Talk:Spinal disc herniation/Archive 3

Merge
I think both source articles could be merged into this article.--Steven Fruitsmaak (Reply) 23:00, 28 August 2006 (UTC)


 * It shouldn't be any problem, since Dematt and myself, Fyslee, used all of their content to make this article, and then we developed it even further to make it more complete. If any small changes have been made since then, anyone is welcome to add them to this article. -- Fyslee 19:58, 29 August 2006 (UTC)


 * If you're sure your article completely supersedes the other two, then you could install a redirect from both pages to yours, and check for any double redirects.--Steven Fruitsmaak (Reply) 22:47, 29 August 2006 (UTC)


 * A check should be made of both articles for any changes in the last week or so. If they are good, they should be incorporated here before deleting those articles.


 * Would it be a good idea to place archived copies of the discussion pages from both articles here? -- Fyslee 04:50, 30 August 2006 (UTC)


 * Yes that would be a good idea.--Steven Fruitsmaak (Reply) 06:25, 31 August 2006 (UTC)


 * I have checked both articles, and there is nothing more to move, so they can both be blanked and replaced by redirects.


 * Before blanking the talk pages, what about archiving them here, as suggested above? -- Fyslee 05:20, 30 August 2006 (UTC)


 * I think it would be a good idea to archive the articles just in case. --Dematt 11:53, 30 August 2006 (UTC)


 * Archives are now made, and all contents are copied to them. Now the old contents and the articles themselves can be blanked, and substituted with redirects. -- Fyslee 14:22, 30 August 2006 (UTC)

Redirects are now in place, and all content is blanked. Now the edit histories need to be blanked as well, but I don't know how that's done. -- Fyslee 16:38, 30 August 2006 (UTC)


 * No, they don't need to be blanked. Also, archives weren't necessary. The page histories already contain that.
 * What you should do is check for double redirect like Lumbar disc prolapse, by going to the redirect page and clicking: what links here. Look for redirect pages there and replace those.--Steven Fruitsmaak (Reply) 06:25, 31 August 2006 (UTC)


 * I think I've succeeded in tracking down and changing all instances of "slipped disc," except of course on talk pages. -- Fyslee 18:16, 30 August 2006 (UTC)

Lumbar Radiculopathy
Is the term "Spinal disc herniation" the same as or sysnonymous with Lumbar Radiculopathy? If so, it would be nice to have a redirct for searches for Lumbar Radiculopathy to this wiki topic. YORD-the-unknown 15:44, 27 September 2006 (UTC)


 * The radicular portion of the nerve is that part of the nerve that is within the spinal canal before it leaves the spinal column. When that part of the nerve is diseased it will cause pain into the leg along with some other symptoms.  This is called Lumbar radiculopathy.  By far the most common reason for Lumbar Radiculopathy is disc herniation, but there may be other reasons as well, especially space occupying lesions (called SOLs) like tumors, vascular anomalies and some types of cysts as well as primary conditions such as diabetes that may affect blood supply to the nerve itself as well as cause nerve damage.  IOW, spinal disc herniations can cause lumbar radiculopathy, but not all lumbar radiculopathies are the result of spinal disc herniations.  It should have an article of its own.  It should also be linked here. I'll take a better look at it.  Thanks for the heads up! --Dematt 04:06, 28 September 2006 (UTC)


 * Lumbar Radiculopathy is more synonymous with sciatica. If we're going to redirect, that is the one to redirect to. Any input?--Dematt 04:11, 28 September 2006 (UTC)


 * Dematt is correct. "Lumbar radiculopathy" and "sciatica" say something about symptoms arising from certain structures, which often give rise to the same symptoms. Lumbar radiculopathy involves the spinal nerve roots and can cause sciatica, while sciatica doesn't necessarily involve the spine at all, often being caused by piriformis syndrome. -- Fyslee 04:28, 28 September 2006 (UTC)


 * Maybe what we need to do is redirect all of the nerve diagnoses to sciatica where we can differentiate and explain each of them. Then we can link them to potential causes such as spinal disc herniation, piriformis syndrome, etc.. --Dematt 11:47, 28 September 2006 (UTC)


 * Okay, I redirected Lumbar Radiculopathy and Radiculitis to Sciatica. If any problems with this, let me know.  --Dematt 23:27, 1 October 2006 (UTC)

Opening sentence
The opening sentence as is, "A spinal disc herniation is a pathological condition in which a tear in the outer, fibrous ring (annulus fibrosus) of an intervertebral disc allows the soft, central portion (nucleus pulposus) to be extruded (herniated) to the outside of the disc.", I would suggest is entirely not understandable to the average non medically qualified person and needs a re-write so that it can be explained in layman's terms. --Rebroad 11:06, 28 January 2007 (UTC)

