HNP Normal Structure And Function

The intervertebral disc is the largest avascular structure in the body. It arises from notochordal cells between the cartilaginous endplates, which regress from about 50% of the disc space at birth to about 5% in the adult, with chondrocytes replacing the notochordal cells. Intervertebral discs are located in the spinal column between successive vertebral bodies and are oval in cross section. The height of the discs increases from the peripheral edges to the center, appearing as a biconvex shape that becomes successively larger by about 11% per segment from cephalad to caudal (ie, from the cervical spine to the lumbosacral articulation). A longitudinal ligament attaches to the vertebral bodies and to the intervertebral discs anteriorly and posteriorly; the cartilaginous endplate of each disc attaches to the bony endplate of the vertebral body. Images of herniated nucleus pulposus are provided below:

Hyaluronan long chains form a backbone for attracting electronegative or hydrophilic branches, which hydrate the nucleus pulposus and cause a swelling pressure within the annulus to allow it to stabilize the vertebrae and act as a shock absorber. Deterioration within the intervertebral disk results in loss of these water-retaining

branches and eventually in the shortening of the chains. Nuclear material is normally contained within the annulus, but it may cause bulging of the annulus or may herniate through the annulus into the spinal canal. This commonly occurs in a posterolateral

thus. which then projects toward the nerve root situated just under the pedicle. These negatively charged regions have a strong avidity for water molecules and hydrate the nucleus or center of the disc by an osmotic swelling pressure effect. The nucleus pulposus consists predominantly of type II collagen. That is. and it provides protection for the neural elements within the acceptable constraints of clinical stability. which is yellow because of the high elastin content and allows significant extensibility and flexibility of the spinal column. including a number of collagen types along with fibronectin. L4-5 has loss of disk height and some facet hypertrophy. and lumican. decorin. Each vertebra of the spinal column has an anterior centrum or body. which have regions with highly hydrophilic. hydrated nucleus within the annulus acts as a shock absorber to cushion the spinal column from forces that are applied to the musculoskeletal system. just as a shark swimming and turning in the water does not buckle its skin. which is connected by link protein to the long hyaluronan. does not affect the hydrostatic pressure of the inner portion of the disc. The centra are stacked in a weightbearing column and are supported by the intervertebral discs.location of the intervertebral disk. the nucleus pulposus. The hydraulic effect of the contained. The disc's annular structure is composed of an outer annulus fibrosus. which is a constraining ring that is composed primarily of type 1 collagen. The major proteoglycan constituent is aggrecan. and each side of the posterior elements has a facet joint or articulation to allow motion. contains the nucleus pulposus. These joints are connected at each level by the ligamentum flavum. A corresponding posterior bony arch encloses and protects the neural elements. as depicted. Decreased disk height causes decreased foramen height to the same degree. In this picture. The facet joints connect the vertebral bodies on each side of the lamina. and the superior articular facet of the caudal vertebral body may become hypertrophic and develop a spur. A fibril network. thereby encroaching on the room available for the exiting nerve root (L4). branching side chains. proteoglycan. forming the posterior arch. A herniated nucleus pulposus within the canal would embarrass the traversing root (L5). the intervertebral disc has the ability to rotate or bend without a significant change in volume and. and hyaluronan long chains. The functional segmental unit is the combination of an anterior disc and the 2 posterior facet joints. This fibrous ring has alternating layers oriented at 60° from the horizontal to allow isovolumic rotation. The spinal nerves exit the spinal canal through the foramina at each level. .

