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• Is a hydrostatic, load
between the vertebral
bodies from C2-3 to
• Nucleus pulposus +
• Is relatively avascular.
• L4-5, largest avascular
structure in the body.
Vital Functions of the IVD
• Restricted intervertebral joint motion
• Contribution to stability
• Resistence to axial, rotational, and bending load
• Preservation of anatomic relationship
The Biochemical Composition
• Water : 65 ~ 90% wet wt.
• Collagen : 15 ~ 65% dry wt.
• Proteoglycan : 10 ~ 60% dry wt.
• Other matrix protein : 15 ~ 45% dry wt.
• Outer boundary of the disc.
• More than 60 distinct, concentric
layer of overlapping lamellae of
type I collagen.
• Fibers are oriented 30-degree angle
to the disc space.
• Helicoid pattern.
• Resist tensile, torsional,
and radial stress.
• Attached to the
cartilaginous and bony
end-plate at the periphery
of the vertebra.
Type II collagen
strand + hydrophilic
Water content 70 ~ 90%
Confine fluid within the
Convert load into tensile
strain on the annular fibers
and vertebral end-plate.
Distribution of load in the
(A) In the normal, healthy disc,
the nucleus distributes the load
equally throughout the anulus.
(B) As the disc undergoes
degeneration, the nucleus loses
some of its cushioning ability
and transmits the load
unequally to the anulus.
(C) In the severely degenerated
disc, the nucleus has lost all of
its ability to cushion the load,
which can lead to disc
Is a medical condition affecting the spine due
to trauma, lifting injuries, or idiopathic, in which a tear in the
outer, fibrous ring (annulus fibrosus) of an intervertebral
disc allows the soft, central portion (nucleus pulposus) to bulge
out beyond the damaged outer rings.
This tear in the disc ring may result in the release of inflammatory
chemical mediators which may directly cause severe pain, even in
the absence of nerve root compression .
Disc herniations are normally a further development of a
previously existing disc "protrusion", a condition in which the
outermost layers of the annulus fibrosus are still intact, but can
bulge when the disc is under pressure.
Types of herniation
posterolateral disc herniation –
protrusion is usually posterolateral into vertebral
canal, compress the roots of a spinal nerve.
protruded disc usually compresses next lower nerve as that
nerve crosses level of disc in its path to its foramen.
(eg.protrusion of fifth lumbar disc usually affects S1 instead.
central (posterior) herniation:
less frequently, a protruded disc above second lumbar vertebra
may compress spinal cord itself or or may result in cauda equina
in the lower lumbar segments, central herniation may result in
lateral disc herniation:
may compress the nerve root above the level of the herniation
L4 nerve root is most often involved & patient typically have
intense radicular pain.
Classifications Of Herniations
Loss of fluid in nucleus pulposus
Bulge in the disc but not a complete rupture
Nucleus forced into outermost layer of annulus
fibrosus- not a complete rupture
A small hole in annulus fibrosus and fluid moves
into epidural space
Disc fragments start to form outside of the disc
b) Bulging disk
c) Focal bulge or protrusion.
The nucleus material remains
within the outermost fibres of
the annulus fibrosus.
d) Prolapse or extrusion.
The nucleus material has
penetrated the annulus
fibrosus but is contained in
front of the posterior
e) Sequester or free fragment.
Cellular and Biochemical Changes of the
Loss of negative charged
proteoglycan side chain.
Water loss within the
Loss of disc height.
distribution on the
Repetitive mechanical activities – Frequent bending,
twisting, lifting, and other similar activities without breaks
and proper stretching can leave the discs damaged.
Living a sedentary lifestyle – Individuals who rarely if ever
engage in physical activity are more prone to herniated
discs because the muscles that support the back and neck
weaken, which increases strain on the spine.
Traumatic injury to lumbar discs-
commonly occurs when lifting while bent at the waist,
rather than lifting with the legs while the back is
Obesity – Spinal degeneration can be quickened as a
result of the burden of supporting excess body fat.
