Herniated Nucleus Pulposus

Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Mary Ann E Keenan, MD more...
Updated: Jan 8, 2010

Normal Structure And Function

Degeneration: Process And Models
Natural History
Herniation

Clinical Evaluation
Conservative Treatment
Surgical Intervention
Controversies And Outcomes
Show All
[ ] References
View Multimedia Library

Clinical Evaluation
Obtaining pertinent patient historical information should begin with an analysis of the chief complaint.
Does the patient's complaint concern dominant leg pain, dominant back pain, or a mixture of significant
problems with both? Next, is the onset acute, subacute, or chronic? Under what circumstances does
onset occur? What is the patient's prior history, particularly regarding similar symptoms or treatment
response?
Identify risk factors, obtain a pertinent medical history, and specifically exclude red flags, such as
nonmechanical pain, which causes pain at night without activities because pressure in the pelvic veins
may be increased upon reclining. Nonmechanical pain may be indicative of a tumor or infection. A
progressive neurologic deficit or cauda equina syndrome is considered a surgical emergency because
irreversible consequences may result if these are left untreated.
Obtaining a thorough history of activity intolerance requires some time and attention to the details of
specific examples and the positions or actions that cause problems. Also, it is helpful to determine which
activities the patient is unable or less able to perform and which activities exacerbate or moderate the
pain. An assessment of the physical demands of the patient's occupation and daily activities provides the
perspective for the described activity intolerance. A pain drawing can be very helpful in assessing the
pattern of pain, such as a dermatomal distribution, or in assessing the organicity of the complaints.
Physical examination classically involves range-of-motion (ROM) testing of the lumbar and cervical spine,
but these findings may be more reflective of aging or deterioration in the intervertebral disks and joints
than any quantifiable assessment of impairment. The remainder of the examination is essentially a
neurologic assessment of weakness, dermatomal numbness, reflex change, and, most important, sciatic
or femoral nerve root tension in the lumbar spine.
Numerous examination maneuvers (eg, Lasegue classic test, Lasegue rebound sign, Lasegue differential
sign, Braggard sign, flip sign, Deyerle sign, Mendel-Bechterew sign, well leg test or Fajersztajn sign, bothlegs or Milgram test) are available but cloud the issue, because the sciatic nerve root tension or straightleg raising test is the basis for nearly all of them. They are essentially modifications for subtle differences,
but the provocation of radiating pain down the leg is of a neural compressive lesion and compression of
the sciatic nerve root, if it goes below the knee. Furthermore, the provocation of radiating pain down the
leg is the most sensitive test for a lumbar disk herniation.
For a higher lumbar lesion, reverse straight-leg raising or hip extension that stretches the femoral nerve is
analogous to a straight-leg raising test. The Spurling test in the cervical spine is used to detect foraminal

stenosis (Kemp's test is used in the lumbar region) rather than specifically for intervertebral disk
herniation or nerve root tension. Careful hip, rectal, and genitourinary examinations help exclude
complications of those organ systems in the diagnosis of higher lumbar lesions.
After obtaining plain radiographs, further imaging studies (eg, MRI, computed tomography [CT] scanning,
CT myelography) may be indicated to assess degenerative disk disease, loss of disk height, and facet
deterioration, such as sclerosis or hypertrophy. MRI clearly provides the most information, perhaps too
much, as it has a 25% false-positive rate (asymptomatic herniated nucleus pulposus [HNP]). An HNP that
is noted on imaging studies must be correlated with objective examination findings; otherwise, it must be
presumed to be an asymptomatic HNP if there is no correlation between the imaging findings and pain or
clinical symptoms. Therefore, imaging studies should perhaps be reserved for cases in which positive
physical findings have been documented.
Other causes of significant back pain in the absence of neurologic findings should be considered. Sciatic
nerve irritation may result from sacroiliac dysfunction or degenerative joint disease caused by the
proximity of the sciatic notch to the sacroiliac joint or peripheral entrapment, includingpiriformis syndrome.
Careful examination with an adequate differential for the diagnosis may prevent prolonged ineffective
empirical care for presumed lumbar disk disease.
The facet syndrome has been controversial, but neurophysiologic studies have shown discharges from
the capsule consistent with pain, as well as inflammation and degenerative joint disease. [19] However,
large numbers of patients have reported significant relief after facet joint injections for nonspecific LBP; as
a result, the facet syndrome has become more widely accepted. Clinically, patients usually have pain only
to the knee, not below, as would be expected from an HNP.

