Robert F. McLain, M.D., a spine surgeon in the Spine and Orthopedic Institute at St. Vincent Charity Medical Center, recently published the following article to provide information regarding cervical disc injury, cervical fusion, disc replacement surgery and more.
The human spine is a very complex thing, and the things that can go wrong with it are very complex processes. Worse still, the terminology we use when we're talking about these problems can be more complex and confusing still. Doctors don't always explain things well.
I've had this conversation...
"What can I do for you?"
"Something in my back is exploded. The x-rays say I've got a herniated lumbar disc. My MRI says I've got a protruding thing. My doctor says my disc exploded and the surgeon said it's a big rupture and I need surgery right away. To be honest, I'm kind of nervous..."
"Gee...well, how's your pain?"
"Oh, it went away. But I'm afraid to move!"
Maybe you've been in this conversation. If so, you probably felt like the words you were hearing were worse than the pain you were feeling. And if you had one doctor tell you that your disc had "ruptured and exploded" with a "massive fragment crushing your nerve," while another simply explained that you had had a disc injury, with a "protrusion" putting "pressure on the nerve," you might have been pretty confused. Who's telling the truth?
The first thing you should know is most primary medical doctors only see serious back or neck problems a few times a year. They usually don't read MRIs and they are a little bit at the mercy of the radiologist's report. And, there's a lot of variation in the way different radiologists will interpret the same imaging study. There's no standard scale for what is big, bigger or biggest, and some radiologists will call any slight disc bulge a herniation. So, your doctor may be genuinely concerned for your safety when he or she reads that you have a "large extruded fragment" with "severe nerve root compression" or "multiple herniations throughout the cervical spine." And that's OK - they should be concerned about you.
In trying to explain what that means - and because they want you to take this seriously - the description can drift and the terms that you hear can get scarier. Even if they use the proper medical terms, confusion is common. For instance, arm pain or leg pain is often caused by a pinched nerve, and referred to medically as radicular pain. More than once I've met a patient who thought their local doctor called it "ridiculous pain" and they weren't too happy with that attitude!
The truth is that even the formal medical terms we use in diagnosing back and neck problems are largely descriptive. It's helpful to know what they mean, so here's a short list of terms that shouldn't scare you:
Disc herniation: disc bulge, slipped disc, protrusion, herniation, rupture, extrusion, herniated nucleus pulposus - these all mean exactly the same thing. And what one MD calls large, or extensive, or significant, may seem moderate to another. Disc herniations are like noses - what looks huge to one person looks pretty ordinary to another, depending on what you've seen before. And even a small one can cause trouble if it sticks in where it doesn't belong.
Radiculopathy: this is the medical term for the symptom you get when a nerve is pinched, compressed or irritated. It can crop up from any of a number of very different causes. Nerve symptoms can vary from a little bit of numbness and tingling, to almost complete paralysis of one or a group of muscles. The point to remember is - radiculopathy is something you feel and your doctor picks up on examination, and we treat it based on that exam, not on the MRI picture.
Stenosis or nerve root compression: if this is on your MRI report, think "it looks like there might be..." If your doctor decides this based on your symptoms and examination, then you probably do have significant pressure on the nerves in your back or neck. Terms you may see are impingement, compression, effacement, stenosis or compromise. These all mean the same thing. The nerve may be pinched, effaced, compressed or crushed - again, all the same thing. The MRI picture is interesting, but it only hints at what needs to be done - that depends on the examination. Some patients with "Severe Stenosis" on their imaging report, don't have a lick of pain, and may not need any treatment, let alone surgery. Others, with spinal cord compression in their neck, may need surgical treatment whether they are experiencing pain or not.
Spinal cord compression: as long as we're talking about it, everyone knows that spinal cord injury is a serious and a fearful thing. However, most people - including many doctors - aren't aware that the spinal cord doesn't actually get to the lumbar spine! It stops, in most people, at the L2 level of the lumbar spine. Below that level the spinal canal is filled with spinal nerves, still crucial but much tougher. A really large disc herniation at the lumbosacral level can put a lot of pressure on individual nerves, but it doesn't "compress the spinal cord." If the herniation is in the neck – that is a different story. A disc herniation at that level can compress and injure the spinal cord, and needs to be checked out by an expert in the field.
Paralysis: everyone knows what paralysis is, and probably knows someone who has been paralyzed. The possibility of becoming paralyzed is terrifying, and it can drive people to have surgery they don't need, or to avoid surgery they really do. Here is what you need to know - the vast majority of low back problems, even those that pinch nerves and cause radiculopathy - aren't going to cause paralysis. I've seen many patients over the years who were told, "If you don't have surgery you could be paralyzed!" That's almost never true. However, if we are talking about your neck, and you are having symptoms of neck and arm pain, that needs to be taken seriously. Fear of surgery can be more dangerous than the surgery itself in those cases.
Take home message: Spine problems are complex and confusing even to the medical professionals you depend on for your routine care. Without context and a careful examination and understanding of your specific condition, the names we give things and the descriptions we give can be very scary. In situations where you've been told something that sounds that scary, it's oh so important that you get advice and counsel from a genuine expert. If you need treatment, you'll get the right kind. And you may find out you didn't need to be scared at all. Nothing is exploded, there are things we can do to get you better, and you're actually healthier than your MRI would lead you to believe!
Robert F. McLain, M.D., a spine surgeon in the Spine and Orthopedic Institute at St. Vincent Charity Medical Center, has more than 20 years of experience in disc replacement surgery, and has served as an instructor and educator in disc replacement surgical training, as Principal Investigator for an FDA cervical disc replacement clinical trial, and provides both lumbar and cervical disc replacement to carefully selected patients who need those procedures.