Practicing poor posture – Improper spinal alignment while
sitting, standing, or lying down strains the back and neck.
Tobacco abuse – The chemicals commonly found in
cigarettes can interfere with the disc’s ability to absorb
nutrients, which results in the weakening of the disc.
Mutation- in genes coding for proteins involved in the
regulation of the extracellular matrix, such
as MMP2 and THBS2, has been demonstrated to
contribute to lumbar disc herniation.
There is now recognition of the importance of
“chemical radiculitis” in the generation of back pain.
A primary focus of surgery is to remove “pressure” or
reduce mechanical compression on a neural element:
either the spinal cord, or a nerve root.
But it is increasingly recognized that back pain, rather
than being solely due to compression, may also be
due to chemical inflammation.
There is evidence that points to a specific
inflammatory mediator of this pain.
This inflammatory molecule, called tumor necrosis
factor-alpha (TNF), is released not only by the
herniated disc, but also in cases of disc tear (annular
tear), by facet joints, and in spinal stenosis.
In addition to causing pain and
inflammation, TNF may also contribute to disc
symptoms of a herniated disc can
vary depending on the location of the
herniation and the types of soft
tissue that become involved.
They can range from little or no pain
if the disc is the only tissue
injured, to severe and unrelenting
neck or low back pain that will
radiate into the regions served by
affected nerve roots that are irritated
or impinged by the herniated
Often, herniated discs are not
diagnosed immediately, as the
patients come with undefined pains
in the thighs, knees, or feet.
sensory changes such as numbness, tingling, muscular
weakness, paralysis, paresthesia, and affection of
If the disc protrudes to one side, it may irritate the dural
covering of the adjacent nerve root causing pain in the
buttock, posterior thigh and calf (sciatica).
Unlike a pulsating pain or pain that comes and goes,
which can be caused by muscle spasm, pain from a
herniated disc is usually continuous or at least is
continuous in a specific position of the body.
A large central rupture may cause compression of the
A posterolateral rupture presses on the nerve root
proximal to its point of exit through the intervertebral
foramen; thus a herniation at L4/5 will compress the
fifth lumbar nerve root, and a herniation at L5/S1, the
first sacral root.
Sometimes a local inflammatory response with oedema
aggravates the symptoms.
CLINICAL FEATURE OF ACUTE DISC
• Acute disc prolapse may occur at any age, but is
uncommon in the very young and the very old.
• The patient is usually a fit adult aged 20–45 years.
• Typically, while lifting or stooping he has severe back pain
and is unable to straighten up.
• Either then or a day or two later pain is felt in the buttock
and lower limb (sciatica).
• Both backache and sciatica are made worse by coughing
• Later there may be paraesthesia or numbness in the leg or
foot, and occasionally muscle weakness.
• Cauda equina compression is rare but may cause urinary
retention and perineal numbness.
• The patient usually stands with a slight list to one
• Sometimes the knee on the painful side is held
slightly flexed to relax tension on the sciatic nerve;
straightening the knee makes the skew back more
• All back movements are restricted, and during
forward flexion the list may increase.
• There is often tenderness in the midline of the low
back, and paravertebral muscle spasm.
• Straight leg raising is restricted and painful on the
affected side; dorsiflexion of the foot and
bowstringing of the lateral popliteal nerve may
accentuate the pain.
• Sometimes raising the unaffected leg causes acute
sciatic tension on the painful side (‘crossed sciatic
• With a high or mid-lumbar prolapse the femoral
stretch test may be positive.
• Neurological examination may show muscle weakness
(and, later, wasting), diminished reflexes and sensory
loss corresponding to the affected level.
• L5 impairment causes weakness of knee flexion and
big toe extension as well as sensory loss on the outer
side of the leg and the dorsum of the foot.
• Normal reflexes at the knee and ankle are
characteristic of L5 root compression.
• Paradoxically, the knee reflex may appear to be
increased, because of weakness of the antagonists
(which are supplied by L5).
• S1 impairment causes weak plantar-flexion and
eversion of the foot, a depressed ankle jerk and
sensory loss along the lateral border of the foot.
