disc prolapse

Synonyms in the broader sense

  • herniation
  • Nucleus pulposus prolaps (NPP)
  • prolapse
  • protrusio

Related terms

  • sciatica
  • disc bulge
  • disc protrusion
  • lumbago
  • Lumbalgia / Lumbago
  • lumboischialgia
  • back pain
  • disc

English

  • prolapsed intervertebral disc
  • herniated disc

Definition of herniated disc

A herniated disc is defined as the sudden or slowly increasing displacement, or the exit of tissue of the nucleus pulposus ( disc nucleus of the intervertebral disc ) of an intervertebral disc in the spinal canal (spinal canal) or posteriorly ( nerve root ). This can cause irritation of the nerve roots to pain, paralysis and / or emotional disorders. This can then lead to nerve root compression. Herniated discs in the lumbar region (lumbar spine) occur much more frequently than herniated discs in the area of ​​the cervical spine (cervical spine).

Illustration of a herniated disc

Symptoms of pressure against a nerve root

Pressure on nerve roots always causes intense pain that can radiate into the arms and / or legs.

With these severe pains also emotional disorders and their consequences can occur, one speaks of:

  • pins and needles
  • tingling sensation
  • deafness

Depending on the stage and extent of the herniated disc, symptoms can also result in the reduction of muscle power or even paralysis of individual muscle areas

  • Consequences of a herniated disc
  • Deafness due to a herniated disc
  • Herniated disc with nerve damage

Symptoms of pressure against the spinal cord

Depending on the location of the herniated disc, the symptoms vary. Disc prolapses in the area of ​​the thoracic spine can cause feelings of discomfort, convulsions ( spasms ) or even paralysis, whereas a lumbar disc prolapse in the area of ​​the lumbar spine can cause, for example, bladder paralysis. Also paralysis of the leg muscles are possible.

Symptoms of pressure against nerve fiber bundles, the horse tail (Cauda equina)

Lack of control of bladder and rectal function, sensory disturbances (eg deafness) in the anal and / or genital area of ​​the inner thighs, possibly associated with paralysis of the legs.

  • Symptoms of a herniated disc
    and even more special
  • Symptoms of lumbar disc herniation
  • Symptoms of a herniated disc of the cervical spine
  • Symptoms of a herniated disc of the thoracic spine

causes

The intervertebral disc consists of a fiber ring with a galertigen core. If it comes to a weakening or cracking of the fiber ring due to malfunction or overloading the spine, the jelly-like nucleus can escape from the intervertebral disc = herniated disc. This is usually due to wear, so that among other things, obesity and pregnancy are considered risk factors for a herniated disc.
Read more on this topic under: herniated disc during pregnancy

Other causes include:

  • in genetics
  • the profession
  • the statics of the spine (scoliosis, hollow back)
  • sports injuries
  • Muscle weakness (muscular dysbalance)
    and
  • many more

to see.

Prognosis of a herniated disc

One can not make an accurate prediction regarding the prognosis and the course of a disc disease / herniated disc.
Also, the duration of a herniated disc can not be named exactly because the course differ individually significantly.
The course and duration of the disc herniation also depends considerably on the localization (cervical, thoracic, thoracic, lumbar spine).
Older patients, however, are more likely to experience chronic pain, while younger patients with acute pain may experience prolonged pain-free intervals.
Modern treatment methods can also make a chronic illness bearable for patients. However, the degree of improvement depends to a great extent on personal initiative. Physiotherapy applications provide effective support in the acute phase.
In most cases, conservative measures achieve complete freedom from symptoms after a herniated disc.

  • Course of a herniated disc
  • Duration of a herniated disc

How long does a herniated disc last?

Both the duration and the chances of recovery of a herniated disc depend on the severity. The greater the severity of the spinal disc tissue, the longer it takes for this material to be broken down by the body, ie, the more severe the disc prolapse, the longer healing can continue.

As a rule, the symptoms should have passed within 6-8 weeks. If this is not the case, the chances of a successful conservative treatment are reduced and chronic pain and discomfort caused by the herniated disc can occur. Especially in elderly patients, it can often lead to chronic pain.

Prophylaxis / Prevention

There is no specific precaution that basically protects against a herniated disc. By changing and adjusting the lifestyle, for example in the form of strengthening the back muscles and abdominal muscles by training at an adequate power station, however, the risk can be reduced. From our experience and experience such training is the best and most important prophylaxis.

