Anatomy

The intervertebral disk is the largest avascular structure in the body. It arises from notochordal cells
between the cartilaginous endplates, which regress from about 50% of the disk space at birth to about 5%
in the adult, with chondrocytes replacing the notochordal cells.
Intervertebral disks are located in the spinal column between successive vertebral bodies and are oval in
cross-section. Their height 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 disks anteriorly and posteriorly; the cartilaginous endplate of each disk attaches to the
bony endplate of the vertebral body. (See the images below.)

Nuclear material is normally contained within anulus, but it may cause bulging of anulus or may herniate
through anulus into spinal canal. This commonly occurs in posterolateral location of intervertebral disk, as
depicted.

Spinal nerves exit spinal canal through foramina at each level. Decreased
disk height causes decreased foramen height to same degree, and superior articular facet of caudal
vertebral body may become hypertrophic and develop spur, which then projects toward nerve root situated
just under pedicle. In this picture, L4-5 has loss of disk height and some facet hypertrophy, thereby
encroaching on room available for exiting nerve root (L4). Herniated nucleus pulposus within canal would
embarrass traversing root (L5).

The disc's anular structure is composed of an outer anulus fibrosus, which is a constraining ring that is
composed primarily of type 1 collagen. This fibrous ring has alternating layers oriented at 60° from the
horizontal to allow isovolumic rotation. That is, just as a shark swimming and turning in the water does not
buckle its skin, the intervertebral disk has the ability to rotate or bend without a significant change in
volume, so that the hydrostatic pressure of the inner portion of the disk (ie, the nucleus pulposus) is not
affected.
The nucleus pulposus consists predominantly of type II collagen, proteoglycan, and hyaluronan long
chains, which have regions with highly hydrophilic branching side chains. These negatively charged regions
have a strong avidity for water molecules and hydrate the nucleus or center of the disk via an osmotic
swelling pressure effect. The major proteoglycan constituent is aggrecan, which is connected by link protein
to the long hyaluronan. A fibril network, including a number of collagen types along with fibronectin,
decorin, and lumican, contains the nucleus pulposus.
The hydraulic effect of the contained hydrated nucleus within the anulus acts as a shock absorber to
cushion the spinal column from forces that are applied to the musculoskeletal system. Each vertebra of the
spinal column has an anterior centrum or body. The centra are stacked in a weightbearing column and are
supported by the intervertebral disks. A corresponding posterior bony arch encloses and protects the neural
elements, and each side of the posterior elements has a facet joint or articulation to allow motion.
The functional segmental unit is the combination of an anterior disk and the two posterior facet joints, and it
provides protection for the neural elements within the acceptable constraints of clinical stability. The facet
joints connect the vertebral bodies on each side of the lamina, forming the posterior arch. These joints are
connected at each level by the ligamentum flavum, which is yellow because of the high elastin content and
allows significant extensibility and flexibility of the spinal column.
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.  [6] Any disruption of the components holding
the spine together (ie, ligaments, intervertebral disks, facets) decreases the clinical stability of the spine.
When the spine loses enough of these components to prevent it from adequately providing the mechanical
function of protection, surgery may be necessary to reestablish stability.

Pathophysiology
Degeneration: process and models
LBP is ubiquitous, with 60-80% of people having an activity-limiting episode at least transiently in their
lifetime. Genetic factors appear to play a dominant role, with LBP starting at an earlier age than previously
suspected on the basis of subsequent structural changes; men begin having LBP about a decade earlier
than women do. [7]
The water-retaining ability of the nucleus pulposus (the inner portion of the intervertebral disk) declines
progressively with age. The decline in the mechanical properties of the nucleus pulposus is associated with
the degree of proteoglycan deterioration and the decrease in hydration, which lead to excessive regional
peak pressures within the disk. As the hyaluronan long chains shorten and swelling pressure decreases as
a result of this deterioration, the mechanical stiffness of the disk decreases, which causes the anulus to
bulge, with a corresponding loss of disk and foramen height. [8] (See the image below.)

Hyaluronan long chains form backbone for attracting

electronegative or hydrophilic branches, which hydrate nucleus pulposus and cause swelling pressure
within anulus to allow it to stabilize vertebrae and act as shock absorber. Deterioration within intervertebral
disk results in loss of these water-retaining branches and eventually in shortening of chains.

