herniated disc
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Etiology
(risk factors)
- aging
- genetic factors
- obesity
- lack of exercise
- ergonomic
- smoking
- history of back injury
- back surgery
Pathology
- generally involves lumbar spine
- herniation of the central gelatinous material (nucleus pulposus) of an intervertebral disc through its fibrous outer covering (anulus fibrosis)
- impingement on nerve root
Genetics
- susceptibility to lumbar disk herniation may be associated with
- defects in COL9A3
- polymorphisms in THBS2[7]
Clinical manifestations
- acute pain
- acute back pain
- deep back muscle pain, muscle spasms
- pain varies with changes in position
- radicular pain, sciatica
- most frequent cause of sciatica[8]
- straight leg raising has good sensitivity[3]
- pain during urination may be noted
- acute back pain
- abnormal posture
- limitation of spine movement
- numbness or weakness in one or both legs & feet
- diminished reflexes
- cauda equina syndrome
- loss of bowel & bladder control
- may be asymptomatic[8]
Radiology
- MRI of lumbar spine in patients with persistent sciatica (4-6 weeks), & epidural glucocorticoid injections or spinal surgery being considered[8]
Differential diagnosis
Management
- patients with severe or progressive neurologic deficits require a referral for surgery[8]
- acetaminophen or NSAIDs as needed
- epidural steroid injections (weekly x 3)
- do not reduce need for surgery[8]
- pulsed radiofrequency, delivered into the back with a thin needle (anesthesia not required)
- 1-2 days of bedrest maximum
- supervised exercise
- discectomy
- probably management of choice
- indications for elective surgery:
- surgery may still be effective after 6 months of symptoms[5]
- observation & discectomy with similar outcomes[2]
- disc herniations often shrink
- without surgery, pain decreases in ~87% of patients within 3 months[8]
- outcomes of non-surgical management similiar in older vs younger patients[4]
More general terms
References
- ↑ Buttermann GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am. 2004 Apr;86-A(4):670-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15069129
- ↑ 2.0 2.1 Weinstein JN et al, Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA 2006, 296:2441 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17119140
Weinstein JN et al, Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006, 296:2451 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17119141
Flum DR Interpreting surgical trials with subjective outcomes. JAMA 2006, 296:2483 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17119146 - ↑ 3.0 3.1 Medical Knowledge Self Assessment Program (MKSAP) 15, 18. American College of Physicians, Philadelphia 2009, 2018,
- ↑ 4.0 4.1 Suri P et al. Nonsurgical treatment of lumbar disk herniation: Are outcomes different in older adults? J Am Geriatr Soc 2011 Mar; 59:423. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21391933
- ↑ 5.0 5.1 Rihn JA et al. Duration of symptoms resulting from lumbar disc herniation: Effect on treatment outcomes. Analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am 2011 Oct 19; 93:1906. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22012528
- ↑ Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
- ↑ 7.0 7.1 OMIM https://mirror.omim.org/entry/603932
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Deyo RA, Mirza SK CLINICAL PRACTICE. Herniated Lumbar Intervertebral Disk. N Engl J Med 2016; 374:1763-1772. May 5, 2016 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27144851
- ↑ 9.0 9.1 Susman E Radiofrequency Pulses End Back Pain - Probes guided to herniated disk appears to enhance pain relief and healing. MedPage Today. Nov 30, 2018 https://www.medpagetoday.com/meetingcoverage/rsna/76612
Napoli A, et al T Guided Pulsed Radiofrequency in Patients with Acute Low Back Pain and Sciatica: 1 Year Follow-Up versus Image-Guided Injection Only as Control Group, Radiological Society of North America (RSNA) 2018. - ↑ American Association of Neurological Surgeons http://www.neurosurgerytoday.org/what/patient_e_herniated.asp