Disc Herniation

Definition/Description

A herniated disc in the spine is a condition in which a nucleus pulposus leaves the intervertebral space. It is a common cause of back pain. A patient with herniated disc related pain often recalls an evocative event that caused their pain. Unlike the back of machines pain herniated disc pain is usually burning or painful and may extend to the lower extremities. Additionally in more severe cases, it can be associated with weakness or emotional changes. In some cases, a herniated disc injury can compress the nerve or the spine causing persistent pain with atherosclerosis or spinal cord dysfunction also known as myelopathy.[1].

Herniated Disc’s:

• Can be very painful.
• Within a few weeks, most painful disc herniations heal.
• In many cases, the herniation of the disc causes no pain for that patient.
• Herniated discs are commonly diagnosed on MRI of asymptomatic patients (MRI is the imaging modality of choice).
• Disc herniation management requires a professional team. Initial treatment should be conservative unless a patient has severe neurological impairment.
• Surgery is usually the last resort as it does not always produce predictable results. Patients are often left with residual pain and arthritis, which is often worse after surgery.
• Exercise is the key for most patients. Results depend on many factors but those who engage in regular exercise and maintain a healthy body weight achieve better results than sedentary people[2].

[3]

Clinically Relevant Anatomy

See Lumbar Anatomy for more information

Intervertebral disc: Two adjacent vertebral bodies are connected by the intervertebral disc. Together with the corresponding facet joints, they form a ‘functional unit of Junghans’. The disc is composed of an annulus fibrosus with a nucleus pulposus and two cartilaginous endplates. The difference is between the annulus and the nucleus can only be made in youth because the symmetry of the disc is the same in old age. For this reason nuclear disc protrusion is rare after 70 years. From a clinical perspective, it is important to view the disc as a single, integrated entity as normal whose function depends largely on the integrity of the whole. That means destroying one thing will have negative reactions to the others[4].

The disc contains: Endplate; The annulus fibrosus; The nucleus pulposus

Etiology

The intervertebral disc is a fibrous annulus formed by a dense collagenous ring surrounding the nucleus pulposus.

• Disc herniation occurs when part or all of the nucleus pulposus protrudes through the annulus fibrous. This herniation process starts with failure in the innermost annulus rings and progresses radially outwards.
• Damage to the annulus of the disc appears to be associated with repeated or prolonged complete compression of the spine.
• Herniation may occur suddenly or gradually over several weeks or months.
• Causes
  • The most common cause of disc herniation is a degenerative process (as people age the nucleus pulposus becomes less fluid and weak and can lead to disc herniation).
  • The second most common cause of disc herniation is trauma.
  • Other causes include connective tissue and congenital abnormalities such as short veins.
• Disc herniation is:
  • Most common in the lumbar spine
  • Next, the cervical spine. The high rate of disc herniation in the lumbar and cervical spine can be explained by an understanding of the biomechanical forces in the soft tissue of the spine.
  • The thoracic spine has a low incidence of disc herniation[2].
• Repetitive mechanical processes such as twisting bending without relaxation can lead to disc failure.
• Sitting sedentary makes it easier to stand obesity tobacco smoking can also cause disc prolapse.

Pathophysiology

• The disc consists of an annulus fibrosus (a series of dense fibrous rings) and a nucleus pulposus (a gelatinous core containing collagen fibrous elastin fibers and a fluid gel)[5]. The intervertebral discs and ligaments of the vertebral body on the anterior wall form the spinal canal and by the dorsal vertebrae and muscles on the posterior wall. The spinal cord lies within this spinal canal[6].
• The pathophysiology of herniated discs is believed to be a combination of mechanical compression by the rolling nucleus pulposus and local increases in inflammatory chemokines.[2]
• Tearing may occur in the annulus fibrosus. The contents of the nucleus pulposus can follow through this tear and enter the intervertebral or vertebral foramen to create a nerve structure[6].
• The changes are nuclear degeneration nuclear displacement and stage of fibrosis.