The etiology of back pain for a particular individual cannot be determined, because of the multiplicity of
potential sources. Although periosteal disruption causes pain with fractures, bone itself is devoid of pain
receptors (eg, asymptomatic compression fractures commonly are seen in the thoracic spine of elderly
individuals with osteoporosis). However, the degenerating intervertebral disk is known to have
neurovascular elements at the periphery, including pain fibers.
Disk deterioration and loss of disk height may shift the balance of weightbearing to the facet joint; this
mechanism has been hypothesized as a cause of LBP through the facet-joint capsule, as well as through
other tissues attached to and between the posterior bony elements.
When the anulus is incised in animals, a degenerative cascade is initiated that mimics the natural aging
process observed in humans, thus providing a model of disk deterioration.  [9] As the use of diskography has
increased for various clinical applications, similar anular tears are seen routinely that are associated with
the degeneration of the intervertebral disk, even in patients who are asymptomatic. Anular tears may simply
be the result of aging and the degenerative cascade.
Pathology studies of young patients who died as a result of trauma reveal a surprising degree of articular
surface damage in the facet joints; magnetic resonance imaging (MRI) routinely reveals disk deterioration
in individuals in the second or third decade of life. Injection of chymopapain into the intervertebral disk
causes a repeatable and predictable degenerative cascade in the facet joints, illustrating the coupling
between the disk and the facet joints. Immobilization by facet fusion posteriorly leads to disk deterioration;
this avascular structure is solely dependent upon motion to facilitate the diffusion of nutrients into it.
Whether the deterioration of the disk or that of the facet comes first has not been determined; however,
deterioration is known to occur in both.
Dehydration results from shortening of the hyaluronic chains, deterioration of the state of aggregation, and
decreases in the ratio of chondroitin sulfate to keratan sulfate, leading to disk bulging and loss of disk
height. The consistency of the nuclear material undergoes a change from a homogeneous material to
clumps, which leads to the altered distribution of pressures within the disk and resistance to the flow of
nuclear material; the nuclear material thereby becomes mechanically unstable.  [10] The clumping of the
degenerating nuclear material can be likened to a marble held between two books—that is, it is difficult to
contain.
These clumps may be lateral to the posterior longitudinal ligament and therefore may have the least
resistance to herniating through the corner of the intervertebral disk and into the spinal canal or foramen.
Surgical removal of the herniated fragments is achieved by grasping them with a pituitary rongeur.
This method of surgical removal is not possible with normal homogeneous material, which is encountered
when healthy intervertebral disks are excised anteriorly in patients undergoing surgery because of
deformity or trauma. Using the pituitary rongeur technique to perform a microdiskectomy on a herniated
fragment necessitates a preexisting state of deterioration; the weakened areas in the anulus provide a path
of least resistance for the nuclear material to egress.

Natural history
Much has been written concerning the process of spinal deterioration or spondylosis, which occurs over a
lifetime. Intervertebral disk deterioration leads to decreased stiffness of the disk, as well as diminished
stability, resulting in episodic pain that is common and may be temporarily severe. However, continued
deterioration ultimately leads to restabilization of the spine by collagenization, which stiffens the disk.
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 degenerative cascade.
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. Furthermore, spontaneous recovery from an acute pain episode routinely
occurs; thus, for any treatment to be demonstrated as effective, it must positively alter the expected course
without treatment.
In general practice, the overall incidence of HNP in patients who have new-onset LBP is lower than 2%.
Therefore, most of these patients have deterioration of the intervertebral disk and dysfunction of the
functional segmental unit. They will have LBP, and some will have associated leg pain but without sciatica
(an intractable, radiating pain below the knee) or radiculopathy. A disk fragment that is no longer contained
within the anulus but is displaced into the spinal canal has decreased hydration and deteriorated
proteoglycan that can be expected to undergo further deterioration and consequent anular desiccation,
essentially resembling a grape being transformed into a raisin.
Spontaneous resolution of sciatica may result from shrinkage of a herniated fragment, aided by
macrophages and the evoked inflammatory reaction, but practitioners too often attribute this clinical
improvement to their favorite treatments. Intractable symptoms of sciatica from intervertebral disk
displacements may benefit dramatically from surgical intervention.
Within 20 years of Mixter and Barr's 1934 report, Friedenberg compared operative treatment with
nonoperative treatment. [5, 11] Nonoperative treatment yielded three groups of results: pain-free, occasional
residual pain, and disabling pain. Proportions of these groups remained similar after 5 years. Friedenberg
concluded that even recurrent severe episodes may resolve without surgery; the problem was and remains
patient selection.
Weber presented a randomized, controlled study (marred by dropouts in the surgery control group because
of severe pain) and concluded that patient results were the same with operative as with conservative
treatment, except that those who were treated operatively had better results at 1 year. [12]
The Spine Patient Outcomes Research Trial (SPORT) observational cohort was 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, but at long-term follow-up, the two groups again were not statistically
different. [13]

