MALAYSIA: THE problem with body aches is you normally know where it hurts, but you can only guess what the reason is.
This is especially so when you experience backache, a symptom associated with a wide range of problems, including anything from muscle strain, osteoarthritis and problems of the spine.
While all of the above can cause backache, one of the common causes of back pain is a herniated disk, sometimes called a slipped disk or ruptured disk.
A slipped disk
A herniated disk is a medical term for a condition where the spine experiences the degeneration of, or damage on, its shock absorbers, the soft, spongy disc between the bones that take the brunt of stress on our spine and nerves.
The condition can be caused by gradual, ageing-related degeneration where the disc loses its central fluid, making it less flexible and prone to tearing or rupturing. Sometimes, too much stress or trauma to the spine can result in herniated disks too.
According to MayoClinic.com, herniated disks are most common in the lower (lumbar) spine, but about 10% occur in the neck (cervical spine).
Herniations in the lumbar spine are most common between 35 and 45 years of age. Cervical disk herniation is more common between 50 and 60 years old.
But, not all who have slipped disks feels the pain.
If the affected disk does not press against one of your nerves, you may only have a slight lower back pain, or nothing at all. But if it presses against your nerves, it may cause pain, numbness, and weakness in the area that the nerve travels.
Treatment, thus, seeks to alleviate pain and improve the quality of life of people suffering from slipped disks.
Screening for a slipped disk
A review of your medical history and a few simple physical tests may be all it takes to determine whether you have a herniated disk, wrote Dr S. Craig Humphreys and Dr Jason C. Eck in their article, Clinical Evaluation and Treatment Options for Herniated Lumbar Disc.
''Usually, about 80% of patients complain of acute lower back pain, or buttock pain on one side with sciatica (radiating pain with or without numbness) of one leg (pain going down the side of the thigh and leg, involving the foot),'' said Dr Siow Yew Siong, a spine surgeon practising in a local private hospital.
The remaining 20% would have lower back pain with radiation into both buttocks without lower limb (legs) involvement, he added.
?History taking is the most important part of (diagnosing the condition), and we can highly suspect a slipped disk from that, especially when the patient is young,? said Dr Siow, who observed that there are more cases of slipped disks in those over the age of 30.
For further investigation, a straight-leg-raising-test and cross straight-leg-raising-test can be done. In the former, the doctor will raise the symptomatic leg (with pain or numbness) while you are lying down and the latter involves raising the other leg (without symptoms).
If these tests cause pain in your leg or back, it may indicate a herniated disk. Further tests like MRI (magnetic resonance imaging) and CT (computerised tomography) scan may help your doctor confirm the diagnosis or locate the location of the injury.
Conservative treatment still first-line
Fortunately for herniated disks, surgery is not required most of the time to treat the condition.
''In most cases, if a patient's lower back and/or leg pain is going to resolve after a lumbar herniated disc, it will do so within about six weeks. While waiting to see if the disc will heal on its own, several conservative treatment options can help reduce the back pain, leg pain and discomfort caused by the herniated disc,'' wrote spine-health.com in its own Overview of Lumbar Herniated Disc.
''Normally, when patients feel the migration of pain from the leg or foot to the back, it is a sign of improvement (healing),'' Dr Siow said.
''We are very lucky as most of our patients can be treated by conservative treatments,'' said Dr Achim Luth, a consultant orthopaedic surgeon from Germany who performed a nucleoplasty procedure after a short lecture here at a private hospital.
Ninety percent of the time, patients can be helped by (conservative treatment such as) paravertebral injections, epidural injections with cortisone, medication and physiotherapy, he added.
For his patients, Dr Luth gives conservative treatment a try for eight to 10 weeks before more invasive treatments (surgical methods) such as microdiscectomy or nucleoplasty are considered.
In his experience, only about 5% to 10% of his patients had needed microdiscectomy because they had severe weakness or loss of function as a result of the herniated disk.
''A microdisctectomy involves burning the tissue to release the pressure from the disk. It may result in scarring and patients may have what we call post-discectomy syndrome (persistent back pain),'' he added.
In Dr Siow's experience, about 70% of patients with slipped disks will recover irrespective of whether treatment is sought. The remaining 30% will generally suffer from pain if not treated.
There is one exception to the practise of the conservative-treatment-first approach, Dr Siow said.
''If the herniation is so severe that the patient is suffering weakness, loss of bowel or urinary control (the Cauda Equina Syndrome), then immediate surgery should be carried out so as to save the nerve tissues and prevent irreversible damage.''
Nucleoplasty
The indication for nucleoplasty is when a patient whose symptoms are not very severe is reluctant to go for open surgery (like microdisctectomy) or find conservative treatment ineffective to provide pain relief after eight to 10 weeks, Dr Luth said.
To make it simple, Dr Luth explained that in normal cases, the bulging (herniated) discs would naturally shrink on its own. So, if your symptoms are not very severe, you may want to consider conservative therapy first.
In nucleoplasty, doctors will remove some of your disc pressure, and allow the body to undergo this natural process, Dr Luth added.
''It is a safe and controlled therapy,'' said Dr Luth.
Unlike conventional methods in surgery where tissue is usually removed by burning the tissues or excising them, nucleoplasty uses the patented Coblation technology, which uses radiofrequency energy to create energised particles that have sufficient energy to dissolve tissues inside the disc, which will lower disc pressure and alleviate the pressure exerted on the nerves.
Done in an outpatient setting, a nucleoplasty procedure is carried out with the patient under local anaesthesia and takes about 20 minutes to complete.
However, it takes some time for the therapy to show its effects.
''Pain relief cannot be expected within two to four weeks because the body needs time to heal,'' said Dr Luth, who added that patients who underwent nucleoplasty needs to be extra careful with their back after the procedure.
''You can't sit for too long or carry heavy weights. Do not start playing tennis, golf or other sport that utilise the lumbar (lower back) region until at least three months after the procedure,'' he cautioned.
Nucleoplasty has the advantage of offering minimal pain during and after the procedure, a quick rehabilitation and a long-lasting effect, Dr Luth said.
The procedure can be done for herniated disks at the lumbar (lower back) region and the cervical (neck) region.
Although nucleoplasty promises good results, it comes with a price.
''Nucleoplasty can be costly,'' said Dr Luth, who added that doctors usually would not consider the procedure to be the first option when it comes to treating herniated disks.
''So, if the patient has severe weakness, open surgery is still the way to go as we do not want to wait too long,'' said Dr Luth.
''For other cases, it is only when all conservative treatment fails after eight to 10 weeks that we start to consider nucleoplasty.''
3. Clinical Evaluation and Treatment Options for Herniated Lumbar Disc,
by S. Craig Humphreys, M.D., and Jason C. Eck, M.S.,Chattanooga, Tennessee, American Family Physician, www.aafp.org/afp/990201ap/575.html
This story was first published in The Star on Apr 6, 2008.
