DISC HERNIATION

ANATOMY OF SPINE

DEFINITION
A herniated disc in the spine is a condition during which a
nucleus pulposus is bulged out of beyond the outer ring (annulus
fibrosis). It is a common cause of back pain.
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
o 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).
o The second most common cause of disc herniation is trauma.
o Other causes include connective tissue disorders and congenital disorders
such as short pedicles.
 Disc herniation is:
o Most common in the lumbar spine
o 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.
o The thoracic spine has a lower rate of disc herniation.
 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).
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.
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.
STAGES OF DISC HERNIATION
Signs And Symptoms
 Severe low back pain, radiating pain.
 Walking can be painful and difficult.
 Muscle spasm, tingling sensation, weakness or atrophy.
 loss of bladder or bowel control.
 Slow and deliberate, tip-toe walking.
 Spine, trunk deviation.
 Antalgic or Trendelenburg gait.
 Paraspinal muscle spasm.
 Some people may be asymptomatic.

DIAGNOSTIC EVALUATION
1. History and physical examination
The cervical disc herniation is most often at level C5-C6 and C6-C7. lumbar disc
herniation the L4-L5 and L5-S1 discs are affected.
Cervical spine
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.
On physical examination, particular attention should be given to weaknesses and sensory
disturbances, and their myotome and dermatomal distribution.
Typical findings of solitary nerve lesion due to compression by herniated disc in
cervical spine
 C5 Nerve - 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 Nerve - 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 Nerve - 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 Nerve - 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 Nerve - 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 solitary nerve lesion due to compression by herniated disc in
lumbar spine
 L1 Nerve - pain and sensory loss are common in the inguinal region. Hip flexion
weakness is rare, and no stretch reflex is affected.
 L2-L3-L4 Nerves - 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 Nerve - 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 Nerve - 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 Nerves - 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
Cervical
1. Spurling test.
2. Distraction test.
3. Upper limb tension test.
4. Shoulder abduction test.
5. Tinel's sign
Lumbar
1. The straight leg raise test:
2. The contralateral (crossed) straight leg raise test/ Lasègue’s Test - - see straight leg
raise test
3. Bowstring test
4. Prone knee bending
5. Muscle Weakness or Paresis
6. Reflexes
7. Hyperextension Test The patient needs to passively mobilise the trunk over the full
range of extension, while the knees stay extended. The test indicates that the radiant
pain is caused by disc herniation if the pain deteriorates
Imaging
X-rays
CT Scan
MRI
Medical Management
Acute cervical and lumbar radiculopathies due to herniated disc are primarily managed
with non-surgical treatments.
 NSAIDs and physical therapy are the first-line treatment modalities.
 Oral steroids like prednisone, methyl prednisone.
 Benzodiazepines of low dose.
 Translaminar epidural injections and selective nerve root blocks are the second line
modalities. These are good modalities for managing disabling pain.
 Patients who fail conservative treatment or patients with neurological deficits need
timely surgical consultation
 Rest
Active exercise therapy- It is preferred to passive modalities.

There are a number of exercise programmes for the treatment of symptomatic disc
herniation eg; aerobic activity (eg, walking, cycling), flexibility exercises
 (eg, yoga and stretching),proprioception/coordination/balance (medicineball
and wobble/tilt board),strengthening exercises.
 motor control exercises MCEs( core strengthening excercises)

 Transcutaneous Electrical Nerve Stimulation (TENS) - TENS therapy contribute to

pain relief and improvement of function and mobility of the lumbosacral spine[26].
 Traction - A recent study has shown that traction therapy has positive effects on pain,
disability and SLR on patients with intervertebral disc herniation
 Hot Therapies - may use heat to increase blood flow to the target area. Blood helps
heal the area by delivering extra oxygen and nutrients. Blood also removes waste
byproducts from muscle spasms
 Cryotherapy - reduces spasm and inflammation in acute phase.Shortwave diathermy -
pulsed SWD in acute condition and continuous SWD in chronic condition.
 Ultrasound - As phonophoresis, it increases extensibility of connective tissues.
Surgical Treatment