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Herniated Disc

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Other Names

  • Lumbar Disc Herniation (LDH)
  • Thoracic Disc Herniation
  • Disc Disease
  • Disc Herniation
  • Herniated Nucleus Pulposus (HNP)
  • Degenerative Disc Disease
  • LDH with radiculopathy
  • Lumbar Intervertebral Disc Herniation (IDH)

Background

  • This page refers to all causes of thoraco-lumbar disc disease
    • Can be acute or chronic

History

Epidemiology

  • As much as 80% of people develop lower back pain during their lifetime[1]
  • Nearly all involve L4/5 or L5/S1 levels (need citation)
  • Peak incidence 4th, 5th decade of life (need citation)
  • Males more common than females by a ratio of 3:1 (need citation)

Pathophysiology

  • Dehydration is known to contribute to degenerative disc disease[2]
  • Axial Overloading
    • Not all cases are degenerative, insidious disc disease
    • Static overloading, as opposed to physiologic and dynamic overloading, put the disc at risk for posterior herniation[3]
  • Inflammation
    • The role of inflammatory signaling in producing nerve pain in LDH has been well-established
  • Propionibacterium acnes
    • Gram-positive, facultative anaerobic, fastidious bacterium, which may play a central role in LDH[4]
    • Normally associated with superficial skin infections, most notably ace
    • 2001 study: 53% of patients had gram positive anaeorbes, of which 84% were P. acnes[5]
    • Aghazadeh et al: P. acnes DNA correlates to vertebral edema on preoperative MRI[6]
    • In rabit models, Chen et al demonstrated the bacteria induced disc degeneration[7]
    • Other studies have failed to reproduce these findings and more research is needed
  • Acidosis
    • Cuesta et al: pH of degenerative discs is ~1.0 less than that of healthy discs[8]

Pathoanatomy

  • Intervertebral Disc
    • Consists of inner nucleus pulposus (NP), outer annulus fibrosis (AF)
    • NP: comprised of collagen, proteoglycans, acts to resist axial compression of the spine[9]
    • AF: Composed of type I collagen, supports and maintains the NP
    • Tearing of AF leads to protrusion of NP
  • Posterior Longitudinal Ligament (PLL)
    • Helps stabilize discs posteriorly

Associated Conditions


Risk Factors

  • Genetic

Differential Diagnosis


Clinical Features

  • General: Physical Exam Back
  • History
    • Clasically presents as lower back pain
    • Patients may endorse radicular features, sensory abnormalities and weakness
    • Symptoms may be worse with straining, coughing, sneezing[11]
    • May be worse with sitting, improved with standing
  • Physical Exam
    • Affected dermatome varies based on level of herniation
  • Findings based on level of radiculopathy
    • L3: Hip adduction weakness
    • L4: Knee extension weakness, decreased patellar DTR
    • L5: weakened ankle dorsiflexion, inversion, EHL and hip abduction
    • S1: Weakned plantarflexion, decreased achilles DTR
  • Special Tests
    • Straight Leg Test (SLRT): Elevation of leg while supine or seated recreates radicular pain
    • Contralateral SLRT: Recreates symptoms by raising contralateral leg
    • Lesegue sign: SLRT worse with forced ankle dorsiflexion
    • Bowstring sign: During SLRT, apply pressure to tibial nerve in popliteal fossa
    • Kernigs Sign: pain reproduced with neck flexion, hip flexion, and leg extension

Clinical Diagnosis

  • Initial screening with a positive straight leg test + 3 out of 4 of the following symptoms is sufficient for clinical diagnosis[12]
    • Dermatomal pain, sensory deficits, reflex deficits, and/or motor weakness

Evaluation

Radiographs

MRI

  • Gold standard to confirm lumbar disc herniation, typically without contrast
    • Diagnostic accuracy of 85-97%[13]
  • Findings
    • Increased T2-weighted signal from the posterior 10% of the disc diameter[14]
  • Diffusion tensor imaging (DTI) can be used to detect microstructural changes in the nerve root
  • High rate of abnormal findings in asymptomatic individuals
  • Indications for obtaining MRI
    • Pain lasting >6-12 weeks not responding to normal conservative therapy
    • Presence of red flags

Modic Changes

  • Represent pathologic changes to the vertebral body
  • Type 1: vascular developments in the vertebral body including inflammation and edema
    • correlate significantly with degree of degenerative disc disease
  • Type 2: fatty replacement of the vertebral bone marrow
  • Type 3: fractures or changes of the trabecular bone of the vertebrae

CT

  • With myelography, diagnostically equivalent to MRI for lumbar disc herniation[15]
  • Useful in patients who can not receive MRI

