Herniation of Intervertebral Herniation of Intervertebral DiskDisk

By: The toothless one J.Karl By: The toothless one J.Karl PinedaPineda

BackgroundBackground

Lumbar disk disease Lumbar disk disease is a frequent source is a frequent source of low back pain. of low back pain.

Sciatica is defined as Sciatica is defined as neuralgia along the neuralgia along the course of the sciatic course of the sciatic nerve.nerve.

PathophysiologyPathophysiologyThe intervertebral disks act as shock absorbers and are found between the The intervertebral disks act as shock absorbers and are found between the bodies of the vertebrae. They have a central area composed of a colloidal bodies of the vertebrae. They have a central area composed of a colloidal gel, called the nucleus pulposus, which is surrounded by a fibrous capsule, gel, called the nucleus pulposus, which is surrounded by a fibrous capsule, the annulus fibrosis. This structure is held together by the anterior the annulus fibrosis. This structure is held together by the anterior longitudinal ligament, which is anterior to the vertebral bodies, and the longitudinal ligament, which is anterior to the vertebral bodies, and the posterior longitudinal ligament, which is posterior to the vertebral bodies and posterior longitudinal ligament, which is posterior to the vertebral bodies and anterior to the spinal cord. The muscles of the trunk provide additional anterior to the spinal cord. The muscles of the trunk provide additional support. support. The most common site of disk herniation is at the L5-S1 interspace in the The most common site of disk herniation is at the L5-S1 interspace in the lumbosacral region. This is believed to be due to the thinning of the lumbosacral region. This is believed to be due to the thinning of the posterior longitudinal ligament as it extends caudally. posterior longitudinal ligament as it extends caudally. Nomenclature specific to lumbar disk disease Nomenclature specific to lumbar disk disease Disk bulge - Annular fibers intact Disk bulge - Annular fibers intact Disk protrusion - Localized bulging with damage of some annular fibers Disk protrusion - Localized bulging with damage of some annular fibers Disk extrusion - Extended bulge with loss of annular fibers, but disk remains Disk extrusion - Extended bulge with loss of annular fibers, but disk remains intact intact Disk sequestration - Fragment of disk broken off from the nucleus pulposus Disk sequestration - Fragment of disk broken off from the nucleus pulposus

FrequencyFrequency

In the US: In the US: Sciatica has been reported by Sciatica has been reported by various authors to occur in 1-10% of the various authors to occur in 1-10% of the population. population. Mortality/Morbidity: Mortality/Morbidity: Low back pain usually is Low back pain usually is self-limited and of short duration. self-limited and of short duration. Sex: Sex: The male-to-female ratio is approximately The male-to-female ratio is approximately 1:1. 1:1. Age: Age: The group most commonly affected is The group most commonly affected is adults aged 25-45 years. adults aged 25-45 years.

Clinical ManifestationClinical ManifestationHistory: History: The history may be sufficient to make presumptive diagnosis of a disk The history may be sufficient to make presumptive diagnosis of a disk disorder or may guide the physician's usage of ancillary testing and disorder or may guide the physician's usage of ancillary testing and consultations to further differentiate both the specific type of disk disease and consultations to further differentiate both the specific type of disk disease and potential other etiologies of the patient's back pain. potential other etiologies of the patient's back pain. Patients with disk disease usually are not able to give a precise time that the Patients with disk disease usually are not able to give a precise time that the problem began because it usually is preceded by multiple episodes of less problem began because it usually is preceded by multiple episodes of less severe low back pain.severe low back pain.Asking the patient the location of the pain is important.Asking the patient the location of the pain is important.

Pain that is localized to the lower back and gluteal area often is associated with disk Pain that is localized to the lower back and gluteal area often is associated with disk disease.disease.

Pain associated with nerve root involvement commonly radiates down the leg, Pain associated with nerve root involvement commonly radiates down the leg, particularly below the level of the knee.particularly below the level of the knee.

Ask the patient about any unusual recent activity, especially if it involved the patient Ask the patient about any unusual recent activity, especially if it involved the patient remaining in a flexed or rotated position. Find out if the patient experienced any recent remaining in a flexed or rotated position. Find out if the patient experienced any recent trauma.trauma.

Pain with flexion, rotation, or prolonged sitting or standing, and sharp (rather than dull) Pain with flexion, rotation, or prolonged sitting or standing, and sharp (rather than dull) pain are suggestive of disk disease.pain are suggestive of disk disease.

