Herniated Nucleus Pulposus
that does not move).
Alternative Names
Lumbar radiculopathy;
Cervical radiculopathy;
Herniated intervertebral
disk; Prolapsed
intervertebral disk;
Slipped disk; Ruptured
disk
Definition of
Herniated nucleus
pulposus:
A herniated nucleus
pulposus is a slipped
disk along the spinal
cord. The condition
occurs when all or part
of the soft center of a
spinal disk is forced
through a weakened
part of the disk.
Displacement of the central area of the disc
(nucleus)
resulting in impingement on a nerve root.
The four stages to a herniated disc include:
1. Disc Degeneration: chemical changes
associated with aging causes discs to
weaken, but without a herniation.
2. Prolapse: the form or position of the
disc changes with some slight
impingement into the spinal canal. Also
called a bulge or protrusion.
3. Extrusion: the gel-like nucleus pulposus
breaks through the tire-like wall (annulus
fibrosus) but remains within the disc.
4. Sequestration or Sequestered Disc:
the nucleus pulposus breaks through the
annulus fibrosus and lies outside the disc
in the spinal canal (HNP).
Causes, incidence, and risk factors:
The bones (vertebrae) of the spinal column run
down the back, connecting the skull to the
pelvis. These bones protect nerves that come
out of the brain and travel down the back and
to the entire body. The spinal vertebrae are
separated by disks filled with a soft, gelatinous
substance, which provide cushioning to the
spinal column. These disks may herniate (move
out of place) or rupture from trauma or strain.
The spinal column is divided into several
segments: the cervical spine (the neck), the
thoracic spine (the part of the back behind the
chest), the lumbar spine (lower back), and
sacral spine (the part connected to the pelvis
Radiculopathy refers to any disease affecting
the spinal nerve roots. A herniated disk is one
cause of radiculopathy (sciatica).
Most herniation takes place in the lower back
(lumbar area) of the spine. Lumbar disk
herniation occurs 15 times more often than
cervical (neck) disk herniation, and it is one of
the most common causes of lower back pain.
The cervical disks are affected 8% of the time
and the upper-to-mid-back (thoracic) disks only
1 - 2% of the time.
Nerve roots (large nerves that branch out from
the spinal cord) may become compressed,
resulting in neurological symptoms, such as
sensory or motor changes.
Disk herniation occurs more frequently in
middle-aged and older men, especially those
involved in strenuous physical activity. Other
risk factors include any congenital conditions
that affect the size of the lumbar spinal canal
SYMPTOMS OF HERNIATED LUMBAR DISK
• Muscle spasm
• Muscle weakness or atrophy in later
stages
• Pain radiating to the buttocks, legs, and
feet
• Pain made worse with coughing,
straining, or laughing
• Severe low back pain
• Tingling or numbness in legs or feet
SYMPTOMS OF HERNIATED CERVICAL DISK
• Arm muscle weakness
• Deep pain near or over the shoulder
blades on the affected side
• Neck pain, especially in the back and
sides
• Increased pain when bending the neck
or turning head to the side
• Pain radiating to the shoulder, upper
arm, forearm, and rarely the hand,
fingers, or chest
• Pain made worse with coughing,
straining, or laughing
• Spasm of the neck muscles
Signs and tests:
A physical examination and history of pain may
be all that is needed to diagnose a herniated
disk. A neurological examination will evaluate
muscle reflexes, sensation, and muscle
strength. Often, examination of the spine will
reveal a decrease in the spinal curvature in the
affected area.
Leg pain that occurs when you sit down on an
exam table and lift your leg straight up usually
suggests a herniated lumbar disk.
A foraminal compression test of Spurling is
done to diagnose cervical radiculopathy. For
this test, you will bend your head forward and
to the sides while the health care provider
provides slight downward pressure to the top of
the head. Increased pain or numbness during
this test is usually indicative of cervical
radiculopathy.
DIAGNOSTIC TESTS
• EMG may be done to determine the
exact nerve root that is involved.
(Electromyography (EMG) is a technique
for evaluating and recording the activation
signal of muscles. EMG is performed using
an instrument called an electromyograph,
to produce a record called an
electromyogram. An electromyograph
detects the electrical potential generated by
muscle cells when these cells are both
mechanically active and at rest. The signals
can be analyzed in order to detect medical
