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14

Lumbar Disc Herniation

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Topic updated on 08/16/14 3:12pm
Introduction
  • Epidemiology
    • 95% involve L4/5 or L5/S1 levels
      • L5/S1 most common level
    • peak incidence is 4th and 5th decades
    • only ~5% become symptomatic
    • 3:1 male:female ratio
  • Pathoanatomy
    • recurrent torsional strain leads to tears of outer annulus   which leads to herniation of nucleus pulposis
  • Prognosis
    • 90% of patients will have improvement of symptoms within 3 months with nonoperative care.
    • size of herniation decreases over time (reabsorbed)
      • sequestered disc herniations show the greatest degree of spontaneous reabsorption
      • macrophage phagocytosis is mechanism of reabsorption
Anatomy
  • Complete intervertebral disc anatomy and biomechanics
  • Disc composition
    • annulus fibrosis
      • composed of type I collagenwater, and proteoglycans
      • characterized by extensibility and tensile strength
        • high collagen / low proteoglycan ratio (low % dry weight of proteoglycans) 
    • nucleus pulposus
      • composed of type II collagenwater, and proteoglycans
      • characterized by compressibility
        • low collagen / high proteoglycan ratio (high % dry weight of proteoglycans) 
          • proteoglycans interact with water and resist compression
        •  a hydrated gel due to high polysacharide content and high water content (88%)
  • Nerve root anatomy
    • key difference between cervical and lumbar spine is 
      • pedicle/nerve root mismatch
        • cervical spine C6 nerve root travels under C5 pedicle (mismatch)
        • lumbar spine L5 nerve root travels under L5 pedicle (match)
        • extra C8 nerve root (no C8 pedicle) allows transition
      • horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
        • because of vertical anatomy of lumbar nerve root a paracentral and foraminal disc will affect different nerve roots
        • because of horizontal anatomy of cervical nerve root a central and foraminal disc will affect the same nerve root
Classification
  • Location Classification
    • central prolapse
      • often associated with back pain only
      • may present with cauda equina syndrome which is a surgical emergency
    • posterolateral (paracentral)  
      • most common (90-95%)
      • PLL is weakest here
      • affects the traversing/descending/lower nerve root  
        • at L4/5 affects L5 nerve root
    • foraminal (far lateral, extraforaminal)  post
      • less common (5-10%)
      • affects exiting/upper nerve root   
        • at L4/5 affects L4 nerve root
    • axillary
      • can affect both exiting and descending nerve roots
  • Anatomic classification
    • protrusion
      • eccentric bulging with an intact annulus
    • extrusion
      • disc material herniates through annulus but remains continuous with disc space
    • sequestered fragment (free)
      • disc material herniates through annulus and is no longer continuous with disc space
Presentation
  • Symptoms
    • can present with symptoms of
      • axial back pain (low back pain)
        • this may be discogenic or mechanical in nature
      • radicular pain (buttock and leg pain)
        • often worse with sitting, improves with standing
        • symptoms worsened by coughing, valsalva, sneezing
      • cauda equina syndrome (present in 1-10%)
        • bilateral leg pain
        • LE weakness
        • saddle anesthesia
        • bowel/bladder symptoms
  • Physical exam 
    • see lower extremity neuro exam
    • motor exam
      • ankle dorsiflexion (L4 or L5)
        • test by having patient walk on heels
      • EHL weakness (L5) 
        • manual testing
      • hip abduction weakness (L5)
        • have patient lie on side on exam table and abduct leg against resistance
      • ankle plantar flexion (S1)
        • have patient do 10 single leg toes stands
    • provocative tests
      • straight leg raise
        • a tension sign for L5 and S1 nerve root
        • technique
          • can be done sitting or supine
          • reproduces pain and paresthesia in leg at 30-70 degrees hip flexion
        • sensitivity/specificity