FEATURES OF CAUDA EQUINA SYNDROME
Bladder and bowel incontinence
Bilateral sciatica .
Lower limb weakness
Crossed straight-leg raising sign
Note: Scan urgently and operate urgently if a large
central disc is revealed.
Signs and Symptoms
• Most common
Pain located in
down the back
of the thigh
The majority of spinal disc herniation cases occur
in lumbar region (95% in L4-L5 or L5-S1).
The second most common site is the cervical
region (C5-C6, C6-C7).
The thoracic region accounts for only 0.15% to 4.0%
The rest of the spinal cord,
however, is oriented
differently, so a symptomatic
between two vertebrae will
actually impinge on the
nerve exiting at
the next intervertebral
for example, a herniation of
the disc between the L5 and
S1 vertebrae will impinge on
the S1 spinal nerve, which
exits between the S1 and S2
Occasionally an L4/5 disc
prolapse compresses both L5
Cervical disc herniations occur in the neck, most often
between the fifth & sixth (C5/6) and the sixth and
seventh (C6/7) cervical vertebral bodies.
Symptoms can affect the back of the skull, the neck,
shoulder girdle, scapula, shoulder, arm, and hand.
The nerves of the cervical plexus and brachial
plexus can be affected.
Thoracic discs are very stable and herniations in this
region are quite rare.
Herniation of the uppermost thoracic discs can mimic
cervical disc herniations, while herniation of the other
discs can mimic lumbar herniations.
Lumbar disc herniations occur in the lower back, most
often between the fourth and fifth lumbar vertebral
bodies or between the fifth and the sacrum.
Symptoms can affect the lower
back,buttocks, thigh, anal/genital region (via
the Perineal nerve), and may radiate into the foot
The sciatic nerve is the most commonly affected
nerve, causing symptoms of sciatica.
The femoral nerve can also be affected and cause the
patient to experience a numbness, tingling feeling
throughout one or both legs and even feet or even a
burning feeling in the hips and legs.
DISC LOAD IN DIFFERENT BODY POSTURE
When the spine is straight, such as in standing or lying down,
internal pressure is equalized on all parts of the discs.
While sitting or bending to lift, internal pressure on a disc can
move from 17 (lying down) to over 300 psi (lifting with a
Diagnosis is based on the
history, symptoms, and physical examination.
At some point in the evaluation, tests may be
performed to confirm or rule out other causes of
as spondylolisthesis, degeneration, tumors, metastase
s and space-occupying lesions, as well as to evaluate
the efficacy of potential treatment options.
Main article: Straight leg raise
The Straight leg raise may be positive, as this finding
has low specificity; however, it has high sensitivity.
Thus the finding of a negative SLR sign is important in
helping to "rule out" the possibility of a lower lumbar
A variation is to lift the leg while the patient is sitting.
However, this reduces the sensitivity of the test
Examination With the
patient standing upright
look at his general posture
and note particularly the
any asymmetry or frank
deformity of the spine .
hold the pelvis
stable and ask the
patient to twist first to
one side and then to
the other (rotation).
Note that rotation
entirely in the thoracic
spine (e) and not in the
With the patient upright, select two bony points 10 cm apart
and mark the skin as
the patient bends forward, the two points should separate by
at least a further 5 cm
Examination with the patient prone (a) Feel for tenderness, watching the patient’s face
for any reaction.
(b) Performing the femoral stretch test. You can test for lumbar root sensitivity either by
hyperextending the hip or by
acutely flexing the knee with the patient lying prone.
Note the point at which the patient feels pain and compare the two sides.
(c) While the patient is lying prone, take the opportunity to feel the pulses. The
popliteal pulse is easily felt if the
tissues at the back of the knee are relaxed by slightly flexing the knee.
X-Ray : lumbo-sacral spine;
Narrowed disc spaces.
Loss of lumber lordosis.
CT scan lumber spine;
It can show the shape and size of the spinal canal, its contents, and the
structures around it, including soft tissues.
Bulging out disc.
