H erniated D isc D isease

Normally, the colagen fibers of the

annulus fibrosus are continuous and
thus contain the nuclear material.
If the annular fibers become disrupted,
displacement of the nuclear material
can occur.
This situation is termed Herniated
nucleus pulposus (HNP).

IntervertebralD isc
nucleus pulposus
annulus fibrosus
hyaline cartilage
end plates

H erniated N ucleus Pulposus

H erniated D isc D isease

Herniation :
1. Intraspongi nuclear herniation
2. Protrusion (prolapsed intervertebral
disc)
3. Extruded
4. Sequestered

H erniated D isc D isease

The progression to an
actual HNP varies from
slow to sudden onset
of symptoms.
There are four stages:
(1) disc protrusion
(2) prolapsed disc
(3) disc extrusion
(4) sequestered disc

HNP
A herniated disc occurs most often in
the lumbar region of the spine
especially at the L4-L5 and L5-S1 levels
(L = Lumbar, S = Sacral). This is
because the lumbar spine carries most
of the body's weight. People between
the ages of 30 and 50 appear to be
vulnerable because the elasticity and
water content of the nucleus decreases
with age.

P rogressive Steps Tow ard

H erniation
Many factors increase the risk for disc
herniation:
(1) Lifestyle choices such as tobacco use, lack
of regular exercise, and inadequate nutrition
substantially contribute to poor disc health.
(2) As the body ages, natural biochemical
changes cause discs to gradually dry out
affecting disc strength and resiliency.
(3) Poor posture combined with the habitual use
of incorrect body mechanics stresses the
lumbar spine and affects its normal ability to
carry the bulk of the body's weight.

D ISC RU PTU RES (H N P)

HISTORY :
ONSET :

Prodromal back pain for varying lengths of

time
Intermittent
Acute, followed soon after onset of leg
pain
Direct trauma/sudden weight loading of
the spine are not causal agents of disc
rupture, although may aggravate a
preexisting lesion

SYM PTO M S O F H ERN IATED

LU M BAR D ISK
severe low back pain
pain radiating to the buttocks, legs, and

feet
pain made worse with coughing,
straining, or laughing
tingling or numbness in legs or feet
muscle weakness or atrophy in later
stages
muscle spasm

HNP
HISTORY :
LOCATION OF PAIN :
THE BACK
THE BUTTOCK
THE THIGH
THE LEG
THE FOOT

HNP
HISTORY
AGGRAVATION

BENDING
STOOPING
LIFTING
COUGHING
SNEEZING
STRAINING AT STOOL
RELIEVED BY REST

HNP
PHYSICAL EXAMINATION

The back :

Lumbar spine is flattened, slightly

flexed
Sciatic scoliosis (obvious on bending
forward)
Standing with the affected hip & knee
slightly flexed
Limitation of flexion & extension
Tenderness & muscle spasm in the
standing position

HNP
PHYSICAL EXAMINATION
The extremities

Root tension & irritation

STRAIGHT LEG RAISING
BOWSTRING SIGN
FLIP TEST
CROSSOVER PAIN (WELL-LEG
RAISING SIGN)
FEMORAL NERVE STRETCH

HNP
PHYSICAL EXAMINATION
THE EXTREMITIES
ROOT COMPRESSION
MOTOR WEAKNESS
CHANGES IN SENSORY APPRECIATION
CHANGES REFLEX ACTIVITY

D IAG N O STIC TESTS

A spine X-ray may be performed to rule out

other causes of back or neck pain. However, it

is not possible to diagnosis herniated disk by
spinal X-ray alone.
A spine MRI and/or spine CT will show spinal
canal compression by the herniated disk.
A myelogram may be performed to define the
size and location of disk herniation.
An EMG may be performed to determine the
exact nerve root(s) that is (are) involved.
A nerve conduction velocity test may also be
performed.

R adiographic Evidence of
HNP

Criteria for the diagnosis of the acute

radicular syndrom e (sciatica due to an
H N P):
Leg pain (including buttock) as the dominant
complaint when compared to back pain
2. neurological symptoms that are spesific
(e.g., paresthesia in typical dermatomal
distribution)
3. significant SLR changes (any one or a
combination of these)

SLR less than 50% of normal

Bowstring discomfort

Crossover pain
4. neurological signs weakness, wasting,
sensory loss or reflex alteration (at least 2 of
4)
1.

Treatm ent
Conservative treatment :
Bed rest
Unloading the spine
Antiinflammatory drugs
Analgesics
Muscle relaxant medication

Treatm ent
Surgery, indications :
Increasing neurological deficit
Significant neurological deficit with

significant SLR
Bladder & bowel involvement
Failure of conservative treatment
Recurrent of sciatica syndrome

Treatm ent
Surgery, treatment options

POSTERIOR APPROACH
STANDARD LAMINECTOMY
MICROLAMINECTOMY - POSTERIOR
MICORLAMINECTOMY LATERAL
POSTERIOR LUMBAR INTERBODY FUSION
ANTERIOR APPROACH
ANTERIOR LUMBAR INTERBODY FUSION
PERCUTANEOUS DISCECTOMY APPROACH

SurgicalO ptions
1. Microsurgery is an approach to remove the HNP with minimal

disruption of bone or soft tissue. A number of technical

problems can occur when removing disc herniation without
any bone resection. In many cases of HNP, extruded
fragments may migrate proximally or distally to the disc
space. Adhesions between the nerve root and disc often make
it difficult to mobilize the nerve root to expose the HNP. To
prevent excessive traction of the nerve root many surgeons
refer to microdisectomy as a small incision with adequate
bone removal, including a portion of the superior and inferior
lamina that may require a partial facetectomy to prevent
damage to the nerve root.

2. Laminotomy is a traditional approach used to remove

displaced disc material in patients with HNP. The surgeon
forms a hole in the lamina to reach and remove the disc
without disrupting the continuity of the entire lamina. This
approach is mistakenly called a laminectomy, the more
extensive removal needed for a wider exposure.

SurgicalO ptions
3. Percutaneous discectomy is a method for treatment of HNP.
This procedure uses a localizing probe followed by a cannuia,
which holds the nucleotome probe. The nucleotome probe
simultaneously cuts and sucks nuclear material from the disc
space into a special cannister. This procedure involves no
muscle dissection, bone removal or large skin incision. This is
an outpatient procedure that requires a local anesthetic. The
success of this procedure is based on decompression of the
disc space by producing a hole in the annulus with the cutting
probe and evacuating the nuclear material with the cutting
and suction probe. Proponents of this technique advise its use
limited to disc protrusions (bulging disc with intact annulus contained). The majority of surgical discectomies, however
are for extruded or sequestered discs (non-contained).
4. Chemonucleolysis is a procedure where an enzyme is
injected directly into the disc to dissolve it. This procedure
was widely used from 1969-1975 until a double blind study
demonstrated no significant difference between chymopapain
injections and placebo