Lumbar disc herniation

Dr Ram kishore
assistant professor
department of orthopaedics
rangaraya medical college
 contents
• pathoanatomy
• pathogenesis
• classification
• investigations
• treatment options
 Intervertebral Disc:Normal,Aging,and
Pathologic
• intervertebral disc is a fibrocartilaginous
structure

• principal function is to act as a shock absorber,

transmitting compressive loads between
vertebral bodies.
 Normal Disc
• intervertebral disc is composed of three main
structures
• cartilaginous endplates
• central nucleus pulposus, and
• peripherally located anulus fibrosus
 Cartilaginous Endplates
• intervertebral disc is separated from
adjacent vertebral bodies by a
cartilaginous endplate superiorly and
inferiorly
• endplate serves as the growth plate
for the vertebral bodies with
epiphyseal growth plate structure
• infancy, this growth plate is thick
• 1-mm-thick, avascular layer of hyaline
cartilage in adults
• Biomechanically, most compressive
forces are transmitted through the
• superior vertebral body to the
• endplate, to the
• nucleus pulposus, and to the
• inferior endplate and vertebral body.
 Nucleus Pulposus
• lies between adjacent endplates and forms the
gel-like core of the disc
• consists of a proteoglycan and water matrix held
together by collagen type II and elastin fibers.
• Proteoglycans have - anionic glycosaminoglycan
side chains which allows the nucleus to imbibe
water.
•
 Anulus Fibrosus
• surrounds the nucleus and is composed
of approximately 20 concentric rings
(lamellae) of highly organized collagen
fibers, primarily collagen type I.
• collagen fibers are orientated
approximately 60 degrees to the vertical
axis of the spine
• run parallel within each lamella but
perpendicular between adjacent lamellae
allowing for maximal tensile strength.
• Fibers of the outer anulus attach to the
periphery of the vertebral bodies, whereas
inner f ibers pass from one endplate to
another.
• Tensile properties of the anulus allow the
nucleus to recover its original shape and
position when the compression removed
 Blood Supply
• early fetal life vascular channels traverse the
endplates,
• diminish in size at birth
• complete disappearance by 5 years of age.
• In adults, two capillary plexuses supplies One
plexus penetrates 1 to 2 mm into the outer
anulus,
• The other capillary plexus begins in the vertebral
body and penetrates the subchondral bone
terminating in capillary loops at the bone
cartilage junction.
 Nutrition
• nutrition depends almost on diffusion
• Small molecules (i.e., glucose and oxygen)
readily leave vertebral capillaries and
diffuse across the thin cartilaginous
endplate and the outermost layers of the
anulus into the ECM.
• Metabolic by-products such as lactic acid
are removed from the disc by diffusion in
the opposite direction of nutrient entry.
• the ability of the matrix to imbibe and
release water in relation to applied
stresses allows the disc to cushion
against compressive loads.
• primary proteoglycan is aggrecan,
hydrophilic molecule provides the osmotic
properties needed to resist compression.
• Proteoglycans x aggrecan
• nucleus are initially notochordal origin which has
chondrocyte-like cells synthesize proteoglycans
and collagen type II in response to changes in
hydrostatic pressure.
• functions— shock absorber,
• acting as a pressurized, deformable sphere that
dissipates compressive forces to the anulus and
the adjacent vertebral bodies
• compressive forces on the spine increase,
hydrostatic pressure within the nucleus pushes
outward from its center in all directions.
• anulus and nucleus are uniquely avascular
and lacking neurons under normal
 Disc Composition
• Water- concentration is regulated by the
GAG side chains of proteoglycans.
• concentration of water varies with age,
location within the disc, and body position.
• Water content varies with load, leading to
diurnal changes in disc hydration.
• Water is expressed from the disc during
the day because of the increased forces of
body weight and muscle contractions, and
it is reimbibed at night when the
compressive forces are removed.
• This diurnal cycle results in changes in
disc height and affects the disc’s
mechanical properties.
 disc contents
• collagen content of the disc is highest in
the outer anulus
• aggrecan, numerous other
macromolecules, including elastin, the
decorin and fibromodulin, cartilage
oligomeric matrix protein, and cartilage
intermediate layer protein.
 Lumbar Disc Herniations
• tensile failure of the anulus to contain the
gel-like nuclear portion of the disc causes
herniation
 Pathoanatomy
• The disc is the anterior border of
the spinal canal at the facet joint
level.
• It is covered by posterior
longitudinal ligament, which is
concentrated in the midline, from
which small bands extend laterally
to cover the inferior aspect of the
disc leaves the superior part of the
posterolateral disc bare —
posterolateral (or paracentral)
herniations are the most location
for herniations
• spinal cord ends at L1 level in
adults to form the conus
medullaris.
• The cauda equina is located
within the lumbar spinal canal.
• Nerve roots branch from the
cauda equina one level above
their exiting foramen
• The L5 nerve root leaves the
cauda equina at L4 vertebral
body.
• descends inferolaterally to
pass
• anterior to the L4-5 facet
joint and
• posterior to the L4-5 disc.
Intimately associated with
the inferomedial aspect of
the L5 pedicle, the root turns
lateral to enter the L5-S1
intervertebral (neural)
foramen just proximal to the
L5-S1 disc.
• Within the foramen, sensory
cell bodies forms the dorsal
root ganglion called
postganglionic spinal nerve,
exits the neural foramen at
lateral aspect of the L5-S1
disc.
• short extraspinal course, the
nerve divides into a ventral
and dorsal primary ramus.
 spinal canal can be divided into
longitudinal zones
• central zone - lateral borders of the cauda equina.
• lateral recess -lateral border of the cauda equina
and the medial border of the pedicle
• foraminal zone - medial and lateral borders of the
pedicle.
• far-lateral or extraforaminal zone- beyond the lateral
border of the pedicle