Conservative Treatment
Spontaneous improvement of low back discomfort has allowed ineffective treatments to perpetuate,
because benefits have been ascribed to them when they are prescribed while the patient is still
symptomatic but otherwise improving. Hippocrates expected improvement in sciatica in 40 days, and the
customary and contemporary guideline is 6 weeks. An often-quoted study suggests near-resolution
improvement of 90% of patients within 6 weeks, but this study has been faulted because the criterion for
patient recovery was failure to return to the observing physician. [20] The prevalence of back problems is
consistent with the failure of a subgroup of patients to improve and to have periodic recurrent episodes of
disability.
Analysis of the effectiveness of treatments and attempts to restrict treatment to those modalities that have
demonstrated efficacy are evidence-based medical practice. Bedrest has a long history of use but has not
been shown to be effective beyond the initial 1 or 2 days; after this period, bedrest is counterproductive.
All conservative treatments are essentially efforts to reduce inflammation; therefore, only a very short
period of rest is appropriate, anti-inflammatories are of some benefit (because the pain is from
inflammation of the nerve), and warm, moist heat or modalities may be helpful. Activities should be
resumed as early as tolerated. Exercises and physical therapy mobilize muscles and joints to facilitate the
removal of edema and promote recovery. Muscle relaxants may offer symptomatic relief of the acute
muscle spasms but only in the early stages; however, all are central acting, there is no direct relaxation of
skeletal muscle, and they are also sedating.
For back pain without radiculopathy, chiropractic care has high patient satisfaction when performed within
the first 6 weeks, and it has been shown to have good efficacy acutely from an evidence-based
standpoint.[21]Injections (eg, epidural) may be particularly helpful in patients with radiculopathy by
providing symptom relief, which allows the patient to increase activities and helps facilitate
rehabilitation.[22, 23] Any nuclear material that is herniated may shrink as the proteoglycan deteriorates,
loses its water-retaining ability, and turns from a grapelike object to a raisinlike object.
Untuk nyeri pinggang tanpa radikulopati, perawatan chiropraktik dapat memperoleh kepuasaan pasien
saat dilakukan dalam 6 minggu pertama, dan menunjukkan adanya suatu kemanjuran dengan bukti
medis yang ada. Injeksi (cth, epidural) mungkin dapat sebagian membantu pasien yang mengalami

radiculopati dengan adanya meredahnya gejala, yang membuat pasien dapat meningkatkan aktivitas
mereka dan memfasilitasi rehabilitasi.
Arbitrary time schedules for improvement are inappropriate in any patient who continues to improve and
whose function is relatively maintained. Traction in the acute setting may help muscle spasms, but it does
not reduce the HNP and has no good evidence of efficacy. The use of traction does not justify hospital
admission, as it is not cost-effective and can be administered on an outpatient basis.
Long-term use of physical therapy modalities is no more effective than hot showers or hot packs are at
home. A transcutaneous electrical nerve stimulation (TENS) unit may be subjectively helpful in some
patients with chronic conditions. Encourage patients to essentially compensate for intervertebral disk
incompetence, as possible, by muscular stabilization, and to maintain flexibility by initiating life-long
exercise regimens, including aerobic conditioning, particularly swimming, which allows gravity relief.
Transcutaneous electrical nerve stimulation atau TENS mungkin dapat secara subjektif membantu
beberapa pasien yang berada dalam keadaan yang kronis. Mendorong pasien untuk berkompensasi atas
ketidakmampuan diskus intervertebralisnya, secara mungkin, dengan stabilisasi gerakan otot,
mempertahankan fleksibilitas dengan olahraga seperti aerobic kodisional, renang, yang dapat
mengurangi tingkat gravitasi.
Assess the body mechanics of every patient who is disabled from work. Educate all patients about body
mechanics, and discuss the risk factors for faulty body mechanics, so that applications can be
incorporated into individual work settings, including appropriate seating (eg, lumbar support). The lumbar
facet joints are oriented relatively vertically, thus allowing forward flexion, but the joints impact each other
when a person bends and then rotates. Repetitive bending and twisting have been noted to be
epidemiologic problems in workers, and may be associated with chronic pain and disability. [24] Attention to
lifting techniques and ergonomic modification at workstations may be very appropriate.

