32

LUMBAR DISC HERNIATION

Abstract: Lumbar disc herniation (LDH) is a common condition that is seen in many orthopaedic clinics. Most patients come with a history of lower back pain and radiculopathy. Even though the natural history producing the disease is not fully known the diagnosis can be made by a complete history and physical e!amination. M"# is the imaging of choice. $hough ma%ority of the patients do well with conservative management success rate following standard laminotomy&diskectomy is about '(). Case Report: * +,&year&old gentleman was admitted to our ward with a complaint of lower backache and numbness more towards the right lower limb for the past - months. His pain started after a game of golf and was localised to sacral area. He did not e!perience sciatica like pain. His pain was more of dull aching which increased on standing but was relieved on lying down and sitting. His numbness was e!tending to his calf region. He did not have any bladder or bowel disturbance and there was also no history of fever trauma or chronic cough. .n e!amination his vital signs were stable and he was comfortable lying supine. /pine e!amination did not reveal any tenderness or step deformity. 0either did he have any saddle anaesthesia and his anal tone was normal. Motor e!amination did not reveal any deficit but his straight leg raising test was reduced to 12 degrees on the right and ,2 degree on the left lower limb. However his sensation and refle!es was normal. His total white and differential count and erythrocyte sedimentation rates were normal. "adiograph of lumbo&sacral showed loss of normal lumbar lordosis with

33

normal alignment. Degenerative changes were present by evidence of osteophytes. /ince his pain did not regress after a few months of physiotherapy and analgesia we proceeded with an M"#. M"# showed degenerative changes along vertebral end plate and facet %oint posteriorly of the fifth lumbar vertebrae. $here was a large paracentral disc herniation of L3 & L+ level. * diagnosis of lumbar disc herniation was then made. #ntra& operatively the findings were lateral canal stenosis with se4uestracted disc at L3&L+ level with facet %oint hypertrophy and thickened ligamentum flavum. 5e proceeded to do a laminotomy and discectomy at L3&L+ level with widening of lateral canal. 6nder general anaesthesia with the patient prone a midline incision was made over the affected level. *ll layers were opened. Laminotomy and discectomy was done. $he nerve roots emerging from the right lateral canal appeared unhealthy. $he se4uestrected disc was removed and a fat patch was placed over the dura. 5ound was closed and drains inserted. .n discharge there was minimal pain over his back. He was seen at 1 weeks follow& up and his wound had healed well and there was no more pain. He is due for review again at 7 weeks. Discussion: LDH has an incidence rate of 8) of the general population per year. 88 #t is seen in all ages with increase fre4uency between ages -2 and +2 .$he commonest level is between L3&L+ and L+&/8. "isk factors that contribute to LDH include genetic factor (in case of %uvenile LDH) narrow spinal canal driving of motor vehicle sedentary occupation vibration smoking previous full&term pregnancies physical inactivity increase body mass inde! and a tall stature.
87

9itness and strength is postulated to protect individuals

from disc rupture. $he term disc herniation refers collectively to a process where there

34

is rupture of annulus fibres and subse4uent displacement of the central mass of the disc in the intervertebral space either dorsally or dorso&laterally. $he disc is fibrocartilagenous and accounts for 1+) of total spinal column. #t is attached to the vertebra by hyaline cartilage & the end plates. *s age advances the turgidity of the nucleus pulposus decreases and this e!plains the association of herniation with age related disc degeneration.
81

Hydration of disc changes from '2) during childhood to

,2) by the 7th decade. *lso the ability of proteoglycans to aggregate decrease with advancing age. #mmunological factors such as increase in #g M torsional instability that damage the outer layer of annulus and biomechanics such as the 7+ degrees tilt of the lamella to the a!is of the spine may contribute to the pathophysiology of herniation. 9urthermore nuclear desiccation fragmentation and displacement also play a ma%or role in pathogenesis of herniation. $he composition of the herniated material has been widely debated. Deucher and Love (cited in Moore 8''7) described nucleus and annulus in variable amounts in their specimen. Lipson concluded that annulus fibrosus could not easily herniate because it is securely attached to bone by /harpey:s fibres and suggested that herniated material was newly synthesi;ed fibrocartilagenous tissue. Moore et al concluded from their study of 812 specimens that nucleus was the principal tissue in (') of all specimens whereas none consisted predominantly of annulus and only -) consisted of mainly endplate. $here are - pattern of herniation<& 8 (i) (ii) protrusion (contained) & a discrete localised bulge in the annulus where the disc material is displaced but remains within the annulus e!trusion & the displaced disc material penetrates through disrupted annular fibres but remains connected to material contained within the disc (iii) se4uestration &presence of free fragments separated from the disc and can migrate to other location

