LUMBAR HERNIATED DISC:

A CASE STUDY REPORT

Submitted to:
Mrs. Aida Dapiawen

Submitted by:
POSADAS, Kristina Grace
NCI-MWF 10:30-11:30

10 October 2007
 Introduction

Too much or too little physical activity is the call of

modern living. Most people’s daily routine would comprise

of either spending the day facing the computer or being

subjected to hard labor. As a result, majority complain of

muscle strains especially on the lower back area. But in

spite of the severity of the pain experienced, the common

notion is that such condition is simply due to muscle

tightness, and that minimal interventions will do the

trick. However this may not always be the case, for there

is a great possibility that a nerve may be pinched or

compressed in a particular area. Such impingement may then

lead to disturbances in nerve function characterized by

intense pain and numbness of the affected part. In this

light, this case study report aims to alert the readers on

a more serious underlying cause of what is though of as a

simple back pain—disc herniation. The public’s familiarity

with the disease’s nature, signs and symptoms, and common

management including preventive measures, is the main

objective of this report.

Nonetheless, this case study report is only limited to the

presentation of a single case of lumbar disc herniation (as

there are still other types of such condition); which means

that only one set of patient history (probable cause),

signs and symptoms, and treatment (and in this case, only

non-invasive management) was discussed. Furthermore, the

report was a product of the individual effort and

restraints (including information resources and time

allotment) of a student writer and therefore, highly

technical terms were not elaborated. But then again, with

regards to data collection methods, efficient and effective

techniques were utilized such as the use of internet

resources, medical books and references, and most

importantly, a consultation with the patient herself, as

well as her attending physiatrist.

Nature of the Disease

Your back, or spine, is made up of many parts. Your

backbone, also called your vertebral column, provides

support and protection. It consists of 33 vertebrae

(bones). There are discs between each of the vertebra that

act like pads or shock absorbers. Each disc is made up of a

tire-like outer band called the annulus fibrosus and a gel-

like inner substance called the nucleus pulposus. Together,

the vertebrae and the discs provide a protective tunnel

(the spinal canal) to house the spinal cord and spinal

nerves. These nerves run down the center of the vertebrae

and exit to various parts of the body.

Your back also has muscles, ligaments, tendons, and blood

vessels. Muscles are strands of tissues that act as the

source of power for movement. Ligaments are the strong,

flexible bands of fibrous tissue that link the bones

together, and tendons connect muscles to bones and discs.

Blood vessels provide nourishment. These parts all work

together to help you move about.

A herniated disc most often occurs in the lumbar region

(low back). This is because the lumbar spine carries most

of the body’s weight. Sometimes the herniation can press on

a nerve, causing pain that spreads or radiates to other

parts of the body. The amount of pain associated with a

disc rupture often depends upon the amount of material that

breaks through the annulus fibrosus and whether it

compresses a nerve.

Pain from a herniated disc is often the result of daily

wear and tear on the spine. However, it may also be caused

by an injury. Pain is sometimes the result of pinched

nerves that are crowded by the leaking nucleus pulposus. A

herniated disc can occur slowly over time, taking weeks or

months to reach the point when you feel you must seek

medical attention. Or, pain may occur suddenly from

incorrect lifting or twisting that aggravates a weak disc.

If this is the case, call your doctor right away.

There are four stages to the formation of a herniated disc:

1. Disc Degeneration: During the first stage, the nucleus

pulposus weakens due to chemical changes in the disc

associated with age. At this state no bulging

(herniation) occurs.

2. Prolapse: During prolapse, the form or position of the

disc changes. A slight bulge or protrusion begins to

form, which might begin to crowd the spinal cord.

3. Extrusion: During extrusion, the gel-like nucleus

pulposus breaks through the tire-like wall of the

annulus fibrosus but still remains within the disc.

4. Sequestration: During the last stage, the nucleus

pulposus breaks through the anulus fibrosus and even

moves outside the disc in the spinal canal.