• Herniations in the foraminal or extraforaminal zones

usually affect the exiting nerve.
 Pathophysiology
• Disc Degeneration and Disc herniation
• one of the stage of the lumbar degenerative
cascade
• Herniation occurs through a tear in the anulus
fibrosus.
• Force transfer works only if the nucleus-anulus-
endplate complex acts as a closed volume
system.
•
• Compression across the disc space leads
to increased pressure within soft nucleus -
deforms and flattens, pushing against the
annular fibers, which then generates
tensile hoop stresses.
• if placed under sufficient pressure the soft
nucleus can be pushed through disruption of the
anulus
• The nucleus must be fluid, or “dynamic,” enough
to permit herniation to occur.
• Discs in younger individuals that have a well-
hydrated nucleus are more likely to herniate.
• Older patients with desiccated discs are less
prone to herniation.
• Postural variations can influence intradiscal
pressures. The highest pressures seen in
patients with the torso forward flexed with
weight in hand.
• in a study found — combined lateral bend, flexion,
and axial rotation with 15 minutes of exposure to
vibration can lead to tears which is significant
for occupations with exposure to long periods of
vibratory stimuli, such as truck drivers and
machine workers.
 Disc Herniation and Sciatica
• most classic symptom of a herniated disc
is radicular pain in the lower extremity
following a dermatomal distribution and
Focal neurologic deficits
• pure compression of a noninflamed nerve
produces sensory and motor changes
without pain,
• whereas pain is elicited with manipulation
of inflamed nerves.
• herniated discs will cause mechanical
compression of a nerve root may produce focal
deficits, but that associated sciatic-type pain is
produced only if the nerve root is concurrently
irritated or inflamed.
• Inflammation may be produced by prolonged
neuroischemia of the microvasculature of the
nerve root or by nonmechanical, biochemical,
factors.
• Neurochemical factors also have a role in the
production of sciatic pain. elevated levels of IgM
were found in discs from sciatica patients
• matrix metalloproteinase, nitric oxide,
prostaglandin E2, and interleukin-6 in discs
excised from patients with herniation and
radiculopathy
 Disc Herniation and Back Pain
• Most patients with symptomatic disc
herniations present with leg and back
pain.
• Innervation of the posterior anulus by
branches of the sinuvertebral nerve - are a
suggested pathway of nociceptive pain
transmission from disc degeneration.
 Classification of Disc Herniations
• protruded disc - eccentric
bulging through an intact
anulus fibrosus.
• extrusion - disc material
that crosses the anulus
but is in continuity with
the remaining nucleus
within the disc space.
• sequestered disc -
herniation that is not
continuous with the disc
space; this is the typical
“free fragment.”
 Location
• central zone, lateral recess, foraminal, or
extraforaminal regions
 Timing
• Acute herniations are present for less than
3 to 6 months,
• chronic discs cause symptoms for a
longer time.
 History and Symptoms
• prodromal history of long-standing mild to
moderate back pain
• trauma,fall, a twist, or lifting of a heavy item
attributes to leg and back pain
• Pain is the most common complaint. Axial back
pain is typically present
• Lower lumbar or lumbosacral disc herniations
can lead to the classic symptoms of pain
radiating below the knee.
• S1 radicular pain may radiate to
the back of the calf or the
lateral aspect or sole of the foot.
• L5 radicular pain - on the
dorsum of the foot
• L2 and L3 radiculopathy can
produce anterior or medial thigh
and groin pain.
• Groin pain may also be
indicative of L1 pathology.
• character of radicular pain can be sharp,
dull, burning, or dysesthetic.
• exacerbated by coughing, bending, or lifting.
• Relieving maneuver - lying supine with the
knees and hips flexed, particularly with
lower lumbar herniations.
• lumbar stenosis, patients with disc
herniations more typically complain of
constant pain that is not exacerbated by
ambulation.
• Tenderness to palpation of one or two
levels is more consistent with bony
pathology
• paraspinal muscle Spasm — kiblers test
• Muscular atrophy can be a sign of
longstanding neural compression
 Neurologic Examination
• higher motor functions
• cranial nerves function
• MOTOR AND SENSORY EXAMINATION
• special tests
 motor examination
• bulk
• tone
• power-MCR grading
• reflexs
• involuntery movements
• S1 motor -plantar flexion,
• L5 -toe dorsiflexion, particularly the great toe
(extensor hallucis longus), hip abduction
• L4 -ankle dorsiflexion (anterior tibialis),
quadriceps
• L3 function Knee extension
• L1-2 -hip flexion,
• Motor function is graded as 0 to 5, with 5 being
full strength against active resistance
 sensory examination
• fine touch
• pin prick
• temp
• joint position
• vibration
reflexs
 signs of incordination
• rombergs sign
• finger - nose test
• dysdiadochokinesia
• heel to shin test
• tandom walk
 Specific Tests
• straight-leg raise (SLR) test -provocative
test
• supine position, best for eliciting L4, L5,
or S1 radiculopathy only .The test is
considered positive sciatic pain is
reproduced between 35 degrees and 70
degrees of elevation.
• at 35 degrees or more, tension is placed
on the nerves. More than 70 degrees of
elevation causes no further stretch of the
nerve roots.
• positive SLR test is indicative of nerve
root compression in 90% of cases.
• SLR test bilaterally.
• cross slrt test :raising the contralateral leg
reproduces symptoms in the ipsilateral
side, this is highly suggestive for a
herniated disc and and is more specific
for a free disc fragment.
 Lasègue maneuver
• modification of the SLR test
• The leg is raised until radiating symptoms
are produced.
• Then the foot of the ipsilateral leg is
maximally dorsiflexed.
• exacerbates pain and is considered a
positive examination.
 seated SLR test
• a patient is initially examined, seated at the side
of the examining table with the knees and hips
flexed at about 90 degrees.
• In this position, the heel is cupped, and the leg is
extended at the knee. With a herniated fragment
causing nerve root tension,
• the patient reflexively extends at the hip and
leans back to relieve the ensuing sciatic pain.
 slump test
• Lasègue test and the seating SLR test.
• seated position asked to flex the thoracic and
lumbar spine while fully flexing the neck.
• Next, the SLR test is performed while the foot is
dorsiflexed on the same side, as denoted by the
Lasègue test.
• combination of these maneuvers adds
cephalad gliding of the spinal cord to the
examination, whereas the SLR test and
Lasègue test by themselves produce only
caudal tension on the nerve roots.
• slump test was more sensitive than the SLR
test in patients with lumbar disc herniations,
whereas the SLR test was more specific
 tension sign -bowstring test