Classification

Location

  • Central prolapse
    • Associated with back pain only, cauda equina syndrome
  • Posterolateral (paracentral)
    • Represents >90% of cases due to weak PLL
    • Affects descending or lower nerve root
  • Foraminal (far lateral, extraforaminal)
    • Less common, affecting 5-10% of cases
    • Affects exiting or upper nerve root
  • Axillary
    • Can affect both upper and lower nerve root

Anatomic

  • Protrusion: eccentric bulging, intact annulus
  • Extrusion: disc material herniates through annulus, remains continuous with disc space
  • Sequestered fragment: disc material herniates through annulus, no longer continuous with disc space

Management

Prognosis

  • Gugliotta et al: equivalent medium- and long-term outcomes for conservative and surgical treatment of LDH[16]
  • Other studies have demonstrated improved 1- and 2-year outcomes in the surgical treated group when compared to conservatively managed patients
  • Disc herniation >6.31 mm likely to benefit from surgical intervention
  • Surgery: Improved short term, unclear medium- and long-term benefits[17]
  • One study found that microdiscectomy of L4-5 LDH resulted in superior patient reported outcomes compared to non-operative management[18]
  • 90% of patients will improve at 3 months with non-operative care (need citation)
  • Herniated disc is reabsorbed over time and decreases in size

Nonoperative

  • Treatment of choice for the majority of patients
  • Very brief period of rest following by increasing activity as tolerated
  • Medications
  • Physical Therapy
    • Jewell et al: Emphasis on exercise, core strengthening and jonit mobility improved symptoms of LDH[19]
    • Patients undergoing PT have higher baseline disability score, prefer non operative treatment, more likely to have neurological deficit[20]
  • Corticosteroid Injection (CSI)
    • Widely varied success rates from 20% to 95%[21]
    • Thought to be due be more beneficial in acutely herniated discs, where a true inflammatory response is occurring.
    • Provide short term improvement in radicular pain, sensory symptoms
    • Likely do not reduce rate of surgical intervention, provide any functional benefit[22]
    • Disc herniation <6.23 mm more likely to do well with CSI
  • Spinal Traction
    • One small study showed improvement in 28 day outcomes, however no control arm[23]
  • Spinal Manipulation Therapy
    • Consider chiropractor, massage therapy
  • Platelet Rich Plasma (PRP)
    • Several studies have reported improvement in clinical scores 1 month post PRP injection[24]

Operative

  • Predictors of good surgical outcome
    • Better mental health status[25]
    • Shorter symptom duration[26]
    • Younger age[27]
    • Increased preoperative physical activity
    • Severe preoperative low back pain
  • Factors that do not affect surgical outcome
    • Motor deficit
    • Vertebral level or side of herniation
    • Gender
    • Presence of type I modic changes
  • Indications
  • Technique
    • Microdiscectomy: laminotomy, discectomy
    • Percutaneous lumbar foraminoplasty
    • Far lateral microdiscectomy
    • Open Discectomy

Rehab and Return to Play

Rehabilitation

  • Emphasis on core strengthening, extension exercises

Return to Play

  • Athletes with herniated lumbar disks should rest 6 to 12 weeks following surgical treatment, while those with spinal fusion should wait 1 year to return to activity[28]

Complications

  • Cauda Equina Syndrome (CES)
    • Rare, devastating
    • Risk factors for dveloping CES: diabetes, acute onset of symptoms, L3-L4 involvement, sequestrated discs (fully separated NP from AF), superiorly migrated discs, posterior herniation, primary canal stenosis, and greater canal compromise[29]
  • Dural Tear
    • Rate of 1-17%
    • Increases hospitilization cost, wound dehiscience, post op infection, worsening function, nerve injury[30]
  • Recurrent herniation risk factors[31]
    • Pre-operative disc height index
    • Trauma
    • Older age
    • Smoking
    • Disc protrusion
    • Disc sequestration
    • Longer duration of sick leave
    • Workers’ compensation
    • Greater preoperative symptom severity
    • Diabetes Mellitus
  • Discitis
  • Vascular injury (vena cava or aorta)