Exams & Tests

As you likely know, a herniated disc can cause pain and

interrupt your daily activies. When you visit a spine

specialist, he or she will ask you questions and perform

some exams. This is to try to locate the source of the pain

from the herniation and develop a treatment plan for you—a

way to manage your disc herniation pain and other cervical

and back symptoms and to help you recover overall.

Your doctor will ask about your current symptoms and

remedies you have already tried for your herniated disc.

Typical Herniated Disc Diagnostic Questions

• When did the pain start? Where is the pain(cervical,

thoracic or mid-back, or lumbar or low back)?

• What activities did you recently do?

• What have you done for your herniated disc pain?

• Does the disc herniation pain radiate or travel to

other parts of your body?

• Does anything reduce the disc pain or make it worse?

Your doctor will conduct a physical exam, observing your

posture, range of motion, and physical condition both

standing and lying down. Movement that causes pain will be

noted. A Laségue test, also known as the Straight-Leg

Raising test, may be done. You will be asked to lie down

and extend your knee with your hip bent. If it produces

pain or makes your pain worse, this may indicate disc

herniation.

With disc herniation, you may feel stiff and may have lost

your normal spinal curvature due to muscle spasm. Your

doctor will feel your spine, note its curvature and

alignment, and feel for tightness.

Your spine specialist will also conduct a neurological

exam, which tests your reflexes, muscle strength, other

nerve changes, and pain spread. Radicular pain

(inflammation of a spinal nerve) may increase when pressure

is applied directly to the affected area.

Your spine specialist may order tests to help diagnose your

condition; you may need to visit an imaging center for

these tests. An x-ray can show a narrowed disc space,

fracture, bone spur, or arthritis, which may rule out disc

herniation. A computerized axial tomography scan (a CT or

CAT scan) or a magnetic resonance imaging test (an MRI)

both can show soft tissue of a bulging disc. These tests

will show the stage and location of the disc herniation so

you can receive proper treatment. If your spine specialist

suspects you have nerve damage, he or she may order a test

called an electromyography (an EMG) to measure how quickly

your nerves respond.

To obtain the most accurate diagnosis, your spine

specialist may order additional tests, such as:

• Discogram or discography: A sterile procedure in which

dye is injected into one of your vertebral disc and

viewed under special conditions (fluoroscopy). The

goal is to pinpoint which disc(s) may be causing your

pain.

• Bone scan: This technique creates computer or film

images of bones. A very small amount of radioactive

material is injected into a blood vessel then

throughout the blood stream. It collects in your bones

and can be detected by a scanner. This procedure helps

doctors detect spinal problems such as arthritis, a

fracture, tumor, or infection.

• Lab tests: Typically blood is drawn (venipuncture) and

tested to determine if the blood cells are normal or

abnormal. Chemical changes in the blood may indicate a

metabolic disorder which could be contributing to your

back pain.
Treatment Options

1. Non-surgical treatment for degenerative disc disease

The ongoing pain, as well as the frequency and intensity of

the flares, can be mitigated through a number of non-

surgical options. Modifying activities to preclude lifting

of heavy objects and playing sports that require rotating

the back (e.g. golf, basketball or football) can be a good

first step. Other options include:

o Applying heat to stiff muscles or joints to

increase flexibility and range of motion, or

using ice packs to cool down sore muscles or numb

the area where painful flares are concentrated.

o Medications such as non-steroidal anti-

inflammatories (e.g., ibuprofen, naproxen, COX-2

inhibitors) and pain relievers like acetaminophen

(such as Tylenol) help many patients feel good

enough to engage in regular activities. Stronger

prescription medications such as oral steroids,

muscle relaxants or narcotic pain medications may

also be used to manage intense pain episodes on a

short-term basis, and some patients may benefit

from an epidural steroid injection. Not all

medications are right for all patients, and

 patients will need to discuss side effects and

possible factors that would preclude taking them

with their physician.

