported that the treatment had been effective. Those who did not obtain relief from the injection had a subsequent discectomy, and their outcomes did not appear to have been adversely affected by the delay in surgery resulting from the trial of epidural steroid injection.


Conclusions:

Epidural steroid injection was not as effective as discectomy with regard to reducing symptoms and disability associated with a large herniation of the lumbar disc. However, epidural steroid injection did have a role: it was found to be effective for up to three years by nearly one-half of the patients who had not had improvement with six or more weeks of noninvasive care.

Factors for Predicting Favorable Outcome of Percutaneous Epidural Adhesiolysis for Lumbar Disc Herniation

Background. Lower back pain is a common reason for disability and the most common cause is lumbar disc herniation. Percutaneous epidural adhesiolysis has been applied to relieve pain and increase the functional capacity of patients who present this condition. Objectives. In this study, we retrospectively evaluated the factors which predict the outcome of percutaneous epidural adhesiolysis in patients who were diagnosed with lumbar disc herniation. Methods. Electronic medical records of patients diagnosed with lumbar disc herniation who have received percutaneous epidural adhesiolysis treatment were reviewed. The primary outcome was the factors that were associated with substantial response of ≥4 points or ≥50% of pain relief in the numerical rating scale pain score 12 months after the treatment. Results. Multivariate logistic regression analysis demonstrated that the presence of high-intensity zone (HIZ) at magnetic resonance imaging was a predictor of substantial response to percutaneous epidural adhesiolysis for 12 months (). The presence of a condition involving the vertebral foramen was a predictor for unsuccessful response after 12 months (). Discussion and Conclusion. The presence of HIZ was a predictor of favorable long-term outcome after percutaneous epidural adhesiolysis for the treatment of lower back pain with radicular pain caused by lumbar disc herniation.

1. Introduction

Lower back pain is one of the most common causes of disability worldwide and is often accompanied by radicular pain [1, 2]. The most common cause of lumbar radicular pain is lumbar disc herniation, which is also the most common cause of lower back pain [3, 4]. Although the majority of patients who present with lower back pain and radicular pain improve within 12 weeks, between 6% and 11% of patients continue to have symptoms that persist for more than 3 months, which can lead to medical expenses and disability [3, 5].

Although the natural course in more than 80% and 90% of patients is symptom improvement within the first 6 and 12 weeks, respectively, treatment for relief during the symptomatic period is essential, as significant disability during daily activities may occur [6]. Initial treatment includes conservative management with oral medication for pain relief and physical therapy [7]. If the symptoms persist or the improvements are insufficient, interventions such as epidural steroid injections or, in limited cases, percutaneous epidural adhesiolysis can be applied [4, 8–10]. If the symptoms persist after these interventions, surgery should be considered [11–13].

Since its introduction in the late 1990s, percutaneous epidural adhesiolysis has been applied to relieve pain and increase the functional capacity of patients who present chronic lower back pain with or without radiculopathy, which are refractory to conservative treatment [14, 15]. Many studies have reported the effects of percutaneous epidural adhesiolysis in patients who present persistent symptoms of lower back pain with or without radicular pain diagnosed with various pathological conditions [16–18]. There is sufficient evidence of the short-term (<3 months) efficacy of percutaneous epidural adhesiolysis and moderate evidence on its mid- to long-term (>3 months) efficacy [19]. Indeed, the strength of evidence varies, depending on the diagnosed pathological condition. Two previous studies have described the effects of percutaneous epidural adhesiolysis on the treatment of lumbar disc herniation, and one study analyzed its effects on lumbar disc herniation and postlaminectomy syndrome [9, 10].

In this study, we retrospectively evaluated the factors predicting the outcome of percutaneous epidural adhesiolysis on patients diagnosed with lumbar disc herniation who present symptoms of lower back pain with radicular pain that were refractory to conservative treatments including epidural steroid injections.

2. Methods

This study was approved by the local ethics committee (BD2015-60), and the necessity to obtain informed consent was waived because of the retrospective nature of the analysis that reviewed previously recorded patient data. The electronic medical records of patients who were diagnosed with lumbar disc herniation presenting symptoms of lower back pain with radicular pain that have received percutaneous epidural adhesiolysis treatment were reviewed. The data for every patient treated with percutaneous epidural adhesiolysis for this condition at Seoul Sacred Heart General Hospital between November 2011 and October 2013 were collected. Inclusion criteria for the patient data collection included the following: patient age > 20; symptoms of lower back pain with radiculopathy; subacute or chronic symptoms lasting more than 6 weeks; failure to respond to conservative treatment including medication and physical therapy; symptoms refractory to interlaminar or transforaminal epidural injections; definitive diagnosis of lumbar disc herniation which was confirmed by magnetic resonance imaging (MRI). The percutaneous epidural adhesiolysis technique was standardized to all patients receiving the procedure. Each patient received a transforaminal epidural injection twice in 2- or 3-week intervals, and if the symptoms persisted or the relief was insufficient, the patient received percutaneous epidural adhesiolysis after a >1-month interval between the last epidural block. The patient data including any one of the following exclusion criteria were removed from the analysis: inadequate data or loss to follow-up before the first year after percutaneous epidural adhesiolysis, diagnosis other than lumbar disc herniation, history of previous percutaneous epidural adhesiolysis, previous lower back or lower limb surgery, and percutaneous epidural adhesiolysis techniques other than the catheter-guided technique.

2.1. Percutaneous Epidural Adhesiolysis Technique

All of the procedures were performed under fluoroscopic guidance on an outpatient basis. The patient was placed in a prone position with a pillow under the abdomen to secure the position and minimize lumbar lordosis. The administration of opioids or sedatives for mild sedation and analgesia during the procedure was decided at the discretion of the attending physician. The caudal approach was used under fluoroscopic guidance. The 16 G RK Tuohy introducer needle was inserted through the sacrococcygeal ligament and placed in the sacral canal. A radiopaque contrast dye (Ultravist, Bayer Korea, Seoul, Korea) was injected via the introducer needle to confirm epidural placement of the needle, and epidural filling defects were identified by the epidurogram. The filling defects were further compared with the MRI findings and the dominant symptom of the patient. After appropriate confirmation of the pathology, a metal-reinforced Racz epidural catheter (Epimed, Farmers Branch, TX) was inserted through the epidural needle towards the target area, which was determined by imaging and patient symptoms. A radiopaque contrast dye was again injected to confirm the appropriate position of the catheter tip at the site of pathology and to further verify any intravascular, intrathecal, or other extraepidural filling (Figure 1). The catheter tip was positioned at the anterior epidural space of the target site, and in the case of foraminal diseases, was placed at the lateral recess or opening of the foramen. After confirmation of the catheter tip position, 3–5 mL of 1% lidocaine was administered as a test dose. The patient was observed for 10–15 min after test dose injection and asked for any signs of newly developed motor and sensory blocks. No additional drugs were administered if the patient complained of possible signs of intrathecal, intravascular, loculation or subdural injections such as severe paresthesia, pain, weakness, numbness or paralysis. Then, 10 mL of 0.9% NaCl was slowly injected and after injection of normal saline, 0.125% bupivacaine mixed with 5 mg dexamethasone was injected. After 5 min, 10 mL of 10% hypertonic saline was slowly injected under real-time fluoroscopic guidance while frequently asking the patient to describe any newly developed symptoms. The catheter was removed slowly to prevent catheter sheering, and the insertion site was sutured. The patient was moved to the postprocedure recovery unit in the supine position, and vital signs were continuously checked during recovery.

2.2. Outcome Measures

The patient characteristics, outcome measures, and follow-up data were obtained and reviewed retrospectively from the computerized patient record system. Demographic data including age, gender, height, weight, and body mass index were collected. Past medical history including the presence of oral analgesic medication, history of physical therapies, history of blocks other than epidurals, and history of previous epidural injections were collected. Procedure-related clinical data and radiographic data included the type of herniated intervertebral disc (protrusion, extrusion, sequestration, and foraminal involvement), the presence of HIZ (Figure 2), and the level and location of the lesion. The terms disc protrusion and extrusion were defined according to the classification by Jensen et al. [20]. In this classification, the foraminal type of disc herniation occurs when the herniated intervertebral disc extends to and involves the vertebral foramen; this is type C in the Michigan State University (MSU) classification or the foraminal zone in the McCulloch classification [21, 22]. To evaluate the degree of pain relief after the procedure, the records of pain scores on the 11-point numerical rating scale (NRS: 0 = no pain; 10 = worst unbearable pain) before, 1 month after, and 12 months after the percutaneous epidural adhesiolysis procedure were collected. The patient satisfaction scores presented in a 7-scale global perceived effect scale (GPES: 7 = best ever; 6 = much improved; 5 = improved; 4 = not improved but not worse; 3 = worse; 2 = much worse; 1 = worst ever) which was checked 12 months after the percutaneous epidural adhesiolysis procedure were collected [23]. Responder analysis was performed with the definition of substantial response being a decrease ≥50% or an NRS score of 4 score compared to baseline without increasing the dose of oral medication [23, 24]. Information on any changes in the oral medication regimen at 1 month after the procedure was collected and classified as no change, decreased, or increased. The final epidurogram after the procedure was saved and the presence of transforaminal dye spread was also evaluated. Complications of vasculogram or myelogram during the procedure were noted, and immediate postprocedure complications were evaluated. Patients who needed repeated procedures during the first 12 months after percutaneous epidural adhesiolysis or surgery within the 12-month follow-up period were also identified.

The primary outcome was the factors associated with patients who had a favorable outcome 12 months after percutaneous epidural adhesiolysis treatment. The favorable outcome was defined as patients presenting substantial responses in the NRS pain score. Secondary outcomes included mean NRS scores at each time point, the proportion of substantial responders at each time point, complications, and the proportion of patients who needed surgical treatment during the 12-month follow-up period.

2.3. Statistical Analysis

Descriptive statistics were used to report the demographic and clinical characteristics. Continuous variables were presented as the mean with standard deviation (SD) or median with interquartile range (IQR). Categorical variables were expressed as absolute numbers with frequencies or percentages. For analysis of primary outcome, univariate analysis was first performed. The numerical variables were tested with Student’s -tests or the Mann-Whitney test as appropriate, and categorical variables were tested using the chi-square test with Yate’s correction or Fisher’s exact test as appropriate. The odds ratio (OR) and 95% confidence interval (CI) were provided to show the reliability of the estimates. Multiple logistic regression analysis was used for the multivariate analysis to identify individual predictors of substantial response that were suggested by the univariate analysis. All values < 0.05 by univariate analysis were included in the multivariate analysis. Continuous variables were first assessed for normality using the Shapiro–Wilk test. values less than 0.05 were considered statistically significant, and two-tailed tests were used for all experimental outcomes. SAS version 9.3 (SAS Institute Inc. , Cary, NC) was used for statistical analysis.

3. Results

A total of 875 lower back pain with radicular pain cases treated with percutaneous epidural adhesiolysis between November 2011 and October 2013 were collected and reviewed. Among these, 427 cases were diagnosed with lumbar disc herniation, of which 20 cases were removed from the analysis due to insufficient records. Thus, a total of 407 patients were analyzed. The demographic and clinical characteristics of the study patients are summarized in Table 1. The number of patients presenting with a substantial response 12 months after percutaneous epidural adhesiolysis treatment was 294 (72.2%), and the number of nonresponders was 113 (27.8%). The demographics, clinical characteristics, concurrent medications, initial treatment outcomes of percutaneous epidural adhesiolysis, and presence and type of complications during and after the procedure were compared between the substantial responders and nonresponders (Table 2). There was a statistically significant difference between the two groups regarding the prevalence of type of disc herniation (), initial NRS score at 1 month (), and the presence of HIZ (). The patients in the substantial responder group were more likely to have a lower proportion of disc herniation involving the vertebral foramen, have a HIZ on MRI, and have a lower pain score 1 month after percutaneous epidural adhesiolysis compared to the nonresponder group.


