The spine is composed of a series of connected bones called “vertebrae.” The vertebrae surround the spinal cord and protect it from injury. Spinal nerves branch off from the spinal cord, which carries messages from the brain, and carry signals to the upper limbs. The messages carried by the spinal nerves allow the muscles of the arms and hands to contract and the skin of the upper limbs to have sensation to touch, temperature, and vibration.
The vertebrae are connected by an intervertebral disc, analogous to that found between the vertebrae of the lumbar spine, and two small joints called “facet” joints. The disc, which is comprised of strong connective tissues which hold one vertebra to the next, acts as a cushion between the vertebrae. The disc and facet joints allow for movements of the vertebrae and motion of the cervical spine. Without the discs, our cervical spines would be a single column of bone which would not allow for the essential motions associated with our daily postures and activities.
The disc, often described as a “jelly donut,” is made of a tough outer layer called the “annulus fibrosus” and a gel-like fluid filled center called the “nucleus pulposus.” The cervical discs are not as large as those found in the lumbar spine, and the fluid filled nucleus is not as prominent. Additionally, as we age, the center of the disc cervical discs typically, and perhaps more notably than in the lumbar spine, lose water content, making the disc less effective as a cushion. As a disc degenerates, the outer layer, the annulus, can also wear with tears developing in this outer shell. This can allow displacement of the disc’s center (a herniated or ruptured disc) through an opening or fissure in the outer layer. This herniation of disc material can then result in compression of an exiting spinal nerve, resulting in both mechanical and chemical irritation of the neural tissue. The resulting symptoms can include debilitating pain, numbness, tingling, or weakness radiating from the neck down to the arm or from the back down the leg. These symptoms result in a syndrome sometimes referred to as “sciatica ” or a “pinched nerve.” The medical term for this condition is “radiculopathy.”
The fellowship trained physiatrists of Long Island Spine Rehabilitation Medicine are often consulted for this particularly painful and debilitating syndrome. Fellowship trained physiatrists are particularly proficient in performing a particularly detailed neurological and musculoskeletal examination in patients with disc herniations and radiculopathies.
How is it diagnosed?
Our physicians perform a detailed history and physical examination, which includes a comprehensive assessment examination of the spine, musculoskeletal, and nervous systems. Often, through such an approach, the exact spinal nerve affected by a herniated disc can be identified. Other times, due to the variations in our “wiring” and overlap in the functions provided by neighboring spinal nerves, the identification of the affected spinal nerve may remain less clear. The purpose of such an examination is to quantify the extent, if any, of neurological compromise resulting from the injury and to carefully rule out any contributing or mimicking musculoskeletal processes which might complicate the clinical picture. Rarely, a herniated disc may put pressure directly upon spinal cord. Symptomatic spinal cord compression is a more critical clinical situation, referred to as “myelopathy” or “cauda equina syndrome,” which can be associated with loss of strength and sensation in both the upper and/or lower limbs.
The diagnosis of a sciatica can be confirmed by advanced imaging of the spine in the form of either a CT or MRI. X-ray images can show bone spurs, loss of disc space height, and narrowing of the neural foramen or “tunnels” through which the spinal nerves travel. X-rays, however, cannot show soft tissues such as disc herniations, the spinal nerves, or the spinal cord. CT and MRI scans provide more detailed pictures of each of the structures of the cervical spine and can identify most disc herniations.
Additionally, nerve studies, also referred to as nerve conduction studies or EMG (electromyography), may be performed in an effort to detect evidence of nerve damage that can result from a disc herniation. In particular with syndromes affecting the upper limbs, such testing can help to rule out a non-spinal process such as carpal tunnel syndrome at the wrist or ulnar neuropathy at the elbow, which might mimic or be superimposed on primary cervical radiculopathy. The physicians of Long Island Spine Rehabilitation Medicine have completed extensive training in performing these studies and are either board certified in Electrodiagnostic Medicine or board eligible for subspecialty certification in Neuromuscular Medicine. In our practice, these tests are performed with the latest diagnostic equipment and in a fashion which maximizes patient comfort.
80-90% of patients with a new or recent acute disc herniation improve without surgery. Some literature would suggest an even greater likelihood of a successful non-surgical outcome with cervical syndromes when compared with lumbar spine radicular pain. The physicians at Long Island Spine Rehabilitation Medicine are experts in the non-surgical management of disc herniations and will customize your treatment options to your condition. Surgery is typically recommended for relief of unrelenting pain that has failed to respond to a full spectrum of non-surgical approaches or for profound or progressive neurological deficits.