Of course, changing and adapting also requires a proper working attitude during work-life and household activities. For example, heavy objects should be lifted from the squat with your back straight (into the hollow back). When vacuuming, for example, can be achieved by the adjustment of the suction tube an upright relaxed working position.
For predominantly sedentary activities, it makes sense to get up and walk at shorter intervals. Especially for this professional group, there are also programs with relaxation and loosening exercises. An ergonomic adjustment of the seating by height-adjustable seats and seat backs can help to protect the spine. This is especially true for professional drivers.
You can not completely prevent a herniated disc, but specifically reduce the risk by targeted training of the trunk muscles.

Diagnosis of a herniated disc

The diagnosis of a herniated disc involves various physical and technical examination forms. In addition, diseases that have similar symptoms as the herniated disc must be excluded in a differential diagnosis.

Neurological examination

To diagnose or exclude a herniated disc, a thorough neurological examination is necessary. For example, it can exclude, for example, a circulatory disorder of the legs, the so-called intermittent claudication (= claudicatio intermittens ).
In addition, conclusions about the location, severity, as well as the involvement of the nerves can be drawn.

A neurological examination checks the reflexes, the mobility as well as the sensitivity, but can also include a measurement of the nerve conduction velocity. This is particularly important if the severity of the herniated disc is to be assessed and checked, which nerve roots are affected, or if there is a circulatory disorder.

Conventional X-ray diagnostics (X-ray)

Recordings in two levels:
By means of an X-ray, which should be carried out at least in two levels ( from the front, from the side ), one can assess the bony structure of the spine.

In addition, it is possible to x-ray the patient as part of a functional recording. These special recordings, which are performed, for example, in an inclined position, allow conclusions about the mobility of the spine.
The problem of diagnosing a herniated disc by X-ray imaging is due to the fact that only bony structures are imaged here, the rest of the soft tissue and the intervertebral disc itself are imaged only indirectly. Thus, one can judge the spine from its bony structure, but not - and this seems particularly important in a herniated disc - the situation of the intervertebral disc and their individual problem.

myelography

MRI image of the spine.

As part of a myelography in herniated disc to inject an X-ray contrast agent in the nerve sac ( dural sac ). Due to the contrast agent in the nerve sac, the underlying spinal cord, including the nerve root, becomes visible indirectly in the form of a contrast medium recess. Since, however, can now be used on very good cross-sectional imaging, one uses the myelography now only very rarely.

Especially by the use of MRI (Myelo-MRT) and CT l (Myelo-CT) the most exact statements can be made about the size and localization of a herniated disc. In a computed tomography, however, creates a radiation burden on the organ system.

MRI / CT

The MRI of the respective affected region represents the most important and most valuable diagnosis in a herniated disc. Depending on the affected region, an MRI of the cervical, thoracic or lumbar spine is performed.
If inflammatory processes or healing processes are to be assessed (so-called granulation tissue), an MRI with contrast agent is used.
By MRI, the size and location of the herniated disc can be recognized, and sometimes the age can be assessed.
When two MRI's are being run, one can also derive statements about the course and duration of the symptoms.
Read more under: MRI of a herniated disc

The CT plays only a minor role in the diagnosis of a herniated disc today, because it is inferior in detail to the MRI. Sometimes you can not detect small herniated discs.
Furthermore, there is a radiation exposure in a CT. An MRI, on the other hand, is radiation-free and works via magnetism.
Read more: How can I detect a herniated disc?

Treatment of a herniated disc

On the one hand, there is the minimally invasive and the open surgical procedure in operative therapy.

A herniated disc can be treated both conservatively and surgically. It is individually decided which of these treatments is more suitable for the patient.

As a rule - except for acute herniated discs with motor and / or sensory deficits - the therapy of a herniated disc initially consists of a conservative treatment, which can be composed of a variety of different treatment measures. Important in the first stage is the immobilization and relief of the spine. In order to achieve this in the best possible way, it depends on how high the spinal column is affected: In a herniated disc of the cervical spine, a neck cuff is recommended for stabilization.
In a herniated disc in the lumbar spine, the step bed support helps to relieve the nerve. In this case, the patient positions his lower legs in a supine position on a shelf, so that upper and lower leg are at 90 ° to each other. An immobilization of the spine in the sense of a longer bed rest, however, is not required.

