Prolapsed Intervertebral Disc

Prolapsed Vertebral Disc

A prolapsed intervertebral disc is commonly referred to as a slipped disc.
This is actually rarely a "slipping" of the disc but a bulging out (herniation) of the inner part
of the disc.
Environmental factors include:

Poor weight-lifting technique

Smoking

Occupations involving extended periods of sitting for example office work or taxi driving
Trauma
Age - "wear and tear" of the disc or "drying out" of the disc

Spine and Disc

As the name implies, the interverterbral discs are found between the vertebral bodies of the
spine. The discs are rubber or jelly-like and act to cushion the spine when it bends.
Herniation occurs posteriorly or posterior-laterally beneath the posterior longitudinal
ligament.
This can result in local oedema and pressure on the adjacent nerve root
Depending on the structures involved, different symptoms may be experienced:

Pressure on ligament - Backache

Pressure on dural envelope of nerve root - Sciatica

Compression of nerve root - numbness,

parasthesia and muscle weakness

Compression of Cauda equina - urinary retention [It is a

emergency as damage may become irreversible if left untreated

medical
for too

long!!!]
The disc can herniate at any level in the spine, but it must commonly occurs in the lumbar
region, specifically at L4/L5 and L5/S1.

 Clinical Features
1. The patient is typically a young and fit adult presenting with sudden onset back pain whilst
lifting or stooping.
2. They are unable to straighten up due to severe pain.
3. From the onset of the injury, the patient may present with:

Backache

Sciatica (characteristic pain in buttocks and lower limb)

Paraesthesia or numbness in lower leg or foot

Muscle weakness

Urinary retention

Backache and sciatica persists after the injury and is typically made worse by coughing or
straining.

Observation
Sciatic Scoliosis - the patient may stand with a slight list to
one side, increased during forward flexion
Range of back movements severely limited in all planes

Palpation

Tenderness in the midline of lower back

Paravertebral muscle spasm

Special Tests
Straight Leg Raise (SLR) - Tests for herination at L4/L5
or L5/S1 discs.
This test is performed with the patient lying flat on their
backs on the examination couch or bed.
1.

Raise one leg, keeping the knee joint completely straight, until pain is felt in the
buttock, thigh or calf.

2.

Note the angle at which pain occurs. In normal circumstances pain is felt above
80-90 degrees. The test is positive when pain is felt between 30-70 degrees.

3.

Flexing the knee at this point will relieve buttock pain. Pressing on the popliteal
nerve will reproduce the pain.

4.

Straighten the leg again and then lower the leg to below the angle where pain is
felt.
Dorsiflex the foot. If the pain is due to sciatica, this should reproduce the
pain.

Patients with lumbar herniation will have a limited SLR and it will be painful on
the affected side.
'Crossed Sciatic Tension' - Raising the unaffected leg may cause sciatic tension
on the painful side. This may be observed but is not a common finding.
Femoral Stretch Test - May be positive if nerve root of L3/4 is affected. This test is
performed with the patient lying prone on the examination couch.
1. Flex the knee to 90 degrees
2. Extend the hip
3. Pain is felt in the anterior thigh.

Neurological Examination
At the corresponding level of prolapse, you may find:
Muscle weakness (later wasting)
Diminished reflexes
Sensory loss

L5 impairment
weakness of big toe extension
weakness of knee flexion
sensory loss on the outer side of the foot
sensory loss on the dorsum of the foot

S1 impairment
weak plantar flexion
weak eversion of the foot
a depressed ankle jerk reflex
Sensory loss along the lateral border of the foot.

 Cauda equina syndrome

Is a RED FLAG SYMPTOM.
Causes saddle anaesthesia about the anus, perineum or genitals and loss of anal
sphincter tone or faecal incontinence.
Patients may present with difficulty micturating.

Imaging

MRI is the most valuable method of imaging as it confirms the presence, level,
size and extension of the disc herniation.
An X-ray must be performed to rule out any bone pathology.

Differential Diagnosis
1.

Inflammatory disorders:
Ankylosing Spondylitis causes severe and
more generalised stiffness and typical xray changes.
Tuberculosis of the spine (Potts Spine)
will produce a raised ESR.

2.

Vertebral tumours - Cause constant pain. X-rays show bone

destruction or pathological fracture

3.

Nerve tumours - may cause sciatica but pain is continuous. CT or MRI may
delineate the lesions

Treatment

The majority of herniated discs will heal themselves within 6-8 weeks and do not
require surgery.
Management problems arise if pain lasts longer than 8 weeks.
Non-Surgical or conservative management methods are usually tried first.
These include:

Patient education on body mechanics

Physiotherapy

Heat therapy

Analgesics

Anti-inflammatory drugs

Oral or locally injected steroids

Weight loss

Smoking cessation

Reduction - continuous bed rest and traction for 2 weeks

Once non-surgical methods have failed, discectomy or micro discectomy is

usually the treatment of choice.

Surgical management
The indications for surgical management are:
1.

Cauda equina syndrome which does not clear up within 6 hours of starting bedrest and traction (Medical emergency)

2.

Persistent pain and severely limited straight leg raising after 2 weeks of
conservative management

3.

Neurological deterioration while under conservative management

4.

Frequently recurring attacks

Rehabilitation
Rehabilitation is essential for patients once they have recovered from acute disc
rupture or disc removal.
The patient is taught isometric exercises in order to reduce the strain on their
back.
Light work in resumed after 1 month and heavy work after 3 months.
If the patient fails to recover fully, heavy lifting should be avoided all together.