Herniation

Nuclear material that is displaced into the spinal canal is associated with a significant
inflammatory response, as has been demonstrated in animal studies. Disk injury results in an
increase in the proinflammatory molecules interleukin-1 (IL-1), IL-8, and tumor necrosis factor
(TNF) alpha. Macrophages respond to this displaced foreign material and seek to clear the spinal
canal. Subsequently, a significant scar is produced, even without surgery, and substance P, which
is associated with pain, is detected. Acute neural compression is responsible for dysfunction;
compression of a motor nerve results in weakness, and compression of a sensory nerve results in
numbness. Radicular pain is caused by inflammation of the nerve, which explains the lack of
correlation between the actual size of an intervertebral disk herniation or even the consequent
degree of neural compression and the associated clinical symptoms.
[17]

Furthermore, intervetebral disk degeneration may result in radial tears and leakage of the nuclear
material, which leads to neural toxicity. The subsequent inflammatory response often results in
neural irritation causing radiating pain without numbness, weakness, or loss of reflex, even when
neural compression is absent.
Several factors seem to influence the occurrence of herniated nucleus pulposus. Smoking is a
risk factor in the epidemiology of lumbar disk herniations and has been documented to decrease
the oxygen tension in the avascular disk dramatically, presumably by vasoconstrictive and
rheologic effects on blood. Lumbar disk herniation may result from chronic coughing and other
stresses on the disk. For example, sitting without lumbar support causes an increase in disk
pressures, and driving is also a risk factor because of the resonant coupling of 5-Hz vibrations
from the road to the spine. People who drive signifcant amounts have increased spinal problems;
truck drivers have the additional risk of spinal problems from lifting during loading and
unloading, which, unfortunately, is done after prolonged driving.
Studies have shown that peak stresses within a deteriorated intervertebral disk exceed those from
average loads on a normal disk, which is consistent with a pain mechanism. Further repetitive
stress at physiologic levels did not produce a herniation after prolonged testing, contradicting the
concept of injury accumulation with customary work activities. However, after a simulated
injury to the annulus (cutting), a lower mechanical stress did result in disk herniation, consistent
with intervertebral disk degeneration and with clinical experience on discography.
The presumed traumatic cause of disk herniations has been questioned scientifically in the
literature, particularly with the increased availability of genetic information.
[18, 19]