The focus of further treatment is pain therapy. Only when the affected person has freedom from pain, subsequent measures such as physiotherapy can be successful. Painkillers, anti-inflammatory drugs, and muscle relaxants can be used to eliminate the pain. For severe pain, the use of locally anesthetic medications or cortisone is also helpful. Here especially in the form of a cortisone syringe. In addition, analgesic is the physical therapy, ie heat or cold treatments. Heat applications include, for example, thermal patches (eg ThermaCare ® ), fango and peat packs, hot baths or infrared radiation. Warmth stimulates circulation and loosens tense muscles on the back. Cold applications such as gel pads or cold compresses are more beneficial for nerve irritation. Ultrasound therapy also has a major impact on the treatment of herniated discs: Sound waves generate heat in the tissue through vibrations, thus loosening the back muscles as well. Likewise, massage and acupuncture can contribute to a desired pain reduction. In any case, for a long-term elimination of pain, the back muscles must be strengthened. Accompanying physiotherapeutic measures are thus an essential part of the pain therapy, since the strengthening of the back muscles a guide rail for the spine is formed, which consequently also reduces the burden on the disc.

Only rarely, if the discomfort of the herniated disc can not be controlled by conservative measures, an operative treatment is indicated. This is often the case when nerves have been damaged in the herniated disc and as a result paralysis (motor and sensory) occur. An example of this is a disc herniation in the lumbar spine, which disturbs the intestinal and bladder emptying by damaging a nerve. In a disc surgery, the prolapsed part of the disc material is removed to relieve the constricted nerve.

There are various ways to provide a herniated disc surgery. Either the surgeon can remove the intervertebral disc or the "pre-existing" tissue mass affecting the nerve during an open operation on the spine. Or a minimally invasive procedure ("keyhole surgery") is chosen. In this case, similar to the open procedure, the intervertebral disc is removed, but this time the surgeon works endoscopically, ie he reaches the spine via a small incision. After an intervertebral disc operation, a new herniated disc can occur. It can also happen that scars form through the distant tissue, causing the spinal cord nerve to become irritated again and the original symptoms persist.

  • Treatment of a herniated disc
  • Surgery a herniated disc - What are the advantages and disadvantages?

Medications in a herniated disc

The focus is on alleviating the pain.

For the drug therapy of a herniated disc painkillers are suitable, which inhibit the pain and the inflammation at the same time. Non-steroidal anti-inflammatory drugs, or NSAIDs for short, are excellently suited for this purpose. These include active ingredients such as diclofenac or ibuprofen. NSAIDs inhibit the production of prostaglandins, which are involved in the development of pain and inflammatory reactions, by inhibiting an enzyme called cyclooxygenase (COX).
The analgesic acetaminophen can be taken as an alternative to the NSAIDs, mainly because of its better tolerability. It also has an analgesic, but not as strong anti-inflammatory as the NSAIDs.
Corticosteroids (cortisone) have an anti-inflammatory effect, making inflammation inhibition well-suited. Especially when nerve damage threatens cortisone is a very effective drug for swelling caused by the herniated disc.

Not every herniated disc has to be treated with cortisone.
Muscle relaxants, muscle relaxants, can also help with a herniated disc. They relax muscles and release tension.

For severe and prolonged pain opioids (morphine, tramadol) are recommended. Opioids are powerful analgesics, which can cause serious side effects and are therefore used only under medical treatment under control.

If the pain is chronic and the effects of other pain medicines have been inadequate, there is still the option of using anticonvulsants and antidepressants. These drugs raised the pain threshold, allowing the patient to develop better pain tolerance.

PRT

If previous therapy measures such as medication, physiotherapy and physical measures in the case of existing disc symptoms are not sufficient for a noticeable improvement, the PRT can be used as a further pain-relieving remedy.
The abbreviation PRT is understood to mean periradicular therapy, a relatively new and non-surgical measure that can be performed on all parts of the spine.

Here, under local anesthetic drugs are injected directly to the affected or trapped nerve on the spine by means of a PRT needle. It can also be worked with a small dose of medication, since the exact placement of a soothing effect on the aching nerve root is caused.
A combination of a corticosteroid (cortisone) and a long-acting local anesthetic is often injected. The corticosteroid (cortisone) causes the irritated nerve root and herniated disc to decongest, giving more space to the nerve at its spinal site so that it is no longer trapped,
The local anesthetic causes a decrease in inflammation and localized pain. Using the medication as a depot, this effect should last for a longer period of time. As a control, the PRT is performed using imaging techniques (X-ray, CT or MRI) to ensure accurate placement of the injection needle.

With the help of periradicular therapy (PRT) a significant pain relief or even freedom from pain can be achieved for the patient. As a rule, 2-4 treatments, which should take place at weekly intervals, are usually sufficient for this.

For more information on what to do in case of an existing herniated disc, see our topic: Herniated disc - what to do?

