Disc Herniation


Article Author:
Scott Dulebohn
Ruben Ngnitewe Massa


Article Editor:
Fassil Mesfin


Editors In Chief:
William Gossman


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
8/1/2019 7:50:36 AM

Introduction

In the spine, a disc or a nucleus pulposus is localized between vertebral bodies. It supports the spine by acting as a shock-absorbing cushion. A herniated disc in the spine is a condition during which a nucleus pulposus is displaced from intervertebral space. In some instances, a herniated disc can compress the nerve or the spinal cord that causes pain consistent with nerve compression or spinal cord dysfunction also known as myelopathy.[1][2][3]

Etiology

An intervertebral disc is composed of annulus fibrous which is a dense collagenous ring encircling the nucleus pulposus. Disc herniation occurs when part or all the nucleus pulposus protrudes through the annulus fibrous. The most common cause of disc herniation is a degenerative process in which as humans age, the nucleus pulposus becomes less hydrated and weakens. This process will lead to progressive disc herniation that can cause symptoms. The second most common cause of disc herniation is trauma. Other causes include connective tissue disorders and congenital disorders such as short pedicles. Disc herniation is most common in the lumbar spine followed by the cervical spine. A high rate of disc herniation in the lumbar and cervical spine can be explained by an understanding of the biomechanical forces in the flexible part of the spine. The thoracic spine has a lower rate of disc herniation.[4][5]

Epidemiology

The incidence of herniated disc is about 5 to 20 cases per 1000 adults annually and is most common in people in their third to the fifth decade of life, with a male to female ratio of 2:1[6].

Pathophysiology

The pathophysiology of herniated discs is believed to be a combination of the mechanical compression of the nerve by the bulging nucleus pulposus and the local increase in inflammatory chemokines.

Herniation is more likely to occur posterolaterally, where the annulus fibrosus is thinner and lacks the structural support from the anterior or posterior longitudinal ligaments. Because of the proximity to the nerve roots, a posterolateral herniation is more likely to compress the nerve root and to produce radiculopathies in the associated dermatome. On the other hand, spinal cord compression and clinical myelopathy can occur if there is herniation of a large midline disc. The localized back pain is a combination of the herniated disc pressure on the longitudinal ligament, and chemical irritation due to local inflammation.

History and Physical

Cervical Spine

History

In the cervical spine, the C6-7 is the most common herniation disc that causes symptoms, mostly radiculopathy. History in these patients should include the chief complaint, the onset of symptoms, where the pain starts and radiates. History should include if there are any past treatments.

Physical examination

On physical examination, particular attention should be given to weaknesses and sensory disturbances, and their myotome and dermatomal distribution. The examiner should also pay attention at this point to any sign of spinal cord dysfunction.

Table 1: Typical findings of solitary nerve lesion due to compression by herniated disc in cervical spine

  • C5 Nerve - neck, shoulder, and scapula pain, lateral arm numbness, and weakness during shoulder abduction, external rotation, elbow flexion, and forearm supination. The reflexes affected are the biceps and brachioradialis.
  • C6 Nerve - neck, shoulder, scapula, and lateral arm, forearm, and hand pain, along with lateral forearm, thumb, and index finger numbness. Weakness during shoulder abduction, external rotation, elbow flexion, and forearm supination and pronation is common. The reflexes affected are the biceps and brachioradialis.
  • C7 Nerve - neck, shoulder, middle finger pain are common, along with the index, middle finger, and palm numbness. Weakness on the elbow and wrist are common, along with weakness during radial extension, forearm pronation, and wrist flexion may occur. The reflex affected is the triceps.
  • C8 Nerve - neck, shoulder, and medial forearm pain, with numbness on the medial forearm and medial hand. Weakness is common during finger extension, wrist (ulnar) extension, distal finger flexion, extension, abduction, and adduction, along with during distal thumb flexion. No reflexes are affected.
  • T1 Nerve - pain is common in the neck, medial arm, and forearm, whereas numbness is common on the anterior arm and medial forearm. Weakness can occur during thumb abduction, distal thumb flexion, and finger abduction and adduction. No reflexes are affected.

Lumbar Spine

History

In the lumbar spine, herniated disc can present with symptoms including sensory and motor abnormalities limited to specific myotome. History in these patients should include chief complaints, the onset of symptoms, where the pain starts and radiates. History should include if there are any past treatments.  

Physical Examination

A careful neurological examination can help in localizing the level of the compression. The sensory loss, weakness, pain location and reflex loss associated with the different level are described in Table 2.