Variables Values

Gender Male 173 (42.5%)
Female 234 (57.5%)

Age 52.00 (14.15)

Height 164.32 (8.32)

Weight 65.65 (10.62)

BMI 24.21 (2.55)

Type of HIVD Protrusion 167 (41.0%)
Extrusion 175 (43. 0%)
Sequestration 45 (11.1%)
Foraminal 20 (4.9%)

Concurrent oral analgesics Yes 400 (98.3%)
No 7 (1.7%)

Concurrent physical therapy Yes 190 (46.7%)
No 217 (53.3%)

Previous epidural block Yes 142 (34.9%)
No 265 (65.1%)

Previous blocks other than epidural Yes 16 (3.9%)
No 391 (96.1%)

Number of levels Single 254 (62.4%)
Two 126 (31.0%)
Three 27 (6.6%)

Location of lesion Left 190 (46. 7%)
Right 182 (44.7%)
Both 35 (8.6%)

HIZ at MRI Present 158 (38.8%)
Negative 249 (61.2%)

Baseline NRS score 7.595 (0.93)

The values are presented as a mean (SD) or absolute number (percentage).
BMI: body mass index, HIVD: herniated intervertebral disc, HIZ: high-intensity zone, MRI: magnetic resonance image, NRS: numerical rating scale, SD: standard deviation.

Variables Values
Substantial responders () Nonresponders ()

Gender Male 131 (44. 6%) 42 (37.2%) 0.215
Female 163 (55.4%) 71 (62.8%)

Age 51.5 (14.1) 53.3 (14.2) 0.175

Height 164.5 (8.4) 163.8 (8.2) 0.404

Weight 65.7 (10.9) 65.4 (9.8) 0.832

BMI 24.2 (2.6) 24.3 (2.4) 0.526

Type of HIVD Protrusion 120 (40.8%) 47 (41.6%) 0.005
Extrusion 135 (45.9%) 40 (35.4%)
Sequestration 31 (10.6%) 14 (12.4%)
Foraminal 8 (2.7%) 12 (10.6%)

Concurrent oral analgesics Yes 288 (98. 0%) 112 (99.1%) 0.706
No 6 2.0%) 1 (0.9%)

Concurrent physical therapy Yes 130 (44.2%) 60 (53.1%) 0.134
No 164 (55.8%) 53 (46.9%)

Previous epidural block Yes 98 (33.3%) 44 (38.9%) 0.344
No 196 (66.7%) 69 (61.2%)

Previous blocks other than epidural Yes 9 (3.1%) 7 (6.2%) 0.241
No 285 (96.9%) 106 (93.8%)

Number of levels Single 182 (61.9%) 72 (63.7%) 0.796
Two 91 (31.0%) 35 (31. 0%)
Three 21 (7.1%) 6 (5.3%)

Location of lesion Left 135 (45.9%) 55 (48.7%) 0.874
Right 133 (45.2%) 49 (43.4%)
Both 26 (8.9%) 9 (7.9%)

HIZ at MRI Present 128 (43.5%) 30 (26.5%) 0.002
Negative 166 (56.5%) 83 (73.5%)

Baseline NRS score 7.55 (0.91) 7.71 (0.96) 0.139

NRS score at 1 month 3.56 (1.09) 3.94 (1.14) 0.007

Substantial response at 1 month Yes 205 (69.7%) 69 (61.1%) 0.121
No 89 (30.3%) 44 (38.9%)

Oral analgesic change at 1 month No change 253 (86.1%) 95 (84.1%) 0.772
Decreased 40 (13.6%) 17 (15.0%)
Increased 1 (0.3%) 1 (0.9%)

Repeated procedure Yes 11 (3.8%) 4 (3.5%) 0.844
No 283 (96.2%) 109 (96.5%)

Vasculogram Yes 19 (6.5%) 8 (7.1%) 0.999
No 275 (93.5%) 105 (92.9%)

Myelogram Yes 10 (3.4%) 2 (1.8%) 0.586
No 284 (96.6%) 111 (98.2%)

Immediate complication Yes 20 (6.8%) 6 (5.3%) 0.745
No 274 (93.2%) 107 (94.7%)

The data are presented as a mean (SD) or absolute number (percentage).
BMI: body mass index, HIVD: herniated intervertebral disc, HIZ: high-intensity zone, MRI: magnetic resonance image, NRS: numerical rating scale, SD: standard deviation.

The results of univariate and multivariate analyses are listed in Table 3. Multivariate logistic regression analysis demonstrated that HIZ on MRI and a lower NRS score at 1 month were predictors of a successful response to percutaneous epidural adhesiolysis after 12 months, whereas the presence of lumbar disc herniation involving the vertebral foramen predicted an unsuccessful response after 12 months. The NRS pain scores in the responder and nonresponder groups are shown in Figure 3. The proportion of substantial responders of the HIZ positive and HIZ negative patients are shown in Figure 4. The number and proportion of patients demonstrating transforaminal dye spread to the affected nerve root in the final epidurogram immediately after percutaneous epidural adhesiolysis was 156 (98.7%) in the HIZ positive patient group and 238 (95.6%) in the HIZ negative patient group, respectively (). Patient satisfaction with the treatment results was significantly different between the two groups. The substantial responder group had a mean GPES score of 5.69 (1.13), whereas the nonresponder group had a mean score of 2.19 (1.08) (). The total number of immediate complications was 26 (6.4%, Table 4), with no effect on the primary outcomes. The number of patients who required surgical treatment within the follow-up period of 12 months was 21 (5.2%).


Univariate Multivariate
OR 95% CI OR 95% CI

Gender Male 1
Female 0.736 0.469–1.145 0.178

Age 0.991 0.975–1.006 0.237

Height 1.010 0.984–1.037 0.466

Weight 1.003 0.983–1.024 0.767

BMI 0.985 0.904–1.073 0.727

Type of HIVD Protrusion 1
Extrusion 1.322 0.812–2.160 0.262 1.409 0.852–2.345 0.183
Sequestration 0.867 0.430–1.814 0.696 0.982 0.474–2.110 0.962
Foraminal 0.228 0.081–0.603 0.004 0.295 0.101–0.809 0.020

Concurrent oral analgesics Yes 1
No 2.333 0.393–44.329 0.435

Concurrent physical therapy Yes 1
No 1.428 0.925–2.211 0.109

Previous epidural block Yes 1
No 1.275 0.811–1.995 0.289

Previous blocks other than epidural Yes 1
No 2.091 0.731–5.752 0.153

Number of levels Single
Two 1.029 0.642–1.667 0.908
Three 1.385 0.567–3.898 0.501

Location of lesion Left 1
Right 1.106 0.703–1.743 0.664
Both 1.177 0.534–2.805 0.697

HIZ at MRI Present 1
Negative 0.469 0.288–0.748 0.002 0.507 0.305–0.827 0.007

Immediate complications Yes 1
No 0.768 0.275–1.860 0.582

Baseline NRS score 0.833 0.657–1.053 0.126

1-month NRS score 0.735 0.600–0.894 0.002 0.789 0.640–0.969 0.025

Oral analgesic consumption after 1 month No change 1
Decreased 0.884 0.485–1.669 0.693
Increased 0.375 0.015–9.559 0.490

Substantial response after 1 month Yes 1
No 0.681 0.434–1.074 0.096

Repeated procedure during follow-up Yes 1
No 0.944 0.257–2.827 0.923

BMI: body mass index, CI: confidence intervals, HIVD: herniated intervertebral disc, HIZ: high-intensity zone, MRI: magnetic resonance image, NRS: numerical rating scale, OR: odds ratio.

Complication Group
Responders () Nonresponders ()

Decreased metal status 6 1
Dizziness 1
Hypotension 4 1
Motor weakness 2 1
Decreased sensory 3
Chest pain 2 1
Postprocedure pain 3 2
Dyspnea 1 1
Nausea 1

The data are presented as absolute numbers.


4. Discussion

The results of our present study demonstrate that the presence of HIZ on MRI is an independent predictor of favorable long-term outcome in patients who have received percutaneous epidural adhesiolysis for the treatment of lower back pain with radicular pain that is caused due to lumbar disc herniation. In contrast, vertebral foraminal involvement by the herniated lumbar disc was a predictor of unsuccessful outcome after percutaneous epidural adhesiolysis.

Symptomatic lumbar disc herniation with radiculopathy accompanies lower back pain in approximately 10% of cases [3]. The lifetime prevalence of lower back pain with radiculopathy is about 1.6% [25], but between 45 and 64 years of age, the prevalence increases to 23.7% [3]. In 90% of these patients, symptoms improve within 12 weeks [26], but some studies have shown that more than 30% of patients have some degree of pain and disability even after 1 year [6]. The initial treatment is conservative management, as the majority of patients are expected to have symptom relief in a couple of weeks. However, in cases of severe symptoms that can severely affect daily life or if symptoms persist for more than several weeks, procedures such as epidural steroid injections can be employed. There is sufficient evidence that epidural steroid injections give short-term pain relief [27], but its ability to decrease the rate of surgery is controversial [28–30]. In addition, the success rate of epidural steroid injections for the treatment of radiculopathy due to lumbar disc herniation varies between studies, ranging from 42% to 77% [31–34] and the rate of surgical procedures after epidural steroid injection was between 10% and 25% [3, 28]. To date, there have been few studies on percutaneous epidural adhesiolysis for the treatment of lower back pain with radiculopathy caused by lumbar disc herniation. One prospective study compared percutaneous epidural adhesiolysis with placebo for the treatment of chronic lumbar radicular pain caused by lumbar disc herniation or failed back surgery. The results of percutaneous epidural adhesiolysis were significantly more superior compared with placebo, but the pathology of patients in that study was heterogenic [9]. The results of our current study showed a 1-year response rate of 72.2%, and the failure rate (proportion of patients who needed surgery) was 5.2%, which is in accordance with data from previous studies on percutaneous epidural adhesiolysis and epidural steroid injections [9, 32, 33].

In our present study, we further evaluated the prognostic factors for the successful treatment of percutaneous epidural adhesiolysis. The presence of HIZ and foraminal involvement of the lesion were the 2 important prognostic factors for successful treatment response. The HIZ on the T2-weighted MRI was first described by Aprill and Bogduk in 1992 [35]. It is currently known that HIZ reflects painful tears of the annulus fibrosus in the intervertebral disc. However, the correlation between the presence of HIZ on MRI and the severity of symptoms are known to be controversial [36]. Previous studies have reported high specificity and a positive predictive value of HIZ, but the results of sensitivity varied from 26.7% to 81% [35, 37–39]. The prevalence of HIZ in lower back pain patients is between 25% and 59% [40, 41], but it is also found in 6–33% of asymptomatic patients [42, 43]. The proportion of patients who presented with HIZ in our current study was 38.8%, and interestingly, these patients had a significantly higher rate of treatment success compared to patients without an HIZ (81% versus 66.7%). Previous pathological studies have demonstrated evidence that tissues at the site of the HIZ are disorganized, vascularized, and granulated with significant numbers of inflammatory cells [44, 45]. These reports support the notion that location of the HIZ may be the main lesion of inflammation that causes pain in symptomatic patients, thus making it the direct target of delivery of local anesthetics and steroids by percutaneous epidural adhesiolysis, which may contribute to the superior outcome. Another possible hypothesis is the role of hypertonic saline. Annular tears are filled with fluid or mucoid materials, and injection of hypertonic saline may promote the absorption of fluids and mucoid. Previous studies have demonstrated the efficacy of adding hypertonic saline during transforaminal injections and epidural adhesiolysis [46, 47]. Hypertonic saline is also known to have inhibitory effect on fibroblast cell proliferation and it is thought to have neuromodulatory effects according to previous experimental studies. The high concentrated chloride ions are known to promote persistent C fiber blockade and contribute to changes in pain conductivity [48, 49]. However, administration of hypertonic saline is known to have several complications, thus special care must be taken during the injection of hypertonic saline. The possible complications are pain during injection, paresthesia, and chemical arachnoiditis. Furthermore, the spread of hypertonic saline in the diseased epidural space or to the subdural space is difficult to predict, due to scarring, narrowing, and adhesion. To clarify the role of steroids and hypertonic saline on HIZ, further prospective studies that compare and quantify the extent of HIZ through radiologic images before and after treatment seem essential.