Surgery of a herniated disc

If conservative therapy does not reduce pain in a herniated disc, or if the herniated disc causes neurological disorders and impairments, surgery can be performed.
The indication for surgery on a herniated disc is now more than ever weighed well. The operation is performed under general anesthesia or local anesthesia and can be offered in different variants depending on the surgeon and clinic.
The minimally invasive technique allows the operation of the herniated disc without large skin incisions. However, it is not possible with every type of herniated disc and it must be decided by the surgeon whether minimally invasive work can be done.
There are several minimally invasive methods available. In the microsurgical variant, the patient is usually lying on his stomach - with herniated discs on the cervical spine on the back - and it is about 2cm skin incision set by the surgeon with the smallest instruments on the affected disc can operate.
In the endoscopic variant, a small tube is advanced through a skin incision of about 1 cm to the intervertebral disc. The tube (endoscope) can be inserted from the side or the back. Through the endoscope very small instruments, as well as a camera are introduced via which the surgeon can remove the prolapsed disc. In both variants, a laser can be used instead of scalpels. This herniated disc is not cut away, but evaporated. In addition, so even the smallest disc portions that can not be reached otherwise, so removed.
Furthermore, there is also an electrotherapy. Here is operated on the disc with temperatures of over 90 degrees Celsius.
More complicated disc herniations often need to be operated on in the conventional open surgical version. In doing so, a longer skin incision is made from the back and the surgeon cuts through the posterior ligaments of the spine in order to visualize the spinal canal. It may also be necessary to remove parts of the vertebral arch.

Risks of surgery

The operation of a herniated disc is not risk-free and should therefore not be carried out without a corresponding indication. Basically, every general anesthetic is a risk.
However, the development of minimally invasive procedures, which can also be performed under local anesthesia, is an avoidable risk. After surgery, bleeding, bruising and swelling may occur at the surgical site and the wound may become infected.
It is also relevant that pain, tingling, numbness, and other neurological deficits persist after surgery, or even reoccur, as nerves emerging during the procedure can become irritated or injured. The technical term for these symptoms after the operation of the herniated disc is called Postnukleotomiesyndrom.
In addition to the nerves, there is a risk that vessels or other organs (intestines, bladder, etc.) are injured during surgery. Since the use of the minimally invasive surgical variants, a large proportion of complications can be prevented, since the smaller surgical access results in significantly fewer injuries to other tissues.

Duration of the operation

The most commonly used minimally invasive procedures for herniated disc surgery today take about 30-60 minutes in most cases. However, this time depends on which variant the surgeon uses, how the herniated disc is located and which access path is chosen.
Furthermore, for example, severe obesity or the age of the patient are factors that influence the duration of surgery.
For interventions involving multiple intervertebral discs, the operation can take up to 120 minutes, as multiple access routes need to be created, and the operation time accumulates accordingly.
In conventional open surgery, the lumbar disc herniation operation is between 60 and 120 minutes, depending on location (cervical, thoracic, lumbar, and lumbar spine) and access route.
If in addition to the removal of the incident additionally a stiffening (Spondylodese) of the spine must be performed or an intervertebral disc prosthesis are introduced, then the procedure can take up to several hours.
In addition to the pure operation time, the time for the anesthesia before and after the operation is also to be included. Anesthesia or anesthesia must be performed prior to surgery. After the operation, it takes time to wake up in the recovery room or to remove the local anesthetic.

Herniated disc in pregnancy

During pregnancy, conservative therapies are first tried before medication is given.

Pregnant women are at an increased risk of suffering a herniated disc. Most commonly, a herniated disc occurs during pregnancy in the lumbar region.

The reason for the development is mainly due to the weight of the growing baby. In many cases, the back muscles are not sufficiently trained to withstand this counterweight. Thus, the expectant mother developed a malpractice, which can lead to a herniated disc.

Also, the hormonal change of the woman during pregnancy favors such an event. The intervertebral discs absorb more water and thus become more unstable and are more susceptible to an incident.

For a herniated disc during pregnancy, the conservative treatment is very important. Before pain-relieving medicines are used, they try to help the expectant mother by other means. Exercise, massages, physiotherapy or acupuncture can help relieve the symptoms. Even the stress reduction and the relaxation of the pregnant woman can solve cramps and cause an improvement of the symptoms.

If all else fails, pain-reducing drugs are used. It is important to pay attention to the protection of the unborn child. The physician only prescribes painkillers which, during pregnancy, can not pass over the mother cake into the bloodstream of the child and thus harm the child.
Paracetamol is the first-line pain medication in pregnancy. ( See paracetamol in pregnancy)

Sport and the herniated disc

To strengthen the back muscles, swimming, cycling and walking are suitable.