the fusion rate and outcome were found to be comparable to the results achieved with metallic plates. intervertebral discs. compared to 14% in the control group. Overall.[3] Carragee et al compared progression of common degenerative findings between lumbar discs injected 10 years earlier with those same disc levels in matched subjects who were not exposed to discography.2%) patients.[4] McGirt et al performed a prospective cohort study with standardized postoperative lumbar imaging with CT and MRI every 3 months for a year. to assess same-level recurrent disc herniation. that careful consideration of risk and benefit are necessary in regard to disc injection. revision discectomy was required at a mean of 10. The authors noted that although the findings at 2 years postoperatively suggest that arthroplasty is equivalent to arthrodesis in these cases. they did not evaluate the treatment of retrovertebral compression as occurs with ossification of the posterior longitudinal ligament. According to the authors. When the spine loses enough of these components to prevent it from adequately providing the mechanical function of protection.Clinical stability has been defined as the ability of the spine under physiologic load to limit patterns of displacement so as to avoid damage or irritation to the spinal cord or nerve roots and to prevent incapacitating deformity or pain caused by structural changes. then annually.5 months after surgery. randomized multicenter trials to evaluate the efficacy of cervical disc arthroplasty for myelopathy with a single-level abnormality localized to the disc space. 18% loss of disc height was observed.[1] Any disruption of the components holding the spine together (ie. which progressed to 26% by 2 years. In 11 (10. In this study. surgery may be necessary to reestablish stability. The authors found that patients in both the arthroplasty and arthrodesis groups had improvement following surgery. They noted.5 months postoperatively. patients who had larger anular defects and removal of smaller disc volumes had increased risk of . with 55 new disc herniations occurring in the discography group and 22 in the control group. 83% of the patients had favorable outcomes based on the Odom criteria. Progression of disc degeneration was 35% in the discography group. At 3 months after surgery. discs exposed to puncture and injection had greater progression of degenerative findings than the control (noninjected) discs. The authors found that in all graded or measured parameters. facets) decreases the clinical stability of the spine.[2] Buchowski et al performed a cross-sectional analysis of 2 large prospective. with improvement being similar and with no worsening of myelopathy occurring in the arthroplasty group. at 19. Improvement in all outcome measures was observed 6 weeks after surgery. and the authors concluded that the use of bioabsorbable plates is a reasonable alternative to metal. avoiding the need for lifelong metallic implants. The study also found significantly greater loss of disc height and signal intensity in the discography discs. therefore. The authors found that absorbable instrumentation provides better stability than the absence of a plate but that graft subsidence and deformity rates may be higher than those associated with metal implants. ligaments. Recent studies     Tomasino et al presented radiologic and clinical outcome data on patients who underwent single-level anterior cervical discectomy and fusion (ACDF) for cervical spondylosis and/or disc herniation using bioabsorbable plates for instrumentation.

the degenerating . Results showed no significant difference in relief of leg pain between the 2 approaches. based on United States Preventive Services Task Force (USPSTF) criteria. Although periosteal disruption causes pain with fractures. the indicated evidence for APLD is level II-2 for short. They therefore concluded that the MRI finding of central canal stenosis is a potential indication that CESI may be merited. As the hyaluronan long chains shorten and swelling pressure decreases as a result of this deterioration.[6] Hirsch et al did a systematic review of the literature to determine the effectiveness of automated percutaneous lumbar discectomy (APLD).[9] The water-retaining ability of the nucleus pulposus. According to the authors. concern for recurrent herniation should be increased and that. with 60-80% of people having an activity-limiting episode at least transiently in their lifetime. However. in such cases. controlled trials in the literature covering this subject.   recurrent disc herniation. The decline in the mechanical properties of the nucleus pulposus is associated with the degree of proteoglycan deterioration and the decrease in hydration. or the inner portion of the intervertebral disk. nerve root compromise. and central canal stenosis. which causes the annulus to bulge. However. bone itself is devoid of pain receptors (eg. effective anular repair may behelpful. Reoperation was more common with limited (tubular) exposure but not statistically significant and total complications did not differ. with a corresponding loss of disk and foramina height. indicating that APLD may provide appropriate relief in properly selected patients with contained lumbar disc prolapse. versus the absence.[10] The etiology of back pain for a particular individual cannot be determined because of the multiplicity of potential sources. that in cases of larger anular defects or less aggressive disc removal. neuroforaminal stenosis. declines progressively with age. the mechanical stiffness of the intervertebral disk decreases. The authors found that only the presence. men begin having LBP about a decade earlier than women. and those who had greater disc volumes removed had more progressive disc height loss by 6 months after surgery.[8] Degeneration: Process And Models Low back pain (LBP) is ubiquitous. with LBP starting at an earlier age than previously suspected on the basis of subsequent structural changes. which lead to excessive regional peak pressures within the disk.and long-term relief. The authors suggested.[5] Fish et al performed a retrospective single-center study to analyze whether MRI findings can be used to predict therapeutic responses to cervical epidural steroid injections (CESI) in patients with cervical radiculopathy. based on the findings. of central canal stenosis was associated with significantly superior therapeutic response to CESI. Genetic factors appear to have a dominant role. the authors noted that there is a paucity of randomized. asymptomatic compression fractures commonly are seen in the thoracic spine of elderly individuals with osteoporosis). Patients were categorized by the presence or absence of 4 types of cervical MRI findings: disc herniation.[7] Dasenbrock et al performed a meta-analysis of 6 trials of 837 patients comparing open discectomy with minimally invasive discectomy and found similar visual analog scale (VAS) scores at short and long-term follow-up.

