Hernia Nukleus Pulposus

dr. Rohmania Setiarini

Structure of the Intervertebral

Disc
1) Hyaline Cartilage: is the cartilage of the
superior and inferior surfaces of the
vertebral body. It also forms the top and
bottom border of nucleus pulposus. It bears
the weight and protects the nucleus
pulposus.
2) Annulus Fibrosus: is a fibrous ring, like a
radial tire. It is elastic, embracing and
holding the nucleus pulposus, not leting it
herniate.
3) Nucleus Pulposus: is a kind of gelatinous,
flexible, semifluid material, located in the
center of the annulus fibrosus. Both top
and bottom surface are sealed by hyaline

Intervertebral Disc

Centrum
Hyaline Cartilage
Annulus Fibrosus

Nucleus

flava ligament

posterior longitudinal ligament.

Pedicle

Superior articular facet

Herniated Nucleus Pulposus

Definition
Condition in which part or all of
the soft, gelatinous central
portion of an intervertebral disk is
forced through a weakened part
of the disk.

Three patterns nucleus pulposus herniation

1)Protrusion or bulging: The annulus fibrosus is not torn
but protruding or bulging, compressing the nerve root.

2)Extrusion: The annulus fibrosus is torn, and the nucleus

pulposus herniated to compress the spinal cord or nerve
roots.

3)Sequestration: The annulus pulposus is ruptured, the

fragment of nucleus pulposus has traveled below the
posterior longitudinal ligament and herniated into the spinal
canal, compressing the spinal cord or nerve root.

Normal disc

protrusion or bulging

extrusion

sequestration

Five patterns differentiated by the

location and direction of nucleus
pulposus herniation
Herniation of the nucleus pulposus
can happen in the anterior,
posterior, or lateral direction or in
all four directons. Also there is a
form of herniation called herniation
inside of the vertebral body.
Posterior herniation is divided into two
patterns: posteriolateral
herniation and posteriocentral
herniation.

Posterior herniation

Posterolateral Herniation

Posterocentral Herniation

Etiology
1)Degeneration of the disc.
2)Injury

Epidemiology
Age and sex: Mostly it affects people
in middle age(30-50),males more than
females.
Location: Mainly occurs at L4-5 and at
L5-S1, and secondarily at L3-L4 or L2L3.

Diagnosis
Symptoms:
1) Low back pain: The pain is mainly
located in the lower back area; the
back pain results from pressure on
the posterior longitudinal ligaments
and periphery of the annulus
fibrosus. The painful area is deep,
and it is usually dull pain or severe,
acute pain.

2) Radiating pain in the legs:

Lumbar disc herniation often occurs at the L4-5
or L5-S1 level, causing lower back and and hip
pain radiating down the thigh on the lateral and
posterior sides, down the lateral side of the
lower leg, and to the medial and or lateral side
of the foot, and toes. Coughing or sneezing
can aggravate the pain, causing shooting pain
down the lower limbs.

C
4
T1
3

C5

45

10

L2

C8

C7

T1

5 6

L1
C6

C4 3

C8

11
12

S2

C7
54 3

S2

L4

L3
L4

S2
L5
S1

L5

L4
S1
L4 L5

L5

C6

3) Numbness and tingling:

Protrusion of lumbar discs causes compression
of the spinal nerve roots, and local
inflammation and swelling.
Resulting nerve compression and lack of blood
circulation causes malnutrition to the nerves.
Clinical symptoms are tingling, numbness and
muscle atrophy.

4) Abnormal spinal curvature:

After the lumbar disc herniation, 64%
patients have abnormal spinal curvature.
The curve of the vertebral column is the
bodys way of protecting against low back
pain and leg pain. Lateral curvature can
relax the nerve root and relieve pain.
Clinically, disc protrusion is generally at
the lateral side above the nerve root (45%)
A few disc protrusions are at the medial
side below the nerve root (7%)

Examination
1) Mobility of Lumbar
Vertebral Column:
Normal range of motion
Flexion 90
Extension 30
Side bend 20-30
Twist 30

2) Points painful to pressure

If the lumbar disc is herniated, its
corresponding vertebra has an obvious
tender area. When that area is pressed,
pain occurs along the sciatic nerve
distribution, shooting down along the
lower limb.

3) Abnormal tendon reflexes

If the herniation is at L3-L4, the knee tendon
reflex can be weak or absent, and foot
extension is weak;
If herniation is at L4-L5, the knee tendon
reflex and Achilles tendon reflex is normal but
toe extension is weak;
If herniation is at L5-S1, the Achilles tendon
reflex becomes weak or absent, and foot flexion
becomes weak.

4) Lasegues test: (Supine) If there is pain in the

lumbar area and lateral leg on performing a straight
leg raise up to 70 and dorsiflexing the foot, the test is
positive.

5) Kernigs test: (Supine) While bending the hip joint

and knee joint to 90 degrees, then extending the
knee, if pain is induced, the test is positive.

6) Wassermans test: (Prone) The hip joint is overextended. If pain presents at the anterior border of the
thigh, the test is positive.

Diagnostic tests
X-ray identify deformities
and narrowing of disk
space
CT/MRI

L2

L3

L4

L5
S1

Treatment- Conservative
Bed rest with firm mattress; log
roll; side lying position with
knees bent and pillow between
legs to support legs
Avoid flexion of the spinebrace/corset, cervical collar to
provide support
Medications

Treatment- Conservative
Thermotherapy to decrease
muscle spasms
Progressive mobilization with
approved exercise program
includes abdominal/thigh
strengthening
Teaching good body mechanics
Weight loss

Treatment- Surgery
Laminectomy- removal of a
portion of the lamina to relieve
pressure and to get to the
herniated nucleus pulposus
that is protruding out