See Also


References


  1. Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354(9178):581–585.
  2. Brayda-Bruno M, Tibiletti M, Ito K, et al. Advances in the diagnosis of degenerated lumbar discs and their possible clinical application. Eur Spine J. 2014;23(SUPPL. 3):315–323.
  3. Paul CPL, de Graaf M, Bisschop A, et al. Static axial overloading primes lumbar caprine intervertebral discs for posterior herniation. PLoS One. 2017:1–23
  4. Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy. Eur Spine J. 2013;22(4):697–707.
  5. Stirling A, Worthington T, Rafiq M, Lambert PA, Elliott TSJ. Association between sciatica and Propionibacterium acnes. Lancet. 2001;357(9273):2024–2025. doi: 10.1016/S0140-6736(00)05109-6.
  6. Aghazadeh J, Salehpour F, Ziaeii E, Javanshir N. Modic changes in the adjacent vertebrae due to disc material infection with Propionibacterium acnes in patients with lumbar disc herniation. Eur Spine J. 2016;
  7. Chen Z, Zheng Y, Yuan Y, et al. Modic changes and disc degeneration caused by inoculation of Propionibacterium acnes inside intervertebral discs of rabbits: a pilot study. Biomed Res Int. 2016;2016.
  8. Cuesta A, Del Valle ME, García-Suárez O, et al. Acid-sensing ion channels in healthy and degenerated human intervertebral disc. Connect Tissue Res. 2014;55(3):197–204.
  9. Kadow T, Sowa G, Vo N, Kang JD. Molecular basis of intervertebral disc degeneration and herniations: what are the important translational questions? Clin Orthop Relat Res. 2015;473(6):1903–1912.
  10. Shapiro S. Cauda equina syndrome secondary to lumbar disc herniation. Neurosurg 1993; 32: 743–747.
  11. Vroomen P, de Krom M, Wilmink J, Kester A, Knottnerus J. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry. 2002;72(5):630–634.
  12. Petersen T, Laslett M, Juhl C. Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskelet Disord. 2017;18(1):188.
  13. Kim KY, Kim YT, Lee CS, Kang JS, Kim YJ. Magnetic resonance imaging in the evaluation of the lumbar herniated intervertebral disc. Int Orthop. 1993;17(4):241–244.
  14. Messner A, Stelzeneder D, Trattnig S, et al. Does T2 mapping of the posterior annulus fibrosus indicate the presence of lumbar intervertebral disc herniation? A 3. 0 Tesla magnetic resonance study. Eur Spine J. 2017;26:877–883.
  15. Janssen ME, Bertrand SL, Joe C, Levine MI. Lumbar herniated disk disease: comparison of MRI, myelography, and post-myelographic CT scan with surgical findings. Orthopedics. 1994;17(2):121–127
  16. Gugliotta M, Costa BR, Dabis E, et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open 2016:1–7. 10.1136/bmjopen-2016-012938.
  17. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation. JAMA. 2006;296(20):2441.
  18. Osterman H, Seitsalo S, Karppinen J, Malmivaara A. Effectiveness of microdiscectomy for lumbar disc herniation. Spine (Phila Pa 1976) 2006;31(21):2409–2414.
  19. Jewell DV, Riddle DL. Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica. Phys Ther. 2005;85(11):1139–1150.
  20. Thackeray A, Fritz J, Lurie J, Zhao W, Weinstein J. Nonsurgical treatment choices by individuals with lumbar intervertebral disc herniation in the United States: associations with long-term outcomes. Am J Phys Med Rehabil. 2016:1–8.
  21. Kepes ER, Duncalf D. Treatment of backache with spinal injections of local anesthetics, spinal and systemic steroids. A review. Pain. 1985;22(1):33–47.
  22. Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336:1634–1640.
  23. Isner-Horobeti M-E, Dufour SP, Schaeffer M, et al. High-force versus low-force lumbar traction in acute lumbar sciatica due to disc herniation: a preliminary randomized trial. J Manip Physiol Ther. 2016;39(9):645–654.
  24. Levi D, Horn S, Tyszko S, Levin J, Hecht-Leavitt C, Walko E. Intradiscal platelet-rich plasma injection for chronic discogenic low back pain: preliminary results from a prospective trial. Pain Med. 2015:pnv053.
  25. Oba H, Takahashi J, Tsutsumimoto T, et al. Predictors of improvement in low back pain after lumbar decompression surgery: prospective study of 140 patients. J Orthop Sci. 2017:6–11.
  26. Tschugg A, Lener S, Hartmann S, et al. Preoperative sport improves the outcome of lumbar disc surgery: a prospective monocentric cohort study. Neurosurg Rev. 2017; 10.1007/s10143-017-0811-6.
  27. Wilson CA, Roffey DM, Chow D, Alkherayf F, Wai EK. A systematic review of preoperative predictors for postoperative clinical outcomes following lumbar discectomy. Spine J. 2016;16(11):1413–1422.
  28. Eck JC, Riley LH., III Return to play after lumbar spine conditions and surgeries. Clin Sports Med. 2004;23:367-379
  29. Krishnan V, Rajasekaran S, Aiyer SN. Clinical and radiological factors related to the presence of motor deficit in lumbar disc prolapse: a prospective analysis of 70 consecutive cases with neurological deficit. Eur Spine J. 2017.
  30. Puvanesarajah V, Hassanzadeh H. The true cost of a dural tear. Spine (Phila Pa 1976) 2017;42(10):770–776.
  31. Hegarty D, Shorten G. Multivariate prognostic modeling of persistent pain following lumbar discectomy. Pain Physician. 2012;15(5):421.
Created by:
John Kiel on 17 June 2019 15:27:30
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Last edited:
23 November 2020 15:43:33
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