Previous studies that have evaluated the outcome of percutaneous epidural adhesiolysis reported foraminal stenosis as a predictor of unsuccessful treatment outcome [16, 17]. This is due to the difficulty of delivering the desired medication to the target lesion. Furthermore, when caudal epidural steroid injections have been performed, patients presenting with lumbar herniated discs involving the foraminal zone demonstrated significantly unfavorable treatment outcomes compared to those with discs herniated in the central zone [50]. For the treatment of lesions involving the foramen, utilization of steerable catheter devices may provide a better outcome in this group of patients [10, 51].

There were several noteworthy limitations of our present study. First, only patients who had sufficient data and who were followed up for 12 months were included in our analysis, and those with inadequate data or who were lost to follow-up were excluded. Although the number of follow-up losses or inadequate records was relatively small, and did not exceed 5% of the total number of cases, there is a possibility that these losses may have been due to dissatisfaction with the treatment results. Indeed, in prospective studies with an intention-to-treat design, follow-up losses are occasionally considered to be treatment failures [47]. Second, we did not assess the functional, emotional, and quality of life index, which is an important outcome domain in chronic pain studies [52], because the data were analyzed based on preexisting medical records, which is a limitation of retrospective studies. Third, the classification of lumbar disc herniation is currently not standardized [53]; thus, different interpretations of the results are possible. In this study, we used the classification developed by Jensen et al. [20] and added foraminal type to the MSU and McCulloch classification [21, 22].

In conclusion, the presence of HIZ on MRI is likely to predict a favorable outcome after percutaneous epidural adhesiolysis treatment in patients diagnosed with lumbar disc herniation who present lower back pain with radicular pain. The presence of foraminal disease is a prognostic indicator of an unfavorable outcome. These results may expand the indications for percutaneous epidural adhesiolysis but should be validated by a future randomized prospective study.

Additional Points

Summary. In this study, we retrospectively evaluated the factors predicting the outcome of percutaneous epidural adhesiolysis on patients diagnosed with lumbar disc herniation by review of electronic medical records. Multivariate logistic regression analysis demonstrated that positive high-intensity zone (HIZ) at magnetic resonance imaging (MRI) was a predictor of successful substantial response to percutaneous epidural adhesiolysis for 12 months and the presence of a lumbar disc herniation involving the vertebral foramen was a predictor for unsuccessful response after 12 months.

Competing Interests

The authors declare that there is no conflict of interests regarding the publication of this article.

An Intro to Epidural Steroid Injections For Herniated Discs

A herniated disc is one of the most common injuries treated with epidural steroid injections, but what exactly is a herniated disc? To explain this we should start with quick anatomy of the spine. The spinal column is made up of 33 separate bones called vertebrae that are stacked on one another across the full length of the back. Between each of these vertebrae is a cushiony disc that serves a few purposes, but the one that concerns us the most is to act as a shock absorber in the spine, preventing the bones from rubbing against one another. The discs are made up of two parts: the inner jelly-like layer called the nucleus and the harder outer layer called the annulus. 

Over time from shocks, movements and wear and tear the disc layers can break down. The jelly-like interior can begin to push out causing the outer layer to expand and push against the spinal nerve which runs alongside the whole spine. The spinal cord is responsible for the whole communication network inside the body of nerves which sends pain feelings to each and every part of the body. When the expanding disc pushes against the spinal nerve it can cause sharp pains from the upper back down into the arms if the disc is in the upper back. Or from the lumbar area of the lower back down into the legs.

Epidural steroid injections are one of the safest and most common treatments for herniated discs that we currently know of today. A doctor that specialized in epidural steroid injections can help to consult with you on if the exact solutions they use and any allergy risk. But the steroid injections are made of a solution that contains a steroid or corticosteroid (typically dexamethasone or triamcinolone) and a numbing agent like lidocaine. It is important to note that the steroid is an inflammation reducer giving the body a much-needed break from the constant pressure against the spinal nerve. This can allow the body to stimulate its own hormones to assist the body in the healing process. 

Epidural steroid injections are such a great way to treat the pain and inflammation because it is so minimally invasive. It is a quick procedure that can be done by your local pain management doctor. There is a short recovery time with some limitations on activity for the first day or two, and optimal results can be felt around one week after the procedure. The resulting effects can vary based on the condition and the individual but about 3 months of relief is the average.


Herniated Disc Pain management is something we specialize in treating at Downtown Pain Physicians, To find out if you are a candidate for Epidural steroid injections contact our top of the line office in Manhattan:

Downtown Pain Physicians. 80 Maiden Ln #905A, New York, NY 10038. (212) 404 8070

What It Is, Diagnosis, Treatment & Outlook

Overview

What is a herniated disk?

A herniated disk is an injury of the spine (backbone). You have a series of bones (vertebrae) in your spine, stretching from the base of your skull to your tailbone. Between your vertebrae are round cushions called disks. The disks act as buffers between your bones, allowing you to bend and move with ease. When one of these disks tears or leaks, it’s called a herniated disk.

Are herniated disks common?

Every year, up to 2% of people get a herniated disk. Herniated disks are a leading cause of neck and/or arm, and back and/or leg pain (sciatica). They can happen anywhere along the spine, but herniated disks most often occur in the lower back or the neck. It’s rare for a herniated disk to be in the mid-back.

Who gets herniated disks?

People ages 30 to 50 are most likely to get a herniated disk. The problem affects men twice as often as women. Other risk factors include:

  • Sitting for long periods in the same position.
  • Being overweight.
  • Lifting heavy objects.
  • Repetitive bending or twisting motions for work, sports or hobbies.
  • Smoking.

Symptoms and Causes

What causes a herniated disk?

Disks have soft, gel-like centers and a firmer outer layer, like a jelly doughnut. With time, the outer layer weakens and can crack. A herniated disk happens when the inner “jelly” substance pushes through the crack. The leaked material may press on nearby spinal nerves.

Several factors can contribute to a disk rupture, including:

  • Aging.
  • Excessive weight.
  • Repetitive motions.
  • Sudden strain from improper lifting or twisting.

What are the symptoms of a herniated disk?

Herniated disk symptoms vary depending on where the problem is in your spine. Symptoms worsen with movement and get better with rest.

Herniated or slipped disk in the back (herniated lumbar disk)

It’s common for a herniated disk in the lower back to cause “sciatic nerve” pain. This sharp pain usually shoots down one side of your buttocks into your leg and sometimes the foot. Other symptoms of a herniated disk in your lower back include:

  • Back pain.
  • Tingling or numbness in the legs and/or feet.
  • Muscle weakness.

Herniated or disk in the neck (herniated cervical disk)

Symptoms of a herniated disk in your neck include:

  • Pain near or between your shoulder blades.
  • Pain that travels to your shoulder, arm and sometimes your hand and fingers.
  • Neck pain, especially in the back and on the sides of your neck.
  • Pain that increases when bending or turning your neck.
  • Numbness or tingling in your arms.

Diagnosis and Tests

How is a herniated disk diagnosed?

Your healthcare provider will do a thorough exam. During the physical, your provider will assess your pain, muscle reflexes, sensation and muscle strength. Your provider may also order tests such as:

  • Magnetic resonance imaging (MRI): The most common and accurate imaging test for a suspected herniated disk is an MRI.
  • X-rays: Getting X-rays helps rule out other causes of back or neck pain.
  • Computed tomography (CT): A CT scan show the bones of your spine. Herniated disks can move into the space around your spinal cord and nerves and press on them.
  • Myelogram: A myelogram involves an injection of dye into your spine using X-ray guidance for a CT scan. The dye can reveal a narrowing of the spinal canal (spinal stenosis) and location of your herniated disk.
  • Electromyogram (EMG): This test involves placing small needles into various muscles and evaluate the function of your nerves. An EMG helps determine which nerve a herniated disk affects.

Management and Treatment

What can I do at home to relieve herniated disk pain?

In most cases, pain from a herniated disk can go away in time. To ease pain while your disk heals, you can:

  • Rest for one to three days, if the pain is severe, but it important to avoid long periods of bed rest to prevent stiffness.
  • Take an over-the-counter pain reliever, such as ibuprofen or acetaminophen.
  • Apply heat or ice to the affected area.

When should I see a doctor?

Initially, you can treat herniated disk pain at home. But you should see your doctor if:

  • Pain interferes with daily life, like going to work.
  • Symptoms aren’t better after four to six weeks.
  • Symptoms get worse.
  • You develop loss of bladder or bowel control.
  • You notice tingling, numbness or loss of strength in your arms, hands, legs or feet.
  • You have trouble standing or walking.

What is the best slipped disk treatment?

You may need more advanced treatments if your symptoms aren’t getting better. Your healthcare provider might recommend:

  • Medication: Your provider may prescribe an anti-inflammatory pain reliever or muscle relaxant.
  • Physical therapy: A physical therapist teaches you an exercise program to help relieve pressure on your nerves. Exercise loosens tight muscles and improves circulation.
  • Spinal injections: Called an epidural or nerve block, a spinal injection is a shot of steroid medication directly into your spine. The medication reduces swelling and inflammation of the nerve from the disk herniation. This will allow your body to heal and return to activity faster.
  • Surgery: In rare cases, a large herniated disk might injure nerves to the bladder or bowel. That may require emergency surgery. For nonemergency cases, surgery is an option when other treatments fail. There are various ways to perform spinal decompression surgery, but the goal is to relieve pressure on the nerve.

Will I need to have spinal surgery?

Herniated disks get better on their own over time or with nonsurgical treatment for 9 out of 10 people. If other treatments don’t relieve your symptoms, your healthcare provider may recommend surgery. There are multiple surgical techniques for relieving pressure on the spinal cord and nerves, including:

  • Diskectomy to remove your herniated disk.
  • Laminectomy to remove part of the bone around a herniated disk and expand your spinal canal.
  • Artificial disk surgery to replace a damaged herniated disk with an artificial one.
  • Spinal fusion to directly join two or more vertebrae together to make your spine more stable.

Prevention

How can I avoid getting a herniated disk?

It’s not always possible to prevent a herniated disk. But you can reduce your risk by:

  • Using proper lifting techniques. Don’t bend at the waist. Bend your knees while keeping your back straight. Use your strong leg muscles to help support the load.
  • Maintaining a healthy weight. Excess weight puts pressure on the lower back.
  • Practicing good posture. Learn how to improve your posture when you walk, sit, stand and sleep. Good posture reduces strain on your spine.
  • Stretching. It’s especially important to take stretching breaks if you often sit for long periods.
  • Avoiding wearing high-heeled shoes. This type of shoe throws your spine out of alignment.
  • Exercising regularly. Focus on workouts that strengthen your back and abdomen muscles to support your spine.
  • Stopping smoking. Smoking can weaken disks, making them vulnerable to rupture. Consider quitting smoking.

Outlook / Prognosis

What is the outlook for people with herniated disks?

For up to 90% of people, herniated disk pain gets better on its own or with simple medical care. You’ll probably feel better within a month. If you don’t, you should see your healthcare provider. Some people need more aggressive medical measures, such as spinal injections or surgery.

Will a herniated disk get worse?

An untreated herniated disk can get worse. That’s especially true if you continue the activities that caused it — for instance, if it developed because of your work. A worsening ruptured disk may cause chronic (ongoing) pain and loss of control or sensation in the affected area. See your healthcare provider if you still have symptoms after four to six weeks of conservative care.

Living With

What should I ask my doctor?

Questions to ask your doctor include:

  • Do I need to rest? For how long?
  • How much walking or other activities should I be doing?
  • Are there any exercises that can help?
  • What pain medication should I take?
  • Will ice or heat help?
  • If considering spine injections, what injection is likely to help relieve my pain? What are the risks?
  • If considering surgery, what are my surgical options? What are the risks?

A note from Cleveland Clinic

Having a herniated disk can make you reluctant to move. But don’t head to bed — too little movement can make pain worse when you get up again because muscles stiffen. Try to stay active and follow your healthcare provider’s recommendations for stretching. Gentle movement coupled with an over-the-counter pain reliever helps most people feel better in a few weeks.

Epidural Injections

An epidural (ep-i-doo-rul) injection provides temporary or lasting relief from pain or inflammation in the spine or extremities (arms and legs). Imaging guidance may be used to place the needle in the right location for maximum benefit. The injection may also help confirm the exact site of the pain.

