synonyms:Herniated Nucleus Propulsus, herniated disc
Herniated Disc ICD-9
Herniated Disc Etiology / Epidemiology / Natural History
- Lumbar HNP occurs with flexion, axial compression and rotation.
- Associated with weightlifting, rowing, football, hockey, rugby, bowling.
- Tumor necrosis factor-alph, produced by chondrocyte like cells in the nucleus pulposus may be the key chemical mediator for nerve root pain.
- Mean age = 35 yrs.
Herniated Disc Anatomy
Herniated Disc Clinical Evaluation
- Low back, buttock, thigh pain, paresthesias, numbness, weakness in a dermatomal distribution.
- Decreased lumbar and pelvic flexibility, May demonstrate sciatic shift.
- Straight-leg raise: ipsilateral, concordant leg pain at 35° to 70° of elevation in supine or sitting postions. Indicates L4-5 or L5-S1 disk herniation. High sensitivity, low specificity.
- Contralateral Straight-leg raise: concordant leg pain with contralateral leg elevations.
- Femoral stretch test: anterior thight pain with hip extension and knee flexion with the patient in the lateral or prone postion. Indicates L1-4 disk herniation.
- Pain often increased by coughing, sneezing, Valsava.
- Sensory motor exam of the perineum including a rectal exam is indicated if any question of bowel/bladder dysfunction exists to rule out Cauda Equina Syndrome.
Herniated Disc Xray / Diagnositc Tests
- A/P, lateral, flexion/extension views of effected spinal level (cervical, lumbar, thoracic) indicated. Often normal or normal degenerative changes.
- MRI: best demonstrates acute herniation. Gadolinium enhancement indicated for patients with history of prior surgery.
Herniated Disc Classification / Treatment
- Short period of rest followed by activity limitations, NSAIDS, Physical therapy, muscle relaxants, Narcotics, progressive activity. Consider rigid brace in 15° of lordosis to increase mobilization.
- Systemic glucocorticoids may have some short term benefit, but no lasting benefit. (Finckh A, Spine 2006;31:377).
- Epidural Steroid injection / Selective nerve root injections (Riew KD, JBJS 2006;88A:1722).
- 90% resolve withing 3 months.
- Consider partial discectomy. (Weber H, Spine 1983;8:131), (Weinstein JN, JAMA 2006;296:2441), (Atlas SJ, Spine 2005;30:927).
Herniated Disc Associated Injuries / Differential Diagnosis
- Cauda Equina Syndrome
- Lumbar degenerative disc disease
- Lumbar spinal stenosis
Herniated Disc Complications
- Recurrent Herniation: 5%-10%
Herniated Disc Follow-up Care
Herniated Disc Review References