Prognosis
Patients with "broad-based" intervertebral disk herniations generally have a deterioration of the disk or a
failure of clinical stability with associated back pain, rather than isolated sciatica. These patients are not
appropriate candidates for microdiskectomy alone.
Lumbar fusion is being used increasingly in these cases, and arthroplasty is also being considered;
however, this treatment remains controversial because it is, again, based inevitably on subjective patient
pain and clinical judgment without objective determination. Many reports in the literature have described
specific cytokines elevated, but not comprehensively; endplate changes are observed but no clear
correlation identified to this point. Various nuclear replacements that reduce postoperative loss of disk
height and restore compressive loading are being studied. [14]
With a diskectomy, patients with dominant leg pain have excellent results, with 85-90% returning to full
function. However, as many as 15% of patients have continued back pain that may limit their return to full
function, despite the absence of radiculopathy. Patients who undergo surgery do not necessarily show
better results than those who defer surgery. [15]
The remaining concern of recurrent herniation is small, though it is correlated with obesity.  [16]  Efforts to
minimize this complication have included anulus repair [17]  and injection of hemostatic materials or bioactive
molecules. Etanercept was shown in a small study to be of no benefit for sciatica, though the addition of
butorphanol with corticosteroid was helpful with an epidural injection. [18]
Intervertebral disk degeneration that causes clumping of the nuclear material and relative mechanical
instability is the necessary preceding condition for HNP. However, it is impossible to tell which patients will
do well after microdiskectomy for a herniation and which will have continued problems, of varying severity,
from the disk degeneration. Studies have shown that degenerated disks have different growth factors and
other molecules; thus, even introducing mesenchymal stem cells requires significant further research and
development. [19]
Significant deterioration and accompanying LBP increasingly are being treated with stabilization, via either
an anterior lumbar interbody fusion (ALIF) or a posterior lumbar interbody fusion (PLIF) in association with
posterior decompression (when necessary) and instrumentation. Techniques continue to evolve, and
conclusive results remain to be determined.
Tomasino et al presented radiologic and clinical outcome data on patients who underwent single-level
anterior cervical diskectomy and fusion (ACDF) for cervical spondylosis or disk herniation with the use of
bioabsorbable plates for instrumentation. [20] Overall, at 19.5 months postoperatively, 83% of the patients
had favorable outcomes according to the Odom criteria.
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.  [20] In
this study, the fusion rate and outcome were found to be comparable to the results achieved with metallic
plates, and the authors concluded that the use of bioabsorbable plates is a reasonable alternative to metal,
avoiding the need for lifelong metallic implants.
Buchowski et al performed a cross-sectional analysis of two large prospective randomized multicenter trials
to evaluate the efficacy of cervical disk arthroplasty for myelopathy with a single-level abnormality localized
to the disk space. [21]  Both patients in the arthroplasty group and those in the arthrodesis group had
improvement after surgery, with improvement being similar and with no worsening of myelopathy occurring
in the arthroplasty group. Although the findings at 2 years after surgery suggested that arthroplasty is
equivalent to arthrodesis in these cases, the authors did not evaluate treatment of the retrovertebral
compression that occurs with ossification of the posterior longitudinal ligament.
Carragee et al compared progression of common degenerative findings between lumbar disks injected 10
years previously and those same disks in matched subjects who were not exposed to diskography.  [22] In all
graded or measured parameters, disks exposed to puncture and injection showed greater progression of
degenerative findings than control (noninjected) disks did (35% vs 14%), with 55 new disk herniations
occurring in the diskography group and 22 in the control group. There also was significantly greater loss of
disk height and signal intensity in the diskography disks. The authors recommended careful consideration
of risk and benefit in regard to disk injection.
McGirt et al performed a prospective cohort study using standardized postoperative lumbar imaging with
computed tomography (CT) and magnetic resonance imaging (MRI) every 3 months for 1 year and
annually thereafter to assess same-level recurrent disk herniation. [23] Improvement in all outcome measures
was observed 6 weeks after surgery. At 3 months after surgery, 18% loss of disk height was observed,
which progressed to 26% by 2 years. In 11 (10.2%) patients, revision diskectomy was required at a mean
of 10.5 months after surgery.
In this study, [23] patients who had larger anular defects and removal of smaller disk volumes had an
increased risk of recurrent disk herniation, and those who had greater disk volumes removed had more
progressive disk height loss by 6 months after surgery. The authors suggested, on the basis of these
findings, that in cases of larger anular defects or less aggressive disk removal, concern for recurrent
herniation should be increased and that effective anular repair may be helpful in such cases.