Herniation v. protrusion
We need to distinguish between a true herniation and the condition that precedes it -- a disc protrusion. Now terminology can differ from country to country. I'm an American PT in Denmark, and Midgley is an MD in the UK. What's the proper English terminology. Right now (in the lead) "bulging" is not the same as the former "allows the soft, central portion (nucleus pulposus) to be extruded (herniated) to the outside of the disc." Can we find acceptable language to make sure we describe the subject of the article, and not the subject of some (potential) other article (Spinal disc protrusion). -- Fyslee 21:49, 28 January 2007 (UTC)


 * Extrusion suggests to me detachment - as in plastic components and models made by extrusion of plastic into or though a mould or template. We tend to call the discs between the spinal vertebrae "intervertebral discs" as well. Midgley 13:56, 29 January 2007 (UTC)


 * Agree, for us, protrusion can be any stage that "bulges" until that actual "prolapse" when the pulposus "extrudes" through the outer fibers of the annulus. The prolapsed material could still be directly behind the disc and basically behave in the same manner as just a bulge.  When they acturally seperate and "float" to other areas, they are then "sequestered". --Dematt 14:06, 29 January 2007 (UTC)


 * That's also my understanding of the three stages that can occur: protrusion, prolapse, sequestration (bulge, herniation, separation). -- Fyslee 18:49, 29 January 2007 (UTC)

Slipped disc and references
I have added a refs section with code, and turned all internal links into embedded references. I also found a few references that debunk the "slipped disc" terminology. For plenty more, try this search: "slipped disc" not slip

The references need better descriptions and uniform formatting. More references and more content would also be welcomed.

The three stages described above could be developed into a paragraph. -- Fyslee 18:59, 2 February 2007 (UTC)

Back pain and low back pain and lumbago and lumbar disc herniation
I just moved lumbar disc herniation content from the surgery sections of back pain and low back pain. See rationale.Badgettrg 15:55, 31 May 2007 (UTC)

Treatment
The article says "The majority of herniated discs will heal themselves in about six weeks and do not require surgery." To me, that seems to say that the herniation goes away without treatment. I don't think that's true. Would it be more accurate to say, "In the majority of cases in which a herniated disc causes pain, the pain goes away within six weeks without treament."? Dwasserm 02:01, 26 July 2007 (UTC)


 * The entire treatment section is poorly referenced. I think your question is a good one, and a good start to set the example by including whatever a reliable source says about the issue. Sancho 05:04, 24 September 2007 (UTC)

Number 1 on the list is "bed rest" and I don't think that really is the best treatment. Many patients complain saying the most severe pain they experience is after having slept for 3-4 hours. As such, treatment should emphasize mobility of the affected areas, to the extent possible and comfortable. —Preceding unsigned comment added by 69.113.126.46 (talk) 03:00, 1 May 2008 (UTC)


 * Bed rest is not advised. My parents suggest they were advised bed rest when they had slipped discs 15+ years ago, but today the advice is certainly to remain active.  Including walking, cycling, swimming in conjunction with therapeutic stretches and exercise. Virtualt333 (talk) 00:21, 19 July 2008 (UTC)

In the conservative segment of the treatment section, it says "Osteopathic/Chiropractic manipulation". It then goes on to say how dangerous it can be... Let me just say, that as a student osteopath, that even I know that manipulating a segment with a prolapse is a radiculous and stupid thing to do. I dont think any chiropracter or osteopath in their right mind would do that... —Preceding unsigned comment added by 217.207.114.194 (talk) 12:30, 26 June 2008 (UTC)


 * Never say that a warning of a danger is unnecessary because you know it; it is needed to save others who may not know. Unfortunately, one cannot blindly trust any practitioner in these areas... Including such warnings in wikipedia helps to educate, not just the professional, but the patient, which is important AmirOnWiki (talk) 16:00, 28 June 2008 (UTC)


 * Osteopaths are often cited as a 'quick fix' for back troubles, though sometimes the results are only transient. However, even a GP will refer a patient to an osteopath in the early days of a prolapsed disc, as it is often significantly quicker than physiotherapy.  I have expereinced manipulation from very experienced professionals in both of these disciplines. Virtualt333 (talk) 00:21, 19 July 2008 (UTC)