Your doctor will instruct you on how to prepare and advise you on any changes to your regular medication schedule. You may be told not to eat or drink anything several hours before the procedure. Tell your doctor if there’s a possibility you are pregnant. Leave jewelry at home and wear loose, comfortable clothing. You may be asked to wear a gown. Plan to have someone drive you home afterward.

What is an Epidural Injection?

An epidural injection is an injection of medication into the space around the spinal cord, also known as the epidural space, to provide temporary or prolonged relief from pain or inflammation. The epidural space is the outermost part of the spinal canal. Steroids, anesthetics and anti-inflammatory medications are typically delivered in an epidural injection. The injection may reduce pain and swelling in and around the spinal nerve roots, as well as around damaged nerves which in time may heal.

Imaging guidance, such as fluoroscopy (multiple x-ray images) or computed tomography (CT or “CAT” scan), may be used to help the doctor place the needle in exactly the right location to target the specific area causing the pain so the patient can receive maximum benefit from the injection.

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What are some common uses of the procedure?

An epidural injection is one of many methods doctors use to relieve pain, along with physical therapy, oral medications and surgery if a patient is not responding to conservative treatments.

An epidural injection may be performed to alleviate pain caused by:

  • A herniated or bulging disk that impinges nerves causing pain
  • Spinal stenosis (narrowing of the spinal canal)
  • Post-operative “failed back” surgery syndromes (chronic back or leg pain after spinal surgery)
  • Other injuries to spinal nerves, vertebrae and surrounding tissues
  • Bone spurs

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How should I prepare for the procedure?

You will receive specific instructions on how to prepare, including any changes you need to make to your regular medication schedule.

You may be instructed not to eat or drink anything for several hours before your procedure to prevent you from having an upset stomach following the injection or because some centers may offer sedation during the procedure.

You may need to change into a gown for the procedure.

You will probably be asked to use the restroom before the procedure.

You will then be positioned on your stomach or side on a special fluoroscopic or CT table that will give the doctor easy access to the injection site(s). A nurse and/or technologist will help to make you as comfortable as possible, both during and after the procedure.

Plan to have someone drive you home after your procedure.

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What does the equipment look like?

The injection itself will be administered with a syringe much like one that would be used for a routine vaccination. The doctor will fill the syringe from a small vial of medication. The type of medication used depends on individual patient needs.

The imaging guidance used, such as fluoroscopy or CT, will require additional equipment around the table. Both types of imaging are painless and involve the use of x-rays to obtain essential images that allow the physician to place the needle in exactly the right location of the area of interest for the injection.

This exam typically uses a radiographic table, one or two x-ray tubes, and a video monitor. Fluoroscopy converts x-rays into video images. Doctors use it to watch and guide procedures. The x-ray machine and a detector suspended over the exam table produce the video.

The CT scanner is typically a large, donut-shaped machine with a short tunnel in the center. You will lie on a narrow table that slides in and out of this short tunnel. Rotating around you, the x-ray tube and electronic x-ray detectors are located opposite each other in a ring, called a gantry. The computer workstation that processes the imaging information is in a separate control room. This is where the technologist operates the scanner and monitors your exam in direct visual contact. The technologist will be able to hear and talk to you using a speaker and microphone.

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How does the procedure work?

The different types of medications injected into the epidural space create different effects for patients. Corticosteroids act as anti-inflammatory agents, reducing swelling and nerve irritation to allow the nerve time to heal itself, thereby preventing further discomfort. By delivering an epidural injection directly into the epidural space, the medication moves throughout the epidural space, coating the inflamed or irritated nerve roots. Therefore, a lumbar (lower back) injection could alleviate pain associated with the lower back and the nerves traveling to the lower limbs, such as the sciatic nerves. Similarly, if an epidural injection is performed in the neck, it should spread throughout the cervical epidural space and provide relief to nerve roots in the neck which can also relieve arm pain. (See the Facet Joint Block page for more information). The duration of improvement from the epidural injection varies. Some patients have permanent relief. In others, the effects may not last long. In some cases, you may have a series of injections before you may benefit from significant relief. A patient may experience relief for a matter of days up to several months; however, the pain may eventually return, requiring another series of injections or an alternative treatment.

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How is the procedure performed?

This procedure is often done on an outpatient basis. However, some patients may require admission following the procedure. Ask your doctor if you will need to be admitted.

The epidural injection usually takes only minutes to administer, but positioning in the CT or x-ray unit may take longer.

When you arrive at the office, hospital or surgical center, the nurse or technologist may place an intravenous (IV) line in your arm to deliver a relaxation medication during the procedure; this is seldom needed but will be available if required. You will be situated on your stomach or on your side, on a table in the fluoroscopic room or in a CT scan room and made to feel as comfortable as possible.

The doctor will identify where the injection should be given and will clean and sterilize the skin with an antiseptic solution. A local anesthetic is then injected to help numb the area before administering the epidural injection.

Once the area is numb, the doctor will most likely use imaging guidance to help guide the epidural needle to exactly the right position. When the needle is in place, a contrast material will be injected so the doctor can accurately target the nerves for sufficient distribution of the medication. Then, your doctor will slowly inject the medication, which is typically a combination of anesthetic and anti-inflammatory drugs (cortisone/steroids).

When finished, you will be moved into a chair or bed and allowed to rest for a few minutes to an hour. The nurse or technologist will make sure you do not have any unfavorable reactions to the medication before you are allowed to leave.

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What will I experience during the procedure?

You may have no sensation whatsoever, however you may feel tingling or pressure when the injection is administered. Depending on the amount of swelling in the area, you may experience a burning sensation at the site or in your upper or lower extremities or some mild discomfort as the medication enters the epidural space. When the injection is finished, however, any discomfort usually disappears. It is also possible to feel “pins and needles” in your arms and legs, depending on the injection site. If you feel any sharp pains, however, tell your doctor immediately.

Due to the numbness and any discomfort you may experience after the procedure, you may have some difficulty walking on your own and getting in and out of the car. This is normal and should subside in a matter of hours. You should take it easy for the rest of the day, though, and may resume normal activities the next day.

The epidural may not take effect immediately—it is common for improvement in the pain to occur progressively over the first 48 hours. The effects may last for a matter of days, weeks, and occasionally months.

In some patients, the pain may initially feel slightly worse before it starts to improve. It may also be necessary to have a series of epidural injections to fully improve.

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Who interprets the results and how do I get them?

A radiologist or anesthesiologist will most likely perform the epidural injection, however, a neurosurgeon, orthopedic surgeon, or neurologist may also administer it.

The doctor who delivers the injection will follow up with you to see how you are doing and determine if further action is required. Any imaging that is performed during the procedure itself will conclude with the procedure, and no follow-up image interpretation is necessary.

Your interventional radiologist may recommend a follow-up visit.

This visit may include a physical check-up, imaging exam(s), and blood tests. During your follow-up visit, tell your doctor if you have noticed any side effects or changes.

 

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What are the benefits vs. risks?

Benefits

  • Temporary or prolonged pain relief.
  • Temporary or prolonged reduction of inflammation in the region of the spine causing pain.
  • Improved ability to perform daily activities without the restrictions previously caused by pain.
  • May help confirm the origin of the pain. This is often a problem in patients with more than one possible cause of pain.
  • May reduce the need for invasive procedures.

Risks

  • Temporary increase in pain.
  • Headache is also extremely rare, but possible.
  • Reaction to the medications, such as hot flashes or rash.
  • Infection at the injection site.
  • Bleeding if a blood vessel is inadvertently damaged.
  • Injury to the nerves at the injection site.
  • Temporary paralysis of the nerves leading to the bladder and bowel, causing temporary bladder or bowel dysfunction.
  • When fluoroscopy or CT is used, there will be minimal low-level radiation. See the Safety page for more information about radiation dose.

Women should always tell their doctor and technologist
if they are pregnant. Doctors will not perform many tests during pregnancy to avoid exposing the fetus to radiation. If an x-ray is necessary, the doctor will take precautions to minimize radiation exposure to the baby. See the Safety in X-ray, Interventional Radiology and Nuclear Medicine Procedures page for more information about pregnancy and x-rays.

 

If the epidural injection is given in the neck, more serious complications, such as spinal cord injury, stroke, or death, are possible if the needle is placed incorrectly. However, your doctor will use imaging guidance and a sterile technique to minimize these risks.

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What are the limitations of Epidural Injection?

The effects of an epidural injection may be temporary and may offer little to no long-term relief. Each individual is different; however, sometimes the injection may be repeated after a number of weeks or months to receive maximum benefit from the medication. If the epidural injections do not help alleviate your pain, your doctor will most likely recommend a different therapeutic approach.

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Additional Information and Resources

Society of Interventional Radiology (SIR): Pain Management


This page was reviewed on March, 20, 2019

The inflammatory response in the regression of lumbar disc herniation | Arthritis Research & Therapy

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  • Why Does My Herniated Disk Pain Come and Go?: Woodbury Spine : Orthopaedic Spine Specialists

    Herniated discs are a common cause of chronic back pain, especially among people between the ages of 30-50 years. While many people with herniated discs suffer from chronic, unrelenting pain, others may find their symptoms come and go, or at least vary in their severity.

    At Woodbury Spine, our orthopaedic surgeon, Evan O’Brien, MD, helps patients find the best solutions for their herniated disc pain, offering both conservative and surgical options, depending on each patient’s unique needs. If you have a herniated disc, here’s why your symptoms can change over time.

    Herniated discs: The basics

    Your spine contains a series of bones called vertebrae that link together to form a protective tunnel for your nerves. The nerves travel from your brain through the spine, exiting at intervals to go to all the other parts of your body, including your arms and lgs.

    Between each pair of vertebrae is a spongy disc that acts like a shock absorber for your spine. Each disc has a tough exterior “shell” and a gel-like interior that helps protect your vertebrae and nerves, as well as making your spine flexible.

    Normally, each disc is contained within the boundary of the vertebrae — like a sandwich. But sometimes, a disc can “slip” out of place extending beyond the edge of the bones, or the outside of a disc can rupture allowing the gel to leak out. As you move your back, the bone edges or the protruding gel can irritate or compress the spinal nerves, causing back pain. 

    Depending on where the nerve is heading, you might also have pain, numbness, or weakness in your arms, legs, hands, or feet. Some people may have problems with controlling their bowels or bladder.

    Why symptoms change

    Herniated disc pain can be variable, based on the severity of the disc injury, where the disc is located, and other factors. While some people experience persistent, continual pain, others may have milder pain or symptoms that occur less frequently. In some people, herniated discs may cause mild, occasional pain, punctuated by bursts of more severe flare-ups.

    If your herniated disc pain comes and goes, there’s a good chance it’s related to your activity. If you use your back for lifting or bending on a regular basis, you may find your pain is a lot worse immediately afterward. Even something as simple as sleeping in a specific position could cause symptoms to flare.

    In these instances, it can be very helpful to keep a diary of your symptoms, including the level of pain you experience and what you were doing in the hours before your symptoms flared up. Sharing this diary with Dr. O’Brien can help ensure your treatment is tailored to your needs, so you can relieve your symptoms and get back to the activities you enjoy.

    Your symptoms may also change in frequency and intensity as your disc heals. Many people notice a change in symptoms during therapy, with symptoms sometimes temporarily worsening before they finally get better. 

    Find relief for herniated disc symptoms

    Herniated discs often resolve with nonsurgical treatments like:

    • Physical therapy
    • Activity modification
    • Anti-inflammatory medicine
    • Injections

    Dr. O’Brien performs a comprehensive spinal and overall health assessment before developing a conservative treatment plan for you.

    Sometimes, pain doesn’t go away, even after weeks of conservative treatment. If that’s the case, Dr. O’Brien may recommend a surgical treatment to remove the damaged part of the disc, stabilize the spine, or replace the herniated disc with an artificial disc.

    If you’re having pain from a herniated disc, getting care as early as possible is important for relieving your symptoms and preventing the problem from getting worse. To learn how Dr. O’Brien can help you, call our office in Woodbury, New Jersey, or book your appointment online today.