Types Of Herniations

• Posterolateral Disc Herniation – Protrusion is usually posterolateral to the spinal canal. A protruding disc usually compresses the next inferior vein as the vein traverses the disc segment on its way to its foramen. (Example: L5 protrusion usually affects S1)
• Cental (posterior) Herniation – Not uncommon. A protruding disc above the 2nd vertebra can actually compress the spine or cause Cauda Equina Syndrome.
• Lateral Disc Herniation – The nerve root compression occurs superior to the herniation. L4 nerve roots are most commonly involved.

Stages Of Herniation

There are four types of varicose veins [7] : Bulging; Higher levels of materials; Excretion of substances; Sequestration (see figure below) .

Bulging: the edge of the disc extending beyond the edges of the adjacent vertebral endplatesProtrusion: the posterior longitudinal ligament remains intact but the nucleus pulposus overlies the anulus fibrosusExtrusion: the nuclear material protrudes through the annular fibers but posteriorly the longitudinal ligament remains intactSequestration: the nuclear material passes through the annular fibers and the posterior longitudinal ligament is destroyed. A portion of the nucleus pulposus has protruded into the epidural space

Epidemiology

• The incidence of herniated disc is approximately 5 to 20 cases per 1000 adults per year and is most common in people in their third to fifth decade with a 2:1 male to female ratio.
• In 95% of cases of lumbar disc herniation the L4-L5 and L5-S1 discs are affected[8].
• Lumbar disc herniation occurs 15 times more frequently than cervical disc herniation and is a major cause of back pain[9][10].
• People aged 30 to 50 with a gender gap of 2:
• In individuals between the ages of 25 and 55, approximately 95% of herniated discs occur in the lower lumbar spine (L4/5 and L5/S1 level); disc herniation above this level is more common in people older than 55 years[11].
• It is rare in children and common in young and middle-aged adults.
• Recurrent lumbar disc herniation (rLDH) is a common complication after primary discectomy.
• Cervical disc herniation is severely impacted 8% of the time and is most common at levels C5-C6 and C6-C7.

History And Examination

Cervical Spine

History

In the cervical spine C6-7 is the most common herniation disc causing symptoms mostly radiculopathy. The history in these patients should include the chief complaint and symptoms beginning at the point of onset and radiation of pain. History should include if there is any past treatment.

Physical Examination

In physical examination special attention should be paid to weakness and sensory disturbance and its myotome and dermatomal distribution.

Typical findings in solitary nerve ulcers due to compression by a herniated disc in the cervical spine

• C5 Muscles – neck shoulder and scapula pain posterior arm numbness and weakness when abducting shoulder posterior rotation elbow flexion and forearm supination. The affected motor units are the biceps and brachioradialis.
• C6 Muscle – neck shoulder scapula and posterior forearm forearm and hand pain accompanied by weakness of the thumb and index finger. Weakness during shoulder abduction after rotation elbow flexion and forearm supination and pronation is common. Reflexes affected are biceps and brachioradialis muscle.
• C7 Muscle – neck shoulder middle finger pain is often accompanied by middle index finger numbness. Weakness at the elbow and wrist is common along with weakness while radial extension forearm pronation and wrist flexion may occur. The affected reflex is the triceps.
• C8 Muscles – neck shoulder and middle finger pain with tenderness over middle finger and middle hand. Weakness usually occurs during wrist extension elbow (ulnar) extension wrist to distal flexion extension abduction and adduction are included during distal thumb flexion. It has no addictive feeling.
• T1 Nerves – pain is most common in the middle arms and wrists of the neck while numbness is most common on the forearm and middle fingers. Weakness may occur with abduction of distal thumb flexion and finger abduction and adduction. No theory affects it.[2]

Lumbar Spine

History

In the lumbar spine, a herniated disc can cause symptoms including sensory and motor abnormalities that are limited to a specific myotome. The history in these patients should include chief complaints of symptoms beginning at the point of onset and radiation of pain. History should be included in case there are previous items treatments.