Fish et al performed a retrospective single-center study to analyze whether MRI findings could be used to
predict therapeutic responses to cervical epidural steroid injections (CESI) in patients with cervical
radiculopathy. [24] Patients were categorized by the presence or absence of four types of cervical MRI
findings: disk herniation, nerve-root compromise, neuroforaminal stenosis, and central-canal stenosis. Only
the presence, versus the absence, of central-canal stenosis was associated with significantly superior
therapeutic response to CESI. The authors therefore concluded that the MRI finding of central-canal
stenosis is a potential indication that CESI may be merited.
Hirsch et al systematically reviewed the literature to determine the effectiveness of automated
percutaneous lumbar diskectomy (APLD). [25] The authors noted that according to United States Preventive
Services Task Force (USPSTF) criteria, the indicated evidence for APLD is level II-2 for short- and long-
term relief, indicating that APLD may provide appropriate relief in properly selected patients with contained
lumbar disk prolapse. However, the authors also noted that there was a paucity of randomized, controlled
trials in the literature covering this subject.
Dasenbrock et al performed a meta-analysis of six trials (N = 837) comparing open diskectomy with
minimally invasive diskectomy and found similar visual analogue scale (VAS) scores at short- and long-
term follow-up. [26] No significant difference between the two approaches was apparent with regard to relief
of leg pain. Reoperation was more common with limited (tubular) exposure, but the difference was not
statistically significant. Total complications did not differ.
Yamaya et al assessed early outcomes of transforaminal percutaneous endoscopic lumbar diskectomy in
18 high school athletes (14 male, 4 female) with lumbar HNP.  [27]   All factors assessed by questionnaire—
time to return to competitive sport, complications, and rate of recurrence of herniation—were significantly
improved after the procedure, and the VAS score was improved as well. There were no complications (eg,
dural tear, exiting nerve root injury, or hematoma), and one patient had a recurrence of HNP.
A retrospective single-center study by Harada et al evaluated the application of machine learning
techniques to predict disk reherniation after lumbar diskectomy. [28]  The authors found preoperative leg VAS
score, disability, alignment parameters, elevated body mass index, symptom duration, and age to be the
strongest predictors of recurrent HNP. On the basis of these findings, they developed the re-herniation after
decompression (RAD) profile index as screening tool for identifying patients at low or high risk patients for
HNP recurrence; this tool will require additional validation before it can be broadly implemented.
Clinical Presentation
History
The importance of history-taking as the first integral step in the evaluation of a patient suspected of having
a herniated disk cannot be overstated. 
Many of these patients narrate a history of some sort of prodromal back pain. They may correlate their
symptoms with an episode of trauma, which often (in fact, more often than not) is incidental and not
associated with the pathology. However, certain typical physical activities that the patient claims to have
preceded their symptoms may be of importance and may lead the clinician toward the diagnosis of a
herniated disk. These include sudden twists or jerks, lifiting heavy weights, and falls. 
Pain is usually the chief complaint; it may be axial or, more typically, radicular. It is important to ask the
patient several questions regarding their pain, such as the following:
 Is it predominantly back pain or leg pain?
 What is the character of the pain?
 Is the onset of pain acute, subacute, or chronic?
 Is the pain aggravated by any activity or maneuver?
 Is the pain relieved by a particular posture or maneuver?
 Was there any previous history of similar symptoms, and if so, how were the symptoms
treated?
Red-flag signs (eg, a concomitant history of fever and weight loss, unrelenting night pain, long-term oral
steroid or immunosuppressant use, or a history or suspicion of cancer, particularly in patients older than 50
years) may indicate a more serious underlying pathology and should be promptly investigated. Apart from
pain, pertinent questions related to the symptoms of motor weakness, sensory disturbances, and bladder or
bowel dysfunction should be asked. A progressive neurologic deficit or cauda equina syndrome is
considered a surgical emergency because irreversible consequences may result if these are left untreated.
Risk factors such as the patient's lifestyle—for example, if it involves prolonged sitting and bending forward,
a history of smoking, or a history of antidepressant use—should also be addressed. Pain in disk herniation
often has a psychosocial component, particularly when the symptoms do not follow a fixed dermatomal or
myotomal pattern and do not correlate with the imaging findings. Thus, the clinician must also direct history-
taking towards this important aspect. 
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. Also, it is helpful to determine which
activities the patient is unable or less able to perform and which activities exacerbate or moderate the pain.
An assessment of the physical demands of the patient's occupation and daily activities provides the
perspective for the described activity intolerance. A pain drawing can be very helpful in assessing the
pattern of pain (eg, a dermatomal distribution) or in assessing the organicity of the complaints.