          • most important and predictive physical finding for identifying who is a good candidate for surgery
      • contralateral SLR
        • crossed straight leg raise is less sensitive but more specific
      • Lesegue sign
        • SLR aggravated by forced ankle dorsiflexion
      • Bowstring sign
        • SLR aggravated by compression on popliteal fossa
      • Kernig test
        • pain reproduced with neck flexion, hip flexion, and leg extension
      • Naffziger test
        • pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins
      • Milgram test
        • pain reproduced with straight leg elevation for 30 seconds in the supine position
    • gait analysis
      • Trendelenburg gait
        • due to gluteus medius weakness which is innervated by L5
Imaging
  • Radiographs
    • may show
      • loss of lordosis (spasm)
      • loss of disc height
      • lumbar spondylosis (degenerative changes)
  • MRI without gadolinium
    • modality of choice for diagnosis of lumbar and cervical disc herniations
      • highly sensitive and specific
      • helpful for preoperative planning
      • useful to differentiate from synovial facet cysts
    • however high rate of abnormal findings on MRI in normal people
    • indications for obtaining an MRI
      • pain lasting > one month and not responding to nonoperative management or
      • red flags are present
        • infection (IV drug user, h/o of fever and chills)
        • tumor (h/o or cancer)
        • trauma (h/o car accident or fall)
        • cauda equina syndrome (bowel/bladder changes)
  • MRI with gadolinium
    • useful for revision surgery
    • allows to distinguish between post-surgical fibrosus (enhances with gadolinium) vs. recurrent herniated disc (does not enhance with gadolinium)
Treatment
  • Nonoperative
    • rest and physical therapy, and antiinflammatory medications  
      • indications
        • first line of treatment for most patients with disc herniation
          • 90% improve without surgery
      • technique
        • bedrest followed by progressive activity as tolerated
        • medications
          • NSAIDS
          • muscle relaxants (more effective than placebo but have side effects)
          • oral steroid taper
        • physical therapy
          • extension exercises extremely beneficial
          • traction
          • chiropractic manipulation
    • selective nerve root corticosteroid injections
      • indications
        • second line of treatment if therapy and medications fail
      • technique
        • epidural
        • selective nerve block
      • outcomes
        • leads to long lasting improvement in ~ 50% (compared to ~90% with surgery)
        • results best in patients with extruded discs as opposed to contained discs
  • Operative
    • laminotomy and discectomy (microdiscectomy) post
      • indications  
        • persistent disabling pain lasting more than 6 weeks that have failed nonoperative options (and epidural injections)
        • progressive and significant weakness
        • cauda equina syndrome
      • technique
        • can be done with small incision or through "tube" access
      • outcomes
        • outcomes with surgery compared to nonoperative
          • improvement in pain and function greater with surgery  
        • positive predictors for good outcome with surgery
          • leg pain is chief complaint 
          • positive straight leg raise
          • weakness that correlates with nerve root impingement seen on MRI
          • married status
        • negative predictors for good outcome with surgery
          • worker's compensation  
            • WC patients have less relief from symptoms and less improvement in quality of life with surgical treatment
    • far lateral microdiskectomy post
      • indications
        • for far-lateral disc herniations
      • technique
        • utilizes a paraspinal approach of Wiltse
Complications of Surgery
  • Dural tear (1%)
    • if have tear at time of surgery then perform water-tight repair
  • Recurrent HNP
    • can treat nonoperatively initially
    • outcomes for revision discectomy have been shown to be as good as for primary discectomy
  • Discitis (1%)
  • Vascular catastrophe
    • caused by breaking through anterior annulus and injuring vena cava/aorta