    90,000 Herniated disc with sequestration – treatment, symptoms, causes, diagnosis

    Sequestered disc herniation occurs in 28.6% of all symptomatic disc herniation. Herniated disc sequesters tend to migrate into the spinal canal in many directions, including cranial, caudal, and lateral. However, posterior epidural migration from a sequestered disc in the lumbar region is relatively rare because the posterior longitudinal ligament at the level of the concave vertebral bodies forms an anterior epidural space between itself and the periosteum of the vertebral bodies, this space is separated in the midline by a septum that prevents the hernia from moving intervertebral disc.

    At disc level, the posterior longitudinal ligament is firmly attached to the posterior portion of the annulus fibrosus of the disc and is attached to the lateral membrane (epidural membrane) that extends medially from the lateral edge of the ZPS to the lateral wall of the spinal canal; it limits the movement of the sequestered disc herniation beyond the posterior lateral angle of the dura mater.

    Disc sequestration is the most severe degree of disc herniation, in which the disc nucleus material falls out completely and is separated from the disc.A herniated disc or herniated disc is a ruptured disc. The intervertebral discs perform a shock-absorbing function when the force vectors are applied to the vertebrae, softening the impacts between the vertebrae. The disc consists of a dense annulus fibrosus and a gelatinous (gelatinous) nucleus, and with a herniated disc, the annulus fibrosus ruptures and the contents of the nucleus leave the disc redistribution (protrusion.

    Symptoms

    Symptoms of a ruptured disc (disc herniation) differ depending on how severe the damage to the annulus fibrosus is and in which part of the spine the disc herniation is located.Herniated discs are classified based on their location in relation to the posterior longitudinal ligament and the degree of rupture. The posterior longitudinal ligament extends vertically along the entire spinal column and contacts each vertebra at the back. The ZPS separates the posterior side of the disc from the epidural space, which surrounds the spinal cord roots. There are three types of damage to the annulus fibrosus – protrusion, extrusion and sequestration.

    Protrusion of the disc leads to bulging of the disc, but without affecting the posterior longitudinal ligament.Protrusion can be painful or asymptomatic, depending on the effect on nearby nerve structures. With a herniated disc, a protrusion also occurs against the background of a rupture of the annulus fibrosus, the substance of the disc nucleus can already enter the epidural space. Symptoms, as well as in protrusion, will depend on the presence of a compression effect on the nerve endings.

    When the disc is sequestered, the nucleus pulposus completely leaves the disc, separates from the disc and falls out into the spinal canal.The nuclear material from the disc can then enter the epidural space and is considered a free fragment (sequestration). In such cases, there is often severe back pain, sometimes in the leg. In severe cases, the patient may develop cauda equina syndrome, in which bowel and bladder dysfunction and numbness of the lower extremities occur. This condition is considered a medical emergency and an emergency operation is required, since delaying with operative decompression of the nerve structures of the spinal cord can lead to irreversible neurological symptoms associated with damage to nerve fibers.

    In most cases, disc sequestration occurs in older patients because the integrity of the disc degrades involutionally, making the disc more susceptible to herniation and sequestration. Constant overvoltage, excessive one-time loads, or a combination of both, can cause disc rupture and sequestration. Although most herniated discs do not require surgical treatment, in the case of sequestration of a herniated disc, surgical decompression is often required, especially in the presence of symptoms of cauda equina syndrome or persistent neurological symptoms (muscle atrophy, paresis of the extremities, severe pain syndrome, severe sensory disturbances).

    Diagnostics

    Diagnosis of sequestered disc herniation is based on both the history of the disease, symptoms and data of neurological examination, and instrumental data.

    Radiography does not allow visualization of a herniated disc, providing only indirect signs of a violation of the integrity of the disc. Myelography can usually show a complete block of contrast material at the level of herniated discs, but it fails to visualize root compression.

    CT, especially MSCT, allows you to get a fairly clear picture of morphological changes in the disc, the presence of sequestration, especially if the study is carried out with contrast. But when it is necessary to differentiate a sequestered disc herniation with a tumor, synovial cyst or hematoma, it is necessary to use MRI in addition to CT (MSCT).

    MRI, especially with gadolinium, appears to be the method of choice for diagnosing sequestered herniated discs. Sequestered herniated fragments usually show low signal intensity on T1-weighted images, and in 80% of cases have high signal intensity on T2-weighted images in relation to the degenerative disc.The high signal intensity in T2-weighted images can be explained by the fact that the disc core material has a higher water content than an intact disc. In tumors, the signal intensity is usually increased evenly. The synovial cyst has a characteristic MRI signal intensity similar to that of the facet joints. An epidural abscess may present as a lesion with hypointense signal on T1-weighted images and hyperintensity on T2-weighted images, as well as clear boundaries, however, the absence of associated changes in the disc and in the adjacent end-plates and the absence of clinical evidence of infection suggest another diagnosis.The hematoma usually has an isointense signal, without clear boundaries and a history of trauma.

    Other research methods, such as scintigraphy or laboratory tests, are necessary in the case of differential diagnosis with oncological or infectious diseases.

    Treatment

    The tactics of treatment for sequestered disc herniation depends on the size of the disc herniation, migration of the sequestration, the severity of symptoms and the degree of risk of developing irreversible changes in nerve structures that occur during prolonged compression of nerve fibers.Sequestered disc herniation is most common in the cervical and lumbar spine. Conservative treatment for sequestered disc herniation is rather limited, so the use of manual therapy or exercise therapy is quite risky. But it is possible to use medication methods of treatment, physiotherapy, acupuncture and gentle gymnastics, after reducing the pain syndrome. In some cases, it is possible with the help of conservative methods to stabilize clinical manifestations and avoid surgical treatment.But due to the fact that in recent years minimally invasive neurosurgical techniques for correcting disc herniation have become widespread, the indications for surgery have expanded. Modern technologies with the use of endoscopic techniques allow minimizing tissue damage during surgery (decompression and removal of sequestration) and avoiding complications that arose during classical laminectomy, such as instability of the motor segment, and significantly reduce the risk of recurrent disc herniation.In addition, such minimally invasive techniques avoid the risk of developing such a formidable complication as cauda equina syndrome. Currently, surgical (minimally invasive treatment) is recommended to be carried out within two weeks after the first painful episode has subsided, which significantly reduces the risk of neurological symptoms persisting in the postoperative period. If, after surgical treatment, adequate rehabilitation is carried out, including various methods of physiotherapy, acupuncture and exercise therapy, then the risk of recurrent disc herniation is significantly reduced.

    Removal of intervertebral hernia, treatment of intervertebral hernia without surgery in Moscow

    Indications for endoscopic removal of intervertebral hernia

    Endoscopic spine surgery is the most important direction in modern spinal surgery. The main indications for endoscopic removal of an intervertebral hernia are:

    • long-term non-relieving pain syndrome
    • compression of the nerve root
    • radicular syndrome
    • radiculoischemia

    Sign up for a consultation

    Preparation for operation

    At the consultation, a specialist (neurologist, orthopedic vertebrologist) will question the patient in detail, conduct a medical examination, and appoint the necessary examination.

    All preoperative examination and preparation can also be quickly and comfortably passed in our hospital on high-precision digital tomographs (MSCT 128 slices; MRI 1.5 Tesla), a Philips X-ray system. In our department of radiation diagnostics, you can take a picture of the spine along its entire length, which is rare even for Moscow, which is necessary when planning orthopedic surgeries.

    Based on the results of the examination, the doctors of the Clinical Hospital on Yauza will quickly and accurately find out the cause of back pain, make a clinical diagnosis and determine the optimal method of treatment.If necessary, the patient will undergo a minimally invasive operation, which will relieve him of pain for a long time.

    Before the operation, it is also necessary to undergo a standard examination:

    • Chest X-ray
    • Tests for hepatitis C and B, syphilis, HIV
    • General blood and urine tests
    • Determination of blood group and Rh factor
    • Detailed biochemical blood test with electrolytes and coagulogram
    • ECG
    • Consultation of a therapist

    Course and advantages of endoscopic hernia repair

    • The operation is performed under epidural anesthesia and lasts approximately one hour.The patient remains conscious, it is possible to contact him, but he does not feel pain. Patients are often given sedatives (anti-anxiety) medications to stay calm before surgery.
      For comparison, surgical interventions carried out with a traditional open approach can last up to 6 hours and are performed under general anesthesia.
    • The incision in the skin usually does not exceed 1 cm and is more like a puncture through which a special thin spinal endoscope is inserted. The device is equipped with light guides and a miniature video camera, which provides the surgeon with the ability to visually control all his actions, the image is displayed on the monitor.
    • If the localization of the hernia allows, then its removal is carried out through the natural foraminal opening, where the spinal nerve root leaves the spine (transforaminal approach). This is the most gentle surgical technique performed through a puncture.
    • When the endoscope penetrates, the tissues are not dissected, but moved apart with the help of special manipulators, which allows them to be kept practically intact.
    • The surgeon can quickly stop bleeding thanks to the coagulator and thermal effects on the tissue.
    • The doctor removes the sequestration – hernial protrusion, as well as damaged fragments of the intervertebral disc, restores the integrity of the fibrous ring between the vertebrae, which prevents hernia recurrence.

    After operation

    On the second day after the operation, outpatient treatment is possible. The functions impaired by the disease are fully restored 2-3 weeks after surgery. And the pain syndrome often disappears immediately after the operation.

    Thanks to the special surgical technique and technology of the operation, the risk of postoperative complications is minimized, for example, extensive adhesions, blood loss, etc.

    Modern equipment

    The operation is carried out using special equipment from the world’s leading companies – manufacturers of medical equipment, such as “DePuySynthes”, “Karl Storz”, “Joimax” and others.

    Radiation diagnostics at the stage of planning an operation, intraoperative visual control, and evaluating the effectiveness of treatment is carried out using Philips expert systems that show a detailed picture of the state of the spine and surrounding tissues.

    The results of spinal surgeries performed by our spinal surgeons were highly appreciated by colleagues from the USA, Germany, specialized orthopedic centers in Russia, as well as numerous grateful patients who were saved from pain, who regained their mobility and a decent quality of life.

    Why us

    • Doctors. The Department of Neurosurgery employs spinal surgeons with extensive experience in the successful treatment of herniated discs. Well-known specialists from Germany, Israel and other countries can consult you at the Clinical Hospital on Yauza.
    • Expert equipment. The Yauza Clinical Hospital is equipped with equipment from the world’s leading manufacturers; operations are performed using modern equipment such as Karl Storz, DePuySynthes, Joimax.
    • Innovative OR design. Infection-resistant seamless monolithic blocks, 5 levels of sterility thanks to sophisticated ventilation system.
    • Fast recovery. The patient can return home the next day after the operation.Complete recovery is significantly faster compared to traditional hernia repair.
    • Minor trauma . No visible postoperative scars – operations are performed endoscopically through small incisions.
    • Security. Minimal risks of postoperative complications. There is no harmful effect of anesthesia on the patient.

    You can sign up for a consultation with the specialists of the Center for Vertebrology and Endoscopic Surgery of the Spine of the Clinical Hospital on Yauza through a special form on the website or by calling the phone number indicated on this page.

    You can look at prices for services in the price list or check the phone number indicated on the website.

    The article was checked by an orthopedist-vertebrologist, Ph.D. Abakirov M.D. is for general informational purposes only and does not replace specialist advice.
    For recommendations on diagnosis and treatment, a doctor’s consultation is required.

    Minimally invasive back surgery in Munich

    If, despite conservative therapy, back problems persist, minimally invasive spinal surgery, without open surgery, will help get rid of them.It allows you to gently and effectively treat displaced discs or spinal stenosis, relieving you of long-term pain. These gentle treatments are less stressful and less risky for the body.

    Our interdisciplinary centers have for many years been one of the most demanded in terms of minimally invasive spine interventions. Our patients are offered the possibility of multidisciplinary diagnostics and therapy, the extensive knowledge of our specialists, as well as our many years of experience in the treatment of a wide range of diseases of the musculoskeletal system, especially the spine.

    In Europe we have pioneered many minimally invasive procedures such as epidural catheterization, greatly improved by Dr. Reinhard Schneiderhan as well as microlaser therapy. In addition, our medical team has the greatest experience in this vast and challenging field, having performed over 40,000 minimally invasive spine procedures in Europe.

    We employ specialists in the fields of orthopedics and pain therapy, neurosurgery, neurology, diagnostic radiology, general medicine, physical and rehabilitation medicine.Our healthcare professionals collaborate as part of a multidisciplinary team to develop optimal treatment concepts tailored to the needs of each patient.