Herniated Nucleus Pulposus

Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Mary Ann E Keenan, MD more...
Updated: Jan 8, 2010

Normal Structure And Function

Degeneration: Process And Models
Natural History
Herniation
Clinical Evaluation
Conservative Treatment

Surgical Intervention
Controversies And Outcomes
Show All
[ ] References
View Multimedia Library

Surgical Intervention
The classic presentation of an herniated nucleus pulposus includes the complaint of sciatica, with
associated objective neurologic findings of weakness, reflex change, and dermatomal numbness. Various
surgical procedures have been reported and share the common goal of decompressing the neural
elements to relieve the leg pain. These procedures are most appropriate for patients with minimal or
tolerable back pain, with an essentially intact and clinically stable disk. However, the hope of permanently
relieving the back pain is a fantasy, a false hope.

The most common procedure for a herniated or ruptured intervertebral disk is a microdiscectomy, in
which a small incision is made, aided by an operating microscope, and a hemilaminotomy is performed to
remove the disk fragment that is impinging on the nerves.
Prosedur yang paling umum digunakan dalam hernia nukelus pulposus adalah mikrodiskektomi, dimana
sebuah irisan kecil dibuat, dibantu dengan mikroskop operasi, dan sebuah hemilaminotomi digunakan
untuk memindahkan fragmen diskus yang menimpa syaraf-syaraf.
Many patients who undergo microdiscectomy can be discharged with minimal soreness and complete
relief of leg pain after an overnight admission and observation. Same-day procedures are in the process
of cautious development; patients with dominant back pain have a different problem, even if HNP is
present, and would require stabilization by fusion if unresponsive to well-managed appropriate therapy or
arthroplasty (if there is an isolated level with good facet joints).
Banyak pasien yang menjalani mikrodiskektomi dapat menguragi rasa sakit dan meredahkan nyeri kaki
secara keseluruhan setelah satu malam penerimaan dan observasi. Pasien yang merasakan dominasi
nyeri pada punggung memiliki masalah yang berbeda, meskipun HNP terjadi dan akan membutuhkan
stabilisasi dengan perpaduan terapi yang sesuai serta atroplasti.
Minimally invasive techniques have not replaced this standard microdiscectomy procedure but can be
summarized in 2 categories: central decompression of the disk and directed fragmentectomy.
Teknik invasive memang belum dapat menggantikan standar prosedur mikrodiskektomi nanum dapat di
ringkas menjadi 2 kategori yaitu dekompresi diskus tengah dan fragmentektomi terarah.
Central decompression of the disk can be performed chemically or enzymatically with chymopapain, by
laser or plasma (ionized gas) ablation and vaporization, or mechanically by aspiration and suction with a
shaver such as the nucleotome or percutaneous lateral decompression (arthroscopic microdiscectomy).
Dekompresi diskus tengah dapat dilakukan secara kimiawi atau enzymatic bersama chymopapain,
dengan laser atau ablasi plasma (gas ion) dan penguapan, atau secar mekanik dengan hembusan atau
penyedotan menggunakan pisau seperti nukleotom atau dekompresi lateral (mikrodiskektomi
artroskopik).
The Food and Drug Administration (FDA) initially released and then withheld chymopapain for injection
into lumbar disks because of adverse allergic reactions in patients; skin tests subsequently were used to
determine sensitivity. However, the procedure continued to induce severe muscle spasms that could be
far worse than those of an open operation and thus required hospitalization and bedrest for up to 50% of
patients.[25] This morbidity must be considered a contradiction to the assertion by proponents that the
enzyme is limited to the disk in the chemical digestion of the nucleus pulposus, because the muscles are
severely affected, which would not be expected if the enzyme were contained. In addition, severe
scarring in the spinal canal is noted routinely after this procedure.
The nucleotome and laser central decompressions have been shown only to equal placebo in
effectiveness, and their use has declined. Further development of alternatives, such as nucleoplasty, and
efforts to reduce disk pressure remain under study.
Directed fragmentectomy is similar to an open microdiscectomy and has demonstrated greater
effectiveness than placebo. This procedure uses an arthroscopic approach and a probe that directs a
flexible pituitary rongeur from the center of the intervertebral disk toward the posterior annulus.
Endoscopic techniques to perform a directed fragmentectomy and to minimize disruption of normal
structures continue in development, but superiority has not been demonstrated despite this minimally
invasive approach.
Fragmentektomi terarah mirip dengan sebuah mikrodiskektomi terbuka dan telah medemonstrasikan efek
yang lebih baik daripada placebo. Prosedur ini menggunakan pendekatan artroskopik dan penyelidikan
yang mengarahkan rongeur pituitary yang fleksibel dari diskus intervertebralis tengah menuju annulus
posterior. Teknik-teknik endoskopik untuk melakukan fargmentektomi terarah dan untuk meminimalkan

