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Lumbar Disk
Herniation
Carole A. Miller, MD, FACS
Professor, OSU Department of Neurosurgery
Epidemiology of HNP
• Low back pain (LBP) is extremely prevalent
9 2nd most common reason for seeking
medical attention
• LBP accounts for ~15% of sick leave from
work
• Most common cause of disability in <45 yrs
• Lifetime prevalence range 60-90% and
annual incidence 5%
Epidemiology of HNP
• ~85% of cases of LBP no dx can be made
• The prognosis for most LBP is good even
with little or no medical intervention
• 1% have nerve-root symptoms, and 1-3%
have lumbar disk herniation
Definitions/Classifications
9 Radiculopathy
• Dysfunction of the nerve root. Signs
and symptoms may include: pain in
the distribution of that nerve root,
dermatomal sensory disturbances,
weakness of the muscles innervated
by that nerve root and hypoactive
muscle stretch reflexes on the same
muscles
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Definitions/Classifications
9 Mechanical Low Back Pain
• AKA “musculoskeletal” back pain
(both non-specific terms). The most
common form of LBP. May result from
strain of the paraspinal muscles
and/or ligaments, irritation of facet
joints… Excludes anatomically
identifinable causes (e.g. tumor, disc
herniation, etc….)
Nomenclature for Disk
Pathology
Nomenclature for Disk
Pathology
• Degenerated disc: may cause radicular
pain possibly by an inflammatory
mechanism but not universally
accepted
• Bulging disk: may or may not be
symptomatic
• Vacuum disk: Imaging findings of gas
in the disk space, usually indicates
disk degeneration
Conditions Requiring
Immediate Attention:
Condition
9 Historically, terminology has been
contentious and nonstandardized. Many
diagnostic labels are used
inconsistently (e.g. spondylosis, sprain,
strain, musculoskeletal pain, myofascial
pain…)
Cancer or infection
“Red Flags”
1.Age > 50 or < 20 yrs.
2.History of cancer
3.Unexplained weight loss
4.Immunosuppression
5.UTI, IV drug abuse, fever or chills
6.Back pain not improved with rest
Spinal fracture
1.History of trauma
2.Prolonged use of steroids
3.Age > 70
Cauda Equina
Syndrome or other
severe neurologic
compromise
1. Acute onset of urinary retention of overflow
incontinence.
2. Fecal incontinence of loss of anal sphincter tone
3. Saddle anesthesia
4. Global or progressive weakness in the LEs
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Normal Lumbar
Anatomy
Pathophysiology of HNP
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•
Normal Lumbar
Anatomy
The nucleus pulposis may herniate in any direction.
1st herniation is into tears in the concentric rings of the annulus
fibrosis, eventually causing remaining outer rings to bulge focally
(disk protrusion). If the process continues, the nuclear material may
then escape from the disk (disk extrusion) to lie just anterior to the
posterior ligament (subligamentous disk herniation), or lie free in the
spinal canal (free fragment disk herniation.)
Clinical History of HNP
• Back pain most common symptom but least
useful in making diagnosis
• Differential diagnosis of back pain is enormous
with HNP only a fraction of the cases
• May resolve later in the course of the disease to
be replaced by extremity weakness and
numbness
• Character of back pain may give a clue to
underlying disease process
9 Improved by flexion suggests lumbar stenosis
9 Exacerbated by flexion suggests instability or
advanced disk degeneration
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Clinical History of HNP
• Leg pain common in HNP
9 Hip and buttock pain also frequent their
presence rarely helps to localize the problem
9 Hip pain must be differentiated from hip joint
pathology, especially if radiation to the groin
• Most common radicular leg pain is “sciatica”
9 Deep stabbing pain in posterior thigh and calf.
Worse with standing or walking
9 More severe radicular pain is better localized
accompanied by numbness in an identifiable
nerve
9 Exacerbation by coughing or Valsalva also
suggests radiculopathy
Lumbar Disk Herniation
Lumbar Disk Herniation
9 Suspected benign conditions with symptoms
persisting beyond 4 weeks of great enough
severity to consider surgery including:
• Back related leg symptoms and clinically
specific signs of nerve root compromise
• History of neurogenic claudication or other
findings suggestive of lumbar spinal
stenosis
9 “Red flags”: physical examination or other
test results suggesting other serious
conditions affecting the spine (e.g. Cauda
equina syndrome, fracture, infection, tumor,
or other mass lesions or defects)
Clinical Examination
Standing
Sitting on table Lying of table
• Radiologic Evaluation
9 In the absence of “red flags” for serious
conditions imaging studies should be
considered within a month of onset of
symptoms if they persist or are not
improving.
9 MRI probably the best. If previous
surgery then with & without contrast.
1. Body build, posture
2. Deformities, spinal
alignment
3. Spinal column
movement (Flexion,
extension, rotation)
4. Walking on toes
(Plantar flexion)
5. Walking on heels
(dorsiflexion of feet and
extension of great toe)
1. Straight leg raising
2. Knee jerks
3. Ankle Jerks
4. Strength of hip
flexion, knee extension,
great toe extension and
foot plantar flexion
Supine:
Straight leg raining test:
1.