I have a protrusion myself and found that Valium reduced my pain very effectively (which anti-inflammatories didn't). The doctor explained that this is due to its muscle-relaxing effects. I would be grateful if a knowledgeable editor would introduce to this section an explanation of this phenomenon. AmirOnWiki (talk) 16:00, 28 June 2008 (UTC)


 * I won't profess to explain exactly your situation, but as a sufferer myself, I can provide some insight through my own observations and personal advice from medical practitioners. Most people will have experienced lower back pain in the form of tense muscles, and this is certainly often a complicating factor in prolapsed discs.  Often with a prolapsed disc the back muscles are forced to spasm in order to protect the body from pain and damage induced by flexing the weak vertebra, which itself aches.  But if sciatica is your problem, then there is probably a coincidence of piriformis syndrome, where the piriformis (a small 'pear-shaped' muscle under the large flat gluteus maximus in your buttock) spasms around the sciatic nerve causing shooting pains down your leg.  Valium relieves this spasm, relieving sciatica and back ache.  Unfortunately, I have neither the expertise, nor the references, to begin to write this section! Virtualt333 (talk) 00:21, 19 July 2008 (UTC)

Commercial link ?
I'm very skeptical about this link, given at the bottom of the page :

http://www.herniateddischell.com/herniated-disc-order-faq.html (herniated disk order FAQ)

It's for a specific product and doesn't seem to have any medical references whatsoever... It's just a webpage to buy a videotape (?)

I'm not to familiar with Wiki editing but I thought I'd just let people know... 74.122.211.152 05:57, 26 September 2007 (UTC) Anya 74.122.211.152 05:57, 26 September 2007 (UTC)
 * Good catch. I removed that link along with most of the others. Sancho 22:47, 26 September 2007 (UTC)
 * You can read External links to see what links should be avoided, and feel free to improve the encyclopedia by making these types of edits yourself :-) Sancho 22:48, 26 September 2007 (UTC)

I believe the last reference is also a commercial link. It links to a youtube video which shows the director of the regenexx clinic talking about the benefits of regenexx. It does not provide any solid science or more information except as an advertisement for the clinic. --Abbaroodle (talk) 20:15, 23 April 2009 (UTC)

Surgery Treatments
I would like to suggest a note regarding this treatment:
 * IDET (a minimally invasive surgery for disc pain)

"Patients with severe radicular symptoms due to a herniated disk or patients with severe spinal stenosis are not good candidates [for IDET]." http://emedicine.medscape.com/article/1145641-overview


 * Go for it. -- Brangifer (talk) 02:00, 17 December 2009 (UTC)

Conservative treatment
Again, better sources would be better, but this statement from the Chicago Institute of Neurosurgery and Neuroresearch seems like it should be worked into the summary of this section: "The treatment of lumbar disc herniations can be divided into two categories, conservative (or non-surgical) and surgical. One exception would be in the cases of cauda equina syndrome, sudden loss of foot strength or urinary problems. In these cases, surgery would be considered the conservative approach". DigitalC (talk) 16:02, 30 January 2010 (UTC)

Terminology section needs expansion
The terminology section seems to focus extensively on the "slipped disc" term, and why it's incorrect. Laudable as this is, there are a lot more terminology problems that need to be sorted with herniated discs... more specifically perhaps a discussion as to why "herniation" may be considered a too imprecise term nowadays. Also, discussing the wide variation in terminology might be worthwhile as well; bulge, tear, fissure, prolapse, protrusion, extrusion, herniation, etc. &mdash;/M endaliv /2¢/Δ's/ 13:02, 17 May 2010 (UTC)

Chiropractic treatment disputed
Recent edits have highlighted dissent amonst editors regarding the validity, safety and efficacy of chriopractic treatment of spinal disc herniation. An anonymous IP editor who claims they are a chiropractor has indicated in their edit summaries that they are able to provide references to support the use of chiropractic treatment for this condition. Another editor, whom I believe also has professional qualifications in healthcare, has suggested that people providing chiropractic treatment for spinal disc herniation in the US have been subject to sanction under FDA related laws for doing so. Therefore, I have tagged the entry of "Chiropractic" in the treatment section of the article as dubious, and requiring citations. I accordingly invited interested editors to present the cited evidence for and against chiropractic treatment for spinal disc herniation in the article, for the benefit of all who may read it. I will further suggest that should reliable sources not be provided for the use of chiropractic in this setting within a reasonable time frame, say 1 week, that chiro may be removed as a treatment option from the article. Matto paedia  Have a yarn  01:06, 30 January 2010 (UTC)


