See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/333787518

Nucleus Pulposus Herniation - StatPearls - NCBI Bookshelf

Book · June 2019

CITATIONS READS

0 1,361

2 authors:

Franco Luis De Cicco Gaston Camino-Willhuber

Hospital Italiano de Buenos Aires Hospital Italiano de Buenos Aires
33 PUBLICATIONS   6 CITATIONS    53 PUBLICATIONS   141 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Spine Infections View project

Postoperative Complications in Orthopaedic Surgery View project

All content following this page was uploaded by Gaston Camino-Willhuber on 14 June 2019.

The user has requested enhancement of the downloaded file.

Nucleus Pulposus Herniation - StatPearls - NCBI Bookshelf 14/6/19 20)06

Nucleus Pulposus Herniation

De Cicco FL, Camino Willhuber GO.

Introduction
Nucleus pulposus herniation is the most common cause of sciatic pain and one of the most common indications for spine
surgery worldwide.[1] This condition presents as a displacement of the nucleus pulposus beyond the intervertebral disc
space.

The disc anatomy consists of two main structures, the nucleus pulposus (NP) and the annulus fibrosus (AF).

The nucleus pulposus is composed of water, type II collagen, chondrocyte-like cells, and proteoglycans. This unique
composite allows the NP to be elastic, flexible under stress forces and to absorb compression.[2]

The composition of the AF is mainly concentric layers of collagen type I fibers,[3] forming a fibrous tissue with helical
disposition surrounding the NP, this structure is denser in the anterior part and is attached to the vertebral body by Sharpey
fibers.

Etiology
Disc herniation and disc degeneration are associated terms, being nucleus pulposus herniation a possible evolution from a
degenerative disc. Disc degeneration is usually associated with loss of proteoglycans.[4] Multiple factors influence the
degenerative process such as genetic, mechanical, and behavioral.[5][6]

The intervertebral disc is a structure that provides flexibility and transmits loads through the spine. Mechanical load is
important in maintaining a healthy IVD by generating signals to cells that regulate proper matrix homeostasis.[7][8] On the
other hand, prolonged exposure to hypo or hyper loading correlates with disc degeneration induction.[9][10]

Epidemiology
The estimated prevalence of disc herniation is approximately 1 to 3%. The highest observed incidence is between 30 to 50
years, and it is more frequent in men than in women (Ratio 2 to 1).

Pathophysiology
Disc herniation is a consequence of degenerative changes in the annulus; those changes are age-related adaptive
modifications in the disc structure that encompass desiccation, fissures, disc narrowing, mucinous degeneration, intradiscal
gas (vacuum), osteophytes, inflammatory changes, and subchondral sclerosis. Annulus fissures predispose to a weakness,
which allows disc material to bulge or migrate outside the annulus margins.

Histopathology
Nucleus pulposus herniation results from a failure in the annulus fibrosis integrity, making the content of the nucleus to
protrude into the neural canal, the intervertebral foramen (foraminal) or lateral to the foramen (extraforaminal). Nucleus
pulposus protrusion is the less severe scenario of disc herniation, due to partial rupture of the annulus fibrosis (See figure 1),
when the annulus structure becomes completely disrupted the nucleus content may extrude outside the disc space and in

https://www.ncbi.nlm.nih.gov/books/NBK542307/ Página 1 de 7
Nucleus Pulposus Herniation - StatPearls - NCBI Bookshelf 14/6/19 20)06

some cases a fragment of nucleus pulposus may migrate (sequestration).

Another way to differentiate protrusion from extrusion is related to the shape of the displaced material. A protrusion is when
the greatest distance between the limits of the disc material outside the disc space is less than the distance between the limits
of the base of that disc material outside the disc space. The base is the width of disc material at the outer margin of the disc
space. Extrusion is present when, in at least one plane, the distance between the limits of the disc material beyond the disc
space exceeds the distance between the limits of the base of the disc material beyond the disc space.