The best way to prevent a herniated disc is exercise. As a result, the wear process of the spine can be prevented by supplying the intervertebral disc with nutrients through the movement and thereby strengthening it. But be careful when choosing the sport - because not every movement is soothing to the back.
For people with back problems, however, there is a wide selection that is unquestioning. Swimming, walking and cycling are particularly suitable for back-friendly training of the abdominal and back muscles. In these sports, both the muscles of the abdomen and the back are equally stressed, so that forms a strong backbone.
Even jogging is after a herniated disc is allowed after one. It is advisable to pay attention to an oncoming surface while jogging. It is best to jog on a soft floor covering such as on forest floor and not on hard surfaces such as asphalt to protect the spine against compression. Of sports that strain the spine heavily (eg lift weight) or involve rotational movements (eg tennis), the spine is advised against by experts.

  • Herniated disc and sports
  • Jogging after herniated disc

Localization of the herniated disc

Herniated disc LWS

A herniated disc of the lumbar spine (lumbar spine) - also called a lumbar disc herniation - occurs significantly more frequently in comparison to herniated discs of the cervical spine or thoracic spine. About 90% of all herniated discs are found in the lower part of the spine. The reason for this is the weight on the lumbar spine, which is noticeable above all during movements. During physical work or sports, the lumbar spine is therefore the most heavily loaded.
Also within the lumbar spine there is a frequency distribution. 80% are distributed to the lumbar spine segments L4 / 5 and most often to L5 / S1

  • Herniated disc of the lumbar spine
  • Herniated disc L4 / 5
  • Herniated disc L5 / S1

If there is an incident in the lumbar spine, so that jelly mass escapes from the disc, nerves can be irritated or even pinched. Local pain over the affected lumbar portion of the spine may indicate a herniated disc. In addition, there is a local inflammatory reaction, which sometimes intensifies the pain. Because the nerves that supply the legs in the lumbar spine exit from the spinal canal, the pain can radiate across the leg to the foot, depending on which vertebral segment is affected by the incident. Sensory disorders - such as unpleasant tingling, numbness or even paralysis of the musculature - can also occur in the legs.

In the worst case, a disc herniation of the upper lumbar spine affects those nerves responsible for the regulation of the bladder muscles. In this case, the patient may experience a bladder voiding disorder, meaning that he no longer has control over the emptying of urine in the bladder and becomes incontinent and other symptoms appear.
Additional symptoms such as fecal incontinence and numbness in the genitals and anal area (breeches anesthesia) are called " cauda equina syndrome ". This should be done quickly contact a doctor. An emergency operation is then used to relieve the constricted nerve root. Thus, chronic stool and urinary incontinence is best prevented.

Figure lumbar spine with herniated disc (NPP)


  1. vertebra
  2. disc
  3. Herniated disc / disc protrusion
  4. Spinous process

Herniated disc HWS

Herniated disks in the cervical spine can cause pain in the neck and arms as well as sensory disturbances.

A disc herniation of the cervical spine is also referred to medically as cervical disc prolapse . As less weight is applied to the spinal column than to the thoracic and lumbar spine, disc herniations of the cervical spine are less common. Often, the lower part of the cervical spine is affected, as there the individual vertebral segments have the greatest mobility. In the cervical spine, a herniated disc may press on the nerves exiting the spinal canal. This is especially noticeable due to pain in the neck area, which can spread to the shoulders or head. Because the nerves that feed the arms are located in the cervical spine, a cervical disc herniation often manifests itself with pain radiating to the arm. In addition, the affected person may experience feelings of weakness in the skin area supplied by the affected nerve: unpleasant tingling or numbness up to the hands occur. In the worst case it comes in addition to motor failures of the arm, so paralysis of the arm muscles. Many sufferers also suffer from other symptoms, such as dizziness or balance disorders.

Due to the symptoms, many patients take a restraint, which additionally contributes to the stiffening of the neck and thus further aggravates the symptoms.

The cause of a herniated disc of the cervical spine are excessive and incorrect loads, as well as unfavorable movements of the cervical spine. This also includes long-term stress, such as working in front of the computer with a stiff head posture. Also, cervical disc herniations can be provoked by injuries. This can happen, for example, in a rear-end collision in which the head is thrown forward unprotected and not stabilized. Begünstigt treten Bandscheibenvorfälle im Halsbereich bei älteren Menschen auf, da Abnutzungserscheinungen der Halswirbelsäule, die sich in Form von gelockerten Gelenken zeigen, leichter zu einem Vorfall führen können.

