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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 1 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 2 Normal Lumbar Anatomy Pathophysiology of HNP • • 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 3 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 4 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. 5 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 6 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 7 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 8 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 9 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 • • • • • • • • 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 10