Healing a Herniated Disk: Causes, Treatment & Prevention with Dr. Dominic Pelle

Podcast Transcript

Cassandra H:     Hi, thanks for joining us today. I'm your host, Cassandra Holloway, and you're listening to Health Essentials Podcast by Cleveland Clinic. We're broadcasting at Cleveland Clinic's main campus in Cleveland, Ohio, and we're here today with Dr. Dominic Pelle. Thanks for being here.

Dominic Pelle:   Thanks for having me. Great to be here.

Cassandra H:     Dr. Pelle is a spine surgeon at Cleveland Clinic Center for Spine Health, and today we're going to be talking about herniated disks. Before we begin, we want to remind our listeners that this is for informational purposes only and does not replace your own doctor's advice. So 80% of people in the United States will experience back pain at some point in their life. So we know it's common, we know it's frequent, and most of us are going to have to deal with it at some point or another. So let's start very high level. Why do we have the disks in our back in the first place? What purpose do they serve?

Dominic Pelle:   That's a great question. So the disks are usually thought of as a shock absorber in our spine. So the disk is formed by an outer membrane, okay, or fibrosis, called the annulus fibrosis. It's got the same biomechanical makeup as a ligament. So people have heard of like ACL tears in athletes. An ACL is a ligament that attaches one section of bone to the other. It's made of mostly collagen. The outside of the disk is formed of a ligament too. It's just called the annulus fibrosis. The inside of the disk is called the nucleus pulposus. What that is the shock absorber section of the disk. Now the disk does have some biomechanical properties, where saying shock absorber is a little bit of a misnomer. It prevents certain types of movements and helps us, it helps our spine function with increasing movement in certain areas. So there's a lot of study on exactly what the disk does, but those are its constituents of what it's made up of.

The inside of the disk, the material is gelatinous. And so what that does is it attracts water. There's chemicals inside of it called proteoglycans. And what they do is they, they want water to come into the disk. And so when we're young and our spines are still healthy, our disks are filled with water essentially. And they're tall and they have a nice bright signal on MRI because they have fluid inside of them. As we age, that disk starts to degenerate. Sometimes before we age, that disk herniates which is the topic of our podcast here.

Cassandra H:     So let's talk about that then. What is actually happening when a disk is herniated?

Dominic Pelle:   So when you think of just a traditional herniated disk, the way I think about that is almost like, the disk is a jelly donut. Okay. And so the outside of the disk is the dough of the donut. That's the annulus fibrosis. The inside of the disk is the jelly. Okay. And imagine if you push down on a jelly donut and had a hole in the dough, right? That jelly is going to squirt out of it. And kind of basic thinking. A herniated disk work, functions about the same way. Sometimes you get a little tear in the ligament on the outside, but one way or another the inside of the disk, that nucleus pulposus gets out to the outside of the disk. It herniates out and that's where the word herniation comes from.

Cassandra H:     Can you get a herniated disk anywhere on the spine?

Dominic Pelle:   Yes.

Cassandra H:     Top and bottom? All the way through?

Dominic Pelle:   Top and bottom. So I treat all aspects of the spine from the base of the skull all the way down to the tailbone and herniated disks occur in every segment except the lower sacrum. And so from L5 S1 all the way up to a C2 C3 you can get herniated disks. They are most common in the lower lumbar spine, so L4 L5 L5 S1 is the area where we most commonly get herniated disks, but they occur frequently in the neck as well. A little bit less so in the thoracic spine because there's less motion in the thoracic spine. At least it's thought that's because there's less motion. So the rib cage is support. Our rib cage supports our spine and it functions as a non-mobile segment of our spine when compared to our cervical spine where we could look around and move our head up and down. And our lumbar spine where we can bend down and touch our toes and twist left, to twist right.

Cassandra H:     Got you. So in today's world with people looking for their health conditions online and self-diagnosing themselves, there's a lot of names for this. So I'm going to list four of them.

Dominic Pelle:   Okay.

Cassandra H:     Herniated disk, ruptured disk, bulging disk, and slipped disk. Are these all the same things?