Physical Examination
In the physical examination, the first indication that a patient may have a lumbar disk herniation comes from
the patient's gait itself as he or she walks into the examination room. A characteristic feature is a sciatic list,
which represents an attempt to relieve the neuromeningeal tension by drawing the nerve root away from
the herniated disk. A disk herniation lateral to the nerve root (a "shoulder disk") causes the patient to lean
away from the side of the herniation, whereas a herniation medial to the nerve root (an "axillary disk")
causes the patient to lean towards the side of the herniation. There may be paraspinal muscle spasm, as
indicated by obliteration of the central furrow.
Numerous examination maneuvers (eg, Lasegue classic test, Lasegue rebound sign, Lasegue differential
sign, Braggard sign, flip sign, Deyerle sign, Mendel-Bechterew sign, well-leg test or Fajersztajn sign, both-
legs or Milgram test) are available, but they cloud the issue, in that the sciatic nerve-root tension or straight-
leg raising test (SLRT) is the basis for nearly all of them. They are essentially modifications for subtle
differences, but the provocation of radiating pain down the leg is of a neural compressive lesion and
compression of the sciatic nerve root, if it goes below the knee. Furthermore, the provocation of radiating
pain down the leg is the most sensitive test for a lumbar disk herniation.
The SLRT should always be performed bilaterally. The test is considered positive if sciatic pain is
reproduced between 30º and 70º of elevation. Studies have determined that in the first 35º of elevation, the
slack in the nerves is taken up, and at 35º or more, tension is placed on the nerves. More than 70º of
elevation causes no further stretch of the nerve roots. The SLRT is best for eliciting L4, L5, or S1
radiculopathy.
For a higher lumbar lesion, reverse straight-leg raising or hip extension that stretches the femoral nerve is
analogous to an SLRT. The Spurling test in the cervical spine is used to detect foraminal stenosis (the
Kemp test is used in the lumbar region) rather than specifically for intervertebral disk herniation or nerve-
root tension. Careful hip, rectal, and genitourinary examinations help exclude complications of those organ
systems in the diagnosis of higher lumbar lesions.
A meticulous neurologic examination must follow inspection, palpation, and examination maneuvres. One
must know the dermatomal patterns of the commonly afflicted nerve roots (L4, L5, and S1). The examiner
should be wary of the presence of a glove-and-stocking distribution sensory loss, which can indicate a
peripheral neuropathy, such as may be associated with diabetes, or functional overlay; this is not anatomic.
Standard Medical Research Council (MRC) grading is used to grade muscle power during motor
examination. Upper-motor-neuron signs can be elicited if a cervical disk herniation is causing cord
compression.