MRI lumber spine;
Intervertebral disc protrusion.
Compression of nerve root.
pressure on the spinal cord or nerves, such as herniated discs, tumors,
or bone spurs.
between L5 and S1
intervertebral disc - a
Oral steroids .
Nerve root block .
Non-steroidal anti-inflammatory drugs (NSAIDs).
Patient education on proper body mechanics.
Physical therapy, to address mechanical factors, and may
include modalities to temporarily relieve pain
(i.e. traction, electrical stimulation massage).
Oral steroids (e.g. prednisone or methylprednisolone).
Epidural cortisone injection.
Intravenous sedation, analgesia-assisted traction therapy
Lumbosacral back support.
Spinal manipulation: According to the WHO, in their
guidelines on chiropractic practice, a frank disc
herniation accompanied by progressive neurological
deficits is a contraindication for manipulation.
Non-surgical spinal decompression: A 2007 review of
published research on this treatment method found
shortcomings in most published studies and
concluded that there was only "very limited evidence
in the scientific literature to support the effectiveness
of non-surgical spinal decompression therapy.“
Its use and marketing have been very controversial
The indications for surgery
• persistent pain and signs of sciatic tension
(especially crossed sciatic tension) after 2–3
1 weeks of conservative treatment.
• a cauda equina compression syndrome –
this is an emergency;
• neurological deterioration while under
3 conservative treatment;
Surgery is generally considered only as a last resort, or
if a patient has a significant neurological deficit.
The presence of cauda equina syndrome is considered
a medical emergency requiring immediate attention
and possibly surgical decompression.
Regarding the role of surgery for failed medical
therapy in patients without a significant neurological
deficit, a meta-analysis of randomized controlled
trials by the Cochrane Collaboration concluded that
"limited evidence is now available to support some
aspects of surgical practice".
More recent randomized controlled trials refine
indications for surgery as follows:
The Spine Patient Outcomes Research Trial (SPORT)
Patients studied "intervertebral disk herniation and
persistent symptoms despite some nonoperative
treatment for at least 6 weeks...radicular pain (below
the knee for lower lumbar herniations, into the
anterior thigh for upper lumbar herniations) and
evidence of nerve-root irritation with a positive
nerve-root tension sign (straight leg raise–positive
between 30° and 70° or positive femoral tension sign)
or a corresponding neurologic deficit (asymmetrical
depressed reflex, decreased sensation in a
dermatomal distribution, or weakness in a myotomal
"Patients in both the surgery and the nonoperative
treatment groups improved substantially over a 2-
Because of the large numbers of patients who crossed
over in both directions, conclusions about the
superiority or equivalence of the treatments are not
warranted based on the intent-to-treat analysis"
• The Hague Spine Intervention Prognostic Study
• Patients studied "had a radiologically confirmed
disk herniation...incapacitating lumbosacral
radicular syndrome that had lasted for 6 to 12
weeks...Patients presenting with cauda equina
syndrome, muscle paralysis, or insufficient strength
to move against gravity were excluded."
• Conclusions. "The 1-year outcomes were similar for
patients assigned to early surgery and those
assigned to conservative treatment with eventual
surgery if needed, but the rates of pain relief and of
perceived recovery were faster for those assigned
to early surgery.
The objectives of surgical treatment
1. relief of nerve compression.
2. allowing the nerve to recover.
3. relief of associated back pain.
4. restoration of normal function.
• Chemonucleolysis is the term
used to denote chemical
destruction of nucleus pulposus
• This involves intradiscal injection
ofchymopapain which causes
hydrolysis of he cementing
protein of the nucleus pulposus.
• This causes decrease in water
binding capacity leading to
reduction in size and drying the
• Chemonucleolysis is one of the
methods to treat disc herniation
not responding to conservative
Intradiscal electrothermic therapy (IDET)
• provides a new alternative to other
surgical procedures for patients who
suffer from back pain caused by certain
types of disc problems.
• It is a fairly advanced procedure made
possible by the development of
electrothermal catheters that allow for
careful and accurate temperature control.