The pathologic state of a weakened annulus is a necessary condition for herniation to occur.
Many cases involve trivial trauma even in the presence of repetitive stress. An annular tear or
weak spot has not been demonstrated to result from repetitive normal stress from customary
activities or from physically stressful activities.
Mixter and Barr first recognized that the cartilaginous masses in the spinal canal of their patients
were not tumors or chondromas.
[13]
They proposed that herniation of the nucleus pulposus and
displacement of nuclear material caused neural irritation, inflammation, and pain. They showed
that excising a disk fragment was effective, but their recommendation to perform this procedure
with a fusion was necessitated by relatively aggressive laminectomy. This procedure has been
replaced by techniques that are less invasive, such as microdiscectomy.
Clinical Evaluation
Obtaining pertinent patient historical information should begin with an analysis of the chief
complaint. Does the patient's complaint concern dominant leg pain, dominant back pain, or a
mixture of significant problems with both? Next, is the onset acute, subacute, or chronic? Under
what circumstances does onset occur? What is the patient's prior history, particularly regarding
similar symptoms or treatment response?
Identify risk factors, obtain a pertinent medical history, and specifically exclude red flags, such
as nonmechanical pain, which causes pain at night without activities because pressure in the
pelvic veins may be increased upon reclining. Nonmechanical pain may be indicative of a tumor
or infection. A progressive neurologic deficit or cauda equina syndrome is considered a surgical
emergency because irreversible consequences may result if these are left untreated.
Obtaining a thorough history of activity intolerance requires some time and attention to the
details of specific examples and the positions or actions that cause problems. Also, it is helpful to
determine which activities the patient is unable or less able to perform and which activities
exacerbate or moderate the pain. An assessment of the physical demands of the patient's
occupation and daily activities provides the perspective for the described activity intolerance. A
pain drawing can be very helpful in assessing the pattern of pain, such as a dermatomal
distribution, or in assessing the organicity of the complaints.
Physical examination classically involves range-of-motion (ROM) testing of the lumbar and
cervical spine, but these findings may be more reflective of aging or deterioration in the
intervertebral disks and joints than any quantifiable assessment of impairment. The remainder of
the examination is essentially a neurologic assessment of weakness, dermatomal numbness,
reflex change, and, most important, sciatic or femoral nerve root tension in the lumbar spine.
Numerous examination maneuvers (eg, Lasegue classic test, Lasegue rebound sign, Lasegue
differential sign, Braggard sign, flip sign, Deyerle sign, Mendel-Bechterew sign, well leg test or
Fajersztajn sign, both-legs or Milgram test) are available but cloud the issue, because the sciatic
nerve root tension or straight-leg raising test is the basis for nearly all of them. They are
essentially modifications for subtle differences, but the provocation of radiating pain down the
leg is of a neural compressive lesion and compression of the sciatic nerve root, if it goes below
the knee. Furthermore, the provocation of radiating pain down the leg is the most sensitive test
for a lumbar disk herniation.
For a higher lumbar lesion, reverse straight-leg raising or hip extension that stretches the femoral
nerve is analogous to a straight-leg raising test. The Spurling test in the cervical spine is used to
detect foraminal stenosis (Kemp's test is used in the lumbar region) rather than specifically for
intervertebral disk herniation or nerve root tension. Careful hip, rectal, and genitourinary
examinations help exclude complications of those organ systems in the diagnosis of higher
lumbar lesions.
After obtaining plain radiographs, further imaging studies (eg, MRI, computed tomography [CT]
scanning, CT myelography) may be indicated to assess degenerative disk disease, loss of disk
height, and facet deterioration, such as sclerosis or hypertrophy. MRI clearly provides the most
information, perhaps too much, as it has a 25% false-positive rate (asymptomatic herniated
nucleus pulposus [HNP]). An HNP that is noted on imaging studies must be correlated with
objective examination findings; otherwise, it must be presumed to be an asymptomatic HNP if
there is no correlation between the imaging findings and pain or clinical symptoms. Therefore,
imaging studies should perhaps be reserved for cases in which positive physical findings have
been documented.
Other causes of significant back pain in the absence of neurologic findings should be considered.
Sciatic nerve irritation may result from sacroiliac dysfunction or degenerative joint disease
caused by the proximity of the sciatic notch to the sacroiliac joint or peripheral entrapment,
including piriformis syndrome. Careful examination with an adequate differential for the
diagnosis may prevent prolonged ineffective empirical care for presumed lumbar disk disease.
The facet syndrome has been controversial, but neurophysiologic studies have shown discharges
from the capsule consistent with pain, as well as inflammation and degenerative joint disease.
[20]
However, large numbers of patients have reported significant relief after facet joint injections for
nonspecific LBP; as a result, the facet syndrome has become more widely accepted. Clinically,
patients usually have pain only to the knee, not below, as would be expected from an HNP.
Conservative Treatment
Spontaneous improvement of low back discomfort has allowed ineffective treatments to
perpetuate, because benefits have been ascribed to them when they are prescribed while the
patient is still symptomatic but otherwise improving. Hippocrates expected improvement in
sciatica in 40 days, and the customary and contemporary guideline is 6 weeks. An often-quoted
study suggests near-resolution improvement of 90% of patients within 6 weeks, but this study
has been faulted because the criterion for patient recovery was failure to return to the observing
physician.
[21]
The prevalence of back problems is consistent with the failure of a subgroup of
patients to improve and to have periodic recurrent episodes of disability.
Analysis of the effectiveness of treatments and attempts to restrict treatment to those modalities
that have demonstrated efficacy are evidence-based medical practice. Bedrest has a long history
of use but has not been shown to be effective beyond the initial 1 or 2 days; after this period,
bedrest is counterproductive. All conservative treatments are essentially efforts to reduce
inflammation; therefore, only a very short period of rest is appropriate, anti-inflammatories are
of some benefit (because the pain is from inflammation of the nerve), and warm, moist heat or
modalities may be helpful. TNF decrease in preclinical
models.
[22]
Activities should be resumed as early as tolerated. Exercises and physical therapy
mobilize muscles and joints to facilitate the removal of edema and promote recovery. Muscle
relaxants mayoffersymptomatic relief of the acute muscle spasms but only in the early stages;
however, all are central acting, there is no direct relaxation of skeletal muscle, and they are also
sedating.
For back pain without radiculopathy, chiropractic care has high patient satisfaction when
performed within the first 6 weeks, and it has been shown to have good efficacy acutely from an
evidence-based standpoint.
[23]
Injections (eg, epidural) may be particularly helpful in patients
with radiculopathy by providing symptom relief, which allows the patient to increase activities
and helps facilitate rehabilitation.
[24, 25]
Any nuclear material that is herniated may shrink as the
proteoglycan deteriorates, loses its water-retaining ability, and turns from a grapelike object to a
raisinlike object.
Arbitrary time schedules for improvement are inappropriate in any patient who continues to
improve and whose function is relatively maintained. Traction in the acute setting may help
muscle spasms, but it does not reduce the HNP and has no good evidence of efficacy. The use of
traction does not justify hospital admission, as it is not cost-effective and can be administered on
an outpatient basis.
Long-term use of physical therapy modalities is no more effective than hot showers or hot packs
are at home. A transcutaneous electrical nerve stimulation (TENS) unit may be subjectively
helpful in some patients with chronic conditions. Encourage patients to essentially compensate
for intervertebral disk incompetence, as possible, by muscular stabilization, and to maintain
flexibility by initiating life-long exercise regimens, including aerobic conditioning, particularly
swimming, which allows gravity relief.
Assess the body mechanics of every patient who is disabled from work. Educate all patients
about body mechanics, and discuss the risk factors for faulty body mechanics, so that
applications can be incorporated into individual work settings, including appropriate seating (eg,
lumbar support). The lumbar facet joints are oriented relatively vertically, thus allowing forward
flexion, but the joints impact each other when a person bends and then rotates. Repetitive
bending and twisting have been noted to be epidemiologic problems in workers, and may be
associated with chronic pain and disability.
[26]
Attention to lifting techniques and ergonomic
modification at workstations may be very appropriate.
Surgical Intervention
The classic presentation of an herniated nucleus pulposus includes the complaint of sciatica, with
associated objective neurologic findings of weakness, reflex change, and dermatomal numbness.
Various surgical procedures have been reported and share the common goal of decompressing
the neural elements to relieve the leg pain. These procedures are most appropriate for patients
with minimal or tolerable back pain, with an essentially intact and clinically stable disk.
However, the hope of permanently relieving the back pain is a fantasy, a false hope.
The most common procedure for a herniated or ruptured intervertebral disk is a
microdiscectomy, in which a small incision is made, aided by an operating microscope, and a
hemilaminotomy is performed to remove the disk fragment that is impinging on the nerves.
Many patients who undergo microdiscectomy can be discharged with minimal soreness and
complete relief of leg pain after an overnight admission and observation. Same-day procedures
are in the process of cautious development; patients with dominant back pain have a different
problem, even if HNP is present, and would require stabilization by fusion if unresponsive to
well-managed appropriate therapy or arthroplasty (if there is an isolated level with good facet
joints).
Minimally invasive techniques have not replaced this standard microdiscectomy procedure but
can be summarized in 2 categories: central decompression of the disk and directed
fragmentectomy. Outpatient treatment has been reported.
[27]

