Prolapse of lumbar intervertebral

disc

Li Jieruo

Dept of Orthopedics, the 1st Affiliated Hospital

Orthopaedic Diseases Institute
Jinan University
Definition
• Lumbar intervertebral disc herniation refers that under the
degenerative change of the lumbar intervertebral disc,and the action
of external forces, the partial or total annulus fibrosus rupture, then
alone or with nucleus pulposus, cartilage endplate protrusion,
stimulating or compressing sinus vertebral nerves and nerve roots,
with lumbago and leg pain as the main symptoms of a disease.
• It is a common and frequently occurring disease in Department of
orthopedics, which is a common cause of lumbago and leg pain. The
most common is L4-5 and L5-S1, accounting for about 90%-96%.
 Anatomy
• Lumbar vertebral bony structure:

centrum 、 vertebral pedicle 、

Processus transversus 、
superior articular process 、
inferior articular process 、

laminae of vertebral arches 、

spinous process 、
intervertebral disc
Others: canalis spinalis 、
foramen intervertebrale
 Anatomy

• Ligament ：

ligamenta longitudinale-
anterius 、 ligament-

longitudinale posterius 、
ligamentum flavum 、
ligamenta interspinalia 、

ligamenta supraspinale
Anatomy
• Intervertebral disk ：

Annulus ： it consists of fibrous cartilage containing collagen fiber bundles and is

located around the nucleus pulposus.

Nucleus pulposus ： It is an elastic gelatinous material, wrapped by annulus and

cartilage plates, containing a large amount of water, with elastic effect. As age increases,
its elasticity and tension decrease and are easily damaged.

Cartilaginous plate ： It is composed of hyaline cartilage, covering the bone surface

between the epiphyseal ring of the upper vertebral body and the epiphyseal ring of the
lower vertebral body. It has many micropores and is a pathway for water and
metabolites in the nucleus pulposus.
Anatomy
• Nerve
Sensory distribution of lumbar nerve roots:
 Anatomy
•The relationship between lumbar disc
and nerve root
①Normally,

L3-L4 disc herniation presses L4 nerve roots.

L4-L5 disc herniation presses L5 nerve roots.

L5-S1 disc herniation presses S1 nerve roots.

②The protrusion of lumbar intervertebral

disc in the posterior central part can cause
extensive nerve root and cauda equina
compression.
 Pathogeny
1.Degeneration of the intervertebral disc is the fundamental cause: aging
→ degeneration of the intervertebral disc → loss of elasticity of the nucleus
pulposus, gradual fissure of the annulus fibrosus → external force or strain
rupture of the intervertebral disc → nerve compression

2.Injury: accumulation of injury is the main cause of intervertebral disc

degeneration.

3.Pregnancy: the ligament system is loose, and the lumbosacral part is

stressed.

4.Genetic factors: the incidence of coloured race is low.

5. Dysplasia
 Classification
Expansion Protrusion Dislocation
The fibrous ring is The fibrous ring is The nucleus pulposus
partially ruptured, but completely ruptured, perforating the posterior
the surface is intact and the nucleus pulposus longitudinal ligament,
smooth. Non operative protrudes to the spinal but its root is still in the
treatment can mostly canal, and the posterior intervertebral space,
relieve it. longitudinal ligament is and it needs surgical
intact. Surgery is often treatment.
needed.
Sequestration
Large nucleus pulposus tissue
penetrates the annulus fibrosus
and posterior longitudinal
ligament, completely protrudes
into the spinal canal, and is
detached from the original
intervertebral disc, requiring
surgery.
Schmorl tuberculum and
Osseous protrusion
In the former, the nucleus
pulposus protrudes into the
cancellous bone of the vertebral
body through the superior and
inferior cartilage plates; in the
latter, the nucleus pulposus
protrudes forward between the
cartilage plates of the vertebral
body and the vertebral body.
 Clinical manifestations - Symptoms
①It is commonly in 20-50 years old, male-female ratio of 4-6:1,
most of patients have bending labor or long-term sitting work
history, the first onset offen happens at weight-bearing with semi-
bending posture or process of sudden bending .

②Lumbago ： Most patients have low back pain, irritation of the

outer layer of the annulus fibrosus and the posterior longitudinal
ligament, and sensory pain caused by stimulation on the sinus
vertebral nerve.

③ ischialgia ： radiating pain from the lower back to the

buttocks, the rear area of thigh, the lateral crus, and the dorsum
of the foot.
④Syndrome of cauda
equina ： The central type
of lumbar disc herniation can
oppress the cauda equina
nerve, resulting in
disturbance of the stool and
bowel and abnormal
sensation in the sellar region.
Acute onset should be used
as indication of emergency
operation.
Clinical manifestations - Signs
（ 1 ） Lumbar scoliosis: to releave the pain.
（ 2 ） Limited waist activity: The anterior
flexion is most limited. When anterior flexion
is applied, the nucleus pulposus moves
backward and increases the stretch of the
compressed nerve roots.