therefore. however. a degenerative cascade is initiated that mimics the natural aging process observed in humans. deterioration is known to occur in both. this avascular structure is solely dependent upon motion to facilitate the diffusion of nutrients into it. which leads to the altered distribution of pressures within the disk and resistance to the flow of nuclear material. similar annular tears are seen routinely that are associated with the degeneration of the intervertebral disk. which is encountered when healthy interverterbral disks are excised anteriorly in patients having surgery because of deformity or trauma. may have the least resistance to herniating through the corner of the intervertebral disk and into the spinal canal or foramen. it is difficult to contain.intervertebral disk is known to have neurovascular elements at the periphery. the nuclear material thereby becomes mechanically unstable. as well as diminished stability. Intervertebral disk deterioration leads to decreased stiffness of the disk. homogeneous material. Injection of chymopapain into the intervertebral disk causes a repeatable and predictable degenerative cascade in the facet joints. even in patients who are asymptomatic. and decreases in the ratio of chondroitin sulfate to keratan sulfate. These clumps may be lateral to the posterior longitudinal ligament and. Disk deterioration and loss of disk height may shift the balance of weightbearing to the facet joint. Using the pituitary rongeur technique to perform a microdiscectomy on a herniated fragment necessitates a preexisting state of deterioration. Annular tears may simply be the result of aging and the degenerative cascade. which occurs over a lifetime. Natural History Much has been written concerning the process of spinal deterioration or spondylosis. this mechanism has been hypothesized as a cause of LBP through the facet joint capsule. which stiffens the disk. continued deterioration ultimately leads to restabilization of the spine by collagenization. leading to the disk bulging and disk height loss.[12] The clumping of the degenerating nuclear material can be likened to a marble held between 2 books—that is. the weakened areas in the annulus provide a path of least resistance for the nuclear material to egress. as well as through other tissues attached to and between the posterior bony elements. Surgical removal of the herniated fragments is achieved by grasping them with a pituitary rongeur. Dehydration results from shortening of the hyaluronic chains. Patients in their 50s and 60s customarily have stiffer spines but less pain than patients in their 30s and 40s who are undergoing initiation of the . thus providing a model of disk deterioration. deterioration of the state of aggregation. Whether the deterioration of the disk or that of the facet comes first has not been determined. The consistency of the nuclear material undergoes a change from a homogeneous material to clumps.[11] As the use of discography has increased for various clinical applications. However. resulting in episodic pain that is common and may be temporarily severe. illustrating the coupling between the disk and facet joints. magnetic resonance imaging (MRI) routinely reveals disk deterioration in individuals in the second or third decade of life. Immobilization by facet fusion posteriorly leads to disk deterioration. including pain fibers. This method of surgical removal is not possible with normal. When the annulus in animals is incised. Pathology studies of young patients who died as a result of trauma reveal a surprising degree of articular surface damage in the facet joints.