Physical Examination

A careful neurological examination can help determine the level of pressure. Sensory impairment weakness pain area and loss of reflex associated with the different levels are described below

Typical findings in solitary nerve ulcers due to compression by a herniated disc in the spine

• L1 Nerve – pain and loss of sensation is common in the inguinal region. Hip flexion weakness is rare and no stretch reflex is affected.
• L2-L3-L4 Muscles – back pain radiating to front of thigh and middle of lower leg; loss of sensation to the front of the thigh and sometimes to the midfoot; hip flexion and adduction weakness knee extension weakness; decreased patellar reflex.
• L5 Nnerve – posterior radiating to buttock posterior thigh posterior calf and dorsum of foot big toe; loss of sensation in the dorsal surface of the calf over the wing of the foot between the first and second toes; weakness in hip abduction knee flexion leg dorsiflexion ankle extension and flexion leg inversion and eversion; semitendinosus/semimembranosus reflex a ɛso tew.
• S1 Muscle – dorsal radiation to dorsal or posterior thigh posterior calf or heel foot; loss of sensation in posterior part of calf or lower leg; weakness in hip extension knee flexion leg heel flexion; Achilles tendon; The middle lumbar spine and spine region; weakness may be limited to urinary and urinary incontinence as well as sexual dysfunction.
• S2-S4 Nerves – sacral or buttock pain radiating into the back of the legs or perineum; sensory deficits in the medial buttock perineal and perianal regions; absent bulbocavernosus anal wink reflex[2].

Signs And Symptoms

• Severe low back pain, radiating pain.
• Walking can be painful and difficult.
• Velsava Manuever.
• Smooth muscle tingling sensation weakness or atrophy.
• loss of bladder or bowel control.
• Some people may be asymptomatic.
• Slow and deliberate, tip-toe walking.
• Spine, trunk deviation.
• Antalgic or Trendelenburg gait.
• Paraspinal muscle spasm.

Special Tests

Cervical

1. Spurling test.
2. Distraction test.
3. Upper limb tension test.
4. Shoulder abduction test.
5. Tinel’s sign

Lumbar

1. The straight leg raise test: 
2. The contralateral (crossed) straight leg raising test
3. Lasègue’s Test – – see straight leg raising test
4. Bowstring test
5. Prone knee bending
6. Muscle Weakness or Paresis
7. Reflexes
8. Hyperextension Test The patient should move the trunk passively over the entire range of extension while the knees remain in extension. The test shows that the radiating pain is due to a disc herniation if the pain worsens.
9. Manual Testing and Sensory Testing Monitor hypoaesthesia hypoalgesia tingling or numbness

Differential Diagnosis

There are a number of diseases that can mimic a herniated disc clinically and radiographically that should be considered .

These lesions include those due to.

• vertebral bodies (osteophytes and metastases) .
• intervertebral disc (discal cyst),
• intervertebral foramina (neurinomas)
• interapophyseal joints (synovial cyst)
• epidural space (hematoma and epidural abscess).[12]

Other differential diagnoses include

• Spondylolysis
• Spondylolisthesis
• Cauda equina syndrome
• Muscle spasm
• Mechanical pain     
• Myofascial pain[13] (causing local and/or referred disturbance of pain perception) .

Spinal causes include

• Trauma
• Infection – osteomyelitis
• Inflammation – arachnoiditis ankylosing spinal cord infection
• Neoplasm – benign or malignant with nerve root pressure; multiple myeloma tumors.

Extraspinal causes include

• peripheral vascular disease
• gynacological condition
• OA hip
• sacroiliac joint disease
• peipheral nerve lesions

Complications

• Cauda Equina Syndrome
• Chronic pain
• Permanent nerve injury[14]
• Paralysis

Imaging

X-rays: These are readily available in most hospitals and outpatient offices. This imaging technique can be used to check for system instability. If an x-ray shows a severe fracture, further evaluation with a CT scan or MRI should be performed.

Loss of disc space narrowing can be seen in lumbar lordosis complementary scoliosis.

CT Scan: It is the preferred study to visualize the bones of the pelvis. It can also show calcified herniated discs size shape of spinal cord contents surrounding it including soft tissue. Compared to x-rays, they are less accessible in office settings. But they are more accessible than MRI. Have patients with comparable non-MRI implanted devices can undergo CT myelography to visualize a herniated disc.

MRI: It is the preferred and most sensitive examination to visualize a herniated disc. MRI scans will help surgeons and other providers develop a management plan for the procedure if indicated.[2] Disc protrusion and nerve root compression can be seen.