The procedure works by cauterizing the
nerve endings within the disc wall to help
block the pain signals
• IDET is a minimally invasive outpatient
surgical procedure developed over the last
few years to treat patients with chronic
low back pain that is caused by tears or
small herniations of their lumbar discs.
• This procedure is used
to remove part of an
intervertebral disc that
is compressing the
spinal cord or a nerve
The Tessys method
• The Tessys method
system) is a minimally
procedure to remove
herniated discs .
to relieve spinal
stenosis or nerve
surgery to help alleviate
the symptoms of an
impinged or irritated
nerve root in the spine
• Anterior lumbar fusion is an
operation done on the
front (the anterior region) of the
lower spine. Fusion surgery helps two
or more bones grow together into
one solid bone. Fusion cages are new
devices, essentially hollow screws
filled with bone graft, that help the
bones of the spine heal together
firmly. Surgeons use this procedure
when patients have symptoms from
disc degeneration, disc herniation, or
• lumbar fusion is only indicated for
recurrent lumbar disc herniations,
not primary herniations
• Artificial Disc Replacement
(ADR), or Total Disc Replacement
(TDR), is a type of arthroplasty.
• It is a surgical procedure in which
discs in the spinal column are
replaced with artificial devices in
the lumbar (lower) or cervical
• The procedure is used to treat
chronic, severe low back pain and
cervical pain resulting
from degenerative disc disease.
• Used for cases of cervical disc
• Dynamic stabilization is a surgical
technique designed to allow for
some movement of the spine,
while maintaining enough
stability to prevent too much
• If you need to undergo surgery
for spinal disc problems, you may
also need added stabilization of
the spine to prevent additional
• Nucleoplasty is the most
advanced form of
developed to date.
Nucleoplasty uses a unique
technology to remove tissue
from the center of the disc.
Tissue removal from the
nucleus acts to “decompress”
the disc and relieve the
pressure exerted by the disc
on the nearby nerve root . As
pressure is relieved the pain is
• Disc herniation can occur in any disc in the spine, but the two
most common forms are lumbar disc herniation and cervical
• The former is the most common, causing lower back pain
(lumbago) and often leg pain as well, in which case it is
commonly referred to assciatica.
• Lumbar disc herniation occurs 15 times more often than
cervical (neck) disc herniation, and it is one of the most
common causes of lower back pain.
• The cervical discs are affected 8% of the time and the upper-
to-mid-back (thoracic) discs only 1 - 2% of the time.
• The following locations have no discs and are therefore exempt
from the risk of disc herniation: the upper two cervical
intervertebral spaces, the sacrum, and the coccyx.
• Most disc herniations occur when a person is in their thirties or forties
when the nucleus pulposus is still a gelatin-like substance.
• With age the nucleus pulposus changes ("dries out") and the risk of
herniation is greatly reduced.
• After age 50 or 60, osteoarthritic degeneration (spondylosis) or spinal
stenosis are more likely causes of low back pain or leg pain.
• 4.8% males and 2.5% females older than 35 experience sciatica during their
• Of all individuals, 60% to 80% experience back pain during their lifetime.
• In 14%, pain lasts more than 2 weeks.
• Generally, males have a slightly higher incidence than females.
Spine: 15 January 2012 - Volume 37 - Issue 2 - p 140–149
Who Should Have Surgery for an Intervertebral Disc Herniation?:
• Comparative Effectiveness Evidence From the Spine Patient Outcomes Research Trial
Pearson, Adam MD, MS; Lurie, Jon MD, MS; Tosteson, Tor ScD; Zhao, Wenyan MS; Abdu,
William MD, MS; Mirza, Sohail MD, MPH; Weinstein, James DO, MS
• Study Design. Combined prospective randomized controlled trial and observational cohort
study of intervertebral disc herniation (IDH), an as-treated analysis.
• To determine modifiers of the treatment effect (TE) of surgery (the difference between
surgical and nonoperative outcomes) for intervertebral disc herniation (IDH) using subgroup
Summary of Background Data.