Another type of disc herniation is when disc material migrates in craniocaudal direction through a gap between the endplate
and the disc making a space within the vertebral body (intravertebral disc herniation) better know as Schmorl nodes.[11]

The integrity of the annulus fibrosus has to be compromised to develop a nucleus pulposus herniation. The loss of annulus
fibrosus integrity may be present in different forms, such as radial, transverse, or concentric fissures. These types of fissures
are observable in the early stages of disc degeneration. One important kind of annulus fissure can be observed in T2-
weighted MRI and is called high-intensity zone (HIZ), this changes denote the presence of liquid within an annular fissure
and correlates with acute disc annular tear or fissure.[12]

History and Physical

Proper understanding of anatomical zones and vertebral level is essential to interpret the clinical manifestations secondary to
a disc herniation. Wiltse proposed these anatomical zones, based on the following landmarks: medial border of the articular
facet, lateral, upper and medial borders of the pedicles, coronal and sagittal planes at the center of the disc. On the axial
plane, these landmarks determine the central zone, the subarticular zone (lateral recess), foraminal, and extraforaminal zones.
On the sagittal plane, the levels are termed as follows: The supra pedicular level, the pedicular level, the infrapedicular level,
and the disc level. The correct knowledge of anatomy and relationship between nerve roots and disc herniation allows the
proper understanding of common clinical findings associated with this problem.

There are two main mechanisms to explain radicular pain secondary to a nucleus pulposus herniation: Mechanical
compression and inflammatory reaction. Clinical symptoms may vary according to several factors such as the location of the
herniation (level), neural compression, and evolution. Nucleus pulposus herniation can produce low back pain; however, the
primary clinical manifestation is radiculopathy, which is mainly manifested by radiating pain and sensitive changes that
encompass nerve distribution. Additionally, reflexes assessment (decreased reflex) may help to identify the compromised
nerve root.

We summarize the anatomy, motor function, sensitive distribution, and reflex of the most commons nerve roots involved in
cervical and lumbosacral nucleus pulposus herniation:

Cervical:

C5 nerve root: Exits between C4 and C5 foramina, innervates deltoids and biceps (with C6), sensory distribution:
lateral arm (axillary nerve) and is assessed with biceps reflex.
C6 nerve root: Exits between C5 and C6 foramina, innervates biceps (with C5) and wrist extensors, sensory
distribution: lateral forearm (musculocutaneous nerve), assessed with brachioradialis reflex.
C7 nerve root: Exits between C6 and C7 foramina, innervates triceps, wrist flexors, and finger extensors, sensory
distribution: middle finger, assessed with triceps reflex.
C8 nerve root: Exits between C7 and T1 foramina, innervates interosseus muscles and finger flexors, sensory
distribution: ring and little fingers and distal half of the forearm (ulnar side), no reflex.

https://www.ncbi.nlm.nih.gov/books/NBK542307/ Página 2 de 7
Nucleus Pulposus Herniation - StatPearls - NCBI Bookshelf 14/6/19 20)06

Lumbosacral:

L1 nerve root: Exits between L1 and L2 foramina, innervates iliopsoas muscle, sensory distribution: upper third
thigh, assessed with the cremasteric reflex (male).
L2 nerve root: Exits between L2 and L3 foramina, innervates iliopsoas muscle, hip adductor, and quadriceps,
sensory distribution: middle third thigh, no reflex.
L3 nerve root: Exits between L3 and L4 foramina, innervates iliopsoas muscle, hip adductor, and quadriceps,
sensory distribution: lower third thigh, no reflex.
L4 nerve root: Exits between L4 and L5 foramina, innervates quadriceps and tibialis anterior, sensory distribution:
anterior knee, medial side of the leg, assessed with patellar reflex.
L5 nerve root: Exits between L5 and S1 foramina, innervates extensor hallucis longus, extensor digitorum longus,
and brevis, and gluteus medius, sensory distribution: anterior leg, lateral leg, and dorsum of the foot, no reflex.
S1 nerve root: Exits between S1 and S2 foramina, innervates gastrocnemius, soleus, and gluteus maximus, sensitive
distribution: posterior thigh, plantar region, assessed with Achilles reflex.

Cervical and thoracic disc herniation can also exhibit symptoms of myelopathy such as spasticity, clumsiness, wide-based
gate, and weakness, on physical examination hyperreflexia is the most important sign. The Lhermitte sign is the presence of
an electric shock-like sensation towards the back and lower extremities, especially by flexing the neck.[13][14] Bowel and
bladder dysfunction may indicate poor prognosis.

