Lumbar disc
herniation
Spine anatomy
Intervertebral discs
Two adjacent vertebral bodies
are linked by an intervertebral
disc
Three components:
• An inner nucleus pulposus
• Outer annulus fibrosus
• Cartilaginous endplates
superiorly and inferior
Three functions
• Sock absorber
• Pillar
• Shape the spine
Definition
Herniated lumbar disc is a
displacement of disc material
(nucleus pulposus or annulus
fibrosis) beyond the
intervertebral disc space.
Rate of disc herniation
The rate of disc herniation in the
lumbar spine and cervical spine is
higher because this is the area
that bears the biological lifting
force of the body.
Causes
The degenerative
process Trauma
As humans age, the nucleus Other causes
pulposus becomes less hydrated
and weakens and may lead to Include connective tissue
progressive disc herniation disorders and congenital disorders
Stages Of Herniation
Disc Degeneration: chemical
changes associated with aging
causes discs to weaken, but without
a herniation.
Prolapse: the form or position of
the disc changes with some slight
impingement into the spinal canal.
Extrusion: the gel-like nucleus
pulposus breaks through the tire-like
wall (annulus fibrosus) but remains
within the disc
Sequestration: the nucleus
pulposus breaks through the annulus
fibrosus and lies outside the disc in
the spinal canal.
Zones of lumbar disc herniation
Epidemiology
The prevalence of a symptomatic herniated lumbar disc is about 1%
to 3% with the highest prevalence among people aged 30 to 50
years, with a male to female ratio of 2:1.
In 95% of the lumbar disc herniation the L4-L5 and L5-S1 discs are
affected.
Lumbar disc herniation occurs 15 times more than cervical disc
herniation, and is an important cause of lower back pain.
The cervical disc herniation is most affected 8% of the time and most
often at level C5-C6 and C6-C7
Lumbar Spine
Symptoms
Back pain
• Dull pain
• Decreased when lying down
• Increased pain when suddenly bending quickly and forcefully, cough,
sneeze.
• Pain spreads around the thigh or scrotum on the damaged side
• The pain suddenly decreases with muscle weakness and numbness
due to nerve compression
Examination
- Look
- Touch
- Percussion
Examination: Look
Antalgic or Trendelenburg gait.
Deformed spin, scoliosis
Reduce the range of activities
of the lumbar spine
Neri test
Neri test
Examination: Touch
Scoliosis of the spine Motor function
Bell sign Weak foot flexion
Valleix sign Weak foot extension
Bonnet test Sensory function
Lasègue test Paraesthesia
Siccar test Cauda equina syndrome
Reduced and lost
sensation a round the anus
and genitals
Urinary disorders
Examination: Touch
Dermatomes map
Examination: Percussion
Tendon reflexes are reduced
Achilles tendon (S1)
Knee tendon (L4)
Diagnostic
Saporta's diagnostic criteria in 1980:
Diagnosis of lumbar disc herniation when the patient has 4/6 of the
following symptoms:
• There are factors of lumbar spine injury
• Low back pain along the path of the sciatic nerve root
• Scoliosis of the lumbar spine
• There are signs of loss of the physiological curve of the spine.
• Bell sign (+)
• Lasègue test (+)
Diagnostic Imaging
X-ray
X-rays of the spine taken in two
upright and inclined positions.
Barr's triad: loss of curvature,
reduced intervertebral height,
scoliosis.
Diagnostic Imaging
Nerve root capsule
Diagnostic Imaging
Computed tomography (CT)
• Image is not clear
• Computed tomography is
limited in evaluating disc
structure and degree of
herniation
Diagnostic Imaging
Magnetic resonance imaging
(MRI)
• The "gold standard" test in the
diagnosis of herniated disc.
• Accurately determine the
position of the herniated disc
relative to the canal and the
degree of spinal cord and nerve
root compression.
• Allowing to exclude lesions
inside the spinal cord.
Treatment: Conservative treatment
Immobilize the spine Physical therapy
Medicine
• Analgesic
• NSAID
• Muscle relaxants
Epidural pain relief
Selective nerve root
blockade
Treatment: Surgical
Medical treatment failed after 3 Open surgery (microsurgical
months support)
- Acute nerve compression Endoscopic
(paralysis, Cauda Equina
Syndrome – CES)
Endoscopic
Kambin triangle
Postoperative management
For all techniques, patients are Complications after surgery:
mobilized early. Light sports Ruptured dura
activities allowed after 2 weeks
and return to work after about Cerebrospinal fluid leak
4 weeks. Surgical site infection
Recurrent disc herniation