The onset of pain may begin suddenly or gradually after injury.The onset of pain may begin suddenly or gradually after injury. Typically, the pain is located bilaterally at the posterior belt line.Typically, the pain is located bilaterally at the posterior belt line. The pain pattern usually is referred rather than radicular.The pain pattern usually is referred rather than radicular. Back motion, which includes sitting, standing, lifting, bending, and twisting, usually Back motion, which includes sitting, standing, lifting, bending, and twisting, usually

aggravates the pain; it often is relieved with rest and a recumbent position.aggravates the pain; it often is relieved with rest and a recumbent position.

Clinical ManifestationClinical ManifestationPhysical: Physical: Nerve roots exit the spine below the intervertebral disks; thus, Nerve roots exit the spine below the intervertebral disks; thus, herniation of a disk involves the nerve root below it. herniation of a disk involves the nerve root below it. Observe the patient for abnormal gait, which is suggestive of a loss of the normal Observe the patient for abnormal gait, which is suggestive of a loss of the normal rhythm. Have ambulatory patients walk on their toes to test the function of S1.rhythm. Have ambulatory patients walk on their toes to test the function of S1.Observe the patient for abnormal posture, which is suggestive of splinting or Observe the patient for abnormal posture, which is suggestive of splinting or guarding from pain.guarding from pain.Test the patient's ability to dorsiflex the foot while sitting to test the L5 nerve root. Test the patient's ability to dorsiflex the foot while sitting to test the L5 nerve root. Test for sensory loss that corresponds to a dermatomal area.Test for sensory loss that corresponds to a dermatomal area.Palpation of the lumbar spine and lower back is not helpful in the diagnosis of Palpation of the lumbar spine and lower back is not helpful in the diagnosis of disk disease, but it should be done to rule out other causes of low back pain.disk disease, but it should be done to rule out other causes of low back pain.A positive straight leg-raising test is indicative of nerve root involvement.A positive straight leg-raising test is indicative of nerve root involvement.

This test is performed while the patient is lying supine with one leg either straight or This test is performed while the patient is lying supine with one leg either straight or flexed at the knee, with the sole of the foot flat on the stretcher. The other leg is kept flexed at the knee, with the sole of the foot flat on the stretcher. The other leg is kept straight and lifted by the examiner.straight and lifted by the examiner.

If pain occurs when the leg is lifted between 30-70 degrees from horizontal and travels If pain occurs when the leg is lifted between 30-70 degrees from horizontal and travels down the leg until below the knee, the test is positive.down the leg until below the knee, the test is positive.

Nerve root stretch tests are often negative.Nerve root stretch tests are often negative.Patients may exhibit decreased lumbar range of motion (ROM).Patients may exhibit decreased lumbar range of motion (ROM).The usual motor, sensory, and reflex examinations (including perianal sensation The usual motor, sensory, and reflex examinations (including perianal sensation and anal sphincter tone when appropriate) should be performed.and anal sphincter tone when appropriate) should be performed.A careful abdominal and vascular examination is mandatory in evaluation of A careful abdominal and vascular examination is mandatory in evaluation of these patients.these patients.

CausesCauses

The normal aging process of the The normal aging process of the musculoskeletal system aggravates acute musculoskeletal system aggravates acute events.events.Risk factorsRisk factors AgeAge ActivityActivity SmokingSmoking ObesityObesity Vibration (eg, driving a car)Vibration (eg, driving a car) Sedentary lifestyleSedentary lifestyle Psychosocial factorsPsychosocial factors

Diagnostic TestsDiagnostic Tests

Laboratory tests generally are not helpful in the Laboratory tests generally are not helpful in the diagnosis of lumbar disk disease.diagnosis of lumbar disk disease.Indications for screening laboratory Indications for screening laboratory examinations include a pain of a nonmechanical examinations include a pain of a nonmechanical nature, atypical pain pattern, persistent nature, atypical pain pattern, persistent symptoms, and age older than 50 years.symptoms, and age older than 50 years. Complete blood count (CBC) with differentialComplete blood count (CBC) with differential Erythrocyte sedimentation rate (ESR)Erythrocyte sedimentation rate (ESR) Alkaline and acid phosphataseAlkaline and acid phosphatase Serum calciumSerum calcium Serum protein electrophoresisSerum protein electrophoresis