Evaluation
In the presence of low back pain without symptoms of radiculopathy, there is no need to request studies as most of the
patients improve in a couple of weeks, 4-week follow-up is the usual timeframe.[15]

X-ray is the initial workup study when there is a strong suspicion of a specific cause of cervical or back pain (fracture,
infection, tumor) or in the presence of red flags (fever, age more than 50, recent trauma, pain at night or rest, unexplained
weight loss, progressive motor or sensory deficit, saddle anesthesia, history of cancer or osteoporosis, failure to improve
after six weeks of conservative treatment). Anteroposterior and lateral x-ray is helpful to assess fracture, bony deformity,
decreased intervertebral height, osteophytes, spondylolisthesis, and facet joint osteoarthritis.

MRI is the recommended diagnostic imaging in cases of severe or progressive neurologic deficits, suspicion of an underlying
condition such as infection, fracture, cauda equina syndrome, spinal cord compression. In cases of radiculopathy, most of the
cases improve with conservative treatment, and MRI is indicated in those cases with significant pain or neurologic deficits.
[16]

CT myelogram is the imaging option in patients with contraindications to MRI.

CT scan is not usually requested in nucleus pulposus herniation. However, it can be helpful in some cases when there is a
suspicion of calcified disc herniation (thoracic disc herniation has a 30 to 70% rate of calcification) which is more
challenging especially when surgery is a consideration.

Treatment / Management
Therapeutic management of nucleus pulposus herniation encompasses conservative and surgical treatment. Conservative
treatment is the main strategy due to the natural history of nucleus pulposus herniation, with good response to pain treatment
or nerve root steroid injection as well as some cases of spontaneous regression.[17][18]

https://www.ncbi.nlm.nih.gov/books/NBK542307/ Página 3 de 7
Nucleus Pulposus Herniation - StatPearls - NCBI Bookshelf 14/6/19 20)06

Some patients will not benefit from conservative treatment and will require surgery to decompress the nerve involved.
Classical surgical indications are motor deficit, cauda equina syndrome, and persistent pain after conservative treatment.

In cervical disc herniation, there is no evidence of effectiveness for conservative treatment compared with surgery [Level I].
[19] Different randomized controlled trials (RTC) have compared conservative versus surgical treatment in lumbar disc
herniation, observing faster pain relief and recovery in the early surgery groups, however, similar outcomes in the long term
(one or two years) were found.[20][21] In another trial, carefully selected patients who underwent surgery for lumbar disc
herniation achieved greater improvement compared to nonoperative treated patients at eight years follow up [Level II].[22]

Differential Diagnosis
Nucleus pulposus herniation is the most common cause of radicular pain in the lumbar spine and the second most common
cause in the cervical spine after degenerative spondylosis; however, other conditions in the differential diagnosis should be
considered such as:

Neurinoma/schwannoma
Facet joint/ligamentum flavum hypertrophy
Facet joint cyst
Spondylolisthesis
Conjoined nerve root

Prognosis
The majority of patients suffering from nucleus pulposus herniation experience symptoms resolution without surgery.[23]
Conservative treatment is effective, and patients usually experience symptom relief after a couple of weeks. However, some
cases do not improve with conservative treatment and may require more invasive therapies such as nerve root steroid
injection or even surgery.

The presence of myelopathy in cases of central nucleus pulposus herniation in the cervical or thoracic region is an indication
for surgery, especially in the setting of symptoms progression.

Complications
Complications associated with nucleus pulposus herniation can result from the compression effect on the nerve root in severe
cases resulting in motor deficit, in the cervical and thoracic spine there is also a risk of spinal cord compression in severe
cases. These complications are relatively uncommon but should be considered and properly treated to avoid a permanent
neurological deficit.

Cauda equina syndrome is another complication that results from lumbosacral nerve roots compression with possible bowel
or bladder dysfunction. It is a rarely occurring condition (less than 1%). However, it is considered an absolute indication for
acute surgical resolution, and early decompression is associated with symptoms improvement.[24]

Deterrence and Patient Education

It is crucial for patients to recognize radicular pain because it can be the result of a nucleus pulposus herniation in the
cervical or lumbar spine. It is essential to have a consult after a persistent radiating pain and be examined by a primary care
provider. Most of the symptoms usually improve with conservative treatment; only a few cases with severe pain or

https://www.ncbi.nlm.nih.gov/books/NBK542307/ Página 4 de 7
Nucleus Pulposus Herniation - StatPearls - NCBI Bookshelf 14/6/19 20)06

neurologic deficit may need additional imaging studies and further specialist referral.