Dominic Pelle:   No, and yes, in a sense. So oftentimes what I find is people grab their report from their MRI and they say, listen, I have 27 bulging disk in my spine. That's a problem. First and foremost, a herniated disk is a problem when it presses on a nerve or when it presses upon the spinal cord, that's when a herniated disk is a problem. So even if you have a report in your hand that says you have herniated disks and you're not having any pain and it's not pressing on any nerves, chances are it's not a problem. Obviously not giving specific healthcare advice here, but in general, that's what I tell my patients. Now in terms of the different things that you'd diskuss there, so a herniated disk is when that nucleus pulposus escapes out. The jelly gets out of the donut or the air out of the tire, however you want to think about it.

A bulging disk is more typical of an arthritic process, whereas the disk degenerates, it begins to kind of just bulge out a little bit. Sometimes herniated disk, you can call bulging disk if it doesn't break all the way out of the annulus or the membrane in the back of the spine. There's a ligament that runs down the back of the spine called the posterior longitudinal ligament. Sometimes the herniated disk will stay behind that ligament or it will even stay kind of within the confines of the annulus, but the whole thing will bulge out and hit a nerve. That can be a bulging disk. You said slip disk. I think that's an old term for when a disk would herniate. There's a condition in your spine where the bones will slip upon each other. That's called spondylolisthesis and the bone slip forward. So L4 may slip forward on L5, or L5 may slip forward on S1. So on and so forth. And sometimes patients refer to that as a slipped disk when it's really the bones that are moving.

Cassandra H:     Right. So let's talk about symptoms then. If someone has a herniated disk, what are they experiencing?

Dominic Pelle:   So they experience the symptoms of that when it presses upon a nerve. Okay. Or it presses upon the spinal cord. Let's start when it presses upon a nerve. So they get a syndrome called radiculopathy, okay. And what that is, is it how we describe nerve pressure, how you experience that as a patient. Usually pain, numbness, and or weakness. Okay. It could be one of those three things. It can be all three, it can be two or three. So on and so forth. So let's say you're talking your lumbar spine. You have a herniated disk and now you start to have pain that comes down your leg. Oftentimes it may start in the back, traverse down the buttock region, over the hip into the thigh and down the leg, sometimes all the way into the foot. Depending on the level of that herniated disk, sometimes it's just across the front of the thigh, sometimes all the way into the bottom of the foot. It just depends on which nerves getting pinched.

In the neck, that would cause arm pain. So if you get a herniated disk in your neck that you may have pain that shoots into your shoulder, down your arm, sometimes even into your hand, that's a little bit different than if you have pressure on your spinal cord. Pressure on your spinal cord is a bit more serious when you start to have symptoms from it. And that's usually a constellation of findings called myelopathy. So people may, if it is occurring in the neck, people may describe numb hands. Okay. All five fingers are numb sometimes, trouble with dexterity of their hands or oftentimes they'll say, hey, I used to hold cups of coffee all the time. Now I drop them. Used to be able to open a jar. I can't open a jar. And some ladies say I have trouble putting my earrings and men have trouble buttoning their shirt. So on and so forth. That's dexterity issues in the hand or five motor issues.

And then they feel a little bit wobbly when they walk. So they feel as though I don't know exactly where my feet are in space and I have to kind of widen my feet out to make sure that I'm going to not trip. Or I sometimes like to have my arm on a wall or hand on a wall. These are all symptoms of myelopathy. Now herniated disk can cause pressure on the spinal cord and developed into myelopathy.

Cassandra H:     Interesting. So let's talk about the causes of a herniated disk. What causes this?

Dominic Pelle:   So I mean all disks tend to degenerate over time in most individuals. So if we look at MRIs of even asymptomatic patients over a certain age, we see evidence of disk degeneration in majority of those people. A herniated disk in a young healthy person. Sometimes I just tell people it's bad luck. It's probably a combination of genetics and there's something going on with that disk that has allowed it to herniate. Okay. Not so much a genetic issue, just more prone to a disk herniation. Sometimes it's due to activity, right. And so somebody says, I was weight lifting or I was playing this sport and all of a sudden, bow. Pain shot my leg or down my arm. It could be due to that.

