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Disc Herniation

Online Course: Anatomy …

Definition/Description

A herniated
disc in the
spine is a
condition
during
which a
nucleus
pulposus is
displaced
from intervertebral space. It is a common
cause of back pain. The patient's who
experience pain related to a herniated disc
often remember an inciting event that
caused their pain. Unlike mechanical back
pain, herniated disc pain is often burning
or stinging, and may radiate into the lower
extremity. Furthermore, in more severe
cases, there can be associated with
weakness or sensation changes. In some
instances, a herniated disc injury may
compress the nerve or the spinal cord
causing pain consistent with nerve
compression or spinal cord dysfunction,
also known as myelopathy.[1].

Herniated Disc's:

Can be very painful.

Within a few weeks, most cases of
painful disc herniation heal.
In many instances, the herniation of
the disc does not cause that patient
any pain.
Herniated discs are often seen on MRI
of asymptomatic patients (MRI is the
imaging modality of choice).

The management of disc herniation

requires an interprofessional team.
The initial treatment should be
conservative, unless a patient has
severe neurological compromise.
Surgery is usually the last resort as it
does not always result in predictable
results. Patients are often left with
residual pain and neurological deficits,
which are often worse after surgery.
Physical therapy is the key for most
patients. The outcomes depend on
many factors but those who particpate
in regular exercise and maintain a
healthy body weight have better
outcomes than people who are
sedentary[2].

Herniated Disc - Patient …

[3]

Clinically Relevant
Anatomy

See Lumbar
Anatomy for
great detail

Inter ver tebral

discs:: Two
discs
adjacent
vertebral bodies
are linked by an
intervertebral
disc. Together
with the corresponding facet joints, they
form the ‘functional unit of Junghans’. The
disc consists of an annulus fibrosus, a
nucleus pulposus and two cartilaginous
endplates. The distinction between annulus
and nucleus can only be made in youth,
because the consistency of the disc becomes
more uniform in the elderly. For this
reason, nuclear disc protrusions are rare
after the age of 70. From a clinical point of
view, it is important to consider the disc as
one integrated unit, the normal function of
which depends largely on the integrity of
all the elements. That means that damage
to one component will create adverse
reactions in the others[4].

The disc contain an: Endplate; Annulus

fibrosus; Nucleus pulposus

Etiology

An intervertebral disc is composed of

annulus fibrous which is a dense
collagenous ring encircling the nucleus
pulposus.

Disc herniation occurs when part or

all the nucleus pulposus protrudes
through the annulus fibrous. This
herniation process begins from failure
in the innermost annulus rings and
progresses radially outward.
The damage to the annulus of the disc
appears to be associated with fully
flexing the spine for a repeated or
prolonged period of time.
A herniation may develop suddenly, or
gradually over weeks or months.
Causes
Most common cause of disc
herniation the degenerative
process (as humans age, the
nucleus pulposus becomes less
hydrated and weakens and may
lead to progressive disc
herniation).
The second most common cause
of disc herniation is trauma.
Other causes include connective
tissue disorders and congenital
disorders such as short pedicles.

Disc herniation is:

Most common in the lumbar
spine
Followed by the cervical spine. A
high rate of disc herniation in the
lumbar and cervical spine can be
explained by an understanding
of the biomechanical forces in
the flexible part of the spine.
The thoracic spine has a lower
rate of disc herniation[2].

Repetitive mechanical activities like

twisting, bending, without breaks can
lead to disc damage.
Living a sedentary lifestyle, poor
posture, obesity, tobacco abuse can
also cause disc prolapse.

Pathophysiology

The disc consists of the annulus

fibrosus (a complex series of fibrous
rings) and the nucleus pulposus (a
gelatinous core containing collagen
fibers, elastin fibers and a hydrated
gel)[5]. The vertebral canal is formed
by the vertebral bodies, intervertebral
discs and ligaments on the anterior
wall and by the vertebral arches and
ligaments on the lateral wall. The
spinal cord lies in this vertebral
canal[6].
The pathophysiology of herniated
discs is believed to be a combination of
the mechanical compression of the
nerve by the bulging nucleus pulposus
and the local increase in
inflammatory chemokines.[2]
A tear can occur within the annulus
fibrosus. The material of the nucleus
pulposus can track through this tear
and into the intervertebral or vertebral
foramen to impinge neural
structure[6].
The changes consists of nuclear
degeneration, nuclear displacement
and stage of fibrosis.

Types Of Herniations

Posterolateral Disc Herniation -

Protrusion is usually posterolateral
into vertebral canal. Protruded disc
usually compresses next lower nerve
as the nerve crosses the level of disc in
its path to its foramen. (Example:
protrusion of L5 usually affects S1)
Cental (posterior) Herniation - It is less
frequent. A protruded disc above 2nd
vertebra may compress the spinal cord
itself or may lead to Cauda Equina
Syndrome.
Lateral Disc Herniation - Nerve root
compression happens above the level
of herniation. L4 nerve root is most
often involved.