 * An even more informative option is the one suggested in the section above. Treatments that have been studied and found wanting can be listed with that information and the references to back it up. There is a range of treatments in use, some of which have been studied, others which may seem plausible, but which haven't been studied very well, and still others which are implausible and have actually been disproven. The spectrum from proven to unproven, from experimental to nonsensical, and from disproven to outright quackery can be dealt with. My point is that we don't have to list only proven methods, but can also create a list where the references reveal the state of the evidence for each one. Some will of course be unproven but in use, others will be slightly studied and used based on empirical evidence (IOW further evidence is needed to clarify the true value). -- Brangifer (talk) 01:37, 30 January 2010 (UTC)


 * I agree with Mattopaedia, citations are always important, and uncited information should be removed if dubious. I would also like to ask for a quote from Senstad et al. (is this the best source we can come up with, it is over 13 years old) that Spinal Manipulation is a relative contraindication. From my knowledge, a disc bulge/herniation can present as non-specific low back pain in its beginning stages, and progress to having radiating symptoms. Obivously if this progressio occured after treatment, it would appear that it was a "potential side effect" of the treatment. I will look for more sources, but I think it is worth nothing that the Clinical Practice Guideline from the American College of Physicians and the American Pain Society recommends spinal manipulation for people with acute, subacute, and chronic low back pain that have not improved with self-care methods. It also says "The evidence is insufficient to conclude that benefits of manipulation vary according to [...] presence or absence of radiating pain (108)." I will try to dig for sources, but I have also read that it is not physiologically possible to herniate a disc with the forces of spinal manipulation, and that one would have to shear the facet joints first. DigitalC (talk) 15:12, 30 January 2010 (UTC)
 * Source for natural history of a herniated disc progressing to myelopathy - Murphy DR, Beres JL "Herniated disk in the cervical spine can progress to myelopathy as part of the natural history of this condition. Because of this, any interpretation of myelopathy that occurs after cervical manipulation, or any other procedure, must be made with caution."
 * Another relevant source: Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. "The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for [Lumbar Disc Herniation (LDH)], should stimulate its use in the conservative treatment plan of LDH." Oliphant D, 2004
 * "Serious complications from lumbar spinal manipulation are extremely rare, estimated to be 1 case per 100 million manipulations" Meeker & Haldeman, 2004
 * DigitalC (talk) 16:24, 30 January 2010 (UTC)


 * "There is limited evidence that spinal manipulative therapy is superior to sham therapy in the short term and superior to chemonucleolysis for disc herniation in the long term." Efficacy of Spinal Manipulation, Bronfort et al., in Complementary medicine in clinical practice. 2006. Rakel D, Fass N.
 * This is a higher quality source than the one used for other indicated treatments, and as such should pass for listing spinal manipulation under indicated treatments. Note that this does not refer to chiropractic therapy. DigitalC (talk) 15:55, 30 January 2010 (UTC)


 * FamilyDoctor.org (American Association of Family Physicians) states "Sometimes stretching of the spine, by your doctor or a chiropractor, can help the pain.". Again, this isn't a high quality source for the inclusion of Chiropractic, but it is better than the reference used for the other treatments. DigitalC (talk) 15:58, 30 January 2010 (UTC)
 * Part of what we may be seeing though is people with asymptomatic disc protrusions whose pain comes from some soft tissue problem or facet joint arthropathy garnering some benefit. I don't have a source to support that, but it may provide a hint as to where to look next. I will say though that chiropractic manipulation, regardless of what medical evidence we have for or against it, should be mentioned as it does enjoy significant popularity as a treatment for spinal disorders like this. It's also important to distinguish pure chiropractic manipulation from the chirotherapy programs you see (which may be more like passive PT + manipulation). &mdash;/M endaliv /2¢/Δ's/ 13:11, 17 May 2010 (UTC)

The Greek Version of Lumbar Disk Herniation
Dear Colleagues work of Dr. Harry Gouvas, MD, PhD (Draws, Photos, Texts), it is ready to see the Greek version o Lumbar Disk Herniation. Please see it http://el.wikipedia.org/wiki/%CE%9A%CE%AE%CE%BB%CE%B7_%CE%94%CE%AF%CF%83%CE%BA%CE%BF%CF%85_%CE%9F%CF%83%CF%86%CF%8D%CE%BF%CF%82 and i you want COPY + PASTE + TRANSLATE. Best regards from Greece Dr. Harry GouvasHarrygouvas (talk) 20:14, 25 February 2011 (UTC)