• The Spine Patient Outcomes Research Trial demonstrated a positive surgical TE for IDH at the
• However, individual characteristics may affect TE.
• No prior studies have evaluated TE modifiers in IDH.
• IDH patients underwent either discectomy (n = 788) or nonoperative care (n = 404) and were
analyzed according to treatment received.
• Thirty-seven baseline variables were used to define subgroups for calculating the time-
weighted average TE for the Oswestry Disability Index (ODI) across 4 years (TE =
• Variables with significant subgroup-by-treatment interactions (P < 0.1) were simultaneously
entered into a multivariate model to select independent TE predictors.
Future treatments may include stem cell therapy.
• Doctors Victor Y. L. Leung, Danny Chan and Kenneth
M. C. Cheung have reported in the European Spine
Journal that "substantial progress has been made in
the field of stem cell regeneration of the
• Autogenic mesenchymal stem cells in animal
models can arrest intervertebral disc degeneration
or even partially regenerate it and the effect is
suggested to be dependent on the severity of the
The impact of the Spine Patient Outcomes Research Trial (SPORT) results on
J Am Acad Orthop Surg. 2012 Mar;20(3):160-6
• Department of Orthopaedic Surgery, University of Cincinnati College of
Medicine, Cincinnati, OH, USA.
• The benefits of spinal surgery for relief of low back and leg pain in patients with
degenerative spinal disorders have long been debated. The Spine Patient Outcomes
Research Trial (SPORT) was designed to address the need for high-
quality, prospectively collected data in support of such interventions. SPORT was
intended to provide an evidential basis for spinal surgery in appropriate patients, as
well as comparative and cost-effectiveness data. The trial studied the outcomes of
the surgical and nonsurgical management of three conditions: intervertebral disk
herniation, degenerative spondylolisthesis, and lumbar spinal stenosis.
• Both surgical and nonsurgical care of intervertebral disk herniation resulted in
significant improvement in symptoms of low back and leg pain.
• Still, the treatment effect of surgery for intervertebral disk herniation was less than
that seen in patients who underwent surgical versus nonsurgical treatment of
degenerative spondylolisthesis and lumbar spinal stenosis.
• Across SPORT, more significant degrees of improvement with surgery were noted
in chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with
spondylolisthesis. In addition, no catastrophic progressions to neurologic deficit
occurred as a result of watchful waiting.
epidural steroid injection: Is the success rate predictable?].
Department of Orthopedics and Traumatology, Başkent University, Adana Medical Center, Ankara, Turkey.
• The aim of this study was to determine the relation between the percent of canal compromise and success rate
of epidural steroid injection (ESI) in patients with symptomatic lumbar herniated intervertebral discs.
• Patients with lumbar herniated intervertebral disc suffering from leg pain and treated with ESI were selected.
The axial magnetic resonance (MR) image showing the largest canal compromise by the herniated disc was
selected for measurements. The canal area and discherniation area measurements were calculated from the
total number of pixels per cross-sectional area, multiplied by a scan correction factor, mm2/pixel. The percent
canal compromise was obtained by the disc herniation area divided by the canal cross-section area, multiplied
by 100. For pain assessment, visual analog scale (VAS) was used before (pre-injection VAS) and a month after
ESI (post-injection VAS). Demographic data, duration of symptoms, and location and type of herniation were
• 39 patients (14 male, 25 female) were included in this study. The mean age was 50.2±11.6 years (27-76).
Twenty-one cases (51%) also had back pain. The mean percent canal compromise ratio was 36.1±2.4%. The
mean duration of symptoms was 19.4±6.6 months. The post-injection VAS was significantly decreased when
compared with pre-injection VAS (p<0.0001), and this significance was related with the duration of symptoms
being <3 months (p=0.021). There was also a significant negative correlation between percent canal
compromise and post-injection VAS (p=0.042). However, there was no correlation between post-injection VAS
and age, sex, or location or type of herniation (p>0.05).
• It has been demonstrated that higher benefits of ESI were achieved in patients with short duration of
symptoms and high percent of canal compromise.