Transcription:

Scott Webb: A herniated disc is a condition that can occur anywhere along the spine, but most often occurs in the lower back. And although a herniated disc can be painful, the majority of folks feel better within a few weeks or months of nonsurgical treatment. And I'm joined today by Dr. Andrew Koivuniemi. He's a neurosurgeon at Franciscan Health, and he's here to discuss the causes, symptoms and treatment options.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, it's great to have you on today. We're going to talk about back stuff, right? Herniated discs and the like. So as we get rolling here, a little baseline, make sure we're all on the same page. What is a herniated disc?

Dr. Andrew Koivuniemi: Herniated discs are one of the most common problems that we see as spine surgeons and they affect pretty much all ages and demographics. Long story short is the disc is a part of the spine that acts as a shock absorber. There's two parts of the disc. There's the outside, which is called the annulus, and it's kind of a hard, woven fiber-like material. And then, there's the inside, which is called the nucleus pulposus, and that's kind of a soft, almost crab-like material. And a herniated disc is when that soft stuff on the inside pushes through that hard outer shell, and it starts causing problems.

Host: All right. When we think about the causes, is it just wear and tear? Is it usually some sort of acute injury or kind of all the above?

Dr. Andrew Koivuniemi: Yeah, it's definitely all the above. I mean, we see people who have herniated discs from playing sports, from picking up heavy objects, from working heavy manual labor type jobs. But sometimes, we'll just see patients who wake up with it. So yeah, the causes are wide and varied. Definitely putting extra stress on your spine where you bend over and pick up something, you know, "improperly," that's a common cause. But we see it in people who have all types of backgrounds.

Host: Yeah. And I'm sure that some of the stuff we do to ourselves, some of it's our jobs and so on. So what are the differences between a pinched nerve, a spinal cord defect, and a herniated disc?

Dr. Andrew Koivuniemi: When a disc herniates in the back, it can go in all different directions. It's really a problem for you though, when that disc starts pinching one of the nerves that's inside your back or, even worse, when it starts pinching the spinal cord. We have discs all the way up and down our spine from our neck down to our low back. And if a disc herniates up in the neck, it can pinch the spinal cord and that can cause major issues. Normally, most of the time what we see is those discs herniating in the low back. Down there, there's actually no spinal cord. It's just nerve roots. Still if one of those nerve roots gets pinched or irritated by that herniated disc, it can cause a lot of issues, specifically pain and weakness.

Host: Yeah, I was going to ask you about that. What are the primary symptoms? I assumed, of course, pain, weakness, I don't know if there's any numbness associated in the lower extremities. Maybe you can take us through that.

Dr. Andrew Koivuniemi: The pain that you experience with a herniated disc is classically described as sort of an electric or burning pain that shoots from the back and down into your leg. The reason that pain shoots into your leg is because the nerve carries information from that part of the body. So when that nerve gets irritated, the brain experiences pain in that part of the body because the brain can't map to the nerve. The brain only knows where that information is supposed to be coming from. That's one thing that surprises people is, "Well, doc, why are we looking at my back? It's my leg that's killing me." And so, that's the common symptom.

The other part, yeah, weakness, it just depends on which of the nerves is getting pinched. There are nerves that go down the back of your leg, the S1 nerve that's responsible for your calf muscle. So, you might have a hard time pushing off. There's the L5 nerve that helps raise up your foot. Sometimes, the classic thing that we see is what's called a foot drop where the foot has a hard time lifting its toe up as you're walking and it can catch and drag. Other nerves as they get pinched, they can cause weakness in your knees or in your hips. But those are the two most common, the weakness in pushing off and the weakness in picking up your toes.

Host: All right. So then, how do you diagnose? Is it patient history, a physical exam? Is there any imaging involved?

Dr. Andrew Koivuniemi: It's really important always when you're evaluating a patient to get a good history and physical. And like I said, usually people describe it as sort of an acute onset, shooting type pain that comes down into the leg. Lots of times, they'll report some sort of weakness, that's pretty consistent with a pinched nerve. On exam, we will probably see something the same. Most of the time, there is no weakness and it's just pain. But there's an exam maneuver called a straight leg test where the patient lies flat, you can pick up their leg, and usually what that does is it stretches the nerve and that makes the irritation worse, what we call a provocative maneuver. And that's kind of what we can see in the clinic, but that's not enough to make the diagnosis. We pretty much always want to get some sort of imaging. The best, the gold standard is what's called an MRI where we can actually see the nerves and we can see the disc and we'd know exactly where it is and how it's pinching those nerves. Some people can't get MRIs, they get a procedure called a CT myelogram, and that's the other way to find these types of lesions.

