Herniated Upper Disc and its Signs and Symptoms
The spine supports our back and gives us the ability to be upright. It is normally made up of thirty three vertebrae where the lower nine are fused in the sacrum and coccyx region. The twenty four upper un-fused vertebrae are separated from each other by 12 intervertebral discs.
These intervertebral discs:
- Forms a fibrocartilage joint and permits light movement
- Holds the vertebrae together
- Acts as a shock absorber to prevent harm during injuries
The intervertebral discs are made up of a tough outer coat and a gelatinous inner coat. The outer coat is called the annulus fibrosus consists of fibrocartilage made up of type I and type II collagen. The inner nucleus pulposus is jelly like in nature and helps distribute weight and pressure.
A herniated upper disc occurs when the outer layer of the intervertebral discs becomes damage. As a result, the nucleus pulposus, usually wedged between the two vertebrae, bulges out. It is commonly referred to as a slip disc. They most commonly happen at spinal levels T8-T12, affecting mostly the lower back where the spine is more mobile than other regions.
A herniated upper disc can occur due to a number of reasons such as:
- Vigorous exercise routines: This increases the general wear and tear of the discs
- Physical trauma: This is common in athletes who play contact sports it can lead to blunt impacts against the spine
- Chronic deterioration of the disc due to infections
- Degradation of the disc: This can be caused by aging and disc degradation disease.
Directions of Herniation:
- Lateral Herniation: This occurs when the bulging center of the intervertebral disc moves to either side. It often leads to the irritation of the surrounding nerves.
- Central Herniation: This occurs when the nucleus pulposus is moved towards the spinal canal. It leads to spinal canal stenosis and irritation of the spinal cord
- Centro-Lateral Herniation: In this type of herniation, the disc moves both to the side and towards the center, affecting both the surrounding nerves and the spinal cord.
Signs and Symptoms:
The most common signs and symptoms associated with a herniation of the upper disc are:
- Pain
There is severe back pain that is localized to the region of the rupture. This occurs because the surrounding connective tissue undergoes degradation. This leads to inflammation and the release of tumor necrosis factor alpha (TNF) that can cause pain. This type of pain is called discogenic pain.
The pain often radiates from the localized area to a region of the chest. It occurs because the herniated disc often moves laterally causing the compression of the surrounding nerves. These nerves innervate the ribs and its related chest wall. While it is usually unilateral, it can also be felt as an all-around band in the chest region. In some cases it can be known to radiate down the leg too, a condition called sciatica. This type of pain is burning like or electric shock like in nature. It is called radicular pain.
Muscular spasm can occur when there is an injury to the muscles, which leads to them activating mechanisms that trigger the tightening of the muscles and cause them to spasm. This usually affects the back muscles and can lead to pain in a large region extending across several levels of the back. Pain due to muscle spasm is usually described as pulsating in nature.
- Weakness and Numbness:
The herniated disc can affect nerves that have just branched off the spinal cord and are yet to leave the spinal canal. When this happens, it is called a thoracic radiculopathy. This can manifest in two ways. There can be numbness or there can be radiating pain to the chest.
The herniated disc can also impinge on the spinal cord. When this happens, it is called a thoracic myelopathy. This causes numbness at the region of the spinal cord affected and the area below. It can also lead to a weakness in the legs such that the person might find it difficult to stand upright. Thoracic myelopathy is a dangerous condition as its progression can lead to a number of serious problems like:
- Gait abnormalities: There is trouble walking and incoordination of legs is present
- Sensation around the saddle region
- Bowel and bladder incontinence
Treatment:
Conservative Approach:
This is the most used approach when it comes to treating herniated discs as most patients on conservative therapy can recover in up to three months. This is often the treatment of choice for unilateral herniations too.
A short period of bed rest is recommended and the patient is asked to cease and activity that adds unnecessary pressure on the back for the time being. This is to prevent any further harm to the upper spine. After this, gentle exercise and walking is recommended to bring the spine back to its normal function. This is to be done very slowly and only at an intensity that is doctor recommended. Core strengthening exercises can be added further along the treatment.
Pain management is an instrumental part of this treatment. To alleviate NSAIDS and acetaminophen are recommended. If the back pain is very severe then narcotic pain medication can also be prescribed. The use of epidural corticosteroid injections to manage pain is found to be questionable and is currently not FDA approved. Ice packs can be used when necessary.
Surgical Approach:
Surgery is only needed in very rare circumstances like thoracic myelopathy and progressive neurological deficits associated with it. It is also necessary when the pain can no longer be managed with the conservative approach.
For central and centrolateral herniation, an open thoracotomy is performed. The spine is accessed through the chest cavity. This can also be done by a minimally invasive procedure called Video Assisted Thoracic Surgery (VATS).
For lateral herniated discs, a costotranversectomy is performed. The spine is accessed through the back and this operation requires the removal of a rib and the transverse process of the vertebrae.