35

$he pain accompanying LDH may be caused by <87 i) ii) iii) iv) mechanical compression of the herniated disc chemical stimulation by substances from the degenerated disc autoimmune reactions through the production inflammatory cytokines degenerative instability

=atients typically come with a history of back pain that is gradual or more often sudden accompanied by >sharp burning stabbing electric> pain radiating down the posterior or lateral aspect of one leg below the knee to the heel or foot.$he pain is superficial and localised often associated with numbness or tingling which is aggravated by increased intradiscal pressure or specific movements.5ith rest there is substantial relief of pain but not complete.$he pain distribution is classically radicular and occasionally the leg pain predominates over the back pain..ccationally it may be complicated with urinary retention loss of bladder or bowel control with saddle anaesthesia&so called the cauda e4uina syndrome.$his type of pain which radiates along the dermatome of the involved nerve is called dermatomal or radicular pain and must be differentiate from sclerotomal pain which is dull aching and less well defined resulting from stimulation of the mesodermal structures of the spine(e.g. muscle ligament periosteum capsule annulus fibrosus)."adicular pain is synonymous with sciatica which is characteri;ed by pain radiating from the back into the buttock and into the lower e!tremity along its posterior or lateral aspect or pain anywhere along the course of the sciatic nerve.#t usually is the first indication of a possible nerve root compression.Many a time patients also gives a history of similar pain in their early 12:s which may be provoked by physical trauma.$he long interval between the 8st episode of pain and radicular pain could be attributed to intradiscal degeneration and regeneration forces resulting in ma!imal risk of disabling sciatica around age 32.87 $he weakness can present as the only symptom involving the dorsifle!ors of the foot./ensory changes include numbness or paresthesias that are typically dermatomal in distribution.

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=hysical e!amination should include inspection of the back for posture deformity and gait. =alpation to elicit any tenderness of step deformity and range of movement of the spine. ?lassically those with LDH have a slow and deliberate gait. * flattened lumbar lordosis may also be seen with or without scoliosis. "ange of motion is also reduced. .ther test includes passive straight leg raising test (Lasegue test) in which with the patient supine and knee e!tended the e!aminer raises the leg above the bed. * positive test is one in which there is limitation to full fle!ion of the hip due to pain. 0ormal range of hip fle!ion is from '2&822 degrees. #n&patient with LDH the test is positive. .ther variations include cross straight leg raising test by 9a%ers;ta%n foot dorsifle!ion test which was described by La;arevic and bowstring sign which is raising the straight leg till pain developes and then fle! the knee which should reduce the symptoms. Ma%ority of the pain is felt at -+&,2 degree of elevation as there is ma!imum tension then and is usually absent in the first 12&-2 degree because there is generally no movement of the sciatic nerve 0uerologic e!amination is important not only to determine if the nerve roots are irritated but also to assess the level of involvement. Lower limb refle!es with motor and sensory involvement together with muscle wasting are assessed. Muscle testing is done manually. $he most important strength test involves the e!tensor hallucis longus(EHL) innervated primarily by L+..ther muscle group innervation includes 4uadriceps muscle(L1&L3) hip abductors(L1&L3) tibialis anterior(L3) gluteus medius and tibialis posterior(L+) e!tensor digitorum longus and brevis(L+) fle!or hallucis longus(/8) gluteus ma!imus and gastronumius&soleus(/8&/1).9or screening purposes the strength of EHL is most important because L+ neurologic status cannot be assessed using a refle!. /ensory testing is carried out by means of sharp pins light touch and tuning fork.

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$he following table summari;es the 0eurological Level Diagnosis for LDH<DISC L-&L3 L3&L+ L+&/8 ROOT L3 L+ /8 REFLEX =atellar 0one *chilles MUSCLE *nt. $ibialis E!t. Hall. Long 9le!. Hall Long SENSATION Med. Leg@ foot Lat.Leg@ Dorsum foot Lateral foot

#nvestigations which are carried out include< & (i) (ii) neurophysiological testing imaging studies.