Treatment section
The current "treatments" section is heavily reliant on one online medical source that is no longer available. Other listed 'therapies' had no source at all. It seems that this list has not been 'clleaned-up' in a while. Also, I mentioned above the problems with the spine manipulation text (ie: source does not support contraindicated claim and other sources actually say the opposite). Thus, I have re-done the evidence section (excluding the surgery section). My poposed revision is below, please comment.Puhlaa (talk) 04:23, 7 December 2011 (UTC)


 * I have a few thoughts to express, some of them "in principle"....
 * I welcome improvements to this section. It's never been totally satisfactory and it has been the target of various attempts to promote certain methods.
 * Has the original source been tracked down and the new URL found? The content is usually still available.
 * We need to keep in my the MEDRS guidelines, which strongly discourage the use of primary sources. We need to use reviews of many primary sources. Picking and choosing primary sources is a common form of OR which those guidelines discourage.
 * Strictly speaking (and we should be careful about this point), the article is about herniations, and the treatments mentioned should stick to that point, not to LBP and other forms of back pain, even when provably caused by a herniation. Back pain and sciatica in the presence of a herniation is still a multifaceted problem, with primary and secondary aspects all blended together and causing symptoms. Many treatment methods and techniques may lend themselves to reduction of various symptoms, even if they have no proven effect on the herniation. In such cases, we should not be using such sources or mentioning such methods. That would be more appropriate for the Low back pain article. Stick to the subject. That will severely limit what is mentioned, and so it should be. Other articles deal with the other methods used for back pain and symptoms.
 * In light of these thoughts, I hope you radically rethink your proposal. -- Brangifer (talk) 03:11, 8 December 2011 (UTC)
 * Hey BR, thanks for the input. Of course I will consider your comments, however, some of them seem to just be 'generic' advice? For example, your comment about primary sources? If you look at the reflist below, I am pretty sure that none of the souces I have proposed are primary sources, they are all reviews or systematic reviews that are MEDRS compliant (please correct me if I am wrong).
 * With regard to your comment about herniation Tx specifically, I could not find a systematic review that has discussed the Tx of herniation without a discussion of radiculopathy. Even articles titled "Tx of herniation", when I pull full text, the discussion is all about neurological symptoms...as this is a tangible measure for doctors and patients. For example, a person is rarely a surgical candidate without neurological symptoms present... does this mean that a discussion of surgery is innapropriate here, as they all use neurological symptoms as indication and outcome, not herniation alone? Am i missing the point? These topics are inseparable IMO, If they were separable, then the peer-reviewed literature would indicate this by having reviews discussing each individually. However, I have found the best sources I could that discuss herniation and unfortunately, every one puts lumbar radiculopathy as a part of their review and discussion. Even cochrane reviews look at LBP or LBP with radiculopathy; there is no review on 'individual causes of LBP'. Thus, while I understand your concern here, I feel that we have an option of having no discussion of Tx in this article, or mixing in some discussion of related morbidities like radiculopathy. If we are too stringint, then not even the surgery text could be included, as it all uses neurological signs as an indication for surgery and as an outcome measure for surgical success. So, which is preferable in your opinion, to include Tx here that may be more relevant for Tx of radiculopathy than herniation specifically, or to have no Tx listed? If you can recommend high-quality sources that discuss herniation Tx alone, without a mix with radicular symptoms, I am happy to use them :)
 * Anyways, can you please be more specific? What parts of the proposal do you think are needing a 'radical re-think'? I am hearing that you think that the list of TX is too inclusive? Which items in the list are innapropriate? You will note that my list is shorter than what everyone has been ok with for the past 2 years (at least by my check), and my version actually has sources :) Thus, I am not sure how exactly to interpret your advice to `radically rethink my proposal'? There is no rush, lets make this article better! It should be easy as there is little controversy here, just a dilemma over how to differentiate herniation from back pain from radiculopathy in wikipedia when the peer-reviewed literature is not so good at making this distinction.
 * In the meantime, I will have a look for the current source single source that is used for the entire Tx section that seems unavailable.Puhlaa (talk) 04:15, 8 December 2011 (UTC)

I am still hopeful that there will be some specific feedback given to help me improve the treatment sectin of this article. The proposed new text is impartial (no specific professions are listed, only treatments) and it is well-sourced to multiple systematic reviews, making it IMO, much better than the current text in the treatment section. Puhlaa (talk) 15:32, 10 December 2011 (UTC)

Proposed new text for Treatments section:
There are a variety of treatment options available for a painful disc herniation. The appropriate treatment option is dependent on a patient's clinical presentation and ranges from doing nothing at all to surgical intervention. The literature supports both conservative and surgical interventions as effective options for the treatment of lumbar disc herniation and sciatica. In general, The primary approach to treatment of patients with symptomatic disc herniations should be nonoperative (as long as there are no acute or progressive neurologic deficits). For patients with symptomatic disc herniations who fail to respond appropriately to conservative measures, surgical intervention might be considered.