o An exercise program is essential to relieving the

pain of lumbar degenerative disc disease and

should have several components, including:

 Hamstring stretching, since tightness in

these muscles can increase the stress on the

back and the pain caused by a degenerative

disc

 A strengthening exercise program, such as

Dynamic Lumbar Stabilization exercises,

where patients are taught to find their

‘natural spine’, the position in which they

feel most comfortable, and to maintain that

position

 Low-impact aerobic conditioning (such as

walking, swimming, biking) to ensure

adequate flow of nutrients and blood to

spine structures, and relieve pressure on

the discs

o Chiropractic manipulation can relieve low back

pain by taking pressure off sensitive nerves or

tissue, increasing range of motion, restoring

 blood flow, reducing muscle tension, and, like

more active exercise, promoting the release of

endorphins within the body to act as natural

painkillers

o Epidural steroid injections can provide low back

pain relief by delivering medication directly to

the painful area to decrease inflammation

2. Surgery

Patients unable to function because of the pain, or who

are frustrated with their activity limitations, may

consider lumbar spinal fusion surgery. Fusion surgery

works because it stops the motion at a painful motion

segment. A one-level fusion at the L5-S1 segment does not

significantly change the mechanics in the back and is the

most common form of fusion, as this is the most likely

level to break down for degenerative disc disease. Fusion

of the L4-L5 level does remove some of the normal motion

of the spine as this is a major motion segment (as

opposed to L5-S1 which has really limited motion) Multi-

level fusions are more problematic. A two-level fusion

may be considered for patients with severe, disabling

pain, but three-level fusions are not recommended because

back movement is too diminished and altering the muscle

composition can in and of itself cause pain (this has

been termed fusion disease).

HISTORY OF PATIENT

Mrs. T.P. is a forty year old woman. She is a full-time

mother to two children and does most of the household

chores. Her present condition started when she fell from

their water tank, approximately 5 feet in height, with her

buttocks hitting the ground in September 2005. The incident

left her with nothing but a slight abrasion on her right

leg and a minimal amount of pain on her buttock area. She

considered the fall as a trivial matter and did not seek

any medical attention but instead, continued with her usual

tasks and even got through the holidays of that year. It

was only in January 2006 that Mrs. T.P. started to complain

of left low back pain which radiates towards her left leg

and foot. She applied hot packs on the affected areas, and

took some pain medications such as Biogesic™ and Advil™

for one week; however all these measures were to no avail

for the pain seemed to increase its severity each day even

to the extent that she could barely move her trunk and

lower extremities. The following week, Mrs. T.P. decided to

refer her case to a physiatrist.

PHYSICAL EXAMINATION

Initial observations noted by the physiatrist were the

following:

a. Splinting (or the body is shifted towards the

unaffected area) to the right side

b. Grade 3 tenderness (intolerable pain on area when

palpated or pressed) with moderate muscle spasm (or

sudden/involuntary contractions) of whole left

paralumbar (near or beside the lower back area)

c. Moderate muscle spasm of right paralumbar

d. Pain on lumbosacral (lower back area to upper

buttocks) upon trunkal flexion-extension (forward and

backward bending of torso) and lateral flexion (side

bending of torso)

e. Grade 3 (intolerable pain) deep vertebral tenderness

on L5 (lumbar 5)

f. Difficulty in bed mobility especially in turning

g. No inguinal tenderness

h. Deep tenderness on left iliopsoas (a muscle on the

lower abdominals; prime mover of the thigh)

i. Positive left sciatic nerve exit tenderness

j. Irritable left glutei (buttocks muscle; prime mover of

the thighs) and left piriformis (rotator of the thigh

and hip joint)

 k. Positive straight leg raising test on the left at 40

degrees

l. Neurological Findings:

1. Sensory

• 80-90% on left L5

• 100% on right and left L4 and S1, and right

L5

2. Motor

• 4/5 on right and left L4 and L5

• 0/5 on left and right S1

m. Negative for ankle clonus (involuntary beating of the

foot when flexed backward)

