Wednesday, April 02, 2008

Herniated disc treatment NYC

Herniated disc NYC
Call (212) 645-8151 for Herniated disc treatment in NYC
Dr. Steven Shoshany is the only NYC Chiropractor that has a Patent on his spinal decompression protocol.

I wanted to add some more information for my patients to learn about the herniated disc and how spinal decompression can help. In my Manhattan spinal decompression practice I focus on non-surgical treatment with the DRX 9000 and the Spine-force Core strengthening system.
I pulled the info below from a amazing Chiropractic website that has tons of pictures and descriptions of herniated disc. I posted a brief copy of some of the content on the site but it pays to visit the site to see the pictures and learn by pictures.

Disc Bulge | Disc Protrusion | Disc Extrusion | Disc Sequestration

In layman's terms, a disc herniation occurs when the inside of the intervertebral disc (nucleus pulposus) tears its way through the posterior outer portion of the disc (annulus fibrosus) and invades the space where the delicate neural structures reside (i.e., the anterior epidural space). The presents of this nuclear material in the anterior epidural space may irritate these neural structures, which in turn may cause the patient to suffer severe back and/or leg pain. In this tutorial we will explore just how a disc herniation occurs and discuss some of the more common classification of herniation.

The term 'Disc Herniation' (or 'disc prolapse' as they use in Europe) is a broad and general term that includes three specific types of disc lesions, which are classified based on the degree of disc disruption and posterior longitudinal ligament (PLL). The three main classifications of disc herniation are Protrusion (aka: contained herniation or sub-ligamentous herniation), Extrusion (aka: non-contained herniation, or trans-ligamentous herniation) and Sequestration (aka: free fragment).
General Information and Confusion:

In 1934 the syndrome of "disc herniation" was born when Mixter and Barr first proclaimed that a posterior rupture of the intervertebral disc that allowed nuclear material to escape and compressed the adjacent spinal nerve root(s) was a common cause of back and leg pain - sciatica (125). For nearly 70 years this assertion has held true without much challenge(170).

However, modern research as demonstrated that the relationship between disc herniation and its often associated sciatica are a far more complex and bewildering phenomenon than once realized. For example, since the invent of MRI, we have learned that some patients have disc herniation on MRI, yet have no pain at. And, visa versa, some patients have terrible back and leg pain, yet have no disc herniation! (Click here for the false positive rates for MRI.) Moreover, when post MRI is performed on some patients that once suffered disc herniation induced back and leg pain, the herniation is still there, yet the patient is gone. Conversely, some patients who fail to recover from back and leg pain, demonstrate a disappearance of the once prominent disc herniation.

Other ironies of disc herniation have been discovered as well. For example, we have learned from the work of Karppinen et al. that the size and severity of disc herniation do NOT correlate with the degree of patient pain, disability, or suffering (170). That is, small disc herniations and even disc bulges may causes just as much pain and disability as massive disc herniations and even extrusion.

Another strange irony is the fact that smaller, less complete, and innocent looking disc herniations (i.e., contained herniations, protrusions and/or disc bulges) are usually more difficult to treat and respond less favorably to decompressive surgery (discectomy) than do the larger and more advanced disc extrusions and sequestrations. (50) Moreover, symptomatic contained herniations have a poorer prognosis for recovery than do the larger more complete disc extrusions and sequestrations do. (50) And, to further cloud the water, we now know that sciatica (a horrible burning lower limb pain associated with disc herniation) is not always causes by the direct pressure from a herniated disc. That is, it can be caused from nuclear material "leaking" from the back of the disc onto the adjacent nerve roots, i.e., chemical radiculopathy(3,4) and/or from chemical and pressure irritation of the posterior intradiscal nerve fiber, i.e., the sinuvertebral nerves, which is called discogenic sciatica (1,2).

So, diagnosing a patient with complaints of back and lower limb pain is certainly not as easy as once believed.