（ 3 ） Tenderness and spasm of sacral

spinalis ： There is tenderness in the space
between the spinous processes, radiation
pain along the sciatic nerve at 1 cm
paravertebral compression, and lumbar
sacrospinal spasm is in about 1/3 of the
patients, which fixed the lumbar region in a
forced position.
(4)Straight leg raising test: When the leg is stretched and raised,
the sciatic nerve is pulled, and then the nerve root is pulled
down. When the lumbar intervertebral disc is herniated, the
pulling can aggravate the nerve root stimulation and
compression.
Bragard sign
（ 5 ） Femoral nerve stretching test
（ 6 ） Nervous system examination
1 ） Abnormal sensation
2 ） Decrease of muscle strength
3 ） Reflectance anomaly

Nerve localization in lumbar radiculopathy

Nerve Key sensory area Key motor muscle Reflex
root
L2 Anterior thigh Iliocsoas

L3 medial femoral condyle knee extensor Knee reflex

L4 malleolus medialis musculi hippicus

L5 Dorsal side of third Extensor hallucis longus

metatarsophalangeal
joint
S1 Lateral heel Flexor plantaris Ankle reflex
Imaging examination
X-Ray: Lumbar anterioposterior and lateral 、 Flexion and extension 、 Bilateral
oblique position

①Is Lumbar scoliosis?

②Does physiological lordosis decrease or disappear?③Is the intervertebral space narrow?
CT ： High resolution CT can clearly show the location, size,
shape of the herniated intervertebral disc and the image of the
compression and displacement of the nerve root and dural sac.
MRI ： The degeneration of intervertebral discs can be
observed comprehensively, the degree and position of nucleus
pulposus protrusion can be understood, and other space
occupying lesions can be differentiated.
Other examination
Electrophysiological graph ： electromyogram 、 sensory
evoked potential 、 Motion Evoked Potential
Contrast examination ： invasive examination
Diagnosis

1.History: stoop to work or sit for a long time.

2.Clinical menifestation: lower back pain ， ischialgia ，
Syndrome of cauda equina
3.Signs ： forced position 、 limited waist activity ， lateral
bending ， straight leg raising test or Bragard sign is positive ，
abnormal neurological examination, etc.
4.Imaging examination ： X ray ， CT ， MRI
 Differential diagnosis ：
Lumbar muscle It is related to the long-term maintenance of a working posture;
degeneration chronic soreness and distention without obvious inducement can be
relieved after rest, with a fixed tenderness point, but relieved by
tapping at the tenderness point.

Pyriformis syndrome
Sciatic nerve descends from the lower edge of piriformis muscle or
through piriformis muscle, mainly manifesting pain in buttocks and lower
limbs, which can be relieved by rest; gluteal muscle atrophy, deep hip
tenderness and straight leg elevation test are positive; symptoms can be
induced by hip joint abduction and rotation resistance

Lumbar spinal stenosis It is characterized by neurogenic intermittent claudication, with many

syndrome complaints and fewer positive signs.

Others:Third lumbar transverse foramen syndrome 、 Spondylolisthesis and pedicle isthmus

nonunion 、 Lumbar tuberculosis 、 Spinal tumor 、 Intraspinal tumor 、 Pelvic disease 、 Lower extremity
vascular disease, etc.
Treatment - nonoperative treatment

Indication:
① First onset and shorter course of disease
② Symptoms can be relieved after rest.
③ Because of systemic diseases or local skin diseases, patients
can not be operated
④ Patients who disagree with surgery
Nonoperative treatment:
① Rest in bed, usually stay in
bed for 3 weeks, gradually
move under the waist
protection braces.
② Nonsteroidal
antiinflammatory drugs

③ Traction therapy ， and

pelvic traction is most
commonly used.
④physical treatment
Treatment- surgical treatment

Indication ：
①Patients with serious, recurrent symptoms of lumbago and leg
pain, ineffectiveness after more than half a year of non-surgical
treatment , and symptom is gradually aggravated so that work
and life are affected.
② Central protruding lumbar disc syndrome associated with
cauda equina syndrome ,and patients with sphincter dysfunction
should be operated emergently.
③ There are obvious manifestations of nerve involvement.
Treatment- surgical treatment

（ 1 ） Microsurgical lumbar discectomy ： It is suitable for pure lumbar

disc herniation.
Treatment- surgical treatment
（ 2 ） Total laminectomy for nucleus pulposus removal

It is suitable for lumbar disc herniation with spinal stenosis,

bilateral herniation of the intervertebral disc, large central
herniation or free disc herniation, this surgical decompression is
adequate;

（ 3 ） Hemi laminectomy for removal of nucleus pulposus

Suitable for unilateral disc herniation.
Treatment- surgical treatment
（ 4 ） Percutaneous lumbar diskectomy ： It is suitable for pure lumbar
disc herniation.
Treatment- surgical treatment
（ 5 ） Artificial disc replacement

Replacement of all or part of annulus fibrosus and nucleus pulposus or mere

replacement of nucleus pulposus. It should be prudent to choose this
procedure.
Thanks ！