 

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Qbank (14 Questions)

TAG
(SBQ12.8) A 45-year-old patient complains of leg pain associated with the pathology seen in Figure A. The patient undergoes microdiskectomy. During surgery there is no evidence of instability. Ten months later he re-develops similar symptoms of leg pain. A repeat MRI is consistent with a recurrent lumbar disc herniation. Which of the following most accurately describes the outcomes of revision surgery in comparison to primary surgery? Topic Review Topic
FIGURES: A          

1. Equal limb pain and equal functional outcomes
2. Improved limb pain and improved functional outcomes
3. Worsened limb pain and worsened functional outcomes
4. Worsened limb pain but improved functional outcomes
5. Improved limb pain but worsened functional outcomes

PREFERRED RESPONSE ▶
TAG
(SBQ12.14) A 36-year-old male presents with acute onset of right buttock and leg pain following lifting a heavy object. On physical exam he has weakness to knee extension, numbness over the medial malleolus, and a decreased patellar reflex. Which of the following would most likely explain this clinical presentation. Topic Review Topic

1. Lumbar arachnoiditis
2. L4/L5 paracentral disc herniation
3. L3/L4 far lateral (foraminal) disc herniation
4. L4/L5 far lateral (foraminal) disc herniation
5. L5/S1 far lateral (foraminal) disc herniation

PREFERRED RESPONSE ▶
TAG
(OBQ12.102) In patients with a symptomatic lumbar disc herniation who have failed nonoperative management, which of the following patient characteristics are associated with improved treatment effects with surgery? Topic Review Topic

1. Duration of symptoms > 6 mos, improving symptoms at baseline, Mental Component Score (MCS) > 35
2. Duration of symptoms < 6 mos, worsening symptoms at baseline, Mental Component Score (MCS) > 35
3. Age > 41 years, divorced, presence of worker compensation claim
4. Age < 31 years, absence of joint problems, no workers compensation
5. Age > 41 years, absence of joint problems, married status

PREFERRED RESPONSE ▶
TAG
(OBQ12.230) A 38-year-old male presents with a three month history of low back pain and right leg pain that has failed to improve with nonoperative modalities including selective nerve root corticosteroid injections. He localizes her leg pain and paresthesias to her buttock, lateral and posterior calf, and the dorsal aspect of her foot. On strength testing, he is graded a 4/5 for plantar-flexion and 4+/5 to ankle dorsiflexion. On flexion and extension radiographs there is no evidence of spondylolisthesis. Sagittal and axial T2-weighted MRI images are shown in Figure A and B. Which of the following treatment modalities will allow the greatest improvement of physical functioning? Topic Review Topic
FIGURES: A   B        

1. Observation alone
2. Physical therapy
3. Medical management with GABA analogs
4. Discectomy
5. Disectomy and instrumented fusion

PREFERRED RESPONSE ▶
TAG
(OBQ11.65) A 33-year-old woman reports pain down her right leg and numbness across the dorsum of her right foot which started 3 months ago during a bowel movement. Prior to this she had had 1 month of low back pain. She had a lumbar microdiscectomy at L4/5 3 years ago which was successful. On physical exam she has weakness to ankle dorsiflexion and great toe extension on the right. Her new MRI images are shown in Figure B. After a failure of nonoperative treatment, which of the following is the most appropriate surgical treatment? Topic Review Topic
FIGURES: A   B        

1. L4/5 microdiskectomy through midline approach
2. L4/5 microdiskectomy with far lateral Wiltse approach
3. L4/5 Decompression, TLIF, and instrumented fusion
4. L4/5 Decompression, PLIF, and instrumented fusion
5. L4/5 Anterior Lumbar Interbody Fusion

PREFERRED RESPONSE ▶
TAG
(OBQ11.236) A 35-year-male presents with pain radiating down the left leg, worse in the anterior leg distal to the knee. On physical exam, he is unable to go from a sitting position to a standing position with a single leg on the left, whereas he has no difficulty on the right. His patellar reflex is absent on the left, and 2+ on the right. Which of the following clinical scenarios would best produce this pattern of symptoms? Topic Review Topic

1. Left L2-3 foraminal herniated nucleus pulposis
2. Left L4-5 central herniated nucleus pulposis
3. Left L4-5 paracentral herniated nucleus pulposis
4. Left L4-5 foraminal herniated nucleus pulposis
5. Left L5-S1 paracentral herniated nucleus pulposis

PREFERRED RESPONSE ▶
TAG
(OBQ10.18) Following surgical treatment of a lumbar disc herniations with radiculopathy, patients with worker's compensation claims have which of the following when compared to patients who do not have worker's compensation claims at 5 years? Topic Review Topic

1. Equivalent relief from symptoms and equivalent improvement in quality of life
2. Less relief from symptoms and less improvement in quality of life
3. Improved relief from symptoms and greater improvement in quality of life
4. Significantly decreased return to work status
5. Significantly improved return to work status