Based on nearly thirty years of medical research, I can comfortably conclude the forthcoming with respect to treatment options for disc herniation induced back and lower limb pain: for patients who do not have the danger signs of compressive disc herniation--i.e., loss of bowl and/or bladder control (cauda equina syndrome); progressive worsening of their neurological state (atrophying muscles, progressive muscle weakness [foot drop]); and/or a worsening of their pain--conservative, non-operative care, will work just as well as having back surgery. In 1982, Weber--who won the prestigious Volvo Award for this work--was the first to suggested that back surgery for disc herniation induced back and leg pain was no more effective than letting old man time and mother nature (i.e., having conservative care [i.e., physical therapy, exercise and physical therapy]) work their magic. That is, he experimentally demonstrated that in the long run, patient who had back surgery got no better than those who didn't. The surgery group, however, did get better faster and were doing better at the one year mark; however, by three years, there were no differences between the surgery group and the non-surgery group. [Weber Study] Other investigators have confirms these findings. Recently (2007) Peul et al published the results of their medical investigation into surgical outcome of sciatica in the prestigious New England Journal of Medicine. They also randomized over 200 patients into either a disc surgery group or a conservative care (non-surgical) group. Again, as with the Weber study, the patient who had surgery got rid of their leg pain faster; however, at the one year follow-up, the surgical patients were no better off than that of the non-surgical patients. [An abstract of the study is here]


Treatment for severely symptomatic disc herniation-associate sciatica is best accomplished with traditional open discectomy or micro discectomy (99), BUT ONLY IF conservative measures have failed and/or if you have the danger signs associated with disc herniation: loss of bowl and/or bladder control (cauda equina syndrome); progressive worsening of the neurological state (root-related atrophying muscles, progressive muscle weakness [foot drop]); absent reflexes and/or a worsening of pain. Surgery timing, for disc herniation-related sciatica, is also critical. That is, you certainly don't want to wait any longer than one year before having the surgery (50). See the Surgery Timing Page for more information.


With regard to the non-invasive techniques, such as endoscopic discectomy, laser discectomy, etc. I'm not a believer and I do not recommend them. With regard to Laser discectomy, neither does a 2007 meta-analysis (a study of all the research ever done on Laser discectomy) by Goupille et al (26) who state, "this treatment cannot be considered validated for disc herniation-associated radiculopathy resistant to medical treatment." Until the inventors and proponents of these procedures step-up to the plate and published some high quality medical investigations (like what Peul et al just did) to prove their efficacy (effectiveness), then I'm not a believer. I can only think the reason the inventors of these techniques haven't done so is because they are afraid that the studies will show their techniques are no better than traditional discectomy or even worse. SO, STEP AND SUBMIT YOUR RANDOMIZED CONTROLLED TRAILS! PUT YOUR RESEARCH WHERE YOUR MOUTHS ARE!


Lets begin our tutorial with a quick review of the normal disc, and then proceed through each type of herniation. (For a full review of disc anatomy and physiology, please visit my 'Disc Anatomy Page'.)

The Normal Disc:
The 'Nucleus Pulposus' (pink #1), which is a water-rich gel-like mass of proteoglycan material, has the duty to support the tremendous 'Axial-Load' (weight) of the body. This nucleus is 'corralled' by the stronger 'Annulus Fibrosus' (green #2). The annulus is made out of concentric rings of a cartilage-like material called 'lamellae' (#9). It is this specially arranged collagen that gives the annulus the tremendous strength needed to hold that nucleus in place. Key Concept: The nucleus pulposus, because of the tremendous axial load upon it, is constantly trying to escape from the confines of the center of the disc. If it does manage to escape (tear) through the PLL (#7), the appearance on MRI is called a disc extrusion. The 'Posterior Longitudinal Ligament' (PLL #7) shields the delicate posterior neural structures and acts as a last line of defense against the potentially irritating nucleus pulposus. Note the posterior disc is 'concave' in shape, as outlined by the PLL. (It will not stay concaved for much longer!) The 'posterior neural structures', which are very sensitive to pressure and chemical irritation, include the following: 'Spinal Nerve Roots' (L4, L5, S1), 'Dura Mater or the Thecal Sac ' (red star), and the 'Dorsal Root Ganglion' (DRG). To learn about the anatomy and physiology of the disc go to: [Disc Anatomy]. And finally we have the Sinuvertebral Nerve (# SN). The Sinuvertebral nerve innervates (connects to) the outer 1/3 of the annulus fibrosus. These tiny nerve ending have the ability to carry PAIN messages to the brain and are thought to be on of the causes of discogenic pain. (Read my IDD page, for more information on discogenic pain.) Oh, one more thing; the epidural space (#8) contains the traversing nerve roots (L5) that are often the favorite target of the compressive disc herniation.

THE DISC BULGE: The First Step Toward Disc Herniation:

In order for a disc to herniate, its structural components must first 'weaken'. This weakening occurs as a result of Disc Degeneration. Disc degeneration occurs naturally, to some degree, in all disc, but in some people the process become especially severe and damaging. The 'bottom-line' of the degeneration process is that the annulus becomes dried (desiccation) and brittle, hence allowing for the development of Disc Bulging and full thickness posterior anular tearing, or Internal Disc Disruption.