DIAGNOSTIC EXAMINATIONS

a. CT scan results revealed minimal L4-L5, L5-S1 disc

bulge

b. X-ray examination of the cervical (neck) vertebra

revealed spondylosis (fracture with no vertebral slip)

on the left C3-C4 and mild straightening of the

cervical spine

c. X-ray examination revealed increased lumbosacral angle

and left lumbar functional (can be corrected)

scoliosis (s-curvature of the spine)

 d. X-ray examination of the foot revealed minimal

calcaneal(heel of foot) osteophytosis (excess bone

growth)

DIAGNOSIS

Tests confirmed left L5-S1 radiculopathies secondary to

herniated nucleus pulposus at L4-L5, and L5-S1.

The high level of tenderness on the left paralumbar area,

pain or difficulty in moving the left thigh and lower

abdominals, decreased sensory and motor functions on the

left lower extremities, and a positive straight leg raising

test proved that there is indeed sciatic nerve root

irritation. The sciatic nerve innervates the whole length

of the lower extremities and therefore, any impairment to

its structure would definitely result to unbearable pain

from the lower back (where the nerve exits) down to the

foot which it innervates. The inflammation of the

particular nerve root as characterized by the radiating

pain felt by the patient is termed as “radiculopathy”.

Furthermore, the disc bulge located at L4-L5 and L5-S1 (as

revealed by the x-ray examination) pointed out the cause of

such irritation. The bulge is indicative of a stage 1 disc

herniation in which the fibrous covering of the vertebral

disc is about to be torn due to a potential leakage of the

disc’s gel-like center (nucleus pulposus). Although there

is only a minimal protuberance of the disc, this still puts

a lot of pressure on the proximal (nearby) nerves and

thereby compressing the nerve, which in turn results in a

shooting pain experienced by the patient.

TREATMENT

Mrs. T.P. was confined in a medical institution. Upon

admission, she was placed in a complete bed rest and

underwent an extensive physical therapy program twice a day

with static and later, dynamic lumbar traction, electrical

stimulation, ultrasound, and manual (“hands-on”) therapy.

The lumbar traction involved placing a wide belt or strap

to the patient’s lower back area, and the strap in turn is

coupled with 30-lb weights on both ends. The set-up,

together with ultrasound, electrical stimulation (as

provided by a Transcutaneous Nerve Stimulation machine),

and the therapy itself help alleviate the pain and muscle

spasms.

Medications prescribed were the following:

• Cataflam (50mg)- an anti-inflammatory drug; one tablet

administered every eight hours

 • Neurontin (600mg)- a pain reliever specifically due to

nerve irritation; one-third tablet administered before

going to bed

• Neurobion (1 ampule)- a pain reliever specifically due

to nerve irritation; administered intramuscularly

• Lagaflex- a muscle relaxant

After five hospital days, Mrs. T.P. was discharged with

significant improvements. Both her sensory and motor

functions on the left lower extremities were elevated, and

pain and tenderness felt on the area were notably

decreased. She was advised to continue her physical therapy

program daily on an out-patient or homecare basis, and

lumbar traction at home for an hour with 30-lb weights.

Several medications were also prescribed including Cataflam

(50 mg; one tablet daily), Mecovit (one tablet daily),

Lagaflex (one tablet daily after breakfast), and Topamax

(25 mg; one tablet daily). Furthermore, on the

recommendation of her physiatrist, Mrs. T.P. should only be

allowed to perform a limited set of activities for a

specific timeframe. Transitional activities or those

involving repetitive strokes or movements such as sweeping

the floor were restricted. Her positions (sitting,

standing) should also be maintained only for a maximum

duration of an hour. Proper posture and body mechanics (how

to sit, stand, and get up from a lower position), as well

as weight loss, were also stressed as major areas of

concern.
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