Central decompression of the disk can be performed chemically or enzymatically with
chymopapain, by laser or plasma (ionized gas) ablation and vaporization, or mechanically by
aspiration and suction with a shaver such as the nucleotome or percutaneous lateral
decompression (arthroscopic microdiscectomy).
The Food and Drug Administration (FDA) initially released and then withheld chymopapain for
injection into lumbar disks because of adverse allergic reactions in patients; skin tests
subsequently were used to determine sensitivity. However, the procedure continued to induce
severe muscle spasms that could be far worse than those of an open operation and thus required
hospitalization and bedrest for up to 50% of patients.
[28]
This morbidity must be considered a
contradiction to the assertion by proponents that the enzyme is limited to the disk in the chemical
digestion of the nucleus pulposus, because the muscles are severely affected, which would not be
expected if the enzyme were contained. In addition, severe scarring in the spinal canal is noted
routinely after this procedure.
The nucleotome and laser central decompressions have been shown only to equal placebo in
effectiveness, and their use has declined. Superiority has not been demonstrated; patient selection
is crucial, with a steep learning curve.
[29]

Further development of alternatives, such as nucleoplasty, and efforts to reduce disk pressure
remain under study. The incidence of recurent herniation is small but may be irreducible. Efforts
to seal the annulus are under investigation.
Directed fragmentectomy is similar to an open microdiscectomy and has demonstrated greater
effectiveness than placebo. This procedure uses an arthroscopic approach and a probe that directs
a flexible pituitary rongeur from the center of the intervertebral disk toward the posterior
annulus. Endoscopic techniques to perform a directed fragmentectomy and to minimize
disruption of normal structures continue in development, but superiority has not been
demonstrated despite this minimally invasive approach.
Concerning the cervical spine, HNP customarily is treated anteriorly, because the pathology is
anterior and manipulation of the cervical cord is not tolerated by the patient. The posterior
approach is reserved for disk herniation that is confined to the foramen and for foraminal
stenosis. An alternative to the anterior cervical spine approach is minimal disk excision; clinical
stability following this procedure is dependent upon the residual disk, which is also true in cases
where there is lumbar spine involvement with back pain. Removal of neural compression
dramatically relieves radiculopathy; however, residual axial neck pain may result in significant
impairment.
Anterior cervical interbody fusion is another intervention. Proponents of discectomy alone assert
equivalent results, but the adequacy of follow-up in those case reports is a significant concern.
Patients with more severe disk degeneration, particularly myelopathy, would more uniformly
undergo fusion. Anterior instrumentation is being used more commonly, and interbody cages are
under consideration as a means of attaining more rapid rehabilitation and more consistent results.
Multilevel disc replacement has been suggested as at least similar to fusion.
[30]