gangguan struktur yang normal untuk berkembang, namun keunggulan belum di perlihatkan meskipun
hal ini meminimalkan pendekatan invasif.
Concerning the cervical spine, HNP customarily is treated anteriorly, because the pathology is anterior
and manipulation of the cervical cord is not tolerated by the patient. The posterior approach is reserved
for disk herniation that is confined to the foramen and for foraminal stenosis. An alternative to the anterior
cervical spine approach is minimal disk excision; clinical stability following this procedure is dependent
upon the residual disk, which is also true in cases where there is lumbar spine involvement with back
pain. Removal of neural compression dramatically relieves radiculopathy; however, residual axial neck
pain may result in significant impairment.
Anterior cervical interbody fusion is another intervention. Proponents of discectomy alone assert
equivalent results, but the adequacy of follow-up in those case reports is a significant concern. Patients
with more severe disk degeneration, particularly myelopathy, would more uniformly undergo fusion.
Anterior instrumentation is being used more commonly, and interbody cages are under consideration as a
means of attaining more rapid rehabilitation and more consistent results.

Herniated Nucleus Pulposus

Author: Mark R Foster, MD, PhD, FACS; Chief Editor: Mary Ann E Keenan, MD more...
Updated: Jan 8, 2010

Normal Structure And Function

Degeneration: Process And Models
Natural History
Herniation
Clinical Evaluation
Conservative Treatment
Surgical Intervention

Controversies And Outcomes

Show All
[ ] References
View Multimedia Library

Controversies And Outcomes

The diagnosis of an internal disk derangement is controversial. The classic patient presents with back
pain without imaging abnormalities except for varying degrees of the black disk, which is the converse of
the asymptomatic patient with an intervertebral disk herniation. Patients without a disk herniation have a
favorable course and long-term outcome with conservative treatment or surgery. However, some patients
with prolonged limitations and limited job skills benefit from surgical intervention for segmental instability
or clinical instability as we earlier discussed. A positive discogram properly done and carefully interpreted
in context may raise the expectation of success for surgical treatment in this patient population. The
greatest controversy is over the effectiveness of fusion surgery. Unfortunately, there is no clear objective
criterion; clinical judgment is mandatory and is not perfect; clearly, good patients do well, and patient
selection is paramount.
Patients with "broad-based" intervertebral disk herniations generally have a deterioration of the disk or a
failure of clinical stability with associated back pain, rather than isolated sciatica. These patients are not
appropriate candidates for microdiscectomy alone. Lumbar fusion is being used increasingly in these
cases, and arthroplasty is also being considered; however, this treatment remains controversial because
it is, again, based inevitably on subjective patient pain and clinical judgment without objective
determination.

Pasien dengan hernia diskus intervertebralis umumnya memiliki pemburukan diskus atau kesalahan
stabilitas klinik dengan nyeri punggung dibandingkan skiatika. Pasien-pasien ini tidak sesuai hanya
dengan mikrodiskektomi saja. Penggabungan lumbar juga banyak digunakan pada kasus-kasus ini dan
antroplasti juga dapat dipertimbangkan. Meskipun demikian, pengobatan ini masih controversial karena
bergantung pada nyeri pasien secaa subjektif dan keputusan klinis tanpa pertimbangan objektif.
With a discectomy, patients with dominant leg pain have excellent results, with 85-90% returning to full
function. However, up to 15% of patients have continued back pain that may limit their return to full
function, despite the absence of radiculopathy. Patients who undergo surgery do not necessarily show
better results than patients who defer surgery.[26]
Dengan diskektomi, pasien dengan nyeri kaki dominan memiliki hasil yang baik, dengan 85-90% kembali
pada fungsional normal. Namun, sampai dengan 15 % pasien tetap merasakan nyeri punggung yang
membatasi fungsional yang normal.
Intervertebral disk degeneration that causes clumping of the nuclear material and relative mechanical
instability is the necessary preceding condition for HNP. However, it is impossible to tell which patients
will do well after microdiscectomy for a herniation and which will have continued problems, of varying
severity, from the disk degeneration. Significant deterioration and accompanying LBP increasingly are
being treated with stabilization, via either an anterior lumbar interbody fusion (ALIF) or a posterior lumbar
interbody fusion (PLIF) in association with posterior decompression (when necessary) and
instrumentation. Results are not yet available, as techniques are still evolving, but experience is
accumulating.