PREFERRED RESPONSE ▶
TAG
(OBQ09.206) A 40-year-old female presents with right leg pain localized to the buttock, posterior thigh, and lateral calf. In addition, she describes numbness and tingling on the dorsum of the right foot. Physical exam shows weakness to EHL. Three months of nonoperative treatment including anti-inflammatory medication, physical therapy, and selective nerve root corticosteroid injections failed to provide lasting relief and pain is still severe in nature. Her MRI is shown in Figures A and B. What would be the most appropriate management at this juncture? Topic Review Topic
FIGURES: A   B        

1. Refer the patient to pain management
2. Repeat epidural steroid injection
3. Transforaminal diskectomy
4. Laminotomy and diskectomy
5. Spinal fusion with interbody cage and posterior instrumentation

PREFERRED RESPONSE ▶
TAG
(OBQ09.235) A 45-year-old male comes into your clinic complaining of right leg radicular pain that extends to the dorsal aspect of his right foot. On physical exam he has slight decreased sensation on the top of his right foot as well as 3/5 strength in his right EHL. He has 5/5 strength in the all other muscle groups in his lower extremities and symmetric 1+ patellar and Achilles reflexes bilaterally. Which axial MRI would be consistent with the patients symptoms Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶
TAG
(OBQ08.158) In patients with lumbar disc herniations resulting in significant unilateral leg pain but no functionally limiting weakness, surgical decompression has what long term effects when compared to nonoperative management? Topic Review Topic

1. Worse outcomes in pain, physical function, and return to work status at 4 years.
2. Equivalent outcome in pain and physical function at 4 years.
3. Improved outcome in pain and physical function at 4 years.
4. Improved outcome in return to work status only at 4 years.
5. Worse outcome in return to work status with equivalence in pain and physical function at 4 years.

PREFERRED RESPONSE ▶
TAG
(OBQ08.181) A 32-year-old male presents with left leg pain and weakness. An axial image from his MRI is shown in Figure A. Which of the following physical exam findings would be most consistent with this MRI finding. Topic Review Topic
FIGURES: A          

1. Numbness over dorsal aspect of the foot, weakness to gluteus medius
2. Numbness over plantar foot, weakness to his gastrocsoleus complex
3. Numbness over medial malleolus, and weakness to quadriceps
4. Numbness over medial calf, weakness in his EHL
5. Numbness over lateral malleolus, weakness to hip adduction

PREFERRED RESPONSE ▶
TAG
(OBQ08.240) A far lateral disc herniation at the L4/5 level would likely present with what neurologic symptoms and physical finding. Topic Review Topic

1. Weakness to hip flexion, numbness on the inner thigh, a decreased patellar reflex
2. Weakness to knee extension, numbness on the anterior shin, a decreased patellar reflex
3. Weakness to ankle dorsal flexion, numbness on the dorsal foot, a decreased Achilles reflex
4. Weakness to extensor hallicus longus, numbness in the first web space, a decreased Achilles reflex
5. Weakness to ankle plantar flexion, numbness on the lateral foot, normal reflexes

PREFERRED RESPONSE ▶
TAG
(OBQ06.43) 45-year-old manual laborer presents to the office with acute onset back pain that radiates to his right leg after carrying a heavy object. He also has mild non-progressive weakness with ankle dorsiflexion on that side. A representative MRI cut is shown in Figure A. What should be his initial treatment? Topic Review Topic
FIGURES: A          

1. Microdiskectomy
2. Posterior spinal fusion with instrumentation
3. Decompression only
4. Strict bedrest
5. Anti-inflammatory medication and physical therapy

PREFERRED RESPONSE ▶
TAG
(OBQ04.167) A 34-year-old male has 7 months of right-sided radicular pain to his anteromedial shin and medial ankle which has failed non-operative treatment. Physical exam shows a foot drop and decreased patellar reflexes on the affected side. A MRI is shown in figures A & B. Operative treatment should include: Topic Review Topic
FIGURES: A   B        

1. anterior retroperitoneal approach with anterior lumbar interbody fusion (ALIF)
2. anterior transperitoneal approach with discectomy only
3. posterior midline lumbar laminectomy, decompression and fusion with pedicle screw fixation
4. posterior midline hemilaminectomy with discectomy
5. paraspinal muscle-splitting approach to the intertransverse space and discectomy

PREFERRED RESPONSE ▶
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