Host: Gotcha. So, is there ever a time when this becomes a medical emergency or is it just really sort of annoying, maybe severe pain, some weakness? Or is there ever a time where a herniated disc can lead someone to really need to go to urgent care or even the ED?

Dr. Andrew Koivuniemi: The one thing that we like to always sort of hammer home on all of our medical students who rotate with the neurosurgery department is occasionally this is uncommon, but occasionally that disc can be such a bad herniation that it pinches pretty much all the nerves inside your back at once and puts severe pressure on it. That causes what's called cauda equina syndrome.

And cauda equina syndrome, It's not subtle. You have severe pain. You often have significant weakness associated with this. You have numbness around your groin and around your perineum area. And the thing that people most often notice though, is it affects your bowel and your bladder. What happens is severe pain, weakness, but most importantly, you lose the ability to control your bowel and your bladder, typically what we call an overflow incontinence, where you have a hard time going to the bathroom, and then there's usually a loss of control of the sphincter of the butt, and that leads to fecal incontinence. And when that happens, you got to come to the emergency department to be evaluated. Time is really of the essence in treating that problem. The sooner we get you to surgery, the more likely we are to help you get better.

Host: Yeah, that all sounds entirely unpleasant, definitely something you'd want to have treated. And when we think about the treatment options, doctor, do herniated discs typically need surgery? Will they heal on their own? How does that work?

Dr. Andrew Koivuniemi: So, putting aside the question of cauda equina, which is a surgical emergency, the vast majority of herniated discs are the type of problemS that goes away on their own. In fact, most of the time, we actually recommend that even if you think you have a herniated disc, you really shouldn't have anything "done for it" at least for four weeks. So usually, we'll try some Tylenol. We'll try some Ibuprofen. We'll have you do some light activities, stay mobile, maybe work with physical therapy in about a month. If you're still having the same or worse problems, that's when we get the MRI to go looking for it. Lots of people, before we even get to the point of the MRI, they notice that they're already starting to feel better and they don't need to have anything done. So, we usually like to wait at least four to six weeks before we even start considering doing something like surgery, because a lot of the time it is something that will get better on its own.

Host: Yeah. And of course, as a patient, if we can avoid surgery and just do some surveillance and some OTCs and things get better, we love that, of course. Yeah, it's been really educational today. Doctor, just want to ask about sort of shared decision-making. When it comes to treating something like a herniated disc and folks might be considering surgery, maybe you can just sort of take us through when you work with patients or couples or families, however that works. When you're having these conversations, how do you help them to come to the best decision, even if surgery is, in your mind, the best decision?

Dr. Andrew Koivuniemi: My philosophy for all surgical decision-making is wrapped around this idea called shared decision. And the whole premise is there are basically three ways to make a medical decision. The classic, the old school way is what's called paternalism. That's where the doctor knows what's best and he tells you what to do.

The second way, which is called full medical autonomy, is "You're the patient, it's your body. You tell me what you want done. I'll just go ahead and do it." You know, that sounds great. But what I think is best, especially for these sort of more complicated issues that involve surgery, that involve issues like pain, is an approach called shared decision that says there are actually two experts in the room for every medical problem like this. There's surgeon who's the expert about how to do the surgery and what to expect and who's going to get better and who's not and what your chances are. But there's also you and there's a significant component that I think is gained. So, surgical decision-making is critical that we incorporate your values and your preferences into our ultimate decision.

So if I know where you're coming from, if I know what your expectations are, I can describe the surgery and what I'm hoping to accomplish in a way that you can understand. And as long as we're both on the same page there in terms of our expectations, in terms of what you're going to go through and how long it's going to take you to get better and does that work for you, then I think that it's a good decision to go ahead with surgery. If one of us is not listening to the other though, and we just go full autonomy or full paternalism, there's a very real chance that we might miss an opportunity to do the right thing. And unfortunately, lots of times you don't find that out until after surgery when somebody you think you did a great surgery on, but comes back and they're really disappointed because you didn't take the time to listen to them. So, that's the whole point of shared decision-making, is to avoid that type of issue.

Host: Yeah, I love that. And just love how much medicine has changed. You know, as you say, the paternalism, the "Listen, I'm the expert. You're just going to do what I tell you to do," you know, it is great how much it's changed, and really patients and doctors working together, maybe even spouses, partners, families, but really everybody trying to be on the same page so that everybody knows what to expect and nobody comes back later and is disappointed or unhappy. So, just love it and love everything you brought today. So, thanks so much, doctor. You stay well.

Dr. Andrew Koivuniemi: My pleasure. Have a great day.

Host: And for more information, visit franciscanhealth.org and search herniated discs. And if you found this podcast helpful, please share it on your social channels. And be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.