Imaging Studies
Plain radiography
Plain radiographs cannot show a disk herniation directly. Their main utility in the workup of a patient
suspected of having disk herniation is to show indirect evidence of disk degeneration, such as disk-space
narrowing, endplate changes, osteophytes, facet-joint degeneration, and alteration of sagittal balance. In
fact, in most young patients with disk herniations, plain radiographs may be completely normal, except
insofar as they show loss of lordosis due to muscle spasm or a sciatic tilt. As far as planning for surgery is
concerned, radiography can rule out more serious underlying causes of back pain, such as infections or
tumors; it can also show sacralization or lumbarization of vertebrae.
Magnetic resonance imaging
MRI is the gold standard in the evaluation of a suspected lumbar disk herniation. It provides accurate and
detailed information regarding disk morphology, hydration, herniations, endplate changes, and nerve-root
and cord status. (See the image below.) MRI with gadolinium contrast enhancement is often used to
evaluate patients who have already undergone decompression surgery and are suspected of having
recurrent or residual disk herniation. The postgadolinium T2-weighted images can be used to differentiate
between scar tissue (which enhances) and disk fragments (which do not).

Appearance of lumbar disk

herniation on MRI.
MRI may be useful for predicting the likelihood that a patient with lumbar disk herniation will require
microdiskectomy. [30]
Myelography
Myelography, once considered the investigation of choice, is now rarely used. Its main disadvantage is that
whereas it is capable of showing the level at which the pathology exists, it cannot define the nature or
morphology of the lesion or the precise locationof the lesion in the anatomic segment. Current application
of myelography is restricted to the performance of CT myelography in patients who have a contraindication
for MRI, such as those who have a pacemaker in place or those who are claustrophobic.

Other Tests
Several other blossoming modalities exist that have been sparingly used in the evaluation of patients with
suspected disk herniation, such as the following:
 Magnetic resonance (MR) spectroscopy
 MR neurography
 Electromyography (EMG) and nerve conduction tests
 Dynamic MRI
 Open/standing MRI

Procedures
Diagnostic selective nerve root blocks using bupivacaine have been used to pinpoint a particular nerve root
as the culprit behind a patient's symptoms. This can prove useful when imaging shows disk herniations at
two levels and there is confusion as to which of the two levels is contributing to the patient's symptoms. 

Conservative Treatment
Spontaneous improvement of low back discomfort has allowed ineffective treatments to perpetuate,
because benefits have been ascribed to them when they are prescribed while the patient is still
symptomatic but otherwise improving.
Hippocrates expected improvement in sciatica in 40 days, and the customary and contemporary guideline
is 6 weeks. An often-quoted study suggested near-resolution improvement of 90% of patients within 6
weeks, but this study has been faulted because the criterion for patient recovery was failure to return to the
observing physician. [31]  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.
Analysis of the effectiveness of treatments and attempts to restrict treatment to those modalities that have
demonstrated efficacy are evidence-based medical practice. Bed rest has a long history of use but has not
been shown to be effective beyond the initial 1 or 2 days; after this period, it is counterproductive. All
conservative treatments are essentially efforts to reduce inflammation. Therefore, only a very short period
of rest is appropriate; anti-inflammatories are of some benefit (because the pain is from inflammation of the
nerve), and warm, moist heat or modalities may help. Tumor necrosis factor (TNF)-α antagonism was
experimentally shown to decrease inflammatory events in preclinical models. [32]
Activities should be resumed as early as the patient can tolerate. Exercise and physical therapy mobilize
muscles and joints to facilitate the removal of edema and promote recovery. Muscle relaxants may offer
symptomatic relief of the acute muscle spasms, but only in the early stages; however, all are centrally
acting, they do not directly relax skeletal muscle, and they are also sedating.
For back pain without radiculopathy, chiropractic care has high patient satisfaction when performed within
the first 6 weeks, and it has been shown to have good efficacy acutely from an evidence-based
standpoint. [33]  Injections (eg, epidural) may be particularly helpful in patients with radiculopathy by providing
symptomatic relief, which allows the patient to increase activities and helps facilitate rehabilitation.  [34, 35]  Any
nuclear material that is herniated may shrink as the proteoglycan deteriorates, loses its water-retaining
ability, and turns from a grapelike object to a raisinlike object.
Arbitrary time schedules for improvement are inappropriate in any patient who continues to improve and
whose function is relatively maintained. Traction in the acute setting may help muscle spasms, but it does
not reduce the herniated nucleus pulposus (HNP) and has no good evidence of efficacy. The use of traction
does not justify hospital admission; this is not cost-effective, and traction can be administered on an
outpatient basis.
Long-term use of physical therapy modalities is no more effective than hot showers or hot packs are at
home. A transcutaneous electrical nerve stimulation (TENS) unit may be subjectively helpful in some
patients with chronic conditions. Patients should be encouraged essentially to compensate for intervertebral
disk incompetence, to the extent possible, by means of muscular stabilization, as well as to maintain
flexibility by initiating lifelong exercise regimens that include aerobic conditioning (particularly swimming,
which allows gravity relief).
It is important to assess the body mechanics of every patient who is disabled from work. All patients should
be educated about body mechanics and informed of the risk factors for faulty body mechanics, so that
applications can be incorporated into individual work settings, including appropriate seating (eg, lumbar
support). The lumbar facet joints are oriented relatively vertically, thus allowing forward flexion, but they
impact each other when a person bends and then rotates. Repetitive bending and twisting have been noted
to be epidemiologic problems in workers and may be associated with chronic pain and
disability. [36]  Attention to lifting techniques and ergonomic modification at workstations may be appropriate.

