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Michigan MI 49684
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Herniated Lumbar Disk I. Background A
herniated lumbar disk is a condition in which there is protrusion
of the intervertebral disk. Herniations occur most commonly
through a posterolateral defect, but midline herniations may occur.
Resulting compression of the spinal nerve root causes inflammation
and pain, usually along the anatomic course of the nerve. In the
lumbar spine, this most often occurs at the L4 and L5 disk
levels, causing pressure on the corresponding L5 and S 1 nerve
roots. As a result of both mechanical and biochemical changes
around the nerve root, the patient will experience pain,
paresthesia, and possibly weakness in the leg or legs, usually
be-low the knee. The rare herniations at the L1, L2, and L3
levels are usually associated with pain, paresthesia, and
weakness above the knee. Back pain may or may not be a
presenting complaint with any herniated lumbar disk. Most
acute lumbar disk herniations occur in patients between 35 and
55 years of age, whereas spinal stenosis usually occurs in patients
over 50 years of age. Spinal stenosis may mimic a herniated
disk, but often patients with spinal stenosis will give a
history suggestive of neurogenic claudication and will present
radicular signs and symptoms caused by degenerative changes
involving the intervertebral disks and the facet joints. II. Diagnostic Criteria A. Pertinent Historical
and Physical Findings Back
pain is usually the first symptom and may or may not abate as
the pain and paresthesias begin to radiate down the leg. The leg
pain is often described as a sharp, shooting pain that radiates
along the anatomic course of the nerve from proximal
to distal. The onset may be sudden or insidious. The patient
often has difficulty getting up from sitting or supine positions
and commonly leans or lists to one side or the other. Motion of
the spine is limited due to pain and muscle spasm. The
neurologic examination may be normal if the compressed nerve is
still functional, or it may yield objective evidence of impaired
nerve conduction (e.g. atrophy, weakness, sensory alteration
or diminished reflex) depending upon the anatomic nerve root
affected. Signs of nerve root tension (e.g. positive straight-leg
raising, bow-string test, Lasegue' s test) may also be
present. When the L4 disk herniates, it usually causes pressure
on the L5 nerve root resulting in weakness of the great toe ex-tensor or other dorsiflexor muscles of the foot and
sensory loss along the medial aspect of the foot to the great toe, but it is usually
not associated with a reflex abnormality. When the L5 disk
herniates,
it usually causes pressure on the S l nerve root, resulting
in weakness of the plantar flexors of the foot and a sensory deficit
in the posterior calf area and lateral aspect of the foot in
addition to a diminished Achilles' reflex. B. Appropriate
diagnostic tests and examinations 1.
Clinical diagnosis is supported by these studies: a.
Myelography b.
Computed tomography c.
Magnetic resonance imaging d.
Diskography 2.
Plain radiographs and bone scan of spine to rule out other
conditions such as tumor, infection, fracture, and congenital
anomalies C. Evolving diagnostic
tests and examinations: 1.
Myeloscopy 2.
Dermatomal somatosensory evoked potentials D. Supporting evidence Myelography
is the established test for evaluating the presence of
nerve root compression. Computed tomography may also be used
to confirm the
diagnosis. Because of the potential lack of precise
definition in both
tests, many orthopaedists order both. Appropriate
treatment should be determined only after careful
consideration of the
results of these tests and the clinical fmdings presented by the patient. Electromyography may
determine if the nerve supply to the
involved muscles is
intact, but 21 days of compression are necessary
before signs of denervation can be detected. Because of its lack
of specificity, electromyography is inappropriate as a
sole determinant of the
diagnosis. III. Treatment A. Outpatient treatment 1.
Nonoperative treatment a.
Indications 1)
Absence of severe or progressive abnormal neurologic signs 2)
Quality
of life not significantly impaired b.
Treatment options 1)
Short period of bed rest with analgesics, mild relaxants,
and nonsteroidal anti-inflammatory drugs 2)
Physical
therapy 3)
Low
back school 4) 4) Use of transcutaneous electrical nerve stimulation (TENS)
unit 5)
Injection
of trigger points, spinal nerve blocks 6)
Epidural
steroid injections 7)
Pain
clinic c.
Home health care may be required for a short period d.
Rehabilitation: frequently necessary when symptoms persist longer than two to three months, and consists
of braces, exercises, and physical therapy e.
