In this in-depth discussion we discuss herniated discs, particularly those that cause lumbosciatica, or pain localized in the lower back and radiating to one or both lower limbs.
We have to imagine the intervertebral disc as a kind of cushion between vertebrae, consisting internally of gelatinous material and externally of fibrous material. The innermost part is the most vulnerable and can go through fissuring up to rupture with herniation of the disc.
Causes:
There are many factors that lead to disc suffering and among them are cigarette smoking, overweight, obesity, age, vascular or infectious causes, multiple traumas especially if one is subjected to work that exposes the patient to constant vibration or excessive loads. Still other causes are pathologies of the intervertebral plate such as so-called Schmorl's Knots.
Herniated discs can cause irritation and inflammation within neighboring nerve roots, or external compression on them with painful symptoms in that root's territory.
Diagnosis:
The clinical examination is one that allows us to formulate a diagnostic hypothesis through the history, that is, the patient's medical history, inspection, and performance of certain semeiotic maneuvers.
In support of the algological examination, it is essential to perform diagnostic investigations, particularly an MRI.
Herniated disc is a benign condition, which within a few weeks in most cases resolves.
Very often, however, the pain is so intense that it limits the patient in normal daily activities: in these cases, pain-relieving/anti-inflammatory therapy should be instituted as soon as possible.
Usually the first therapy that is administered is oral or intramuscular therapy. Such therapy is not always effective, and the pain not only does not resolve, but the intranervous or perinervous inflammation worsens by bringing out other symptoms such as tingling and weakness in the limbs, or cramps that assume a nerve motor deficit.
The onset of these symptoms should be a wake-up call as the perceived pain may begin to transform into inflammatory pain mixed with neuropathic. Procrastination could worsen the situation and the pain become only neuropathic, with very little effect of anti-inflammatory drug therapy.
Motor dysfunction, that is, the onset of lack of strength in the limbs, is an important clinical sign suggesting the urgency of a neurosurgical examination.
Treatment:
Low back pain from herniated discs may simply resolve over the course of a few weeks with the administration of anti-inflammatory and muscle relaxant drugs, either orally or intramuscularly. After the first few weeks of therapy if the pain has only slightly subsided or even recurred, sometimes more intensely, to prevent it from becoming chronic, a more targeted treatment is used: echo- or rx-guided peridural infiltration.
The ultrasound-guided procedure makes it possible, through a probe, to see and locate in real time the space where to be able to inject, through a specific needle (tuoy needle), the cortisone-based drug and local anesthetic.
Ultrasound, unlike the guided rx technique, is safer because it emits no radiation and is absolutely harmless.
The recent onset hernia assumes that the inflammatory process is still ongoing, which is why anti-inflammatory drugs are indicated; on the other hand, hernias of older onset, where there are symptoms that assume nerve malfunction, may also need specific therapy for neuropathic pain.
The infiltrative cycle consists of three or four infiltrations: the first two closer together, the third even months apart. The peridural infiltrative procedure presupposes the discontinuation of anticoagulant and/or antiplatelet medications in a manner and time frame decided by the algologist based on the assessment made at the examination and with the consent of the cardiologist in major cases.
It is essential to clarify that the first peridural infiltration, as well as any other initial procedure, is both therapeutic but more importantly diagnostic. This is because the innervation of the various structures of the spine is very complex and, many of them, have the same innervation. This statement clinically results in pain over the same skin territory, which may, however, be the responsibility of more than one structure. So in somewhat more complex cases, during the first visit the algologist makes a presumptive diagnosis that may or may not be confirmed by infiltrative testing.
The relationship that is established between patient and algologist is dynamic and ongoing: in the most complex cases or in those where pain is chronic and prolonged over time, the diagnosis does not come immediately but is reached through a pathway that involves mutual trust between patient and specialist.