Table 2. Typical findings of solitary nerve lesion due to compression by herniated disc in lumbar spine

  • L1 Nerve - pain and sensory loss are common in the inguinal region. Hip flexion weakness is rare, and no stretch reflex is affected.
  • L2-L3-L4 Nerves  - back pain radiating into the anterior thigh and medial lower leg; sensory loss to the anterior thigh and sometimes medial lower leg; hip flexion and adduction weakness, knee extension weakness; decreased patellar reflex.
  • L5 Nerve - back, radiating into buttock, lateral thigh, lateral calf and dorsum foot, great toe; sensory loss on the lateral calf, dorsum of the foot, web space between first and second toe; weakness on hip abduction, knee flexion, foot dorsiflexion, toe extension and flexion, foot inversion and eversion; decreased semitendinosus/semimembranosus reflex.
  • S1 Nerve - back, radiating into buttock, lateral or posterior thigh, posterior calf, lateral or plantar foot; sensory loss on posterior calf, lateral or plantar aspect of foot;  weakness on hip extension, knee flexion, plantar flexion of the foot; Achilles tendon; Medial buttock, perineal, and perianal region; weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction.
  • S2-S4 Nerves - sacral or buttock pain radiating into the posterior aspect of the leg or the perineum; sensory deficit on the medial buttock, perineal, and perianal region; absent bulbocavernosus, anal wink reflex.

The straight leg raise test: With the patient lying supine, the examiner slowly elevates the patient’s led at increasing angle, while keeping the leg straight at the knee joint. The test is positive if it reproduces the patient’s typical pain and paresthesia.

The contralateral (crossed) straight leg raise test: As in the straight leg raise test, the patient is lying supine, and the examiner elevates the asymptomatic leg. The test is positive if the maneuver reproduces the patient's typical pain and paresthesia. The test has a specificity greater than 90%.

Evaluation

Over 85% patients with symptoms associated with acute herniated disc will resolve within 8 to 12 weeks without any specific treatments. However, patients who have an abnormal neurological examination or refractory to conservative treatments will need further evaluation and treatments.[7][8][9]

X-rays: These are very accessible at most clinics and outpatient offices. This imaging technique can be used to assess for any structural instability. If x-rays show an acute fracture, it needs to be further investigated using CT scan or MRI.

CT Scan: It is preferred study to visualize bony structures in the spine. It can also show calcified herniated discs. It is less accessible in the office settings compared to x-rays. But, it is more accessible than MRI. In the patients that have non-MRI comparable implanted devices, CT myelography can be performed to visualize herniated disc.

MRI: It is the preferred and most sensitive study to visualize herniated disc. MRI findings will help surgeons and other providers plan procedural care if it is indicated.

Treatment / Management

Conservative Treatments: Acute cervical and lumbar radiculopathies due to herniated disc are primarily managed with non-surgical treatments. NSAIDs and physical therapy are the first-line treatment modalities. Translaminar epidural injections and selective nerve root blocks are the second line modalities. These are good modalities for managing disabling pain. Patients who fail conservative treatment or patients with neurological deficits need timely surgical consultation.   [10][11][12][13]

Surgical Treatments: As always surgical treatment is the last resort. Surgical treatments for a herniated disc include laminectomies with discectomies depending on the cervical or lumbar area. In addition, a patient with a herniated disc in the cervical spine can be managed via an anterior approach that requires anterior cervical decompression and fusion. This patient can also be managed with artificial disks replacement. Other alternative surgical approaches to the lumbar spine include a lateral or anterior approach that requires complete discectomy and fusion.

Pearls and Other Issues

Thoracic spine herniated disc usually presents with radiculopathy symptoms or myelopathic symptoms depending on the compression of the nerve roots or spinal cord, respectively. As in the cervical and lumbar spine, patients initially are managed conservatively. A patient who has progressive myelopathic symptoms or does not respond to conservative treatment can be managed surgically. The surgical approach for thoracic spine includes the transthoracic or costotransversectomy approach for discectomies and fusion.

Enhancing Healthcare Team Outcomes

Disc herniation is a common problem encountered by the primary care provider, nurse practitioner, emergency department physician and the internist. The management of disc herniation is not satisfactory and thus a multidisciplinary team needs to be involved. The initial treatment should be conservative, unless a patient has severe neurological compromise. Surgery is usually the last resort as it does not always result in predictable results. Patients are often left with residual pain and neurological deficits, which are often worse after surgery. Physical therapy is the key for most patients. The outcomes depend on many factors but those who particpate in regular exercise and maintain a healthy body weight have better outcomes than people who are sedentary.[14][1][15][6]


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Disc Herniation - Questions

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A 35-year-old male presents to the clinic with sudden onset back and leg pain. It started after he lifted a heavy bag. Which is true about lumbar disc herniation?



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At what segments are lumbar disc herniations least common?



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A left sided disc herniation at the L5-S1 level will present with which of the following?



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Which nerve root is involved with disk herniation between L4 and L5?



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What is the best imaging study for L5 disk herniation?



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A posterolateral herniation of the intervertebral disk at disk level L4-L5 may affect which nerves?



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In blunt trauma, which cervical disc is most like to herniate?



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A patient presents with acute severe back pain after trying to catch a falling heavy object. The patient has positive straight leg raise, paraspinous muscle spasm, and absent Achilles deep tendon reflex (DTR). Which of the following is the most likely diagnosis?



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A patient complains of left-sided low back pain with radiation down the left leg. The pain started after moving heavy furniture. The patient had a slipped disc 5 years ago that was treated with rest and pain medication. Which of the following would not be expected on physical exam?