Flex hip with knee
extended (Sciatic
nerve stretch)
2.
2. Flex hip with
knee flexed
Prone:
Spine extension
Hip extension
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Clinical features of unilateral
lumbar HNP by Level
Disk Level
L3-4
L4-5
L5-S1
Root usually
compressed
L4
L5
S1
% lumbar disks
5%
40-45%
45-50%
Reflex
knee
Medial hamstring
ankle
Weakness
Quadriceps femoris
(Extension of knee)
Tibialis anterior
(Foot drop and
extension of great
toe)
Gastrocnemius
(Plantar flexion of
ankle)
Sensory deficit
Medial malleolus
&medial foot
Great toe web &
dorsum of foot
Lateral malleolus &
lateral foot
Pain distribution
Anterior thigh
Posterior lower
extremity
Posterior lower
extremity, often to
ankle
MRI Lumbar Spine
1) 5 Lumbar Vertebrae
Lumbar MRI Scan
MRI: L4-5 Lumbar
Disk Herniation
2) A lot more motion than the thoracic spine
3) Carries the weight of the torso
4) Most frequently injured area of the spine
• The usual posteriolateral disk herniation
compresses the ipsilateral nerve root at its exit
from the dural sac, rather than the neural
foramen.
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MRI: L4-5 Lumbar
Disk Herniation
Herniated
Lumbar Disc
Guide To Treatment
Gary Rea MD PhD
• If the disk herniation is more lateral it compresses the
ipsilateral nerve root exiting through the adjacent neural
foramen. A far lateral disk herniation for instance
compresses the L4 nerve root
Lumbar Myelogram
of HNP
Dept of Neurosurgery OSU
Herniated Disc
Treatment
• Natural history
• Education
• Non-invasive treatment
• Invasive-non-surgical
• Surgical
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Herniated Disc
Natural History
• Fragment dessicates
• Inflammatory substances decrease
Herniated Disc
Treatment
• Non-Invasive Activity
9 Bedrest-Short periods for severe pain
• Pain decreases
9 Work-Return quickly, modify activity
• At 2 years 85% better (same as
surgery)
9 Key Factor-Keep working up to
surgery if you can
Herniated Disc
Treatment
• Education-most important
9 Herniated disc does not equal surgery
9 Herniated disc does not equal
disability
9 Herniated disc natural history improvement
Herniated Disc
Treatment
• Medications
9 Nsaid or tylenol
9 Oral steroids
9 Pain meds
9 Muscle relaxers
9 Nerve activity inhibitors
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Herniated Disc
Treatment
Herniated Lumbar
Disc Treatment
• Opioids
• Nsaids
9 Use cheapest-naproxen
9 Risk-gi and renal
9 Tylenol-if gi problems and mild pain
9 Percocet, vicodin
9 Use cheapest and lowest dose
9 If not effective after 1-2 weeks then
evaluate further
9 Avoid oxycontin
Herniated Disc
Treatment
• Oral steroids
Herniated Disc
Treatment
• Muscle relaxants
9 Excellent for pain relief
9 Use cheapest, useful for sleep
9 Risks-avn hips, ulcers, anxiety
9 Flexoril
9 Dose-60-80 3 days, 40-60 2 days, 2030 1day, 10 for 1 day and stop
9 Avoid valium unless severe
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Herniated Disc
Treatment
• Nerve activity inhibitors
Herniated Disc
Treatment
• Invasive-non-surgical
9 Neurontin
9 Epidural steroids
9 Start low doses at night 300mg qhs
for 3-5 days, then bid for 3 days,
then tid
9 Success rate- 50%
Herniated Disc
Treatment
• Physical therapy
• Passive-heat, massage, ultrasound
• Active-exercises-avoid those that hurt
while they are being done
9 Risks-small
Herniated Disc
Treatment
• Decompressive therapy-traction
9 Cost-$4000-$5000 at some places
9 Insurance often won’t pay
9 Data on success-no data showing it
is superior to natural history or
standard therapy
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Herniated Disc
Treatment
• Surgical treatment-laser discectomy
When to refer to
surgeon
• Radiculopathy-+slr, mri shows hnp that
fits with clinical syndrome
9 Intradiscal-does not treat fragment and
no data is superior to natural history or
standard treatments
• Failure to improve
9 Open laser surgery-increases cost and
no evidence of any superiority
• Pain continues severe or weakness by
exam
• Not working > 1 month
• Pain improves, but effects quality of life
Herniated Disc
Treatment
• Microdiscectomy-gold standard
9 Small incision, microscope
9 Deals with fragment and intradiscal
material
9 Outpatient
9 Success rate 85%-advantage to natural
history-faster relief
Summary
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Educate, educate, educate
Bedrest-only for severe radiculopathy
Keep working
Oral steroids if radiculopathy
Use variety of meds for pain
Avoid oxycontin
Use pt, esi as needed
Microdiscectomy-gold standard
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