MRT eines Bandscheibenvorfall der HWS

MRT Halswirbelsäule:

  1. disc
  2. vertebra
  3. spinal cord
  4. disc prolapse

Further information on this topic can be found under: MRI of the cervical spine

Herniated disc of the thoracic spine

Bei einem Bandscheibenvorfall der BWS können Schmerzen lokal, entlang der Rippen oder in den Armen auftreten.

Ein Bandscheibenvorfall an der Brustwirbelsäule ist viel seltener als ein Bandscheibenvorfall der Hals- oder Lendenwirbelsäule. Oftmals präsentieren sich diese Bandscheibenvorfälle symptomlos und werden teilweise vom Arzt nur als Zufallsbefund in einer CT oder einem MRT der Brustwirbelsäule entdeckt. Doch nicht jeder Patient bleibt verschont. Das Hauptsymptom eines Bandscheibenvorfalls der BWS sind Schmerzen. Und wenn der Betroffene über Schmerzen klagt, dann sind diese meist sehr stark ausgeprägt. Die Schmerzen befinden sich lokal über dem betroffenen Wirbelsegment, gehen in vielen Fällen mit einer lokalen Entzündung oder Muskelverspannungen im Bereich der Brustwirbelsäule einher.

Auch können die Schmerzen vom Rückgrat entlang der Rippen nach vorne zur Mitte des Brustkorbs ausstrahlen. Diese spezielle Schmerzausstrahlung wird als „Interkostalneuralgie“ bezeichnet und wird von Patienten als sehr unangenehm beschrieben. Typisch für die durch den Bandscheibenvorfall der BWS hervorgerufenen Schmerzen ist auch, dass diese durch Husten, Niesen oder Lachen verstärkt werden.

Ebenfalls klagen Betroffenen hin und wieder über weitere Beschwerden, wie Herzrasen oder Herzstolpern und Enge im Brustkorb. Sogar Schwindel und Atemnot wird von manchen betroffenen Patienten angegeben.

Bei einem Bandscheibenvorfall der Brustwirbelsäule strahlen Schmerzen oft zusätzlich in die Arme aus, seltener sind jedoch die Beine betroffen. An Armen und Beinen kann sich der Bandscheibenvorfall wiederum durch sensible Störungen (Kribbeln, Taubheit) und motorische Ausfälle (Lähmungen) äußern. Auch kann es durch Beeinträchtigung der Brustwirbelsäule zu einer Blasen- und Darmentleerungsstörung kommen. Bei diesen Symptomen sollte man sich sofort in ärztliche Hände begeben, da hier eine Schädigung des Rückenmarks vorliegt und eine operative Behandlung von Nöten ist.

Als Ursache für einen Bandscheibenvorfall der BWS ist vor allem der Verschleiß durch höheres Alter zu nennen. Auch körperliche Beanspruchung und Belastung, sowie Fehlhaltungen oder Fehlbelastungen können einen solchen Bandscheibenvorfall provozieren.

Epidemiology

Rückenschmerzen alleine sind kein Indiz für das Vorhandensein eines Bandscheibenvorfalles. Generell ist es sehr schwierig, die Ursachen von Rückenschmerzen ausfindig zu machen. Auch Röntgenbilder können nicht immer die erwünschte Klarheit verschaffen.

Um aufzuzeigen, dass Rückenschmerzen und das tatsächliche Vorhandenseine eines pathologischen (= krankhaften) Bandscheibenbefundes nicht immer zwingend sind, soll an dieser Stelle beispielartig die Studie von Jensen angeführt werden. Diese randomisierte, kontrollierte Studie arbeitete mit MRT-Untersuchungen der Lendenwirbelsäule und untersuchte dabei beschwerdefreie Menschen. Die Ergebnisse verblüffen:

Bei 52 % der Patienten konnte eine Vorwölbung der Bandscheibe (= Protrusio, auch Bandscheibenvorwölbung oder Bandscheibenprotrusion genannt) nachgewiesen werden.

Bei 27 % konnte ein Bandscheibenvorfall diagnostiziert werden und darüber hinaus wies 1% der Patienten einen Bandscheibenvorfall auf, der bereits auf das umliegende Gewebe drückte.

Bei 38 % aller Patienten blieben die Veränderungen nicht nur auf eine Bandscheibe beschränkt.