    See below for a list of our minimally invasive therapeutic procedures.

    Heat probe therapy according to Dr. Schneiderhan

    This minimally invasive, gentle yet highly effective procedure is based on blocking the nerve fibers that transmit pain sensations and can be performed on an outpatient or inpatient basis, if required.Painful nerve fibers are deliberately exposed to heat in such a way as to stop pain conduction, resulting in pain relief without the need for open surgery. Dr. Schneiderhan, one of the leading experts in the field of thermocoagulation, has significantly improved the method of heat probe therapy.

    Microlaser treatment

    Treatment of a herniated disc with a microlaser results in effective and targeted pain relief.This minimally invasive technique does not require an incision and is currently helping to reduce the prevalence of surgery. In our interdisciplinary center alone, more than 12,000 patients have been treated with the “intervertebral disc laser”.

    Spinal catheterization according to Dr. Schneiderhan

    Spinal catheterization is a minimally invasive procedure for the treatment of back pain. With the help of an elastic catheter, targeted treatment of the affected nerve root is carried out.Dr. Schneiderhan has perfected this technique and now, in collaboration with its team, conducts most of this type of operation in Europe. This method of treatment allows most patients to avoid open surgery.

    Endoscopy of the spinal cord (epiduroscopy)

    Epiduroscopy allows obtaining volumetric color images of the anatomical structures of the epidural space. No other method gives such an accurate picture of the state of the spinal canal. In addition, spinal cord endoscopy can remove scars and adhesions in the lumbar spine without major or stabilizing surgery.

    Endoscopic procedures

    By requiring only a few millimeters of percutaneous access to the spinal column for an endoscope, minimally invasive endoscopic surgery allows for a particularly gentle management of back problems. Endoscopic procedures are increasingly replacing traditional open spine surgeries, especially for various forms of herniated discs, as well as for spinal stenosis and osteoporosis.

    Intradiscal injections

    To perform intradiscal injection, the attending physician under local anesthesia and under X-ray control, using a thin needle, penetrates the tissue of the intervertebral disc.Injection of an X-ray contrast agent allows a targeted and effective diagnosis of pain (discography), and injections of various drugs directly into the disc provide immediate pain relief for the isolated disc.

    Electrical Pain Stimulator (SCS)

    Electrical Pain Relief Stimulator is very effective for severe chronic back pain. It generates electrical impulses that mask chronic pain.This minimally invasive procedure has been proven to reduce pain by 80 percent, thereby improving the patient’s quality of life in the long term.

    Biological restoration of the intervertebral disc

    An intervertebral disc damaged due to hernia or wear loses volume. Thanks to Autologous Disc Cell Transplantation (ADCT) technology, we can restore the volume, and therefore the height, of the disc so that it can largely resume its original function.Since the body’s own cells are transplanted, their rejection does not occur.

    Vertebroplasty and kyphoplasty

    Vertebroplasty and kyphoplasty are minimally invasive procedures that are performed in a hospital setting on the lumbar or thoracic spine when vertebral bodies are destroyed. These procedures consist of permanently stabilizing the vertebral body with bone cement, which quickly relieves pain. Kyphoplasty is used for a more deformed vertebral body: first, it is restored with a balloon, and then bone cement is injected into it.

    Tunnel syndrome surgery (peripheral access)

    In the so-called “tunnel syndrome”, important nerve fibers are pinched. This syndrome can manifest itself on the hands, forearms and legs and, depending on the severity, can cause various disorders. The most common carpal tunnel syndrome is carpal tunnel syndrome. When the pinched nerve is removed, neuralgic pain usually resolves immediately after surgery; paralysis passes just as quickly.

    Surgical and conservative pain management

    Pain in the back and lumbar spine occurs, as a rule, against the background of destructive changes caused by osteochondrosis. Walking upright, excess body weight, joint injuries, some chronic pathologies can provoke the onset of destructive processes in the vertebrae. Some of the pathological manifestations are pain attacks, lumbar lumbago and limitation of mobility. Back pain can also occur due to damage to the kidneys and genitourinary organs, as a result of trauma or an infectious-inflammatory process.

    At the V.M. Ankylosing spondylitis, patients with back pain are examined by neuropathologists, therapists, neurosurgeons with extensive practical experience. After a series of diagnostic measures, identifying the cause of the pain and primary pain relief, effective treatment is prescribed.

    Technical equipment of the Institute named after V.M. Ankylosing spondylitis allows you in the shortest possible time to find out the true causes of the onset of pain and provide effective assistance, removing all unpleasant symptoms.In their work, employees use innovative technology, which, with a high degree of safety, makes it possible to examine the state of the spinal column and neurovascular structures.

    Patients with back pain of unknown etiology are subject to comprehensive diagnostics, including:

    Research results are processed in a short time. Qualified specialists, honored doctors of sciences, professors, who have devoted years and decades of their lives to the development of neurology, neurosurgery and the search for effective methods to eliminate back pain, work with patients.

    Back pain causes unbearable suffering to the patient. It deprives you of peace, makes you abandon your plans, leads to motor limitations. The first thing that patients want when contacting our institute is to get rid of back pain. We have all the possibilities for this. Among modern conservative techniques, one can single out gymnastic exercises, massage sessions, acupuncture, wearing bandages and exercising on therapeutic simulators, joint blockages, manual therapy, UHF, etc.

    Drug therapy for a painful attack in the lumbar spine is aimed at eliminating the symptoms and the main cause of the pathology. Pain relievers, anti-inflammatory, hormonal drugs are used. But getting rid of back pain will not be the solution to the problem, because without professional help, thorough examination and a responsible approach, unpleasant and sometimes unbearable sensations will appear again. At the V.M. Bekhterev specialists operate in several areas:

    • act directly on the causative factor (intervertebral hernia, osteochondrosis, stenosis of the spinal canal), which allows avoiding the recurrence of a pain attack after the end of the main therapeutic measures.
    • help to quickly remove back pain using modern analgesics, blockades, physiotherapy, massage, physical therapy;
    • organize a comprehensive examination, using all the diagnostic power of the institute in order to assess the scale of a neurological disease, to understand what triggered the onset of a pain attack and to determine further medical tactics;

    Methods of surgical treatment of back pain are used in the last stages of the disease, when conservative methods are ineffective.Today, patients with pathologies of intervertebral discs and joints have access to low-traumatic methods of surgical intervention using a laser, microscopic endoscopic instruments.

    Our specialists brilliantly perform decompression and stabilization operations using fixation implants. Each patient of our neurosurgical department gets the opportunity to collegially review a clinical case. Professors, doctors of sciences, outstanding scientists who have made a huge contribution to the development of Russian neurosurgery will work to solve your problem.

    Back pain is often combined with other pathological signs. In the first place in terms of frequency of distribution, of course, headaches, often similar to migraines. They arise against the background of osteochondrosis of the cervical and lumbosacral spine. Due to destructive changes in the cartilaginous structures of the vertebrae, bone outgrowths (osteophytes) are formed, which can injure nerve structures with their sharp edges and squeeze the blood vessels that feed the neck and brain.As a result, headaches occur.

    Radiography, MRI, neurosonography and assessment of blood flow in the arteries that carry blood, oxygen and nutrients to the head help determine cervical osteochondrosis. Back pain occurs mainly when the lower parts of the spinal column are affected. If the pain syndrome is permanent, then disc protrusion and the appearance of intervertebral hernias can be suspected, which often threaten the patient’s safety and often even lead to his disability.

    Low back pain may be accompanied by a weakening of muscle strength. If you notice weakness in your arms or legs, especially in combination with tingling and numbness in the limbs and lumbar lumbago or prolonged pain, you should see a specialist as soon as possible. Against the background of osteochondrosis and circulatory disorders, patients feel unsatisfactory throughout the working day. Often they already feel weak in the morning, and drowsiness appears closer to lunch. These symptoms are due to a lack of oxygen and insufficient cerebral circulation.

    Another characteristic sign of osteochondrosis of the lumbar spine is malfunctioning of the pelvic organs: intestines, uterus, bladder. Against the background of intervertebral hernias, disc protrusion, problems with the functioning of the small pelvis may appear, impotence often occurs, libido in women and men decreases, reproductive disorders and prerequisites for the development of diseases of the uterus and ovaries appear.

    At the present stage of development of medicine, the concept of algology appears (the field of medicine for the study of pain).It is well known that pain can have a different character, intensity, localization, in addition, with long-term pain (when, for one reason or another, pathogenetic treatment has not been carried out), the pain closes a vicious circle by reinforcing itself. In our department, methods of treating pain syndromes of various localization are used with the use of drug blockades, including under ultrasound and X-ray control, neuromodulation methods, drug therapy. Institute specialists use methods:

    • Treatment and diagnostic blockade (incl.h. under Rg and ultrasound control, prolonged epidural anesthesia)
    • Repetitive magnetic stimulation and physiotherapy
    • Minimally invasive and open surgical treatment with the available anatomical substrate.
    • Selection and optimization of pain therapy
    • Possibility of developing complex treatment tactics with the participation of several specialists

    Pay attention to the slightest pathological signs, because spinal diseases are insidious and rapidly progressing.At the initial stage, they have almost no signs, but over time they lead to severe pain in the back, thoracic, cervical spine, dysfunctions of internal organs and restrictions on physical activity.

    At the V.M. Ankylosing spondylitis will always help you to overcome the pain attack and you can return to your normal life as soon as possible. Our doctors are focused only on a positive result of treatment and always act in the interests of their patients.

    90,000 Herniated discs: classification – Advice to Patients

    Hernias are distinguished by localization, size, age of occurrence, level of the spine, on which the hernia was formed.

    Schmorl’s hernia is an X-ray phenomenon of emptiness in the vertebral body, with the base facing the disc. Described by a German physician at the beginning of the 20th century. Such changes in the vertebral bodies do not play any role in the supporting and dynamic function of the spine, and do not require special treatment. Modern spinal surgeons say “something like a mole on the vertebra”

    Anterior disc herniation is a favorable, but rare type of hernia. A prolapse of a hernia anterior to the vertebral body is often discovered by chance and does not require special treatment.

    Posterior disc herniation is the general name for disc herniation that can be treated surgically, in other words, a hernia that has fallen back into the lumen of the spinal canal. The most common variant of a herniated disc. If conservative treatment is ineffective for 4-8 weeks, spinal surgery is indicated.

    Median disc herniation – a rare location of hernial protrusion, almost always – at the L5-S1 level.With a large disc herniation, the operation must be performed to prevent dysfunction of the pelvic organs.
    Paramedian disc herniation is the most common type of disc herniation among patients who come to the surgeon when the hernial sac protrudes in the projection of the root cuff (the most painful place near the nerve), and also causes compression of the dural sac and several nerve roots passing through it , which lubricates the classic neurological picture of the disease.Patients with such hernias can be treated by a neurologist for quite a long time – sometimes up to six months – with varying success, until they get a consultation with a neurosurgeon, and, having experienced a long period of constant pain, come to the conclusion that surgery is inevitable. At the same time, in the postoperative period, many regret that they endured for so long and did not know that spinal surgery is an easy and quick way to live without pain
    Lateral herniated disc is the second most frequent variant of the herniated disc, when the cartilage breaks through all the ligaments of the spine and takes a position in the lateral pocket – the narrowest place at the entrance of the nerve root into the lumen of the spinal canal.Typically, conventional pain relievers never completely relieve leg pain with this herniated disc location. Patients, having quickly tried various therapy options on themselves, as soon as they find out about the true cause of pain, quickly agree to spinal surgery.
    Foraminal disc herniation – a rare type of disc herniation, can be combined with isthmic spondylolysis, which in turn is diagnosed by spiral computed tomography.Difficult to diagnose, since a hernia is not found in the lumen of the spinal canal, but the pain is very strong. In this case, a small – 3-4 mm disc herniation is located in the narrowest place – the foraminal opening, where a very small piece of cartilage can strongly clamp the nerve root. Treatment is exclusively surgical.