Stages Of Herniation

There are four stages of herniated discs [7] :

Bulging; Protrusion; Extrusion;
Sequestration (see image below)

Bulging
Bulging: extension of the disc margin
beyond the margins of the adjacent
vertebral endplates

Protrusion
Protrusion: the posterior longitudinal
ligament remains intact but the nucleus
pulposus impinges on the anulus
fibrosus

E xtrusion
xtrusion: the nuclear material
emerges through the annular fibers but
the posterior longitudinal ligament
remains intact

S e questration
questration: the nuclear material
emerges through the annular fibers and
the posterior longitudinal ligament is
disrupted. A portion of the nucleus
pulposus has protruded into the
epidural space

Epidemiology

The incidence of herniated disc is

about 5 to 20 cases per 1000 adults
annually and is most common in
people in their third to the fifth
decade of life, with a male to female
ratio of 2:1.
In 95% of the lumbar disc herniation
the L4-L5 and L5-S1 discs are
affected[8].
Lumbar disc herniation occurs 15
times more than cervical disc
herniation, and is an important cause
of lower back pain[9][10].
The prevalence of a symptomatic
herniated lumbar disc is about 1% to
3% with the highest prevalence
among people aged 30 to 50 years,
with a male to female ratio of 2:1.
In individuals aged 25 to 55 years,
about 95% of herniated discs occur at
the lower lumbar spine (L4/5 and
L5/S1 level); disc herniation above this
level is more common in people aged
over 55 years[11].
It occur rarely in children, and are
most common in young and middle-
aged adults.
Recurrent lumbar disc herniation
(rLDH) is a common complication
following primary discectomy.
The cervical disc herniation is most
affected 8% of the time and most
often at level C5-C6 and C6-C7.

History And Examination

Cervical Spine

History

In the cervical spine, the C6-7 is the most

common herniation disc that causes
symptoms, mostly radiculopathy. History in
these patients should include the chief
complaint, the onset of symptoms, where
the pain starts and radiates. History should
include if there are any past treatments.

Physical Examination

On physical examination, particular

attention should be given to weaknesses
and sensory disturbances, and their
myotome and dermatomal distribution.

Ty
pi
ca
l
fin
di
ng
s
of
sol
ita
ry
ne
rv
e lesion due to compression by
herniated disc in cer vical spine

C5 Ner ve - neck, shoulder, and

scapula pain, lateral arm numbness,
and weakness during shoulder
abduction, external rotation, elbow
flexion, and forearm supination. The
reflexes affected are the biceps and
brachioradialis.

C6 Ner ve - neck, shoulder, scapula,

and lateral arm, forearm, and hand
pain, along with lateral forearm,
thumb, and index finger numbness.
Weakness during shoulder abduction,
external rotation, elbow flexion, and
forearm supination and pronation is
common. The reflexes affected are the
biceps and brachioradialis.

C7 Ner ve - neck, shoulder, middle

finger pain are common, along with
the index, middle finger, and palm
numbness. Weakness on the elbow and
wrist are common, along with
weakness during radial extension,
forearm pronation, and wrist flexion
may occur. The reflex affected is the
triceps.

C8 Ner ve - neck, shoulder, and

medial forearm pain, with numbness
on the medial forearm and medial
hand. Weakness is common during
finger extension, wrist (ulnar)
extension, distal finger flexion,
extension, abduction, and adduction,
along with during distal thumb
flexion. No reflexes are affected.

T1 Ner ve - pain is common in the

neck, medial arm, and forearm,
whereas numbness is common on the
anterior arm and medial forearm.
Weakness can occur during thumb
abduction, distal thumb flexion, and
finger abduction and adduction. No
reflexes are affected.[2]

Lumbar Spine

History

In the lumbar spine, herniated disc can

present with symptoms including sensory
and motor abnormalities limited to specific
myotome. History in these patients should
include chief complaints, the onset of
symptoms, where the pain starts and
radiates. History should include if there are
any past treatments.

Physical Examination

A careful neurological examination can

help in localizing the level of the
compression. The sensory loss, weakness,
pain location and reflex loss associated with
the different level are described below

Typical findings of solitar y ner ve

lesion due to compression by
herniated disc in lumbar spine

L1 Ner ve - pain and sensory loss are

common in the inguinal region. Hip
flexion weakness is rare, and no
stretch reflex is affected.

L2-L3-L4 Ner ves - back pain

radiating into the anterior thigh and
medial lower leg; sensory loss to the
anterior thigh and sometimes medial
lower leg; hip flexion and adduction
weakness, knee extension weakness;
decreased patellar reflex.

L5 Ner ve - back, radiating into

buttock, lateral thigh, lateral calf and
dorsum foot, great toe; sensory loss on
the lateral calf, dorsum of the foot,
web space between first and second
toe; weakness on hip abduction, knee
flexion, foot dorsiflexion, toe
extension and flexion, foot inversion
and eversion; decreased
semitendinosus/semimembranosus
reflex.

S1 Ner ve - back, radiating into

buttock, lateral or posterior thigh,
posterior calf, lateral or plantar foot;
sensory loss on posterior calf, lateral or
plantar aspect of foot; weakness on
hip extension, knee flexion, plantar
flexion of the foot; Achilles tendon;
Medial buttock, perineal, and perianal
region; weakness may be minimal,
with urinary and fecal incontinence
as well as sexual dysfunction.
S2-S4 Ner ves - sacral or buttock
pain radiating into the posterior
aspect of the leg or the perineum;
sensory deficit on the medial buttock,
perineal, and perianal region; absent
bulbocavernosus, anal wink reflex[2].

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