Radicular pain is caused by inflammation of the nerve. and compression of a sensory nerve results in numbness. but at long-term follow-up. the problem was and remains patient selection. Macrophages respond to this displaced foreign material and seek to clear the spinal canal. Spontaneous resolution of sciatica may result from shrinkage of a herniated fragment.[17] .[13. and substance P. Subsequently. but practitioners too often attribute this clinical improvement to their favorite treatments. compression of a motor nerve results in weakness. Friedenberg compared operative treatment with nonoperative treatment. below the knee) or radiculopathy. which explains the lack of correlation between the actual size of an intervertebral disk herniation or even the consequent degree of neural compression and the associated clinical symptoms. spontaneous recovery from an acute pain episode routinely occurs. as has been demonstrated in animal studies. even without surgery. the overall incidence of herniated nucleus pulposus (HNP) in patients who have new LBP onset is less than 2%.degenerative cascade. and disabling pain.[15] The Spine Patient Outcomes Research Trial (SPORT) observational cohort is similarly limited in its conclusions by crossovers: 50% of the surgery arm had surgery within 3 months and 30% of the nonsurgical group had surgery. IL-8. Weber presented a randomized. Therefore. most of these patients have deterioration of the intervertebral disk and dysfunction of the functional segmental unit. Friedenberg concluded that even recurrent severe episodes may resolve without surgery.[16] Herniation Nuclear material that is displaced into the spinal canal is associated with a significant inflammatory response. They will have LBP. 14] Nonoperative treatment yielded 3 groups of results: pain free. except that those who were treated operatively had better results at 1 year. A disk fragment that is no longer contained within the annulus but is displaced into the spinal canal has decreased hydration and deteriorated proteoglycan that can be expected to undergo further deterioration and consequent annular desiccation. radiating pain. both groups again were not statistically different. aided by macrophages and the evoked inflammatory reaction. which is associated with pain. and some will have associated leg pain but without sciatica (an intractable. so any treatment must be demonstrated as effective by positively altering the expected course without treatment. In general practice. Proportions of these groups remained similar after 5 years. Acute neural compression is responsible for dysfunction. Within 20 years of Mixter and Barr's 1934 report. controlled study (marred by dropouts in the surgery control group because of severe pain) and concluded that patient results were the same whether treated operatively or conservatively. is detected. Furthermore. essentially like a grape being transformed into a raisin. and tumor necrosis factor (TNF) alpha. Disk injury results in an increase in the proinflammatory molecules interleukin-1 (IL-1). Patients who ask if they have to live with this pain "for the rest of their lives" can be reassured to some extent by this natural history. occasional residual pain. a significant scar is produced. Intractable symptoms of sciatica from intervertebral disk displacements may benefit dramatically from surgical intervention.

intervetebral disk degeneration may result in radial tears and leakage of the nuclear material. which leads to neural toxicity. dominant back pain. unfortunately. Does the patient's complaint concern dominant leg pain. Further repetitive stress at physiologic levels did not produce a herniation after prolonged testing. which is consistent with a pain mechanism. Many cases involve trivial trauma even in the presence of repetitive stress. presumably by vasoconstrictive and rheologic effects on blood. Lumbar disk herniation may result from chronic coughing and other stresses on the disk. particularly regarding similar symptoms or treatment response? . but their recommendation to perform this procedure with a fusion was necessitated by relatively aggressive laminectomy. is the onset acute. Mixter and Barr first recognized that the cartilaginous masses in the spinal canal of their patients were not tumors or chondromas.[18. However. is done after prolonged driving. even when neural compression is absent. An annular tear or weak spot has not been demonstrated to result from repetitive normal stress from customary activities or from physically stressful activities. Smoking is a risk factor in the epidemiology of lumbar disk herniations and has been documented to decrease the oxygen tension in the avascular disk dramatically.[13] They proposed that herniation of the nucleus pulposus and displacement of nuclear material caused neural irritation. Studies have shown that peak stresses within a deteriorated intervertebral disk exceed those from average loads on a normal disk. truck drivers have the additional risk of spinal problems from lifting during loading and unloading. a lower mechanical stress did result in disk herniation. or a mixture of significant problems with both? Next. and pain. People who drive signifcant amounts have increased spinal problems. consistent with intervertebral disk degeneration and with clinical experience on discography. sitting without lumbar support causes an increase in disk pressures. Several factors seem to influence the occurrence of herniated nucleus pulposus. such as microdiscectomy. which. This procedure has been replaced by techniques that are less invasive. or chronic? Under what circumstances does onset occur? What is the patient's prior history. 19] The pathologic state of a weakened annulus is a necessary condition for herniation to occur. For example. subacute. inflammation. They showed that excising a disk fragment was effective. or loss of reflex. after a simulated injury to the annulus (cutting). Clinical Evaluation Obtaining pertinent patient historical information should begin with an analysis of the chief complaint. contradicting the concept of injury accumulation with customary work activities. and driving is also a risk factor because of the resonant coupling of 5-Hz vibrations from the road to the spine. weakness. particularly with the increased availability of genetic information. The presumed traumatic cause of disk herniations has been questioned scientifically in the literature.Furthermore. The subsequent inflammatory response often results in neural irritation causing radiating pain without numbness.