0europhysiological testing is carried out using sophisticated somato&sensory &evoked potentials (/E=s). #t is use to evaluate the neural elements of the sensory pathways< dorsal roots the root entry ;one the dorsal horns the dorsal column and its pro%ections to the corte!. $he nerves used are posterior tibial sural or common peroneal nerves of the lower limbs. *mong the imaging studies available for the diagnosis of LDH include< (i) (ii) (iii) (iv) (v) plain !&ray ?$ scan Magnetic resonance imaging (M"# ) Myelography ?$& myelography

$he goal of diagnostic imaging is to provide reliable information that directly affects patientAs treatment. #t is typically not necessary to order imaging studies to assess the status of a lumbar disc or spinal neural elements during the initial 3&7 weeks after the onset of pain unless in cases of cauda e4uina syndrome progressive neurological deterioration severe unresponsive intractable pain or constitutional sign suggestive of infection or tumor

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B& rays taken on *= lateral obli4ue may reveal degenerative spine narrow neural foramina collapse of vertebrae or spondylolisthesis all of which could co&e!ists with LDH. /ince the advent of ?$ and M"# myelography is rarely indicated because of its limitation such as incomplete evaluation of a disc space when there is large disc space inade4uate evaluation of neural foramina and e!traforaminal ;ones and its accuracy is almost the same or lower than M"# or ?$ scan. However it may still be indicated in cases where patients are too large to fit into a M"# or ?$ scanner or if patients have a metallic construct which may produce e!cessive artifacts on a ?$ or M"# scanner. ?$ has its limitations in that it produces images in a single plane only and it uses ioni;ation radiation. M"# is the imaging of choice. #t has the advantage of producing multiplanar images with spatial and contrast resolution. #t also provides more comprehensive e!amination of the entire lumbar spine including conus medullaris and cauda e4uina. 9urther more it can detect physiochemical changes occurring in a degenerating or aging disc before alterations of disc contour as well as tears in annular ligament. $he scan protocol should include at a minimum 3 mm thick sagittal $8 and $1 se4uences along with stacked contiguous a!ial images from pedicle of L- through the L+&/8 disc level along with a set of a!ial images parallel to the disc spaces. =resently positron emission tomography is the newest techni4ue of imaging. $he treatment of LDH could be either conservative or surgical. *ll patients are treated conservatively during the initial 3 C 7 weeks of acute symptoms unless surgery is indicated.1 ?onservative treatment includes bed rest in supine position for a few days analgesic anti C inflammatory drugs psychoactive drugs muscle rela!ants in cases of paraspinal spasms aerobic e!ercise weight control avoidance of smoking instructions to avoid lifting heavy loads repetitive bending or twisting and to use chair with ade4uate lower back support. *pplication of brace corset and belts may prove to be helpful.
7

$raction acupuncture and transcutaneous electrical stimulation

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have 4uestionable effects. Lumbar epidural steroid in%ection may prove useful in some patients in decreasing pain. #n comparing conservative treatment and surgical intervention 5eber found 72) of patients had improvement and reduction of pain within first year as compared with '1) who were treated surgically. 87 *t 3 years the surgical group still had significant better results but at 82 years follow&up there was no significant difference between the two groups. Most authors also believe that conservative treatment should be given during the initial 3 C 7 weeks which should be followed by imaging studies should there be no improvement. 5hen considering surgical intervention the following principals should be borne in mind< (i) (ii) (iii) (iv) the surgeon is not doing disc surgery he is decompressing a nerve root leave the nerve root mobile and undamaged leave as little scar as possible must not create additional instability in the segment

$he indications for surgery may be absolute or relative *bsolute indication < (i) (ii) (iii) cauda e4uina syndrome intractable pain severe motor deficit

"elative indication< Depends on (i) (ii) (iii) duration of radicular pain C chances of resolution decreases with time type C contained e!truded or se4uestrected. /ymptoms decreases with well contained or small disc fragments presence of nerve root or central canal stenosis C resolution higher with normal si;e canal

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(iv)

4uality and severity of symptoms C surgery likely for patients with severe e!clusively radicular pain than moderate back pain.

$he various method include<

(i)

/tandard laminotomy C diskectomy < is the gold standard operation .#t has a reported success rate of '() at 82 year follow C up.8,#ndicated for cauda C e4uina syndrome.