• Starting with a typical SLR test, the leg is

raised until symptoms are produced.
• leg is flexed at the knee, and the tibial and
peroneal nerves (distal aspect of sciatic
nerve) are placed on tension by palpation
in the popliteal space.
• Reproduction of pain is considered a
positive sign of root tension.
 femoral stretch test
• Wasserman sign
• prone position.
• Leg is flexed at the knee while pulling the
hip into extension.
• Reproduction of anterior thigh pain is
indicative of upper lumbar root pathology.
 Differential Diagnosis
• Radicular pain can be caused by
numerous compressive disorders, such as
spinal stenosis, abscess, tumor, or
vascular disease.
 Diagnostic Imaging
• within the first 2 weeks of the incident, the
examination is typically masked by a large
amount of spasm, back pain, and
generalized tenderness.
• plain radiographs are obtained in trauma
• low energy, radiographs can be delayed
until the follow-up examination at 6 weeks
• pain has not improved or perhaps has
worsened, plain radiographs are obtained.
• Advanced imaging is reserved for patients
in whom pain is persistent, the diagnosis
is unclear, or surgical treatment is planned
• “Red flags” in a patient’s history that
should prompt early MRI include
constitutional symptoms (i.e., fever, chills,
and sweats), a history of malignancy,
osteoporosis, progressive neurologic
deficits, or bowel and bladder
incontinence.
 x rays
• Plain radiographs cannot show a herniated
disc but can show changes that are suggestive
of a herniated disc.
• scoliotic list can be present on radiographs.
This list may be convex or concave to the
ipsilateral side and is not specific for a level.
• changes consistent with disc degeneration,
including osteophytes; disc space narrowing;
or subtle changes in translation, facet
hypertrophy, or changes in sagittal alignment.
• films are important in ruling out obvious
underlying problems, such as lytic lesions,
tumors, infections, inflammatory spinal
disorders, or instabilities (e.g.,
spondylolisthesis
• High-quality anteroposterior and lateral
radiographs are prerequisites to planning
discectomy.
• recognize if there is an anomalous spine
with a “lumbarized” first sacral segment (i.e
., six lumbar vertebrae), because this can
influence intraoperative identification of the
correct disc level.
 Magnetic Resonance Imaging
• most popular modality for
advanced imaging of lumbar
disc herniations. MRI is superior
to CT in delineating soft tissues.
• Free fragments (sequestered)
can be differentiated from
extruded disc herniations, and
• symmetrical bulge can be
differentiated from a contained
protrusion
• Neural
encroachment
can be detected
• differentiating
disc herniations
from tumors,
vascular
anomalies, or
bony
compression.
 Myelography
• Plain myelography previously was the imaging
modality of choice in detecting herniated discs.
• It involves injection of intrathecal contrast
material to outline the boundaries of the
subarachnoid space and silhouette the enclosed
neural elements.
• It is invasive and cannot show compression
beyond subarachnoid space.
• Advantages —dynamic test because images can
be made with the patient standing.
 Computed Tomography