and. Lasegue differential sign. MRI clearly provides the most information. Numerous examination maneuvers (eg. well leg test or Fajersztajn sign. sciatic or femoral nerve root tension in the lumbar spine. Deyerle sign. An assessment of the physical demands of the patient's occupation and daily activities provides the perspective for the described activity intolerance. Lasegue classic test. They are essentially modifications for subtle differences. and facet deterioration. and specifically exclude red flags. An HNP that is noted on imaging studies must be correlated with objective examination findings. it must be presumed to be an asymptomatic HNP if there is no correlation between the imaging findings and pain or clinical symptoms. as it has a 25% false-positive rate (asymptomatic herniated nucleus pulposus [HNP]). computed tomography [CT] scanning. reflex change. most important. and genitourinary examinations help exclude complications of those organ systems in the diagnosis of higher lumbar lesions. Mendel-Bechterew sign. A progressive neurologic deficit or cauda equina syndrome is considered a surgical emergency because irreversible consequences may result if these are left untreated. rectal. . A pain drawing can be very helpful in assessing the pattern of pain. After obtaining plain radiographs. obtain a pertinent medical history. the provocation of radiating pain down the leg is the most sensitive test for a lumbar disk herniation.Identify risk factors. further imaging studies (eg. because the sciatic nerve root tension or straight-leg raising test is the basis for nearly all of them. Furthermore. imaging studies should perhaps be reserved for cases in which positive physical findings have been documented. perhaps too much. Also. flip sign. CT myelography) may be indicated to assess degenerative disk disease. loss of disk height. For a higher lumbar lesion. which causes pain at night without activities because pressure in the pelvic veins may be increased upon reclining. Physical examination classically involves range-of-motion (ROM) testing of the lumbar and cervical spine. if it goes below the knee. otherwise. or in assessing the organicity of the complaints. both-legs or Milgram test) are available but cloud the issue. Nonmechanical pain may be indicative of a tumor or infection. Braggard sign. reverse straight-leg raising or hip extension that stretches the femoral nerve is analogous to a straight-leg raising test. dermatomal numbness. Careful hip. but the provocation of radiating pain down the leg is of a neural compressive lesion and compression of the sciatic nerve root. Lasegue rebound sign. The Spurling test in the cervical spine is used to detect foraminal stenosis (Kemp's test is used in the lumbar region) rather than specifically for intervertebral disk herniation or nerve root tension. The remainder of the examination is essentially a neurologic assessment of weakness. such as sclerosis or hypertrophy. Therefore. Obtaining a thorough history of activity intolerance requires some time and attention to the details of specific examples and the positions or actions that cause problems. but these findings may be more reflective of aging or deterioration in the intervertebral disks and joints than any quantifiable assessment of impairment. such as a dermatomal distribution. MRI. it is helpful to determine which activities the patient is unable or less able to perform and which activities exacerbate or moderate the pain. such as nonmechanical pain.

Sciatic nerve irritation may result from sacroiliac dysfunction or degenerative joint disease caused by the proximity of the sciatic notch to the sacroiliac joint or peripheral entrapment. Activities should be resumed as early as tolerated. including piriformis syndrome. and turns from a grapelike object to a raisinlike object. Clinically. all are central acting. after this period. but this study has been faulted because the criterion for patient recovery was failure to return to the observing physician. The use of . not below. Traction in the acute setting may help muscle spasms. Exercises and physical therapy mobilize muscles and joints to facilitate the removal of edema and promote recovery. as well as inflammation and degenerative joint disease. however. Analysis of the effectiveness of treatments and attempts to restrict treatment to those modalities that have demonstrated efficacy are evidence-based medical practice. as a result. loses its water-retaining ability. large numbers of patients have reported significant relief after facet joint injections for nonspecific LBP. Bedrest has a long history of use but has not been shown to be effective beyond the initial 1 or 2 days. chiropractic care has high patient satisfaction when performed within the first 6 weeks. which allows the patient to increase activities and helps facilitate rehabilitation. 24] Any nuclear material that is herniated may shrink as the proteoglycan deteriorates. All conservative treatments are essentially efforts to reduce inflammation. the facet syndrome has become more widely accepted.[23. therefore. and it has been shown to have good efficacy acutely from an evidence-based standpoint.[21] The prevalence of back problems is consistent with the failure of a subgroup of patients to improve and to have periodic recurrent episodes of disability.[22] Injections (eg. moist heat or modalities may be helpful. Muscle relaxants may offer symptomatic relief of the acute muscle spasms but only in the early stages. Hippocrates expected improvement in sciatica in 40 days. anti-inflammatories are of some benefit (because the pain is from inflammation of the nerve). there is no direct relaxation of skeletal muscle. The facet syndrome has been controversial. For back pain without radiculopathy. Careful examination with an adequate differential for the diagnosis may prevent prolonged ineffective empirical care for presumed lumbar disk disease. patients usually have pain only to the knee.Other causes of significant back pain in the absence of neurologic findings should be considered. and the customary and contemporary guideline is 6 weeks. Arbitrary time schedules for improvement are inappropriate in any patient who continues to improve and whose function is relatively maintained. but it does not reduce the HNP and has no good evidence of efficacy. because benefits have been ascribed to them when they are prescribed while the patient is still symptomatic but otherwise improving. but neurophysiologic studies have shown discharges from the capsule consistent with pain. Conservative Treatment Spontaneous improvement of low back discomfort has allowed ineffective treatments to perpetuate. epidural) may be particularly helpful in patients with radiculopathy by providing symptom relief. only a very short period of rest is appropriate. as would be expected from an HNP. An often-quoted study suggests near-resolution improvement of 90% of patients within 6 weeks.[20] However. and warm. bedrest is counterproductive. and they are also sedating.