    Extraforaminal disc herniation is also a rather rare and difficult to diagnose type of hernia, it can also be called a postero-lateral disc herniation – in this case, a large sequestration breaks through the fibrous ring along the postero-lateral surface, enters the area of ​​the vascular nerve bundle, pushes the nerves and blood vessels, and envelops the nerve root from all sides.In this case, the pain clearly corresponds to one diseased root, is constant, does not depend on the position of the body. Surgical treatment always leads to quick relief of pain symptoms.

    Sequestered disc herniation – disc herniation with a detached piece of nucleus pulposus. 100% indications for surgery.

    Sequestered hernia with sequestration migration – displacement of the cartilage in the lumen of the spinal canal up or down makes it difficult to find a fragment during surgery, is often accompanied by bleeding from varicose epidural veins, is associated with a high risk of damage to the nerve root or dural sac, – these are the hernias that gave rise to a large number of rumors that spinal surgery is associated with a high risk of complications and disability.To perform such a delicate surgery, high-tech support is required in the operating room – a good microscope, a good illuminator, high-quality bipolar and monopolar coagulation, microinstruments, and most importantly – an experienced surgeon who can delicately isolate and release nerve roots and remove a herniated disc.

    Calcified disc herniation is always a surprise for the surgeon if CT scan has not been performed before surgery – because, unfortunately, it is impossible to determine on MRI whether there is calcification of disc herniation or not.Calcified (i.e., ossified) fragments are difficult to remove and additional instrumentation is required for adequate surgery. Therefore, in our clinic, both CT and MRI are always performed before spinal surgery.

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    This many-sided osteochondrosis | Internet edition “News of Medicine and Pharmacy”

    The article was published on p. 22-24 (Ukr.)

    Types of hernias and protrusions

    A herniated disc is a direct consequence of traumatic injury or dystrophic changes in the annulus fibrosus. Hernias can fall out in any direction – posterior, posterolateral, anterior, anterolateral. However, so to speak, hernias have preferences. Lateral, for example, are 2 times more common than posterior ones (Fig. 1).

    Nevertheless, the clinical picture of the disease and, therefore, the patient’s health directly depends on the direction of protrusion, on the site of inflammation of the pulpous complex when the annulus fibrosus ruptures.

    The direction of protrusion is important, but not overarching. The clinical picture consists of many components. In particular, the vegetative pathologies of the upper lumbar segments differ from the lower lumbar segments (the latter are devoid of a white connective vegetative branch). That is, the course of the disease depends not only on the place of prolapse on the “dial” of the vertebra, but also on the “registration” of the pathology in one or another part of the spine. In addition, in 4 percent of cases ( Yakhno A.A. et al., 1992 ), radicular symptoms are recorded on the contralateral side of the hernia.

    Let us consider in more detail the directions of protrusions and hernias on an imaginary dial covering the horizontal surface of the vertebral body.

    Dorsal direction

    At fig. 1 this direction is indicated by an hour hand pointing to 12 o’clock. The hernia rests against the space under the posterior longitudinal ligament – a subligamentary arrangement, irritates the receptor fields there, the pain annoys the lumbar region.

    Posterior hernia is characterized by osteoporosis of the posterior corner of the vertebral body (clearly defined radiographically). This is a consequence of the impact on the vertebra of the dropped mass. Over time, the prolapsed nucleus pulposus can become limy.

    Gradually, pain in the lumbar region becomes chronic, its intensity increases. Also because the posterior longitudinal ligament contains substance P, which is absent in the disc and the yellow ligament. The specified substance is an additional component that enhances the sensation of pain.

    Epidural hernia

    Another threat to the dorsal direction of protrusion. The hernia destroys the posterior longitudinal ligament and penetrates the epidural tissue ( Fig. 1 , on the “dial” – 12a). The most rapid neurological syndromes occur (relatively more often) with the defeat of the two lower lumbar discs – due to the sufficient width of the posterior longitudinal ligament in this area of ​​the spine.

    The clinical picture (the occurrence and intensification of pain syndrome) is no longer simply associated with the tension of the posterior longitudinal ligament, but with its destruction.In addition, the aseptic inflammatory process in the epidural tissue makes itself felt. These are already prerequisites for the onset of auto-aggressive phenomena. True, autoimmune reactions proceed slowly here, but by the 6th month after the onset of the disease, they lead to tissue scarring.

    In general, an epidural hernia initiates the mechanism of resorption and calcification of the pulpous complex. At the same time, fibrosis of the disc makes itself felt, which in the end can lead to sequestration of the disc and, therefore, induce aseptic epiduritis with the development of scars and adhesions.This often results in less pressure on the root and therefore less pain. However, here you do not know – to be happy or upset. For, if we call a spade a spade, there are all the signs that the disease has lurked and acquired a chronic character.

    Subdural hernia

    The contact of the pulp complex with the lamina interna dura mater, which is usually called the dura mater, is very painful due to the density of the receptor fields in it.The dura mater is the main protection of the spinal cord, any tension on it, and this is what happens when the pulpous complex reaches the boundaries of the membrane, responds with pain and other troubles for the simple reason that the receptor endings in the dura mater are irritated. In addition, the liquor circulation is blocked ( Fig. 1 , on the “dial” – 12b). Moreover, with lumbar osteochondrosis, calcification of the arachnoid membrane of the spinal cord is possible. Hence – the typical complaints characteristic of sciatica lumbosacral.Increasing spinal disorders are also possible.

    Myelomeric hernia

    A direct consequence of the compression of the myelomer by the pulp complex. Starting with intervertebral disc L I , myelomeric hernia is possible in almost any cranial disc. Clinically, myelomeres are most often affected in the cervical spine. Hernias from IV and above are often incompatible with life. Although the media, greedy for sensations, are silent about this for some reason.

    Not so long ago, the country was agitated by the death of a schoolboy from the Luhansk region. During a break between lessons, the teenager went out into the yard, pulled himself up on a horizontal bar, fell and died. A week later, a schoolboy died in Western Ukraine. At recess, he threw the ball into a basketball basket and suddenly fell down lifeless. In both cases, the accusations fell on the physical education teacher and school health workers. They say, they overlooked, did not warn that sports are contraindicated for these students. In both cases, children fell on their backs, so a spinal fracture is unlikely.But the prolapse of the nucleus pulposus in C II -C III or in C III -C IV is quite possible. A herniated disc in these segments inevitably leads to paralysis of the diaphragm and almost instant death.

    If an X-ray of the cervical spine was included in the mandatory examination of schoolchildren, it is safe to say that both teenagers – the one from the Luhansk region and the one from Western Ukraine – would have survived. After all, this is an axiom: patients with dorsal hernias should be under the supervision of neurosurgeons.

    Foraminal hernia (protrusion)

    Clinically, the most common dorsal-lateral direction of protrusions and hernias ( Fig. 1 , on the “dial” – 10-11 and 1-2), which on the imaginary dial correspond to 10-11 and 1-2 hours. Perhaps this orientation of hernias is due to the fact that the posterior longitudinal ligament is missing here, which is firmly attached to the intervertebral discs and therefore keeps them from protruding.

    The neurological picture in such hernias is the most severe in terms of pain, it extends to the entire territory of the affected metamer.

    I do not accept humor on medical topics, and even when talking about pain, but how can you not remember the phrase of a young fool from an old children’s book, who, when asked what worries him, answered: “ And the head hurts, and the arm hurts, and the leg hurts – everything hurts! “If that young student had stopped taking time off from his studies and took up his studies, he would eventually find out that he marked the territory of several metamers at once. This is possible only in the case when the irritating influences with the indicated protrusions and hernias are directed to the receptor fields of the meninges of the spinal cord and the capsule of the spinal node.

    When the receptor fields of the sinuvertebral nerve are subjected to extreme stress, the neuronal complexes of the irritated spinal ganglion (only in the lumbar region in such a node up to 50 thousand neurons) and autonomic neurons (Dogel type II cells) of the corresponding ganglion of the border sympathetic trunk are involved in a stable pathological state.

    The pain increases due to the fact that at the points of prolapse of the pulpous complex, the integumentary tissue of the elements of the nervous system changes.Dura mater changes to nerve sheaths. Nature, so to speak, “sewed” completely different fabrics in this place (if by analogy with light industry products – silk with velvet). Here, in the suc de sac (“blind pocket”), up to half of the cerebrospinal fluid circulating in the human body is absorbed.

    Let’s take this opportunity and talk in more detail about the fluid system of the nervous system. The liquor system somehow makes itself felt in virtually all situations when herniated intervertebral discs irritate the receptor fields, both in the dorsal-lateral direction of protrusions, and in other directions.

    The cerebrospinal fluid is adjacent to the spinal cord from the side of the spinal cord. The posterior root is provided with an arachnoid sheath. In the aforementioned suc de sac (“blind pocket” at the place where the dura mater passes into the capsule of the spinal cord), CSF is absorbed into the lymphatic system. Only half of the cerebrospinal fluid circulating through the body is absorbed in the pachyon granulations of the head, the second half of the cerebrospinal fluid is absorbed in the pachyon granulations near the spinal nodes. It seems that it is in the places of cerebrospinal fluid absorption that it is necessary to look for the cause of intoxication polyneuritis.

    The junction of the arachnoid and perineural CSF circulation is at the level of the spinal node. And a nerve approaches the distal pole of the spinal node, which obeys the laws of construction of the peripheral cerebrospinal fluid system.

    Lateral direction

    This direction of hernias is of particular importance for the cervical spine, since the hernias press on the vertebral artery. First of all, the vegetative plexuses covering the artery react to the aggression of the hernia.In addition, a protruding hernia can prevent venous outflow ( Fig. 1 , on the “dial” – 3 or 9).

    Patients with such hernias develop vertebral artery syndrome. There are already complaints not only from neurologists. Patients with this syndrome are often forced to seek help from otolaryngologists, ophthalmologists, psychiatrists. Especially when the neurologist is not up to par …

    With these hernias, the advancement of the anterior edge of the articular process anteriorly from the posterior tubercle of the transverse process deforms the vertebral artery.Moreover, it is possible that transverse (due to arthrosis) bone growths in the direction of the vertebral artery canal threaten. Which, again, is fraught with compression of the artery.

    Vegetative hernia

    May occur due to ventrolateral protrusion of the pulpous complex ( Fig. 1 , on the “dial” – 4 or 8). This direction affects the borderline sympathetic trunk. Protrusions, and even more hernias, stretch the ganglionic branch, to which the receptors in the membranes of these vegetative branches and the axons of autonomic neurons (both efferent and afferent) immediately react.Hence the visceral ailments of the patients.

    Vegetative hernias in the cervical spine impede blood circulation in the brain, disrupt the rhythm of cardiac activity and respiration, are fraught with coughing, can cause panic attacks, etc.

    When vegetative hernias occupy the thoracic spine, coronary pains appear that mimic myocardial infarction, breathing difficulties appear, the functions of the organs of the upper abdominal cavity (liver, stomach, pancreas, duodenum) are impaired – a consequence of irritation of the large internal nerve.If such hernias have settled in the lumbar region, then the functions of the large intestine, prostate gland (in men) and pelvic organs (in women) suffer.

    Autonomic hernia syndromes consist of autonomic sensory manifestations and dysfunctions of smooth muscles of internal organs.

    Ventral hernias

    Ventral hernias, or the ventral direction of protrusions and hernias ( Fig. 1 , on the “dial” – 5, 6 and 7), are accompanied by irritation of the anatomical structures located near the anterior ligament of the spine.

    With anterior hernias, the anterior parts of the vertebrae (along the limbus) grow in the areas of attachment of the anterior longitudinal ligament. The anterior zones of the annulus fibrosus can also be a focus of growth. These growths in every two out of three cases, if not more often, calcify. And every tenth patient experiences fatty degradation of the vertebral bodies.

    In addition, anterior hernias are often prone to sequestration. On radiographs in such cases, a triangular shadow appears, and the vertebral bodies are beveled in the anterior zone of the marginal border.

    Due to the proliferation of tissue conglomerates during an aseptic inflammatory process and an auto-aggressive immunological reaction, these morphological structures can begin to stick together with adjacent structures. For example, in the lumbar and lower thoracic spine – with the aorta. And this is already fraught with circulatory failures in the lower half of the body.