Initial treatment usually begins with a short course of rest. Pain management may also include a prescription for a moderate NSAID. Patients with more substantial pain might be treated with mild narcotic pain medication on an as-needed basis. Treatment should include mild stretching and pain relief modalities, such as ultrasound, whirlpool, ice and heat pack therapy, electrical stimulation, and/or massage. Those individuals found to have progressive neurological symptoms, or a history of more than six months of persistent symptoms, should have a consultation with a surgeon.

Treatment options:
 * 1) Do nothing - The majority of people with disc herniation and sciatica will heal spontaneously without surgery. However, the clinical course varies; in some people the symptoms decline after 1-2 weeks; in others the pain may continue for many months or years.
 * 2) Mild stretching or massage.
 * 3) Pain relief modalities, such as ultrasound, electrotherapy, ice or heat.
 * 4) Non-steroidal anti-inflammatory drugs (NSAIDs) – NSAIDs are slightly effective for short-term symptomatic relief in patients with acute and chronic low-back pain without sciatica. In patients with sciatica, NSAIDs were no better than placebo.
 * 5) Steroid injections – There is strong evidence for short-term relief and limited evidence for long-term relief of lumbosacral radicular pain with epidural steroid injections.
 * 6) Spinal manipulation – Moderate quality evidence suggests that spinal manipulation is more effective than placebo for the treatment of disk herniation and acute sciatica.  While some concerns exist, research currently suggests that spinal manipulation is safe for the treatment of disk-related pain.
 * 7) Non-surgical spinal decompression - There is only limited evidence to support the effectiveness of non-surgical spinal decompression therapy for painful disks and most research to date has methodological shortcomings.
 * 8) Surgery - existing text in article

Conservative therapy for disk herniation
I see that there was a brief discussion of this above, but no resolution. Currently, the article says that spinal manipulation is contraindicated for lumbar disk herniation, however, the source does not support this claim. The source says:"It is likely to be safe when used by appropriately-trained practitioners, however some of the reports discussed highlight the importance of a thorough case history and physical examination." Moreover, other recent sources seem to suggest that it is relatively safe and effective:
 * "Moderate evidence favors....manipulation over sham manipulation...." and "These reviews suggest that some concerns remain over the potential for manipulation to cause or exacerbate a LDH, although no adverse events related to manipulation were reported by the trials in our review." []
 * "There is moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy" []
 * "Active manipulation is more effective than sham manipulation..." and "Concerns exist regarding possible further herniation from spinal manipulation in people with severe herniation who are surgical candidates." (They state concerns, but unfortunately provide no refs to support those concerns) []
 * "The apparent safety of spinal manipulation, especially when compared with other "medically accepted" treatments for LDH, should stimulate its use in the conservative treatment plan of LDH" []

The WHO does state that "frank herniation with progressive neurological signs" is a contraindication to manipulation, however, I cannot find a source that suggests manipulation is outright contraindicated for simple LDH, or for LDH with radiculopathy.Puhlaa (talk) 16:14, 6 December 2011 (UTC)


 * It seems that this entire section needs a re-write and some sources (right now 1 common online source is used for all Tx, but the source is no longer available). I am going to work on a revision of the treatment section, I will post it heref for review soon.Puhlaa (talk) 19:23, 6 December 2011 (UTC)


 * I have fixed the wrongful 'contraindicated' label for spinal manipulation, as mentioned above.Puhlaa (talk) 15:43, 10 December 2011 (UTC)

Chiropractic as contraindication to "frank disc herniation"
I have removed chiropractic manipulation as the only contraindication to disc herniation treatment. amended the listing as chiropractic manipulation as the only contraindicated treatment for according to the WHO 2005 publication. In the US, Centers for Medicare and Medicaid Services (CMS) are the current "gold standard" when it comes to chiropractic standards of care, billing, and documentation. These federal guidelines do not include disc herniations in the list of absolute or relative contraindications which are as follows:

"A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart.The following are relative contraindications to dynamic thrust:


 * Articular hypermobility and circumstances where the stability of the joint is uncertain;


 * Severe demineralization of bone;


 * Benign bone tumors (spine);


 * Bleeding disorders and anticoagulant therapy;


 * Radiculopathy with progressive neurological signs.

Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:

anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;
 * Acute arthropathies characterized by acute inflammation and ligamentous laxity and


 * Acute fractures and dislocations or healed fractures and dislocations with signs of instability;


 * An unstable os odontoideum;


 * Malignancies that involve the vertebral column;


 * Infection of bones or joints of the vertebral column;


 * Signs and symptoms of myelopathy or cauda equina syndrome;


 * For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and


 * A significant major artery aneurysm near the proposed manipulation.CMS guidelines

The general public is not able to distinguish between varying degrees of disc herniations and a "frank herniation" which is severe enough to damage the spinal cord eliciting progressive neurological changes; also, "frank" disc herniation is not common terminology in the U.S. The isolated listing leads the reader to assume that although chiropractic manipulation is listed as a treatment for disc herniations, it is also contraindicated. Thank you.--Kfav (talk) 04:50, 19 July 2012 (UTC)

I have a couple questions. Are you saying that the WHO no longer includes "frank herniation with progressive neurological signs" in their publication? Removal of the reference to the WHO would only be justified if that were the case. Also, are you saying that we (as practitioners) should err on the side of increased risk of patient injury? I treat patients (I'm a PT) and see CT scans and MRIs (I have continual daily access to the medical imaging department) all day long. It still fascinates me to literally have "x-ray vision"! I can look inside my patients. Practitioners in outpatient clinics (like DCs and PTs) don't usually see these in practice and should be careful, because bulging (but not yet herniated) discs (not always visible on X-rays) can get destabilized/herniated relatively easily. It always shocks me when DCs treat this subject with such casualness and seeming indifference to the dangers. PTs and MDs are generally much more cautious, possibly because we work closer together, usually deal with more serious issues, and have access to better imaging and diagnostic tests. (FYI, I was one of the original authors of this article, together with a fine DC.) -- Brangifer (talk) 07:50, 21 July 2012 (UTC)


 * For me, the inclusion of this 'contraindicated' tx it is too much detail for the article, many things could be contraindicated as treatments to many conditions if we make the situation complex enough. SM is not contraindicated for a disc herniation, only for a 'frank disc herniation with accompanying signs of progressive neurological deficit'. To say that we want this included is kind-of like saying at the headache article that tylenol is indicated, but contraindicated when the user has consumed any alcohol? or, at the physio article that pysiotherapy is good for acute injury, but is contraindicated if the patient has an acute fracture? or at the MMR article that childhood vaccinations are advised, but subsequent childhood vaccinations are contraindicated when the first MMR dose results in a severe reaction? What about at the MRI/CT articles, where we could mention that using contrast is contraindicated if there is a known allergy, liver or kidney problems, etc. This is too much detail for the public, as it is beyond their level of understanding, the inclusion of SM as contraindicated seems more like just a knock at SM than a useful piece of info for the public or a common inclusion in wikipedia articles? If it is to be left in the article, perhaps the statement of SM contraindicated when there is progressive neurological deficit can just be added to the discussion of SM, rather than have a whole section dedicated to it, otherwise, perhaps we should find more things to add to the list of contraindications, as there are lots of things that would be contraindicated when there is a progressive neurological deficit? Puhlaa (talk) 14:23, 21 July 2012 (UTC)


 * Articles here aren't just for the general public, but also for medical specialists, who now commonly use Wikipedia as their first source for medical information. The quality of our medical articles has actually reached that niveau! If you have other things using MEDRS, then add them. This just happened to be one of the listed items and we arranged it in groups. That's why it ended in this group, since the RS said that's where it belonged. Many other procedures also have things for which they are indicated and contraindicated. It's a common misunderstanding that SM is good for anything, so it's good to know what it's not good for, and specialists need to know that since they are often told the opposite. -- Brangifer (talk) 07:37, 22 July 2012 (UTC)

Inflamation
I went to see the rheumatologist today to discuss my herniated disc. He said that the gel that breaks out would never come into contact with the body's immune system normally. It is therefore attacked by the immune system, as would any foreign body, which then causes inflamation and more pain. If this is true, could someone turn it into appropriate language and add it to the articleDunc22 (talk) 19:23, 7 January 2013 (UTC)dunc22

Causes
I see this, in the 'causes' section: "The jelly-like contents of the disc then move into the spinal canal, pressing against the spinal nerves, thus producing intense and usually disabling pain and other symptoms.[citation needed]" This use is 'citation needed" is particularly moronic. While the long term context for risk is hard to define, there is little doubt when that visceral effusion of jelly is felt, followed immediately by debilitating pain and poor mobility, that protrusion turned directly to prolapse! Anyone who imagines that this event is a fiction until proven otherwise writes like a 'doctor' who is paid by a government to force invalids into work to satisfy a coarse ideology while ignoring any pain they do not themselves feel. I wonder if the writer of such lazy denial might be convinced if I personally attended his back with a leap onto it from behind while he was sitting hunched over while putting his shoes on in the morning. 'Citation needed' has its place, but foolish denial makes a mockery of a strongly evident reality. Documentation of the actual mechanics and results of a prolapse are surely in reach of any doctor, they do not become fake just because some Wikipedia reader doesn't want to beleive it! — Preceding unsigned comment added by 86.180.234.159 (talk) 07:31, 16 March 2012 (UTC)