It can be due to an injury. Okay. Some people may get in a motor vehicle accident and have a big herniated disk thereafter. Other times it's something as simple as I was bending down to tie my shoe and then I noticed it. Most often people will know when it happens because the pain usually happens right away. Okay. Especially if you're talking about a pinched nerve, they have a disk herniation and then the pain comes on and they say, oh I was doing this. I remember exactly when it happened.

Cassandra H:     Are there any things that put you at risk? Are there are certain jobs or duties that kind of increase your risk of getting this?

Dominic Pelle:   You know, yes, I think the answer is yes. I think it's kind of hard to talk about that though in a sense of everybody tends to do things in their job that may prompt a herniated disk. Okay. I wouldn't necessarily say some jobs people should avoid or are exceptionally high risk. I know we see sometimes increased levels of certain cervical spine conditions in truck drivers. I mean I'm a surgeon, I look down and operate most of the day. I imagine my next is going to have to be looked at at some point. Certain high impact exercises and high impact activity can prompt disk herniations. But I've also seen it in people that have a relatively straightforward non-laborious job that end up with a disk herniation. So I wouldn't necessarily say that I would avoid one thing or the other in a way of preventing it.

Cassandra H:     Got you. So earlier you mentioned spondylolisthesis. What is that?

Dominic Pelle:   So spondylolisthesis is a term for when one vertebral body is translated upon another. Most often that is when one is translated in front of another. Okay. So at L4 L5 or L5 S1, the bones can move forward. Okay. That becomes sometimes a problem when you lay down and let's say it reduces back and then you stand up and they translate forward. That can often lead to mechanical type back pain. Whereas I'm sitting here, I'm pretty comfortable. I go to move, to stand, I start to get pain in my back. Or when I'm up and loading my spine with gravity, I get pain. As the bones move forward on each other sometimes that'll press the nerves and cause a radiculopathy. Okay. And cause pain to shoot down the leg or cause stenosis of all the nerves as they come down and cause pain in the buttocks, down the back of the legs when you walk.

The spondylolisthesis can be due to a variety of different things. Sometimes it's just due to arthritis, the joints sort of change as they become more arthritic and allow the bones to slip. Sometimes it's due to what we call an isthmic spondylolisthesis where people actually have a defect in the back of their spine that allow the bones to slip. And other reasons as well.

Cassandra H:     Interesting. So can the pain be intermittent? Can it come and go with a herniated disk or is it pretty all the time?

Dominic Pelle:   It can. Often people have pain that is sort of always there that comes on with specific activities worse, right. And so one way we test that is when we raise someone's leg in the office, it's called a straight leg raise. And so we raise their leg and it causes the pain to shoot down their leg, the nerve type pain. And usually they find in certain aspects, like when they walk upstairs or they have to flex their body down, they tend to stretch that nerve and cause it to be painful. It usually doesn't wax and wane too much until it starts to get better. Sometimes it just goes away on its own. It'll wax and wane for a little while and then just resolve.

Cassandra H:     Interesting. So if someone listening to this podcast is thinking they're suffering from a herniated disk, how long do you recommend that they try to wait it out? They try to baby it a little bit or should they see someone right away if they think this is what they have?

Dominic Pelle:   I think if you're worried about anything that's going on, I think good advice is always to see a healthcare provider. That's sort of why we feel like we exist in the world, right. There's never a wrong time to do that. I would never worry about seeing someone unnecessarily. Yeah, if it gets better, let's say you have a herniated disk in your neck, it's causing pain to shoot down your arm. And then by the time that you see me, let's say it's gone away. Well, great. Well at least I know if this ever pops up, we know each other. You come back and see me again. So I would say to answer your question specifically, if you have unrelenting pain down your arm or leg, seek some medical input. If you have the symptoms of myelopathy that I described. Numb hands, wobbly gait, dexterity issues, then I would urge you to seek medical treatment because that's a bit more serious of an issue than just a pinched nerve in the neck or a pinched nerve in the back.