Enhancing Healthcare Team Outcomes

Nucleus pulposus herniation is a common complaint among young adults; clinical symptoms such as low back or cervical
pain with radicular pain (brachialgia or sciatica) may raise suspicion of a possible nerve root inflammation/compression and
further referral to a specialist. In cervical disc herniation, there is no evidence of effectiveness for conservative treatment
compared with surgery [Level I], on the other hand, carefully selected patients who underwent surgery for lumbar disc
herniation achieved more significant improvement compared to nonoperative treated patients [Level II]. A coordinated effort
between the primary care provider, specialty-trained nurses, spine specialists, physical therapists and chiropractors (who may
be the patient's first point of contact), communicating across professions, is vital to guide proper management in patients
with symptomatic nucleus pulposus herniation [Level V].

Questions
To access free multiple choice questions on this topic, click here.

Figure
Figure 1. A) Normal disc anatomy B) Disc Protrusion C) Disc Extrusion D) Disc Sequestration.
Contributed by Franco De Cicco MD

References
1. Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA. Reoperation rates following lumbar spine surgery
and the influence of spinal fusion procedures. Spine. 2007 Feb 01;32(3):382-7. [PubMed: 17268274]
2. Chen S, Fu P, Wu H, Pei M. Meniscus, articular cartilage and nucleus pulposus: a comparative review of cartilage-like
tissues in anatomy, development and function. Cell Tissue Res. 2017 Oct;370(1):53-70. [PMC free article:
PMC5645221] [PubMed: 28413859]
3. He Y, Qiu Y, Zhu F, Zhu Z. Quantitative analysis of types I and II collagen in the disc annulus in adolescent idiopathic
scoliosis. Stud Health Technol Inform. 2006;123:123-8. [PubMed: 17108414]
4. Roughley PJ, Alini M, Antoniou J. The role of proteoglycans in aging, degeneration and repair of the intervertebral disc.
Biochem. Soc. Trans. 2002 Nov;30(Pt 6):869-74. [PubMed: 12440935]
5. Hadjipavlou AG, Tzermiadianos MN, Bogduk N, Zindrick MR. The pathophysiology of disc degeneration: a critical
review. J Bone Joint Surg Br. 2008 Oct;90(10):1261-70. [PubMed: 18827232]
6. Battié MC, Videman T, Kaprio J, Gibbons LE, Gill K, Manninen H, Saarela J, Peltonen L. The Twin Spine Study:
contributions to a changing view of disc degeneration. Spine J. 2009 Jan-Feb;9(1):47-59. [PubMed: 19111259]
7. MacLean JJ, Lee CR, Alini M, Iatridis JC. The effects of short-term load duration on anabolic and catabolic gene
expression in the rat tail intervertebral disc. J. Orthop. Res. 2005 Sep;23(5):1120-7. [PubMed: 16140193]
8. MacLean JJ, Lee CR, Grad S, Ito K, Alini M, Iatridis JC. Effects of immobilization and dynamic compression on
intervertebral disc cell gene expression in vivo. Spine. 2003 May 15;28(10):973-81. [PubMed: 12768134]
9. Lotz JC, Chin JR. Intervertebral disc cell death is dependent on the magnitude and duration of spinal loading. Spine.
2000 Jun 15;25(12):1477-83. [PubMed: 10851095]

https://www.ncbi.nlm.nih.gov/books/NBK542307/ Página 5 de 7
Nucleus Pulposus Herniation - StatPearls - NCBI Bookshelf 14/6/19 20)06