(ii) Limited diskectomy< same as the above but only the e!truded part or se4uestrected part is removed. (iii) Microsurgical diskectomy< reported by 5illiams in 8',((cited in Mc?ulloch 8''7). #t decompresses nerve root and has advantage of less soft tissue trauma permitting surgery to be preformed as outpatient. /uccess rate is about (7). ?omplication includes dura tear infection epidural hematoma and wrong level. $ullberg (cited in Mc?ulloch 8''7) found no difference in outcome between standard and microdiskectomy. (iv) ?hemonucleolysis< coined by Lyman 5. /mith (cited in Drown 8''7). #tAs a lysing agent that causes en;ymatic dissolution of the nucleus palposus of the intervertebral disc. ?hymodiactin a formulary of chymopapain was initially used. .ther en;ymes like collagenase have shown to be effective. /uccess rate was (1) with complication ranging from anaphyla!is to transverse myelitis
(v)

=ercutaneous automated diskectomy< nucleotome is placed in disc space and using fluoroscopy the disc material is cut and suctioned out. #t gives a success rate of ,2) as reported by Eambin. =atient selection and learning curve may give similar outcome as macro or microdiskectomy. '

(vi) Laser diskectomy< an e!tradural approach which is still in the e!perimental stage.

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Recurrent LDH patient with successful results after disc surgery has a +) chance of recurrent disc rupture. Most are due to newly e!truded pieces of disc material not present in the spinal canal at the time of original surgery. .thers may be due to rein%ury to the back usually presenting with the same symptoms or disc herniation at a different level. Due to previous surgery interpretation of imaging studies and complication of another surgery is a risk. LDH in A o!escent: Due to high content of proteoglycan in the disc material and prevalence of disc protrusion rather than disc e!trusion optimum treatment for these age group is chemonucleolysis. LDH in Spina! Stenosis: .ften difficult to detect. 6sually leg pain symptoms and "educed /L" predominates. 9or asymptomatic stenosis with LDH Microdiskectomy with canal decompression is the treatment. Re"erences: 8. An ersson #$B$%& 'einstein %$N$ Disc herniation. Editorial. /pine 8''7F 18<8+ 1. An ersson #$ B$ % & Bro(n M$D& D)ora* %&Her+o, R$%& -a.bin /& 'einstein %$N$: simple

Ma!ter A& McCu!!oc0 %$A& Saa! %$A& Spratt -$F an 18<,+/ &,(/ -.

?onsensus summary on the diagnosis and $reatment of LDH. /pine 8''7F

An ersson #B%& De1o RA$ History and physical e!amination in patient with Herniated lumbar disc. /pine 8''7F 18< 82/ C8(/

3.

Bro(n MD$ 6pdate on chemonucloelysis. /pine 8''7F 18< 71/& 7(/

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+.

D)or* % . 0europhysiologic test in diagnosis of nerve root compression caused by Disc herniation . /pin 8''7F 18< -'/ C 33 /

7.

#or on D$ Diagnosis and management of Lumbar Disc Disease. Mayo ?linic =roceedings 8''7F ,8(-) < 1(- C 1(,.

,.

#re)itt& M $ / & Mc Laren A&S0ac*!e"or Goint /urg 8''+F /pine ,, C D(3) < 717 C 71'.

I$M an

Mu!0o!!an

F$C$:

*utomated percutaneous lumbar diskectomy < an .utcome study. G. Done

(. '.

Her+o, R$%$ $he radiological assessment for a LDH. /pine 8''7F 18< 8'/&-(/ -a.bin /& 20ou L$ History and current status of percutaneous arthroscopic disc /urgery. /pine 8''7F 18< +,/&78/

82.

-o.ari H & S0ino.i1a* -& Na*ai O& 3a.aura I& Ta*e a S an Furu1a -$ $he natural history of herniated nucleus palposus with radiculopathy. /pineF 18< 1++&'

88.

Mc Cu!!oc0 % A$ 9ocus issue on LDH< Macro H microdiskectomy. /pine 8''7 18< 3+/ C +7/

81. 8-.

Moore$ .rigin and fate of herniated disc tissue. /pine 8''7F 18< 183' C 18+3. /ostacc0ini F$ "esult of surgery compared with conservative management

of LDH. /pine 8''7F 18< 8-(- C , 83. Saa! % A $ 0atural history and non&operative treatment of LDH . /pine 8''7F 18 < 1/ C '/.

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8+.

S*inner H B$ ?urrent diagnosis and treatment in orthopedics. *ppleton H Lange 8''+F 8/$. Ed. 8(+ C 7.

87.

'eber H$ $he natural history of disc herniation H influence of intervention. /pine 8''3F 8' < 11-3 C (

8,.

'et+e!& To

F$ /urgery for Herniated Disc. G. *m. Med *sso 8''7F Iol

1,+(,)< +8-&+83

8 8 8 8 8 8 1 7 8 8 '