Cassandra H:     Makes sense. So let's talk about diagnosis then. If someone comes in complaining of a herniated disk, what typically happens?

Dominic Pelle:   So the first thing we do is we take a history and we do a physical examination. Okay. So I need to know kind of what's going on. And most people, like I said, will know, oh man, I was doing this. And bam, my leg just started hurting. That's a good history for a herniated disk. Pain, numbness, weakness can all shoot down the leg. Okay. Also part of the history. And then physical, we test motor strength. We want to test every single lumbar nerve root. If we're looking at a lumbar issue to make sure everything is strong and symmetric. Reflexes is something else that we test. Sometimes if you have for instance an S1 radiculopathy or your first sacral nerve is getting pinched from a herniated disk, you'll lose your ankle jerk reflex. Not a big deal from a how does this affect my life standpoint. But it helps us from a diagnosis standpoint to know that's what's going on.

I described a straight leg raise earlier where we lay a patient down and we raise the effected leg up and usually that can reproduce the radiculopathy or the pain that shoots down the leg. Sometimes we do a contralateral straight leg where we raised the other leg and it still produces pain down the leg that always hurts. And that's even more specific for a pinched nerve in the back. We usually pair that with imaging. So upright x-rays are a mainstay of the imaging that I use. I want to see what your spine looks like when gravity is acting upon it. Right? And so I want to know, do the bones slip? Is there a spondylolisthesis? Do you have an abnormal curve to your spine? These are all things that I know better with an upright x-ray than I would with an MRI.

But I would say the mainstay of diagnosis, at least to nail the diagnosis down, would be an MRI examination. That shows a disk herniation quite nicely, it shows the nerves as they exit. MRIs have great imaging modality to see the nervous tissue, to see disks and disk degeneration and disk herniations. And so we pair that with a physical examination and with the history to make a diagnosis.

Cassandra H:     Great. So say someone got the x-ray and you diagnose them with a herniated disk, what does treatment look like? Start off maybe the very basics, with rest or ice and then kind of go on from there.

Dominic Pelle:   So you're right. So we start off with the basics, right? So let's say you herniated your disk and I saw you the next day, I would say give it some time. Okay. We might start some physical therapy. We might give some medications, but ultimately the data would suggest that you'll get better without a surgery, right? So 80 to 90% of people with a herniated disk, the pain will eventually go away. And so that's what we tell people. We want to avoid surgery if we can avoid surgery. Not that there's anything wrong with doing surgery, but it's always better to avoid invasive treatment if we can. So usually it's time, is the number one thing we talk about. Physical therapy, core strengthening, stretching the lumbar spine, all good things from a biomechanical standpoint to help your spine feel better.

And then certain medications we give, sometimes membrane relaxing medication to relax the nerve a little bit. Sometimes anti-inflammatories, a common mainstay of treatment may be to start somebody out on a dose pack of steroids. Where they start at a higher dose and then over duration of a few days, they taper down to a lower dose to try to just get the inflammation down. What happens, that disk herniates and then you have this scenario where the nerve's getting pinched, it's angry. The disk is not used to being out of where it usually lives and it's causing all this inflammation around the nerve. That inflammation causes the nerve to get angry and you experience the pain. So anti-inflammatories are great to just relax that whole process, right? Calm the crowd down, everything's going to be fine. And usually people tend to feel a little bit better.

Cassandra H:     What about surgery then? Let's talk a little bit about what that typically looks like for a herniated disk.

Dominic Pelle:   So in the lumbar spine, a herniated disk without a spondylolisthesis or anything else that we talked about, and the patient meets the criteria for surgery. So let's start with there. What's the criteria for surgery? Usually have to have pain that's at least there for six weeks. So I always tell people there are three criteria for elective surgery, and although people with terrible leg pain may not feel like it's elective, it still is.

So the first criteria is the physical examination, the history that I get and the imaging all has to fit together. All the puzzle pieces has the coalesce into a nice picture.