10. Lotz JC, Colliou OK, Chin JR, Duncan NA, Liebenberg E. Compression-induced degeneration of the intervertebral
disc: an in vivo mouse model and finite-element study. Spine. 1998 Dec 01;23(23):2493-506. [PubMed: 9854748]
11. Takahashi K, Miyazaki T, Ohnari H, Takino T, Tomita K. Schmorl's nodes and low-back pain. Analysis of magnetic
resonance imaging findings in symptomatic and asymptomatic individuals. Eur Spine J. 1995;4(1):56-9. [PubMed:
7749909]
12. Jha SC, Takata Y, Abe M, Yamashita K, Tezuka F, Sakai T, Higashino K, Nagamachi A, Sairyo K. High intensity zone
in lumbar spine and its correlation with disc degeneration. J. Med. Invest. 2017;64(1.2):39-42. [PubMed: 28373626]
13. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Efficacy of steroid and
nonsteroid caudal epidural injections for low back pain and sciatica: a prospective, randomized, double-blind clinical
trial. Spine. 2009 Jun 15;34(14):1441-7. [PubMed: 19525834]
14. Turk O, Antar V, Yaldiz C. Spontaneous regression of herniated nucleus pulposus: The clinical findings of 76 patients.
Medicine (Baltimore). 2019 Feb;98(8):e14667. [PMC free article: PMC6407986] [PubMed: 30813213]
15. Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, Thomeer RT, Koes BW., Leiden-The
Hague Spine Intervention Prognostic Study Group. Surgery versus prolonged conservative treatment for sciatica. N.
Engl. J. Med. 2007 May 31;356(22):2245-56. [PubMed: 17538084]
16. Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, Verhagen A, Koes B, Peul WC.
Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J.
2011 Apr;20(4):513-22. [PMC free article: PMC3065612] [PubMed: 20949289]
17. Benoist M. The natural history of lumbar disc herniation and radiculopathy. Joint Bone Spine. 2002 Mar;69(2):155-60.
[PubMed: 12027305]
18. Srikandarajah N, Boissaud-Cooke MA, Clark S, Wilby MJ. Does early surgical decompression in cauda equina
syndrome improve bladder outcome? Spine. 2015 Apr 15;40(8):580-3. [PubMed: 25646751]
19. Siivola SM, Levoska S, Tervonen O, Ilkko E, Vanharanta H, Keinänen-Kiukaanniemi S. MRI changes of cervical spine
in asymptomatic and symptomatic young adults. Eur Spine J. 2002 Aug;11(4):358-63. [PMC free article:
PMC3610480] [PubMed: 12193998]
20. Uribe JS, Smith WD, Pimenta L, Härtl R, Dakwar E, Modhia UM, Pollock GA, Nagineni V, Smith R, Christian G,
Oliveira L, Marchi L, Deviren V. Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial
multicenter clinical experience. J Neurosurg Spine. 2012 Mar;16(3):264-79. [PubMed: 22176427]
21. Chou R, Qaseem A, Snow V, Casey D, Cross JT, Shekelle P, Owens DK., Clinical Efficacy Assessment Subcommittee
of the American College of Physicians. American College of Physicians. American Pain Society Low Back Pain
Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American
College of Physicians and the American Pain Society. Ann. Intern. Med. 2007 Oct 02;147(7):478-91. [PubMed:
17909209]
22. Lateef H, Patel D. What is the role of imaging in acute low back pain? Curr Rev Musculoskelet Med. 2009 Jun;2(2):69-
73. [PMC free article: PMC2697333] [PubMed: 19468875]
23. Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical
disc: a systematic review. Spine. 2012 Jan 15;37(2):E109-18. [PubMed: 21587105]
24. Lurie JD, Tosteson TD, Tosteson AN, Zhao W, Morgan TS, Abdu WA, Herkowitz H, Weinstein JN. Surgical versus
nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial.
Spine. 2014 Jan 01;39(1):3-16. [PMC free article: PMC3921966] [PubMed: 24153171]

Publication Details

https://www.ncbi.nlm.nih.gov/books/NBK542307/ Página 6 de 7
Nucleus Pulposus Herniation - StatPearls - NCBI Bookshelf 14/6/19 20)06

Author Information

Authors

Franco L. De Cicco1; Gaston O. Camino Willhuber2.

Affiliations

1 Hospital Italiano de Buenos Aires

2 Hospital Italiano de Buenos Aires

Publication History

Last Update: June 1, 2019.

Copyright
Copyright © 2019, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/),
which permits use, duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, a link is provided to the Creative Commons license, and any changes made are indicated.

Publisher

StatPearls Publishing, Treasure Island (FL)

NLM Citation

De Cicco FL, Camino Willhuber GO. Nucleus Pulposus Herniation. [Updated 2019 Jun 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2019 Jan-.

https://www.ncbi.nlm.nih.gov/books/NBK542307/ Página 7 de 7

View publication stats