Outcome Measures

If the disc herniation is symptomatic outcome measures can be used:

• Short Form-36 physical pain (SF-36 BP) .
• Oswestry disability index
• Roland-Morris disability index
• VAS-score: one for leg pain and one for back pain[15].
• McGill pain Questionnaire[15]: this questionnaire assesses the location and severity of pain and factors that alleviate and aggravate pain[16].

Management

Medical Management

Severe cervical and spinal hernias due to a herniated disc are primarily managed with non-surgical treatment.

• NSAIDs are the first line of physiotherapy and treatment modalities.
• Oral medications such as prednisone methyl prednisone.
• Benzodiazepines of low dose.
• Translaminar epidural injections and selective nerve root block are the secondary methods. These are great ways to deal with crippling pain.
• Patients unable to respond to conservative treatment or patients with neuropathy require timely surgical intervention[2].

Surgical Treatment

As always, curative surgery is the last resort.

• Surgeries to treat a herniated disc include laminectomies a discectomies microdisectomies based on cervical or spinal segment.
• Patients with cervical spine stenosis can be managed through a proactive approach that involves reduction and fusion of the cervical arch. This patient can also be managed with modified disks.
• Other methods of spine surgery include a posterior or anterior approach that requires a complete discectomy and fusion.[2]
• Intradiscal electrothermic therapy
• Nucleoplasty
• Chemonucleolysis
• Disc arthroplasty

Physical Therapy Management

Physical therapy generally plays an important role in herniated disc recovery. Including the points below

• Ambulation and resumption of exercise
• Pain control
• Education re maintaining healthy weight

Exercise programs are often recommended to treat pain and restore functional and motor deficits associated with symptomatic disc degeneration.

Active exercise therapy

It is preferred to passive modalities.

There are a number of exercise programs to treat symptomatic disc herniation e.g

• aerobic activity (e.g., pedestrian cycling) .
• preferred direction (McKenzie method) .
• flexibility exercises (e.g., yoga and stretching) .
• proprioception/planning/balance (medicine ball and wobble/tilt board) .
• strengthening exercises.
• motor control exercises MCEs

MCEs (standing/core exercises) .

They are common therapeutic exercises prescribed for patients with symptomatic disc herniation[17].

• designed to redefine the coordination of the abdominal paraspinals gluteals pelvic floor musculature and diaphragm
• The biological rationale for MCEs is largely based on the concept of altered spinal stability and compliance in patients with LBP.
• the program begins by determining the natural position of the spine (midway between lumbar flexion and extension) which is considered a position of balance and ability to be effective in various sports
• Initially, sustained low isometric contraction of the muscles that stabilize the trunk and their gradual incorporation into functional tasks are the requirements of MCEs
• MCE is usually administered in 1:1 supervised therapy and sometimes includes the use of palpation ultrasound imaging and/or pressure biofeedback units to provide feedback on tail vein function
• Core stability programs reduce pain levels improve functional status to increase health-related quality of life and static endurance of trunk muscles in lumbar disc herniation patients[18]. High-quality individual tests found moderate evidence that stability exercises were more effective than no treatment is available[19].

Studies have shown that a combination of techniques will be the best treatment for a herniated disc. Exercise and ergonomic design should be considered as very important components of this integrated treatment[20].

General rules for exercise/ Do and Donts

• Exercise slowly. Hold an exercise position for a slow first 5. Start with a 5 repetition and work up to 10. Rest completely between repetitions.
• Do exercise for 10 min twice a day.
• Care must be taken when performing potentially painful exercises.
• Exercise daily without fail.