• Using bone and soft tissue imaging

techniques, herniations can be detected
• disc herniations can contain gas
(Knuttson phenomena), noted on CT
images
 Methods of Nonoperative
Treatment
• Treatment goals are to restore strength,
flexibility, and function that were lost
secondary to pain, splinting, and spasm.
• Postural education to avoid activities that
can increase intradiscal pressure or
neuromeningeal tension
• Bed rest should be limited to no more than
2 to 3 days.
• Exercise therapy and physical
rehabilitation
• physical therapy prescription —torso
stabilization training; paraspinal muscle
stretching and strengthening;
• focus on gluteal, hamstrings, and abdominal
exercises

• These muscles are important in the static and

dynamic stabilization of the spinal column.
• ultrasound treatment, electrical stimulation,
and massage helpful in short-term,
symptomatic relief of back pain.
• Traction is also commonly prescribed. —may
diminish intradiscal pressure, increase
foraminal dimensions, and possibly relieve
radicular pain secondary to herniated discs.
 Pharmacologic Treatment
• Nonsteroidal anti-inflammatory drugs
(NSAIDs) are first-line agents.
cyclooxygenase-2 inhibitors used in
syptomayic relief
• acute setting, Short-term narcotic use,
such as a single dose of a
morphinederivative analgesic, can be
useful.
• in the acute setting, a tapering dosage
regimen of oral steroids can be helpful in
decreasing inflammation-generated pain
from nerve root irritation.
• muscle relaxants such as diazepam and
methocarbamol should be used sparingly.
• antispasmodic medications such as baclofen or
cyclobenzaprine can have a more direct effect on
muscle spasms.
• Selective transforaminal steroid injections can
produce symptomatic relief
• patients who have failed noninvasive measures,not
interested or are not good candidates for
discectomy. In patients with more than one level of
herniation, selective nerve root injection can be
useful in determining the symptomatic level.
 Operative Treatment
• absolute indication for lumbar discectomy
is a progressive neurologic deficit
• open laminectomy as the procedure of
choice for herniated lumbar disc.
• Microscopic lumbar disc excision
• Endoscopic discectomy
• Percutaneous Automated Discectomy
• Chemonucleolysis
Open Simple Discectomy
 MICROSCOPIC LUMBAR DISCECTOMY
• incision from the
midspinous process of the
upper vertebra to the
superior margin of the
spinous process of the
lower vertebra at the
involved level
• elevate the deep fascia and
muscle subperiosteally from
the spinous processes and
lamina on the involved side
only
• lateral radiograph with a metal
clamp attached to the spinous
process to verify the level.
• annular tear with a Penfield no. 4
dissector and remove the disc
material with the appropriate-sized
pituitary rongeur.
• Remove the exposed disc material.
Remove additional loose disc or
cartilage
 Chemonucleolysis
• chemical digestion of nucleus material via
injection of an agent, such as
chymopapain, into the intervertebral disc.
 Endoscopic Discectomy
• translaminar epidural
endoscopic discectomy
lateral decubitus position,
• small paramedian incision
arthroscope (endoscope) is
inserted through a 6-mm
working cannula.
• An additional lateral
paraspinal incision is made
for an outflow cannula.
• A shaver is used to remove bone within
the interlaminar window
• A root retractor pulls the nerve root and
dura medially, allowing access to the disc
space.

• The anulus is incised, and the herniation is

removed. The endoscope can be inserted
into the disc space to look for any
additional loose fragments (so-called
discoscopy).
 Percutaneous Automated
Discectomy
• posterolateral approach, a tissue-removing
device is introduced into the disc space in a
similar path as the needle of a discogram; this is
guided by intraoperative fluoroscopy.
 reference

• campbell edition 14
• rothman simeone the spine
• david magiee
• grays anatomy
thank you