abnormalities or analyze the biomechanics
of human or animal movement.)
• Nerve conduction velocity test may also
be done. (nerve conduction study (NCS)
is a test commonly used to evaluate the
function, especially the ability of electrical
conduction, of the motor and sensory
nerves of the human body. Nerve
conduction studies are used mainly for
evaluation of paresthesias (numbness,
tingling, burning) and/or weakness of the
arms and legs.)
• Myelogram may be done to determine
the size and location of disk herniation.
(Myelography is a type of radiographic
examination that uses a contrast medium to
detect pathology of the spinal cord,
including the location of a spinal cord injury,
cysts, and tumors. The procedure often
involves injection of contrast medium into
the cervical or lumbar spine, followed by
several X-ray projections.)
• Spine MRI or spine CT will show spinal
canal compression by the herniated disk.
• Spine x-ray may be done to rule out
other causes of back or neck pain. However,
it is not possible to diagnosis herniated disk
by spinal x-ray alone.
Treatment:
The main treatment for a herniated disk is a
short period of rest with pain and anti-
inflammatory medications, followed by physical
therapy. Most people who follow these
treatments will recover and return to their
normal activities. A small number of people
need to have further treatment, which may
include steroid injections or surgery.
MEDICATIONS
Nonsteroidal anti-inflammatory medications
(NSAIDs) and narcotic pain killers will be given
to people with a sudden herniated disk caused
by some sort of injury (such as a car accident or
lifting a very heavy object) that is immediately
followed by severe pain in the back and leg.
If the patient has back spasms, muscle
relaxants are usually given. On rare occasions,
steroids may be given either by pill or directly
into the blood through an IV.
NSAIDs are used for long-term pain control, but
narcotics may be given if the pain does not
respond to anti-inflammatory drugs.
LIFESTYLE CHANGES
Any extra weight being carried by an individual,
especially up front in the stomach area, will
make back pain worse. Diet and exercise are
crucial to improving back pain in overweight
patients.
Physical therapy is important for nearly
everyone with disk disease. Therapists will tell
you how to properly lift, dress, walk, and
perform other activities. They will also work on
strengthening the muscles of the abdomen and
lower back to help support the spine. Flexibility
of the spine and legs is taught in many therapy
programs.
Some health care providers recommend the use
of back braces to help support the spine.
However, overuse of these devices can weaken
the abdominal and back muscles, leading to a
worsening of the problem. Weight belts can be
helpful in preventing injuries in those whose
work requires lifting of heavy objects.
INJECTIONS
Steroid injections into the back in the area of
the herniated disk can help control pain for
several months. Such injections reduce swelling
around the disk and relieve many symptoms.
Spinal injections are usually done on an
outpatient basis, using x-ray or fluoroscopy to
identify the area where the injection is needed.
SURGERY
Diskectomy removes a protruding disk. This
procedure requires general anesthesia (asleep
and no pain) and 2 - 3 day hospital stay. You
will be encouraged to walk the first day after
surgery to reduce the risk of blood clots.
Complete recovery takes several weeks. If more
than one disk needs to be taken out or if there
are other problems in the back besides a
herniated disk, more extensive surgery may be
needed. This may require a much longer
recovery period.

Other surgical options include

microdiskectomy, a procedure removing
fragments of nucleated disk through a very
small opening.

Chemonucleolysis involves the injection of an

enzyme (called chymopapain) into the
herniated disk to dissolve the protruding
gelatinous substance. This procedure may be
an alternative to diskectomy in certain
situations.

Expectations (prognosis):
Most people will improve with conservative
treatment. A small percentage may continue to
have chronic back pain even after treatment.
It may take several months to a year or more to
resume all activities without pain or strain to
the back. People with certain occupations that
involve heavy lifting or back strain may need to
change job activities to avoid recurrent back
injury.

Complications:
• Long-term back pain
• Loss of movement or sensation in the
legs or feet
• Loss of bowel and bladder function
• Permanent spinal cord injury (very rare)