Physiotherapy Modalities and evidence for their use in disc herniation

• Stretching – There is limited empirical evidence to suggest that the addition of hyperextension to a vigorous exercise program may not be more effective than vigorous exercise alone for functional status or pain which is the result of. There were also no clinically or statistically significant differences seen in disability and pain between combined strength training and stretching and strength training alone[21].
• Muscle Strength – Strong muscles are a great support system for your spine and manage pain effectively. Once core stability is fully restored and fully under control, strength and power can be trained. But only when this is necessary for the function/function of the patients. This power must be is avoided in the core stability exercises because of its two combined properties: strength and speed. This combination increases the risk of back problems and back pain[22].
• Traditional Chinese medicine for back pain – proven effective. Research has shown that acupressure acupuncture and cupping can be effective in pain and disability for chronic low back pain including disc herniation[23][24].
• Spinal Manipulative Therapy and Mobilization – Spinal manipulative therapy and mobilization provides temporary pain relief while suffering from acute low back pain. From the perspective of chronic low back pain, changes have NSAID-like effects[25].
• Behavioral Activities Activity Program – Global perceived recovery after a standard exercise therapy program than after a behavioral intervention program in the short term but no differences were found in the long term[21].
• Transcutaneous Electrical Nerve Stimulation (TENS) – TENS therapy helps to relieve pain and improve function and motion of the lumbosacral spine[26].
• Manipulative Treatment – Manipulative treatment for lumbar disc herniation appears to be safe and appears to be better than other treatments. However high quality evidence needs further investigation[27].
• Traction – A recent study has shown that traction therapy has a positive effect on pain disability and SLR in patients with intervertebral disc herniation[28].One trial also found some additional benefits from mechanical traction combined with medication and electrotherapy
• Aquatic Vertical Traction – In patients with low back pain and signs of neuromuscular tension this technique had a significant effect on longitudinal spine pain relief reducing the centralization response and increasing pain intensity to assume a supine flexing position on the ground ].
• Hot Therapies – can use heat to increase blood flow to the target area. Blood helps heal the area by providing extra oxygen and nutrients. Blood also removes wastes from soft tissues[6].
• Cryotherapy – reduces spasm and inflammation in acute phase.
• Shortwave diathermy – pulsed SWD in acute condition and continuous SWD in chronic condition.
• Ultrasound – For phonophoresis it increases the width of the connective tissue.

Example of a Protocol for Rehabilitation after Lumbar Microdiscectomy

The following activity is an example of a rehabilitation program after spinal microdiscectomy[31]:

• Duration of restoration planning: 4 weeks
• Frequency: every day
• Duration of one session: about 60 minutes
• Treatment: dynamic lumbar stabilization exercises + home exercises
• Exercises: Prior to performing DLS training, patients are given instructions or a strategy to ensure a neutral and protected position of the lumbar spine. For the first 15 minutes of each session, the posterior extensors hip flexors hamstrings and Achilles tendon should be stretched.
  (The DLS consists of: Quadratus exercises Abdominal strengthening Bridging with ball Straightening of external abdominal oblique muscle Single leg raise in crawling position Crossed arm and leg raising in crawling position Lunges)
• Home Exercises – should be included in the treatment. These should be done daily. 5 repetitions in the first week up to 10-15 reps in subsequent weeks

Post Surgical Intervention

In case surgical procedures begin regularly 4-6 weeks after surgery[32].

• providing details of the restoration plan to be followed over the next few weeks.
• Patients are instructed and accompanied in daily activities such as: getting out of bed to the bathroom and getting dressed
• patients should pay attention to back ergonomics throughout back schooling[33][32][31][34].

Studies show that different types of postoperative treatment indicate

• rehabilitation programs beginning four to six weeks after surgery with exercise versus no treatment found that exercise programs were more effective than no treatment after pain in a short period of time
• high-intensity exercise programs are slightly more effective in terms of pain and functional status in the short term compared with low-intensity exercise programs.
• long-term follow-up results for both pain and functional status showed no significant differences between the groups.
• there is no significant difference between supervised exercise programs and home exercise programs for short-term pain relief[21].

Clinical Bottom line

• Initial treatment should be conservative unless a patient has severe neurological impairment. Surgery is usually the last resort as it does not always produce predictable results. Patients are often left with residual pain and arthritis, which is often worse after surgery. Physical treatment is the priority for most patients. Results depend on many factors but those who engage in regular exercise and maintain a healthy body weight achieve better results than sedentary people.[2]
• Intervertebral disc herniation is one of the most common causes of low back pain and/or leg pain in adults. It usually occurs due to age-related degeneration of the annulus fibrosis. Disc herniation is usually asymptomatic and 75% of cases are intervertebral disc herniation you automatically recover within 6 months.
• Disc herniation can occur in different locations in the spine. A herniated disc commonly affects the spinal discs between vertebra L4-L5 and L5-S1. Cervical disc herniation is less common than lumbar disc degeneration. Cervical disc degeneration is greatest at levels C5-C6 and C6-C7.