Supporting evidence The
value of short periods of bedrest has been demonstrated. Complete bedrest for prolonged periods
may be
be deleterious to the body and should be closely
monitored. Approximately 90% of patients will respond to a nonoperative treatment program for herniated
lumbar disk. The physician should be aware that surgery may be
necessary in those patients who have early and marked limitation of straight-leg raising and
for those patients who have symptoms or physical fmdings
suggestive of cauda equina syndrome. If cauda equina syndrome is
suspected, close patient monitoring is indicated 2.
Ambulatory surgery a.
Indications 1)
Contained herniated disc, confirmed by myelography
computed tomography and/or MRI 2)
Presence
of significant or persistent radiculopathy 3)
Quality
of patient's life significantly impaired 4)
Failure
of nonoperative treatment to relieve symptoms b.
Procedure options 1)
Automated
percutaneous diskectomy 2)
Chemonucleolysis B. Inpatient treatment 1.
Nonoperative treatment a.
Indications for admission 1)
Inability
to control pain 2)
Failure
to improve with outpatient treatment 3)
Progressive
neurologic deficit 4)
Need
for myelogram and/or other studies requiring
hospitalization. Myelograms may occasionally
be performed as outpatient procedures. 1)
Monitored bedrest with medications, physical therapy, TENS 2)
Epidural steroid injections, nerve blocks, and observation
of results Indications
for discharge 1)
Uncomplicated a)
Relief or improvement of leg and/or back pain b)
No complications or persisting symptoms within one day
after myelogram. 2)
Exceptions a)
No response to nonoperative treatment options requiring
consideration of surgical intervention b)
Spinal headache after myelogram requiring IV fluids Home
health care may be required for a short period e.
Rehabilitation: frequently necessary when symptoms persist
longer than two to three months, and consists of braces, exercises, and physical therapy 2. Operative treatment a.
Indications (two or more of the following) 1)
Failure of nonoperative treatment to relieve symptoms 2)
Quality of patient's life significantly impaired 3)
Presence of significant or progressive neurologic deficit
4)
Diagnosis confirmed by one or more of the following: a)
Myelography b)
Computed tomography c)
MRI d)
Challenge diskography b.
Procedure options 1)
Laminectomy with diskectomy 2)
Laminotomy with diskectomy 3)
Microdiskectomy 4)
Percutaneous discektomy 5)
Chemonucleolysis c.
Indications for discharge 1)
Uncomplicated a)
One to three days after chemonucleolysis, microdiskectomy
or percutaneous diskectomy b)
Three to five days after open diskectomy 2)
Complicated—after wound infection, thrombophlebitis,
spinal fluid leak, or other significant complication has been controlled d.
Home health care may be required for a short period e.
Rehabilitation 1)
Some monitoring of the patient's activities may be
necessary. 2)
General fitness is probably more important than simple
spinal muscle strengthening. 3)
f.
Supporting evidence Diskectomy
has proven to be a safe and effective procedure in some patients
with herniated disk. Such surgical intervention remains elective
(in the absence of cauda equina syndrome) and the decision is
based on the orthopaedist's clinical judgment and the patient's
personal assessment of the extent to which quality of life has
been impaired. Chemonucleolysis should be regarded as a surgical
procedure because the complications can be severe and the
technique is challenging. C.
Estimated duration of care 1.
Nonoperative
treatment—three to six months 2.
Operative
treatment—six to 12 months D.
Anticipated outcomes 1.
Reduction
of back and leg pain 2.
Improved
quality of life 3.
Satisfactory
results in 70% to 85% of patients treated E.
Evolving procedures 1.
Percutaneous
nuclear diskectomy 2.
Laser
treatment of disk disease 3.
Disk
injections F.
Modifiers (age, sex, and co-morbidity) Patients
with symptoms suggestive of cauda equina syndrome will require a
different approach to treatment. Cauda equina syndrome is usually
caused by a central herniated disk. Symptoms include low back
pain, unilateral or bilateral leg pain and weakness, saddle
anesthesia, and paralysis with loss of bladder and bowel control.
Once this diagnosis is suspected, the patient should undergo
prompt neurodiagnostic evaluation. Early surgery is recommended;
however, there is no evidence that neurologic recovery will be
affected.
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