Surgical Intervention The classic presentation of an herniated nucleus pulposus includes the complaint of sciatica. Many patients who undergo microdiscectomy can be discharged with minimal soreness and complete relief of leg pain after an overnight admission and observation. but the joints impact each other when a person bends and then rotates. thus allowing forward flexion. A transcutaneous electrical nerve stimulation (TENS) unit may be subjectively helpful in some patients with chronic conditions.[26] Central decompression of the disk can be performed chemically or enzymatically with chymopapain. and a hemilaminotomy is performed to remove the disk fragment that is impinging on the nerves. reflex change. and would require stabilization by fusion if unresponsive to well-managed appropriate therapy or arthroplasty (if there is an isolated level with good facet joints). Encourage patients to essentially compensate for intervertebral disk incompetence. Assess the body mechanics of every patient who is disabled from work. particularly swimming. or mechanically by . even if HNP is present. as it is not cost-effective and can be administered on an outpatient basis. including appropriate seating (eg. Same-day procedures are in the process of cautious development. Educate all patients about body mechanics. and discuss the risk factors for faulty body mechanics.[25] Attention to lifting techniques and ergonomic modification at workstations may be very appropriate. with associated objective neurologic findings of weakness. in which a small incision is made. However. Repetitive bending and twisting have been noted to be epidemiologic problems in workers. lumbar support). and to maintain flexibility by initiating life-long exercise regimens. Outpatient treatment has been reported. Long-term use of physical therapy modalities is no more effective than hot showers or hot packs are at home. patients with dominant back pain have a different problem.traction does not justify hospital admission. with an essentially intact and clinically stable disk. Various surgical procedures have been reported and share the common goal of decompressing the neural elements to relieve the leg pain. by laser or plasma (ionized gas) ablation and vaporization. Minimally invasive techniques have not replaced this standard microdiscectomy procedure but can be summarized in 2 categories: central decompression of the disk and directed fragmentectomy. These procedures are most appropriate for patients with minimal or tolerable back pain. by muscular stabilization. and dermatomal numbness. a false hope. which allows gravity relief. The lumbar facet joints are oriented relatively vertically. and may be associated with chronic pain and disability. the hope of permanently relieving the back pain is a fantasy. as possible. so that applications can be incorporated into individual work settings. including aerobic conditioning. aided by an operating microscope. The most common procedure for a herniated or ruptured intervertebral disk is a microdiscectomy.