Surgical Intervention
The classic presentation of an HNP includes the complaint of sciatica, with associated objective neurologic
findings of weakness, reflex change, and dermatomal numbness. Various surgical procedures have been
reported, which havev the common goal of decompressing the neural elements to relieve the leg pain.
These procedures are most appropriate for patients with minimal or tolerable back pain who have an
essentially intact and clinically stable disk. However, the hope of permanently relieving the back pain is a
fantasy—a false hope.
The most common procedure for a herniated or ruptured intervertebral disk is a microdiskectomy, in which
a small incision is made, aided by an operating microscope, and a hemilaminotomy is performed to remove
the disk fragment that is impinging on the nerves.
Many patients who undergo microdiskectomy can be discharged with minimal soreness and complete relief
of leg pain after overnight admission and observation. Same-day procedures are in the process of cautious
development. Patients with dominant back pain have a different problem, even if HNP is present, 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).
Minimally invasive techniques have not replaced this standard microdiskectomy procedure but can be
summarized in two broad categories: central decompression of the disk and directed fragmentectomy.
Outpatient treatment has been reported. [37, 38]
Central decompression of the disk can be performed chemically or enzymatically with chymopapain, by
laser or plasma (ionized gas) ablation and vaporization, or mechanically by aspiration and suction with a
shaver such as the nucleotome or percutaneous lateral decompression (arthroscopic microdiskectomy).
The Food and Drug Administration (FDA) initially released and then withheld chymopapain for injection into
lumbar disks because of adverse allergic reactions in patients; skin tests subsequently were used to
determine sensitivity. However, the procedure continued to induce severe muscle spasms that could be far
worse than those of an open operation and thus necessitated hospitalization and bedrest for up to 50% of
patients. [39]
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, because the muscles are severely affected,
which would not be expected if the enzyme were contained. In addition, severe scarring in the spinal canal
is noted routinely after this procedure.
The nucleotome and laser central decompressions have been shown only to equal placebo in
effectiveness, and their use has declined. Superiority has not been demonstrated; patient selection is
crucial, and the learning curve is steep. [40]
Further development of alternatives, such as nucleoplasty, and efforts to reduce disk pressure remain
under study. The incidence of recurent herniation is small but may be irreducible. Efforts to seal the anulus
are under investigation.
Directed fragmentectomy is similar to open microdiskectomy and has demonstrated greater effectiveness
than placebo. 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 anulus. Endoscopic techniques for
performing a directed fragmentectomy and minimizing disruption of normal structures continue in
development, but superiority has not been conclusively demonstrated despite the theoretical advantages of
this minimally invasive approach.
With respect to the cervical spine, HNP customarily is treated anteriorly, because the pathology is anterior
and manipulation of the cervical cord is not tolerated by the patient. The posterior approach is reserved for
disk herniation that is confined to the foramen and for foraminal stenosis. An alternative to the anterior
cervical spine approach is minimal disk excision; clinical stability following this procedure is dependent
upon the residual disk, which is also true in cases where there is lumbar spine involvement with back pain.
Removal of neural compression dramatically relieves radiculopathy; however, residual axial neck pain may
result in significant impairment.
Anterior cervical interbody fusion is another intervention. Proponents of diskectomy alone assert equivalent
results, but the adequacy of follow-up in those case reports is a significant concern. Patients with more
severe disk degeneration, particularly myelopathy, would more uniformly undergo fusion. Anterior
instrumentation is being used more commonly, and interbody cages are under consideration as a means of
attaining more rapid rehabilitation and more consistent results. Multilevel disk replacement has been
suggested as being at least similar to fusion. [41]