Figure #2 demonstrates the 'pre-cursor' to a disc herniation. This type of disc lesion - that bulges into the anterior epidural space without any area of focal-ness or out-pouching - would be called a 'Disc Bulge' on MRI (only because the MRI can NOT show the condition within the disc), although in reality it is a 'Grade 3 Radial Anular Tear' (you would need CT discography to identify the tear) that has disrupted the posterior annulus and allowed irritating nucleus pulposus material to enter into the outer fibers of the disc. Again, this in of itself (IDD) may cause severe and disabling pain in some unfortunate people; however, the subject of Internal Disc Disruption is not the focus of this page. Also note that the PLL, although bulged, continues to be intact and has not ruptured. As well shall see later, the PLL is the 'key' to differentiating between a disc protrusion and a disc extrusion. Finally, note that the Sinuvertebral nerves are irritated (red) and are sending pain signals on to the brain through the sympathetic nervous system (gray ramus communicans). Also note that this IDD may cause some referred lower leg pain as well (spinal nerve has some orange in it to indicate referred pain.)

DISC PROTRUTION: Posterior Longitudinal Ligament is still Intact.

Figure #3 demonstrates a 4 millimeter disc protrusion and represents a worsening of our disc bulge. The posterior of the disc is 'focally' or 'eccentrically' pushing backwards into the anterior epidural space and has contacted, and even somewhat compressed, the traversing nerve root (white star) and right front corner of the thecal sac. Note that the PLL (blue) still has NOT be disrupted and is still "containing" the near-herniated nuclear material.

The type of presentation in Figure #2. would be 'officially' classified as a 'Disc Herniation' or, more explicitly, a Disc Protrusion (aka: contained herniation or subligamentous disc herniation).

Although disc protrusions are seen in about 30% of the normal non-symptomatic population, nerve root compression is not, and if much more indicative of a 'problem. This patient may well be suffering right sided radicular pain (sciatica) and/or lower back pain as a result of compression/irritation of the traversing nerve root and/or irritation of the sinuvertebral nerves in the posterior of the disc.

THE DISC EXTRUSION: The Posterior Longitudinal Ligament has ruptured.

Figure #4. demonstrates a more serious progression of our pathologically degenerated disc: An 8 millimeter Disc Extrusion (aka: non-contained herniation, transligamentous herniation) is now present. The PLL (blue) has finally been defeated and has completely ruptured, hence allowing for further migration of the the nucleus pulposus into the anterior epidural space. Note the marked displacement of the traversing nerve root (white star) AND the exiting nerve root (green star) (which has now turned completely red with inflammation and venous congestion - the precursors for Radiculopathy). This Disc Extrusion is NOT typically seen in the asymptomatic person and is often an indication for surgical decompression; the sooner the better IF you're NOT improving with conservative care. Another interesting phenomenon about extrusions are the fact that these larger disc lesions have a greater ability to be 'reabsorbed' by the body! This 'shrinkage phenomenon' has been demonstrated time and time again in the literature; in fact, you can expect that in 80% of large disc extrusions, there will be at least a 50% 'shrinkage' of size (5,6). Unfortunately, this doesn't always mean that the pain associated with the extrusion will fade! Some patients recover from disc extrusion yet demonstrate NO change in the size of their extrusion at all, where others fail to recover yet their extrusion has markedly decreased in size! That just goes to prove that we still have a lot to learn about the relationship between disc herniation and pain!

DISC SEQUESTRATION: The Final End-Phase of the Disc Herniation.

Figure #5. represents the end-of-the-line for the cycle of disc herniation. Now we can see that a big 'chunk' or 'fragment' of nuclear material has detached itself from the main body of the extrusion is and loose in the epidural space. Note the resulting severe compression of the traversing nerve root (white star), the exiting nerve root (green star) and the lateral aspect of the Thecal Sac (blue star).

Sequestration (aka: sequester, free-fragment) may be excruciatingly painful (back and leg pain - sciatica) and, if centrally located, may occasionally cause the patient to lose control of their bowl and bladder function, i.e., Cauda Equina Syndrome, which is considered a 'Medical Emergency'!

As with the disc extrusion, the sequestration may also undergo a reduction in size from a combination of an immune attack {macrophage attack} and dehydration, although frequently the patient will need immediate decompressive surgery to beat this monster!

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