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A posterolateral herniation of the intervertebral disk at disk level L4-L5 affects which of the following nerves?



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A patient presents with acute severe back pain after trying to catch a falling heavy object. The patient has positive straight leg raise, paraspinous muscle spasm, and absent Achilles deep tendon reflex. Which of the following is the most likely diagnosis?



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A 40-year-old man complains of left sided low back pain with radiation down the left leg. The pain started after moving heavy furniture. The patient had a slipped disc 5 years ago that was treated with rest and pain medication. Which of the following would not be expected on physical exam?



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A 65-year-old male complains of back pain with pain radiating down the left leg. Exam is remarkable for decreased ankle jerk but no weakness or sensory deficits. The patient has been on NSAIDS for 3 weeks but the pain persists. MRI shows a left L5-S1 lateral herniated disc but no other abnormalities. What should be done?



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A patient has left low back pain that radiates to the left leg. The patient is leaning to the right. What is the most likely direction of the disc herniation?



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A patient that is 24 weeks pregnant is suspected of having a herniated lumbar disc. Select the test that would not be contraindicated.



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A 34-year-old male presents with new onset of back pain starting 2 weeks ago after playing basketball. He notes pain in the lower back that radiates into the left posterior thigh. He has no point tenderness. He notes subjective weakness with left foot movements and altered sensation in the left foot. A straight leg test is positive bilaterally. He denies fevers and chills. What is the name of the test where the foot is forcefully dorsiflexed while the straight leg raise is occurring?



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Disc Herniation - References

References

Sharma SB,Kim JS, A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations. Neurospine. 2019 Mar;     [PubMed]
Huang R,Meng Z,Cao Y,Yu J,Wang S,Luo C,Yu L,Xu Y,Sun Y,Jiang L, Nonsurgical medical treatment in the management of pain due to lumbar disc prolapse: A network meta-analysis. Seminars in arthritis and rheumatism. 2019 Mar 4;     [PubMed]
Tang C,Moser FG,Reveille J,Bruckel J,Weisman MH, A Review of Cauda Equina Syndrome in Ankylosing Spondylitis: Challenges in Diagnosis, Management, and Pathogenesis. The Journal of rheumatology. 2019 Apr 1;     [PubMed]
Park CH,Park ES,Lee SH,Lee KK,Kwon YK,Kang MS,Lee SY,Shin YH, Risk Factors for Early Recurrence After Transforaminal Endoscopic Lumbar Disc Decompression. Pain physician. 2019 Mar;     [PubMed]
Huang JS,Fan BK,Liu JM, [Overview of risk factors for failed percutaneous transforaminal endoscopic discectomy in lumbar disc herniation]. Zhongguo gu shang = China journal of orthopaedics and traumatology. 2019 Feb 25;     [PubMed]
Fjeld OR,Grøvle L,Helgeland J,Småstuen MC,Solberg TK,Zwart JA,Grotle M, Complications, reoperations, readmissions, and length of hospital stay in 34 639 surgical cases of lumbar disc herniation. The bone     [PubMed]
Carlson BB,Albert TJ, Lumbar disc herniation: what has the Spine Patient Outcomes Research Trial taught us? International orthopaedics. 2019 Apr;     [PubMed]
Hassan KZ,Sherman Al, Epidural Steroids 2019 Jan;     [PubMed]
Johnson SM,Shah LM, Imaging of Acute Low Back Pain. Radiologic clinics of North America. 2019 Mar;     [PubMed]
Silvinato A,Simões RS,Buzzini RF,Bernardo WM, Lumbar herniated disc treatment with percutaneous hydrodiscectomy. Revista da Associacao Medica Brasileira (1992). 2018 Sep;     [PubMed]
Harper R,Klineberg E, The evidence-based approach for surgical complications in the treatment of lumbar disc herniation. International orthopaedics. 2019 Apr;     [PubMed]
Lavi ES,Pal A,Bleicher D,Kang K,Sidani C, MR Imaging of the Spine: Urgent and Emergent Indications. Seminars in ultrasound, CT, and MR. 2018 Dec;     [PubMed]
Alvin MD,Lubelski D,Alam R,Williams SK,Obuchowski NA,Steinmetz MP,Wang JC,Melillo AJ,Pahwa A,Benzel EC,Modic MT,Quencer R,Mroz TE, Spine Surgeon Treatment Variability: The Impact on Costs. Global spine journal. 2018 Aug;     [PubMed]
Heo DH,Sharma S,Park CK, Endoscopic Treatment of Extraforaminal Entrapment of L5 Nerve Root (Far Out Syndrome) by Unilateral Biportal Endoscopic Approach: Technical Report and Preliminary Clinical Results. Neurospine. 2019 Mar;     [PubMed]
Shen Z,Zhong ZM,Wu Q,Zheng S,Shen X,Chen J, Predictors for poor outcomes following percutaneous endoscopic lumbar discectomy: A retrospective study of 241 patients. World neurosurgery. 2019 Feb 27;     [PubMed]

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