Diagnostic TestsDiagnostic Tests

Radiographic studies are very helpful in the diagnosis of lumbar disk Radiographic studies are very helpful in the diagnosis of lumbar disk disease, but several important caveats should be taken into account disease, but several important caveats should be taken into account with the use of these tests.with the use of these tests.Most patients with pain from lumbar disk disease will have Most patients with pain from lumbar disk disease will have resolution of their symptoms with conservative treatment.resolution of their symptoms with conservative treatment.For an otherwise healthy individual, unless the patient is For an otherwise healthy individual, unless the patient is immobilized completely by the pain and requires admission, or the immobilized completely by the pain and requires admission, or the pain has been present for more than 6 weeks, diagnostic studies pain has been present for more than 6 weeks, diagnostic studies are not recommended. Elderly patients or those with a history of are not recommended. Elderly patients or those with a history of cancer or chronic infection (including tuberculosis), trauma, or cancer or chronic infection (including tuberculosis), trauma, or osteoporosis should have imaging performed as part of their routine osteoporosis should have imaging performed as part of their routine workup during initial presentation.workup during initial presentation.MRI is the imaging modality of choice in evaluating patients with MRI is the imaging modality of choice in evaluating patients with lumbar disk disease. Studies have shown that as many as 60% of lumbar disk disease. Studies have shown that as many as 60% of people without back symptoms have disk bulges and protrusions on people without back symptoms have disk bulges and protrusions on MRI. Therefore, these findings may not correlate with the patient's MRI. Therefore, these findings may not correlate with the patient's symptoms.symptoms.

Diagnostic TestsDiagnostic TestsCT scanning is useful for diagnosing disk disease but is less CT scanning is useful for diagnosing disk disease but is less sensitive than MRI. CT scanning of the abdomen can help to sensitive than MRI. CT scanning of the abdomen can help to evaluate and rule out other etiologies of pain such as aortic evaluate and rule out other etiologies of pain such as aortic aneurysm, ureteral calculi, and intra-abdominal causes. Combining aneurysm, ureteral calculi, and intra-abdominal causes. Combining CT scan with myelography can increase the sensitivity of the CT scan with myelography can increase the sensitivity of the modality for spinal cord pathology.modality for spinal cord pathology.Myelography may provide a definitive diagnosis on its own, but this Myelography may provide a definitive diagnosis on its own, but this is an invasive test requiring a lumbar puncture and the use of is an invasive test requiring a lumbar puncture and the use of contrast material.contrast material.Plain films of the lumbar spine generally are not helpful in the Plain films of the lumbar spine generally are not helpful in the diagnosis of lumbar disk disease, except to rule out other diseases diagnosis of lumbar disk disease, except to rule out other diseases and to evaluate for possible skeletal etiology as the cause of the and to evaluate for possible skeletal etiology as the cause of the patient's symptoms. They should be performed in patients who are patient's symptoms. They should be performed in patients who are elderly or those with a history of cancer or chronic infection elderly or those with a history of cancer or chronic infection (including tuberculosis), trauma, or osteoporosis.(including tuberculosis), trauma, or osteoporosis.Bone scan (scintigraphy)Bone scan (scintigraphy)

Technetium-99m labeled phosphorus indicates active Technetium-99m labeled phosphorus indicates active mineralization of bone.mineralization of bone.

A bone scan is indicated to rule out tumors, trauma, or infection.A bone scan is indicated to rule out tumors, trauma, or infection.

MRI image of herniated diskMRI image of herniated disk

TreatmentTreatmentPrehospital Care: Prehospital Care: Little is needed in the way of prehospital care. Little is needed in the way of prehospital care. Appropriate spinal immobilization should be considered if the patient Appropriate spinal immobilization should be considered if the patient has evidence of trauma; otherwise, simple transportation in the has evidence of trauma; otherwise, simple transportation in the position of comfort is all that is indicated. position of comfort is all that is indicated. Emergency Department Care: Emergency Department Care: Patients should lie in a position in which they are most comfortable.Patients should lie in a position in which they are most comfortable.Muscle relaxants are of limited use and clinical studies have not Muscle relaxants are of limited use and clinical studies have not proven their efficacy. This class includes benzodiazepines, proven their efficacy. This class includes benzodiazepines, methocarbamol, and cyclobenzaprine. Patients should be warned methocarbamol, and cyclobenzaprine. Patients should be warned that all of these drugs are sedating.that all of these drugs are sedating.Opioids provide very effective acute pain relief, but they should not Opioids provide very effective acute pain relief, but they should not be used in patients with chronic pain.be used in patients with chronic pain.Salicylates, acetaminophen, and nonsteroidal anti-inflammatory Salicylates, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) all have been used in the treatment of pain from drugs (NSAIDs) all have been used in the treatment of pain from lumbar disk disease, but none of these has been shown to be lumbar disk disease, but none of these has been shown to be superior to the others. Acetaminophen lacks anti-inflammatory superior to the others. Acetaminophen lacks anti-inflammatory activity.activity.