I am summarizing the deposition of an experienced neurosurgeon. He says that the vast majority of his patients with herniations DO NOT REPORT a specific physical activity or mention the pain began after an inoculous activity, like coughing or bending over to pick up a paperclip. He said the primary factor in herniation is a congenital, genetic weakness of the disc material. Therefore, it is NOT ACCEPTED that people in certain types of jobs or regularly performing certain types of activities are causing herniations. Unless a credible source can be cited, these assertions need to be removed. Strenuous or improperly-performed activities can cause other damage to the spine, but are not significant in herniation.99.122.89.227 (talk) 06:09, 1 March 2013 (UTC)

Hidden references moved to talk
I'm not sure why these were added, nor left since. --Ronz (talk) 02:51, 30 April 2013 (UTC)
 * 1.Karajan, Nils. "Multiphasic Intervertebral Disc Mechanics: Theory and Application." Archives 	of Computational Methods in Engineering 19.2 (2012): 261-339. ABI/INFORM 	Complete. Web. 27 Jan. 2013.
 * 2.Dworkin, G. E. "Advanced Concepts in Interventional Spine Care." Journal of American 	Osteopathic Association 3rd ser. 102.9 (2002): 58-61. Academic Search Premier 	(EBSCO). Web. 27 Jan. 2013.
 * 3.Morrone, Lisa, P.T. Overcoming Back and Neck Pain. Pg 70Eugene: Harvest House, 2008. Print.
 * 4.Morrone, Lisa, P.T. Overcoming Back and Neck Pain. Pg 72 Eugene: Harvest House, 2008. Print.

Request that more information be added.
I am requesting that information be added about herniated discs which have fragmented and the fragments have become trapped in the sacrum (or wherever they may migrate). This is a condition which definitely requires surgery. The fragments can do additional damage to the spine by compressing the spinal cord, nerves which exit from the spinal cord, and other areas. The injury can damage areas by physical pressure or an inflammatory response. This is a serious medical/surgical emergency and can cause permanent damage and/or chronic pain. It can be disabling because of lack of muscle control and/or intractable pain. There is also a danger that the surgery to remove these fragments can do further damage.

It seems to be difficult to find information on this injury and the consequences of the injury. I do not know if this is because it is not as common as a simple herniated disc, or because there may not be much known about the condition, or some other reason. I do know from personal experience that this can be a permanently disabling sequence of events. In some places doctors may not consider this possibility when the patient presents with extreme leg and foot pain (but no back pain).--Antigone2 05:06, 21 January 2007 (UTC)


 * Please feel free to add information from verifiable and reliable sources. Your concern is shared by others, but we have the same limitations as yourself, we have to use verifiable and reliable information.  You may also have another concern with minority POV, but I personally don't have a probelm with your adding whatever information you have, just make sure it is presented NPOV and does not advocate any particular POV. --Dematt 16:04, 21 January 2007 (UTC)


 * Can you provide us with some form of documentation for your condition? Do you have any references from the medical literature we could read? -- Fyslee 10:14, 22 January 2007 (UTC)


 * Sounds like a sequestrated (prolapsed intervertebral) disc. That would do for the 4th picture in the main illustration.  I'd not expect it to migrate to the sacrum if it is above L5/S1 Midgley 21:39, 28 January 2007 (UTC)

Request more information on herniated disks in the thoracic spine. Why is it left out? Though it is a small percentage it does happen. — Preceding unsigned comment added by 72.86.46.251 (talk) 03:31, 30 October 2013 (UTC)

Section Treatment / Subheading Surgical Options / Item Chemonucleolysis
Could someone please correct the link referenced here as it no longer directs to the page on Chemonucleolysis but now redirects to Chymopapain which is a commercial product no longer being produced. Also, a Chemonucleolysis whilst not involving the scalpel is considered to be a Surgical Treatment which should only really be administered by a Neurosurgeon. I speak from personal experience here in Europe. — Preceding unsigned comment added by 77.92.72.214 (talk) 13:16, 22 November 2013 (UTC)