Non-surgical treatments recommended by our doctors may include a short period of relative rest, anti-inflammatory medications to reduce inflammation and swelling, analgesic medications to control pain, physical therapy, or epidural steroid injection therapy. Strict bed rest is often avoided, as studies have demonstrated improved outcomes with quicker functional recovery in patients who progress their activity as their symptoms allow. Additionally, prolonged bed-rest may ultimately result in stiffened joints and muscle weakness, which can ultimately slow one’s functional recovery and prolong pain.
The goals of comprehensive physiatric non-surgical treatment are to reduce the inflammatory and mechanical aspects of injury while gradually and strategically progressing activity and overall function. This can be accomplished in the majority of patients with disc herniations using a comprehensive treatment program.
An important part of your treatment plan is exercise therapy that is specially designed to reduce your neck and arm or low back and leg symptoms. Our doctors have identified a group of therapists throughout the region that have attained specialized training in treating patients with spinal conditions. We can assist you in locating these therapists so that you receive the best spine care available.
Throughout your treatment, we remain in contact with your treating therapist to ensure that your therapy is progressing appropriately. If needed, your program may be modified from time to time, depending on your clinical response. The physiatrists at Long Island Spine Rehabilitation Medicine work closely with therapists certified by the McKenzie Institute. These therapists have spent many hours treating patients with spinal disorders and have passed written and practical examinations assessing their knowledge and hands-on skills. We also regularly seek feedback from our patients to assure that one-on-one care is being provided and the treatment environments are satisfactory.
Most pain can be treated with non-prescription medications such as aspirin, acetaminophen, non-steroidal anti-inflammatory medications (NSAIDs). If you have severe persistent pain, you may be prescribed stronger analgesics for a short period of time. With any medication, the goal in prescribing is to maximize benefits realized through as low a dosage as possible to minimize adverse side effects (such as constipation and drowsiness). All medications should be taken only as directed. Medications are prescribed by your treating physiatrist in an individualized fashion and only after a careful consideration of your past medical history and current medication regimen.
Non-surgical therapies are geared toward addressing both the mechanical and chemical or inflammatory aspects of spinal nerve injury resulting from an acute disc herniation. The scientific literature has shown that non-surgical treatments for disc herniations are a safe, recommended and often effective approach for this condition. The physicians of Long Island Spine Rehabilitation Medicine, experts in the field of non-surgical spinal care, are uniquely trained to evaluate and treat patients presenting with the full spectrum of symptoms arising from a disc herniation.
Transforaminal selective epidural injections performed with fluoroscopic guidance may be recommended if you have severe neck and arm or low back and leg pain arising from a disc herniation. These are targeted injections of a corticosteroid/local anesthetic mixture into the epidural space immediately surrounding the inflamed and compressed spinal nerve. The initial injection may be followed by one or more injections at a later date. These injections are performed in a target and diagnosis specific fashion and are offered to aggressively control the acute inflammatory phase of injury and as a component of a comprehensive rehabilitation program.
Both our experience and the spinal literature suggest that patients with debilitating limb pain arising from an acute disc herniation will often realize significant relief from a transforaminal injection approach, even when previous therapies have failed. While the clinical outcomes arising from cervical injection therapy can be particularly gratifying for our patients and physicians, these injections require advanced training on the part of the treating clinician, a careful selection process in determining appropriate candidates, and adherence to meticulous procedural technique. The physiatrists of Long Island Spine Rehabilitation Medicine have completed unique and highly specialized fellowship training in Spine Medicine and Interventional Spine Care. Injection procedures are performed in our practice by your treating physiatrist with a skilled and seasoned medical team utilizing the latest in imaging technology and in a comfortable office setting.
What About Surgery?
If your symptoms fail to respond to a reasonable trial of non-surgical approaches, our physicians may refer you to a surgical colleague. We are affiliated with regional surgeons with expertise in the surgical approaches to spine. The goal of surgical intervention is to remove the herniated portion of the disc that is compressing the spinal nerve or spinal cord. This is achieved by a procedure called a “discectomy.”
Depending on the exact location of the herniated disc, the surgeon may choose to make an incision either in the front (anterior approach) or back (posterior approach) of the body to reach the spine and problematic disc herniation. The surgeon’s decision of which approach to utilize is influenced by many factors including the location of the disc herniation and the experience and preference of the treating surgeon. With either approach, the disc material is removed and compression of the nerve is relieved, typically with good results. Because removal of the herniated disc fragment from the front (anterior approach) removes most of the disc between the cervical vertebrae at the involved level, fusion is generally recommended and performed at the same time.