Erschreckend ist dabei, dass nur etwa 33 % aller Untersuchten angaben, unter Rückenschmerzen zu leiden. Dies verdeutlicht, dass eine diagnostische Treffsicherheit nur dann erreicht werden kann, wenn die diagnostischen Maßnahmen möglichst vollständig ergriffen werden. Stets müssen dabei unterschiedliche Symptome gegeneinander abgegrenzt werden, um eine sichere Diagnose "Bandscheibenvorfall" stellen zu können.

Alter und Häufigkeit

Die Bandscheibenvorfälle treten am häufigsten im Bereich der Lendenwirbelsäule auf, gefolgt von Banscheibenvorfällen im Bereich der Halswirbelsäule, Vorfälle im Bereich der Brustwirbelsäule sind als weitere Möglichkeit relativ selten.

Während Lendenwirbelsäulenvorfälle am häufigsten zwischen dem 30. und 50. Lebensjahr auftreten, ist die Halswirbelsäule zwischen dem 40. und dem 60. Lebensjahr erst später betroffen. Eine Bandscheibenprotrusion (Bandscheibenvorwölbung su ) kann schon wesentlich früher auftreten.

Im weiteren Lebensverlauf sind Bandscheibenvorfälle dann wiederum seltener vorzufinden, da dann verstärkt der Wasserverlust der Bandscheibe auftritt. Dies hat im Hinblick auf den Bandscheibenvorfall den „Vorteil“, dass der Gallertkern dickflüssiger wird und somit nur noch erschwert vorfallen kann.

Differenzierung Bandscheibenvorfall

Im Rahmen eines Bandscheibenvorfalles differenziert man zwischen:

  • einer Bandscheibenprotrusion ( Bild unten ), durch die es zu einer Vorwölbung des Annulus fibrosus kommt,
  • einem Bandscheibenprolaps (= Bandscheibenvorfall; Bild unten ) in die Zwischenwirbellöcher oder – was wesentlich seltener vorkommt – in den Spinalkanal hinen.
  • einer Sequestration, in deren Folge die prolabierten Anteile keinerlei Verbindung mehr mit der ursprünglichen Bandscheibe haben.

Man sollte sich das so vorstellen:

  • Bei einer Bandscheibenprotrusion bleibt die Bandscheibe als solches zunächst noch intakt. Der innere Gallertkern wölbt sich nach vorne und drückt dabei auf den aus Bindegewebe bestehenden, knorpeligen äußeren Ring.
  • Beim einem Nucleus pulposus prolaps (NPP) hingegen tritt der Gallertkern durch den äußeren Ring teilweise aus. Der Teil, der austritt bleibt dabei allerdings mit dem restlichen inneren Gallertkern verbunden und kapselt sich nicht ab.
  • Ein Abkapseln des ausgetretenen Bereiches findet hingegen bei einer Sequestration statt: Der prolabierte Teil des Gallertkernes ist nicht mehr mit dem inneren Bereich verbunden.

Vorfallende Bereiche der Bandscheibe können mehr oder weniger stark auf Nervenwurzeln drücken, die unmittelbar an die Bandscheibe angrenzen. Hierzu zählt im unteren Lendenwirbelbereich auch der Ischiasnerv, der bei Druckausübung unter Umständen sehr heftige, starke Schmerzen auslösen kann (Ischiasschmerz = Ischialgie).

Gesunde Bandscheibe

  1. Nucleus pulposus ( Gallertkern )
  2. Anulus fibrosus ( Faserring )

Bandscheibenvorwölbung (Protrusion)

  1. Nucleus pulposus (Gallertkern)
  2. Anulus fibrosus (Faserring)
  3. Vorwölbung

Abbildung Bandscheibenvorfall (Prolaps)

  1. Nucleus pulposus (Gallertkern)
  2. Anulus fibrosus (Faserring)
  3. Vorfall

Anatomie zum Thema Bandscheibenvorfall

Anatomie der Bandscheibe

Bevor auf den Bandscheibenvorfall eingegangen wird, sollte zunächst der Begriff der Bandscheibe ausreichend geklärt werden. Erst wenn die Aufgaben und Eigenschaften der Bandscheiben geklärt sind, kann das Ausmaß des Bandscheibenvorfall und dessen Therapiemaßnahmen verstanden werden.

Position – Wo befinden sich „Bandscheiben“?

Zwischen zwei Wirbelkörpern der Wirbelsäule befindet sich eine knorpelige Verbindung, die man als Bandscheibe bezeichnet. Da sie zwischen zwei Wirbelkörpern liegt, bezeichnet man sie häufig auch als Zwischenwirbelscheibe. Wirbelkörper und Bandscheibe sind fest miteinander verwachsen.