The second thing is it has to have been there for long enough. If you've seen me two days ago, and that's exactly when you had your herniated disk and you've only had a couple of days of pain, well then it'll probably get better without me. So you don't meet that criteria.

And the third one is I always tell is what the patient tells me and is probably the most important one is, how bad did this bother you? If you're like, listen, it was really bad, it still hurts. It's starting to get better. I can get by. I notice it's improving. I say, let's wait it out for a little while. But if you get to the point where the pain is so bad, you have a poor quality of life because you can't do the things that you want to do and it's due to a herniated disk pressing on the nerve and you're interested in surgery, the data would suggest that surgery would be an effective treatment option for you.

So to answer your first question a long time ago, what would I do surgically-wise? Typically that's called a microdiskectomy. It's a minimally invasive type surgery where we make a small incision in your back, approach to the spine and use a microscope to take the disk out. So we drill over the bone that lives over where the nerve sits, okay. And we expose the nerve. Then we move that nerve out of the way and we take the herniated part of the disk out. We don't take the whole disk out and subject you to effusion. What we do is we just take that herniated part out that's pressing on the nerve. The goal of most spine surgeries is to decompress the nerve, whether that's doing a laminectomy for stenosis, where we take all the bone away in the back. Or a diskectomy like we're talking about here, where we just kind of sort of pluck out the disk herniation. At the end of the day, I should be able to look at that nerve and notice that it's decompressed. And usually that's predictable in treating the leg pain effectively.

Cassandra H:     Interesting. So the last thing I want to touch base on here is prevention. If a listener is listening to this podcast and they're trying to be mindful about preventing a herniated disk, maybe they're just getting older, maybe it's hereditary, what advice would you give them in terms of preventative measures?

Dominic Pelle:   So if you're listening to this podcast, I'm going to go out on a limb and say most people are kind of interested because maybe they have some leg pain. So if you end up with a herniated disk, the first thing I'd tell you is it's not necessarily that you did anything wrong. Give yourself a break. A lot of people come to my office and they're like, I don't know why I was doing this or why I was doing that, or so on and so forth. And oftentimes I tell them, listen, I've had people that herniated disk when they're just tying their shoe and that's just normal human activity to do. So the first thing I'd say is, give yourself a break. We'll figure this out, we'll take care of it.

The second thing I would say, if you really don't have any leg pain, you just want to prevent it and have a healthy back. Eating a healthy diet for weight control, doing core strengthening, so you strengthen your abdominal musculature, it unloads the pressure on the spine. Your thoracic spine, you don't have a lot of disk herniations there because you have that rib cage, right, that's really supporting it. The only thing that supports your lumbar spine is your abdominal musculature. And then keeping the weight down is very important for your spine health. The reason being is because your spine functions like a crane, or at least it's a good way to think about it. And so that crane, when it lifts a heavy load, it needs a counterweight in the back, right? And so the counterweight is your spine, the facet joints in the back, your spine muscles that are all holding the weight up the way it is, your weight in front of you, the weight that you hold in your chest and belly.

So the less you have weight in front of you, the less you need to stress that counterweight or use that counterweight. And so a lot of times with just some weight loss patients will notice that some of the pain tends to get better and go away. That's a very easy thing to say. Somebody that has really bad leg pain due to herniated disk, it's easy for me to sit in a chair and say lose weight. It's a harder thing to do it, but nonetheless, it's something we have to have a conversation about and it leads to long-term spine health.

Cassandra H:     That's great advice. Thank you. So that's all the time we have today. Thank you Dr. Pelle for being here.

Dominic Pelle:   Thanks for having me.

Cassandra H:     And thanks for listening. If you're looking to learn more about herniated disks and treatment options available, visit clevelandclinic.org/spine. If you're looking to listen to more Health Essentials Podcast featuring Cleveland Clinic experts, visit clevelandclinic.org/hepodcasts or subscribe on iTunes. And as always, don't forget to follow us on Facebook, Twitter, and Instagram at ClevelandClinic. All one word. Thanks for listening. We hope you enjoyed the podcast.