    In our clinic, a patient was treated in whom, according to the initial diagnosis of qualified surgeons, a ventral hernia in the thoracic region provoked a clinical picture of a diaphragm rupture …

    Axial hernias, or Schmorl’s hernias

    These are vertically directed hernias, when the nucleus pulposus, as a result of trauma or dystrophy of the hyaline plate, is pushed into the body of the higher or lower vertebra ( Fig.1 , arrow axis – I). In case of axial overload, hernias abut against the center of the vertebra, with flexion overload, in the dorsal, dorsal zones. In addition, depending on the place of formation, lateral, posterolateral and anterior Schmorl’s hernias are distinguished.

    At first, when axial hernias rupture the hyaline plate, they signal their appearance with pain. After that, such hernias, as a rule, do not bother the patient. True, multiple Schmorl’s hernias in the thoracic region lead to curvature of the spine, kyphosis with wedge-shaped deformity of the vertebrae.Most often this happens even in adolescence.

    Intradiscal hernias

    Caused by intradiscal displacement of the nucleus pulposus ( Fig. 1 , somewhat to the side of the “arrows” axis – II). As a rule, these are manifestations of sequestration within the annulus fibrosus. Infringement of the breakaway tissue leads to dysfunctions of the segment. This type of sequestration raises serious questions for chiropractors, because as a result of possible complications, the displacement of the nucleus pulposus can turn from intradiscal to non-disk.

    Multiple hernias

    Selective localization of osteochondrosis in segments C VI -C VII and L IV -L V due to:

    a) ultimate loads on these metameres;

    b) the minimum strength of these metamers.

    Once it appears, the disc herniation “does not go underground and does not go to the bottom”, following the example of deeply conspiratorial saboteurs or spies from film detectives.She reminds of herself from time to time. Due to various, including immunological, reasons, it provokes the emergence of the following hernias at the top or bottom of the spine. They are capturing more and more new positions.

    Not all of them. Statistics say about 2.5–2.7% of patients with osteochondrosis who have multiple hernias. It would seem that with such a ratio, you can live a century and not meet a patient with many hernias. It depends on where. In our clinic, which deals with the rehabilitation of patients with vertebrogenic diagnoses, we, unfortunately, daily receive visitors who do not have a single healthy disc.

    Even mono-defeats can lead to defeats two, three, four, etc. roots. And in 70 percent of cases (more often than in every two out of three patients) there is a combination of lumbar osteochondrosis with cervical. Or vice versa. From which, as you know, it is not easier.

    Over time, in the segment of the lesion, the posterior lower corner of the cranially located vertebra sharpens. Then exostosis (osteophyte) occurs, which contours the herniated disc from above. Exostosis increases in the direction of the intervertebral foramen until it reaches a third or half of the size of the hernia.And the lower contour of the osteophyte models the upper edge of the hernia.

    The deeper the osteochondrosis takes root in the segment, the more clearly the manifestations of spondylosis – “thorns”, exostoses, “ears” and “beaks” join. In parallel, calcification of the ligamentous apparatus, vertebral muscles and the anterior longitudinal ligament occurs. That is, the signs of Forestier fixing ligamentosis make themselves felt. In the end, the pathology ends with disc fibrosis – the proliferation of fibrous connective tissue.

    We have already remembered that, as a rule, exostoses with hernias of the disc grow in a horizontal direction, and the growth of the limbus with spondylosis is vertical.The formation of osteophytes is facilitated by calcium, the concentration of which in the ligamentous apparatus quadruples with age – from 2 to 8%. The relative increase in calcium is accompanied by a decrease in the amount of trace elements – zinc, manganese, copper, causing the prerequisites for ossification.

    In other words, osteochondrosis, spondylosis and spondyloarthrosis develop synchronously, only slightly lagging behind each other in phase. They are closely intertwined, negatively affect each other, increasing the patient’s suffering.

    It is important to know that vertebral radiculopathy (“non-hernial radiculitis”) can be induced, as the name suggests, not only by herniated discs. Let us name, in decreasing order of frequency, the causes that can lead to such a disease:

    – exostoses, bone growths formed by bone tissue;

    – Displacement of the yellow ligament;

    – displacement and growth of the articular process;

    – aseptic epiduritis (epidural adhesions), arachnoiditis.

    After the prolapse of the nucleus pulposus, a stable pathological condition occurs. It’s not even a bulging herniated disc. Or rather, not only in her. For, as we already know, in parallel and synchronously with the disc herniation, other processes develop, as a result of which the vertebral bodies are deformed, and growths appear on them. Posture changes, the functions of internal organs are disrupted. The list of troubles is long and, what is most offensive, it does not decrease over the years, but shows a tendency to increase.

    A herniated disc in most cases is a source (or focus) of pain in one or another part of the spine. But surgical removal of a hernia in most cases (70 percent out of 100) does not relieve a person of pain and other complications. Sluggish processes provoked by a hernia in the vertebrae, ligaments, muscles, internal organs and other components of the metamere (metameres) continue to quietly aggravate the situation. Concomitant diseases, especially diseases of the digestive system, are increasingly raising their heads, in turn aggravating the course of osteochondrosis.

    The fourth period of osteochondrosis, it can be called the fourth stage of osteochondrosis, most often embodies the entire “vertebral trio” – osteochondrosis, spondylosis and spondyloarthrosis. But this trio does not rest on its laurels, even if it goes into chronic or recurrent forms. True, some options are possible: progressive, that is, with an increase in syndromes, and a regressing course of the disease.

    The duration of the disease, the severity and duration of exacerbations depend on many factors: not only on the attending physician, but also on the patient’s active desire to go towards recovery, i.e.That is, sorry for the repeated reminders, strictly follow the doctor’s orders.

    Regularities of osteochondrosis syndromes

    Spinal osteochondrosis syndromes can be divided into two types, depending on the processes that cause them:

    – compression syndromes;

    – reflex syndromes.

    In turn, compression syndromes, that is, compression-induced syndromes, differ in place and conditions of occurrence:

    a) spinal – the consequences of exposure to the spinal cord;

    b) radicular, provoked by exposure to the membrane of the spinal cord, dura mater and the membrane covering the roots of the spinal cord;

    c) nervous, here we are already talking about the compression of the nerve trunks by a hypertrophied ligamentous apparatus and tunnel syndrome caused by fibrosed muscles;

    d) vascular – due to compression of the arteries.

    Moreover, reflex syndromes have their own gradation:

    – neurovascular;

    – neurodystrophic;

    – muscle tonic.

    At fig. 2 presents a metameric analysis of the pathogenesis of osteochondrosis. As you can see, in the target tissues of the affected metamer, in all its structures, sensory, reflex and trophic-dystrophic changes are slowly but steadily going on.

    We marked all 7 structures of the metamer in capital Latin letters: D – dermatome; N – neurotome; V – vazot; S – sclerotome; M – myotome; E – enterotome; G – by gulp (immune and endocrine systems).

    Let’s take another look at fig. 1 and make sure that 14 variants of protrusions and hernias are possible in each of the 24 discs. Consequently, the number of neurological syndromes is 24 x 14 = 336. The number of symptoms of the disease is even greater. At times, as today’s advanced economists say. The number of symptoms far exceeds two thousand – 2352 variants. It is not for nothing that in the scientific literature the number of works of specialists engaged in the study of osteochondrosis and its manifestations is constantly growing.

    There are plenty of places for the application of forces during treatment.At fig. 3 presents a metameric analysis of pain points and reflexes.

    But there are still many empty, unfilled cells. These are directions-hints (I turn to young doctors!), Where and what to look for.

    In principle, reflexes can be triggered anywhere in the human body. It remains only to determine which reflexes, as well as their number.

    Behold at the root – in the trophism of tissues

    It is finally necessary to understand the patterns of development of trophic disorders, in the mechanisms of neurotrophic supply of tissues.I will explain how important this is with a clinical example.

    A forty-year-old woman, an accountant from Voronezh, was admitted for treatment. Diagnosis: thoracalgia due to chest osteochondrosis. She underwent a standard course of treatment in our clinic: metameric injections of cerebrolysin into thoracic neurometamers. Four months later I came for a second course. And made me happy. She explained that she had arrived in Kiev rather for prophylaxis, because the pains in the chest were gone. Together with them, believe it or not, cystic mastopathy resolved … Further examinations (over the years we met several times, the patient wanted not so much to insure herself as to make sure that her feelings were correct), including with the help of paraclinical methods, convinced: achieved a stable remission of diseases – both thoracalgia and mastopathy.

    Since then, for almost 20 years, all patients with such a concomitant (or side) disease as mastopathy have been given metameric injections of Cerebrolysin, with the same predicted positive result.

    And here is a case four years ago. A young woman (24 years old) came from New York for treatment with banal lumbodynia caused by protrusions in segments L IV -L V L V -S I . 10 sessions of metameric administration of Cerebrolysin relieved the pain syndrome.According to the agreed treatment plan, after 6 months the patient was admitted for a second course. Complaints of back pain are a thing of the past. Already after the first course of treatment, dramatic changes took place. This is what the woman said:

    – Before leaving for Kiev, I visited a gynecologist, he was observed for endometriosis. Suddenly he asks me: “ Who else was treated for endometriosis? What hormones did you take? “She replied that over the past six months I had only received metameric injections of Cerebrolysin.The American doctor listened to me attentively, but did not believe me. This has never happened in his practice …

    After this incident, the doctors of our clinic began to consider endometriosis as a stable gynecological pathological condition caused by disorders in the neurotrophic state of the uterus – a consequence of lumbar osteochondrosis. As a result, a group of patients with this concomitant osteochondrosis disease was treated and a statistically significant therapeutic effect was obtained. By the way, the earliest sign of developing osteochondrosis in women is painful periods.

    Blockade of the lumbosacral spine in Kiev

    This procedure has been gaining popularity lately and is increasingly replacing caudal and interlaminar epidural blocks.

    In our practice, we use the German protocols for the treatment of low back pain developed at MARIANOWICZ MEDIZIN (Munich)

    The purpose of transforaminal epidural blockade is to identify the specific spinal nerve root that causes pain and the introduction of the necessary anti-inflammatory drugs into the peri-radicular space.

    Indication for use:

    • spinal hernia
    • protrusion of the intervertebral disc
    • radiculopathy
    • epidural fibrosis
    • phantom pain
    • diabetic polyneuropathy
    • postherpetic neuralgia
    • Pain syndromes caused by oncological diseases

    Epidural corticosteroid injections are the most effective non-surgical treatment for low back pain

    Procedure

    Before the procedure, the patient assumes a prone or supine position (depending on the level of the required block).The skin at the injection site is disinfected and, if necessary, a local anesthetic is injected. Under X-ray control, the required root is identified, followed by the introduction of steroidal anti-inflammatory drugs.

    Time for this procedure: 5-7 minutes.

    We have the largest experience of epidural blockades in Ukraine

    What to expect during the procedure

    The administration of drugs itself can be slightly painful, however, as soon as the local anesthetic begins to act, the pain syndrome stops.After the blockade, within 10-20 minutes, the patient may notice numbness in certain areas of the upper or lower extremities. For a while, until this numbness completely disappears, it is recommended not to get up.

    It is advisable, after the blockade, not to use personal vehicles.

    You can return to your normal lifestyle the very next day.

    Indicator of the effectiveness of transforaminal epidural blocks

    As a rule, regression of pain syndrome is noted within 24 hours after manipulation.If the patient does not notice a decrease in pain in the back, arms or legs from the first block, then there is no point in carrying out further injections. If the patient notes at least a slight decrease in pain, then repeated blockages can be performed.

    How often can transforaminal epidural blocks be done?

    Transforaminal epidural blockade should be performed no more than once every 2 weeks, but no more than 5 injections over 6 months.

    Potential complications and side effects

    As with any medical procedure (lower back epidural block), transforaminal epidural block is a potential risk factor for certain complications.

    Allergic reactions to injected drugs (before the blockade, you will be asked about possible allergic reactions, if necessary, they will make the necessary tests)

    • Raising blood pressure (blood pressure monitoring is required during the procedure)
    • Infections (very rare)
    • Bleeding (very rare)
    • Nerve damage (very rare)
    • Subdural administration of the drug (1-2%) (with subdural administration of the drug, it is possible to obtain the effect of spinal anesthesia, i.