Eigenschaften einer Bandscheibe

Eine Bandscheibe besteht aus dem so genannten Annulus fibrosus, dem bindegewebigen, knorpeligen Außenring und dem Nucleus pulposus, dem inneren Gallertkern. Insgesamt besitzt der Mensch 23 Bandscheiben, sodass sie in ihrer Gesamtheit in etwa ¼ der Gesamtlänge der Wirbelsäule darstellen.

Funktion der Bandscheibe

Die Beweglichkeit der Wirbelsäule:

Dargestellt sind 2 Wirbelkörper und der Nucleus pulposus, auf dem sich die Wirbelkörper freie gegeneinander wie auf einem elastischen Ball bewegen können.

Der oben beschriebene Nucleus pulposus, der gallertartige Kern der Bandscheibe steht unter Druck. Dabei ist die Konsistenz dieses Kerns stets vom Wasserhaushalt der Zwischenwirbelscheibe abhängig. Es gilt die Faustregel:

Je mehr Wasser er Schwamm ähnlich aufsaugt, desto praller, elastischer und fester ist er.

Nebenstehend soll der „Vollsaugeprozess“ verständlich aufgezeigt werden. Das Vorhandensein des Wasserhaushaltes und dessen Abnahme lässt sich im Rahmen des Alterungsprozesses eines Menschen verdeutlichen: Im Laufe des Lebens reduziert sich der Wassergehalt der Zwischenwirbelscheibe automatisch. Nach außen sichtbar wird das beispielsweise im Rahmen des Alterungsprozesses, in dessen Verlauf der Mensch kleiner wird.

Ferner kann man täglich an sich selbst feststellen, dass der gleiche Mensch morgens etwa 1 bis 3 cm (ca. 1%) größer ist als abends, was damit zusammenhängt, dass sich die Bandscheiben durch die nächtliche Entlastung erholen und erneut voll saugen konnten. Sinnbildlich kann man sich einen ausgewrungenen Schwamm vorstellen, der in Wasser gelegt wird und sich bestmöglich voll saugt. Genau wie ein Schwamm gewinnt die Bandscheibe dadurch an Höhe.

Allerdings benötigt eine Bandscheibe nicht nur Wasser, sondern auch so genannte Vitalstoffe. Da sich Bandscheiben nicht über die Blutzufuhr ernähren, können diese Vitalstoffe nur dann aufgenommen werden, wenn sie vorhanden und durch vielseitige menschliche Bewegungen (Biegen nach hinten, Kreisen der Hüfte, Gehen, Joggen, Bücken, ...) vorher ausgetrieben wurden.

Es gilt folgender Leitsatz:

Je vielseitiger die Bewegung eines Menschen ist, desto intensiver arbeiten Vitalstoffzufuhr und Wasserversorgung dieses hochsensiblen Knorpelgewebes.

Belastung der Bandscheibe in Abhängigkeit der Körperposition

burden

Durch die Bandscheiben ergibt sich erst die Beweglichkeit der Wirbelsäule. Ohne sie wäre die Wirbelsäule steif, vergleichbar besipielsweise mit einem Besenstiel. Die Bandscheiben ermöglichen somit die Elastizität und Biegsamkeit der Wirbelsegmente.

Eine Gewichtsverlagerung nach vorne, hinten oder zur Seite ruft eine Verlagerung des des Kerns in entsprechende Richtung hervor. Durch diese Verlagerung der Kerne wird der knorpelige Ring, die so genannte knorpelige Faserscheibe einseitig und je nach Bewegung unterschiedlich stark zusammengedrückt, so dass die Last, die eine Bandscheibe aushalten muss, recht unterschiedlich sein kann.

Das Schaubild unten soll die unterschiedliche Belastung aufzeigen, die bei alltäglichen Bewegungen auf die Bandscheiben lasten. Es fällt dabei auf, dass im Liegen ( Rückenlage ) der Druck auf die Bandscheibe am geringsten ist. Durch falsche Haltungen oder falsche Bewegungen (Mitte rechts, unten) werden die Belastung der Bandscheibe erhöht. Liegt bereits eine Knorpelabnutzung vor, kann im Rahmen solcher Bewegungen ein Bandscheibenvorfall auftreten. Eine Knorpelabnutzung wiederum wird durch fortgeschrittenes Alter und / oder Wasserverlust stark begünstigt.

  1. vertebra
  2. Protrusion (Vorwölbung der Bandscheibe)
  3. spinal cord
  4. disc prolapse

Back Pain: Lumbar Disc Injury (December 2019).


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