Drugs to takeDrugs to takeIbuprofen (Ibuprin, Advil, Motrin) -- Usually Ibuprofen (Ibuprin, Advil, Motrin) -- Usually DOC for treatment of mild to moderately DOC for treatment of mild to moderately severe pain if no contraindications severe pain if no contraindications

Drugs to takeDrugs to take

Ketoprofen (Oruvail, Orudis, Actron) -- Ketoprofen (Oruvail, Orudis, Actron) -- Used for relief of mild to moderately Used for relief of mild to moderately severe pain and inflammation. Administer severe pain and inflammation. Administer small dosages initially to patients with small dosages initially to patients with small body size, to the elderly, and to small body size, to the elderly, and to those with renal or liver disease. Doses those with renal or liver disease. Doses higher than 75 mg do not increase higher than 75 mg do not increase therapeutic effects. Administer high doses therapeutic effects. Administer high doses with caution and closely observe patient with caution and closely observe patient for response. for response.

Drugs to takeDrugs to take

Flurbiprofen (Ansaid) -- May inhibit Flurbiprofen (Ansaid) -- May inhibit enzyme cyclooxygenase, which in turn enzyme cyclooxygenase, which in turn inhibits prostaglandin biosynthesis. These inhibits prostaglandin biosynthesis. These effects may be mechanism of its effects may be mechanism of its analgesic, antipyretic, and anti-analgesic, antipyretic, and anti-inflammatory activities. inflammatory activities.

More drugs to takeMore drugs to take

Naproxen (Anaprox, Naprelan, Naprosyn) Naproxen (Anaprox, Naprelan, Naprosyn) -- Used for relief of mild to moderately -- Used for relief of mild to moderately severe pain. Inhibits inflammatory severe pain. Inhibits inflammatory reactions and pain by decreasing activity reactions and pain by decreasing activity of enzyme cyclooxygenase, causing of enzyme cyclooxygenase, causing decrease in prostaglandin synthesis. decrease in prostaglandin synthesis.

Herniated disk is not funHerniated disk is not fun

InterventionsInterventions

InterventionsInterventions

Prescribe medication on schedule and Prescribe medication on schedule and document effectivenessdocument effectivenessUse distraction Use distraction Heat or ice applicationHeat or ice applicationMoving by log rolling and repositioning Moving by log rolling and repositioning every 2 hours (if not contraindicated by every 2 hours (if not contraindicated by maintaining traction)maintaining traction)High protein, iron and vitamin enriched High protein, iron and vitamin enriched dietdiet

InterventionsInterventions

Observe dressing for bleeding or Observe dressing for bleeding or cerebrospinal fluid leakagecerebrospinal fluid leakageAntiembolic stockings if orderedAntiembolic stockings if orderedDocument I&ODocument I&OIt is important to monitor the patient for It is important to monitor the patient for evidence of respiratory and paralytic ileus evidence of respiratory and paralytic ileus as complications may occur in as complications may occur in laminectomy patientslaminectomy patientsMove by log rolling Move by log rolling

InterventionsInterventions

Spend as little time as possible in sitting positionSpend as little time as possible in sitting position

Braces or corsets if prescribed are applied Braces or corsets if prescribed are applied before patient gets out of bedbefore patient gets out of bed

Encourage ADLEncourage ADL

No lifting or carrying anything heavier than 5 No lifting or carrying anything heavier than 5 pounds for at least 8 weekspounds for at least 8 weeks

Avoid twisting motions of the trunkAvoid twisting motions of the trunk

Reinforce importance of follow-up visit to Reinforce importance of follow-up visit to physicianphysician

PrognosisPrognosis

With conservative treatment, some With conservative treatment, some patients will receive relief of symptomspatients will receive relief of symptoms

If neurological pathology develops, If neurological pathology develops, surgical intervention is neededsurgical intervention is needed

Prognosis is usually quite favorablePrognosis is usually quite favorable

Herniated disks can be a hairy Herniated disks can be a hairy situationsituation

Randy, Mike, Glen, Jay, Mr. DaveRandy, Mike, Glen, Jay, Mr. Dave