The incidence of recurent herniation is small but may be irreducible.aspiration and suction with a shaver such as the nucleotome or percutaneous lateral decompression (arthroscopic microdiscectomy). because the muscles are severely affected. Efforts to seal the annulus are under investigation. This procedure uses an arthroscopic approach and a probe that directs a flexible pituitary rongeur from the center of the intervertebral disk toward the posterior annulus. would more uniformly undergo fusion. severe scarring in the spinal canal is noted routinely after this procedure. In addition. and interbody cages are under consideration as a means of attaining more rapid rehabilitation and more consistent results. Directed fragmentectomy is similar to an open microdiscectomy and has demonstrated greater effectiveness than placebo. but superiority has not been demonstrated despite this minimally invasive approach. because the pathology is anterior and manipulation of the cervical cord is not tolerated by the patient. and efforts to reduce disk pressure remain under study. which would not be expected if the enzyme were contained. such as nucleoplasty. An alternative to the anterior cervical spine approach is minimal disk excision.[27] This morbidity must be considered a contradiction to the assertion by proponents that the enzyme is limited to the disk in the chemical digestion of the nucleus pulposus. Controversies And Outcomes . which is also true in cases where there is lumbar spine involvement with back pain. The posterior approach is reserved for disk herniation that is confined to the foramen and for foraminal stenosis. Concerning the cervical spine. but the adequacy of follow-up in those case reports is a significant concern. Patients with more severe disk degeneration. The nucleotome and laser central decompressions have been shown only to equal placebo in effectiveness. patient selection is crucial. skin tests subsequently were used to determine sensitivity. Endoscopic techniques to perform a directed fragmentectomy and to minimize disruption of normal structures continue in development. particularly myelopathy. Proponents of discectomy alone assert equivalent results. the procedure continued to induce severe muscle spasms that could be far worse than those of an open operation and thus required hospitalization and bedrest for up to 50% of patients. however. clinical stability following this procedure is dependent upon the residual disk. The Food and Drug Administration (FDA) initially released and then withheld chymopapain for injection into lumbar disks because of adverse allergic reactions in patients. Superiority has not been demonstrated. However. Anterior cervical interbody fusion is another intervention. Anterior instrumentation is being used more commonly. with a steep learning curve. HNP customarily is treated anteriorly. Removal of neural compression dramatically relieves radiculopathy. and their use has declined. residual axial neck pain may result in significant impairment.[28] Further development of alternatives.

The classic patient presents with back pain without imaging abnormalities except for varying degrees of the black disk. patients with dominant leg pain have excellent results.[30] The remaining concern of recurrent herniation is small.[31] Efforts to minimize this complication have included annulus repair[32] and injecting hemostatic materials or bioactive molecules. and arthroplasty is also being considered. as techniques are still evolving. The greatest controversy is over the effectiveness of fusion surgery. Lumbar fusion is being used increasingly in these cases. Various nuclear replacements that reduce postoperative loss of disc height restoring compressive loading are being studied. from the disk degeneration. Patients who undergo surgery do not necessarily show better results than patients who defer surgery. via either an anterior lumbar interbody fusion (ALIF) or a posterior lumbar interbody fusion (PLIF) in association with posterior decompression (when necessary) and instrumentation. it is impossible to tell which patients will do well after microdiscectomy for a herniation and which will have continued problems. which is the converse of the asymptomatic patient with an intervertebral disk herniation. with 85-90% returning to full function. despite the absence of radiculopathy.[33] Intervertebral disk degeneration that causes clumping of the nuclear material and relative mechanical instability is the necessary preceding condition for HNP. endplate changes are observed but no clear correlation identified to this point. rather than isolated sciatica. These patients are not appropriate candidates for microdiscectomy alone. clearly. However. Significant deterioration and accompanying LBP increasingly are being treated with stabilization. again. up to 15% of patients have continued back pain that may limit their return to full function. of varying severity. A positive discogram properly done and carefully interpreted in context may raise the expectation of success for surgical treatment in this patient population. although is is correlated with obesity. Unfortunately. However. some patients with prolonged limitations and limited job skills benefit from surgical intervention for segmental instability or clinical instability as we earlier discussed. Results are not yet available. there is no clear objective criterion.[29] With a discectomy. however. and patient selection is paramount. this treatment remains controversial because it is. good patients do well. Patients with "broad-based" intervertebral disk herniations generally have a deterioration of the disk or a failure of clinical stability with associated back pain.The diagnosis of an internal disk derangement is controversial. clinical judgment is mandatory and is not perfect. . but experience is accumulating. but not comprehensively. Etanercept was shown in a small study to be of no benefit for sciatica. Many reports in the literature have described specific cytokines elevated. Patients without a disk herniation have a favorable course and long-term outcome with conservative treatment or surgery. based inevitably on subjective patient pain and clinical judgment without objective determination. although the addition of butorphanol with corticosteroid was helpful with an epidural injection. However.