Herniated Nucleus Pulposus

Author: Mark R Foster, MD, PhD, FACS, President and Orthopaedic Surgeon, Orthopaedic Spine
Specialists of Western Pennsylvania, PC
Contributor Information and Disclosures
Updated: Jan 8, 2010

Background

Nuclear material that is displaced into the spinal canal is associated with a significant
inflammatory response, as has been demonstrated in animal studies. Disk injury
results in an increase in the proinflammatory molecules interleukin-1 (IL-1), IL-8, and
tumor necrosis factor (TNF) alpha. Macrophages respond to this displaced foreign
material and seek to clear the spinal canal. Subsequently, a significant scar is
produced, even without surgery, and substance P, which is associated with pain, is
detected. Acute neural compression is responsible for dysfunction; compression of a
motor nerve results in weakness, and compression of a sensory nerve results in
numbness. Radicular pain is caused by inflammation of the nerve, which explains the
lack of correlation between the actual size of an intervertebral disk herniation or even
the consequent degree of neural compression and the associated clinical symptoms.16

Furthermore, intervetebral disk degeneration may result in radial tears and leakage of
the nuclear material, which leads to neural toxicity. The subsequent inflammatory
response often results in neural irritation causing radiating pain without numbness,
weakness, or loss of reflex, even when neural compression is absent.

Several factors seem to influence the occurrence of herniated nucleus pulposus.

Smoking is a risk factor in the epidemiology of lumbar disk herniations and has been
documented to decrease the oxygen tension in the avascular disk dramatically,
presumably by vasoconstrictive and rheologic effects on blood. Lumbar disk
herniationmay result from chronic coughing and other stresses on the disk. For
example, sitting without lumbar support causes an increase in disk pressures, and
driving is also a risk factor because of the resonant coupling of 5-Hz vibrations from
the road to the spine. People who drive signifcant amounts have increased spinal
problems; truck drivers have the additional risk of spinal problems from lifting during
loading and unloading, which, unfortunately, is done after prolonged driving.

Studies have shown that peak stresses within a deteriorated intervertebral disk exceed
those from average loads on a normal disk, which is consistent with a pain
mechanism. Further repetitive stress at physiologic levels did not produce a herniation
after prolonged testing, contradicting the concept of injury accumulation with
customary work activities. However, after a simulated injury to the annulus (cutting),
a lower mechanical stress did result in disk herniation, consistent with intervertebral
disk degeneration and with clinical experience on discography.

The presumed traumatic cause of disk herniations has been questioned scientifically
in the literature, particularly with the increased availability of genetic information.17,18

The pathologic state of a weakened annulus is a necessary condition for herniation to

occur. Many cases involve trivial trauma even in the presence of repetitive stress. An
annular tear or weak spot has not been demonstrated to result from repetitive normal
stress from customary activities or from physically stressful activities.
Mixter and Barr first recognized that the cartilaginous masses in the spinal canal of
their patients were not tumors or chondromas.12 They proposed that herniation of the
nucleus pulposus and displacement of nuclear material caused neural irritation,
inflammation, and pain. They showed that excising a disk fragment was effective, but
their recommendation to perform this procedure with a fusion was necessitated by
relatively aggressive laminectomy. This procedure has been replaced by techniques
that are less invasive, such as microdiscectomy.

Anatomy
The intervertebral disc is the largest avascular structure in the body. It arises from
notochordal cells between the cartilaginous endplates, which regress from about 50%
of the disc space at birth to about 5% in the adult, with chondrocytes replacing the
notochordal cells. Intervertebral discs are located in the spinal column between
successive vertebral bodies and are oval in cross section. The height of the discs
increases from the peripheral edges to the center, appearing as a biconvex shape that
becomes successively larger by about 11% per segment from cephalad to caudal (ie,
from the cervical spine to the lumbosacral articulation). A longitudinal ligament
attaches to the vertebral bodies and to the intervertebral discs anteriorly and
posteriorly; the cartilaginous endplate of each disc attaches to the bony endplate of the
vertebralbody.

Hyaluronan long chains form a backbone for attracting electronegative or

hydrophilic branches, which hydrate the nucleus pulposus and cause a swelling
pressure within the annulus to allow it to stabilize the vertebrae and act as a
shock absorber. Deterioration within the intervertebral disk results in loss of
these water-retaining branches and eventually in the shortening of the chains.
Nuclear material is normally contained within the annulus, but it may cause
bulging of the annulus or may herniate through the annulus into the spinal
canal. This commonly occurs in a posterolateral location of the intervertebral
disk, as depicted.

The spinal nerves exit the spinal canal through the foramina at each level.
Decreased disk height causes decreased foramen height to the same degree, and
the superior articular facet of the caudal vertebral body may become
hypertrophic and develop a spur, which then projects toward the nerve root
situated just under the pedicle. In this picture, L4-5 has loss of disk height and
some facet hypertrophy, thereby encroaching on the room available for the
exiting nerve root (L4). A herniated nucleus pulposus within the canal would
embarrass the traversing root (L5).

The disc's annular structure is composed of an outer annulus fibrosus, which is a

constraining ring that is composed primarily of type 1 collagen. This fibrous ring has
alternating layers oriented at 60° from the horizontal to allow isovolumic rotation.
That is, just as a shark swimming and turning in the water does not buckle its skin, the
intervertebral disc has the ability to rotate or bend without a significant change in
volume and, thus, does not affect the hydrostatic pressure of the inner portion of the
disc, the nucleus pulposus.

The nucleus pulposus consists predominantly of type II collagen, proteoglycan, and

hyaluronan long chains, which have regions with highly hydrophilic, branching side
chains. These negatively charged regions have a strong avidity for water molecules
and hydrate the nucleus or center of the disc by an osmotic swelling pressure effect.
The major proteoglycan constituent is aggrecan, which is connected by link protein to
the long hyaluronan. A fibril network, including a number of collagen types along
with fibronectin, decorin, and lumican, contains the nucleus pulposus.

The hydraulic effect of the contained, hydrated nucleus within the annulus acts as a
shock absorber to cushion the spinal column from forces that are applied to the
musculoskeletal system. Each vertebra of the spinal column has an anterior centrum
or body. The centra are stacked in a weightbearing column and are supported by the
intervertebral discs. A corresponding posterior bony arch encloses and protects the
neural elements, and each side of the posterior elements has a facet joint or
articulation to allow motion.

The functional segmental unit is the combination of an anterior disc and the 2
posterior facet joints, and it provides protection for the neural elements within the
acceptable constraints of clinical stability. The facet joints connect the vertebral
bodies on each side of the lamina, forming the posterior arch. These joints are
connected at each level by the ligamentum flavum, which is yellow because of the
high elastin content and allows significant extensibility and flexibility of the spinal
column.

Clinical stability has been defined as the ability of the spine under physiologic load to
limit patterns of displacement so as to avoid damage or irritation to the spinal cord or
nerve roots and to prevent incapacitating deformity or pain caused by structural
changes.1 Any disruption of the components holding the spine together (ie, ligaments,
intervertebral discs, facets) decreases the clinical stability of the spine. When the
spine loses enough of these components to prevent it from adequately providing the
mechanical function of protection, surgery may be necessary to reestablish stability.

Pathophysiology
Low back pain (LBP) is ubiquitous, with 60-80% of people having an activity-
limiting episode at least transiently in their lifetime. Genetic factors appear to have a
dominant role, with LBP starting at an earlier age than previously suspected on the
basis of subsequent structural changes; men begin having LBP about a decade earlier
than women. [6]
The water-retaining ability of the nucleus pulposus, or the inner portion of the
intervertebral disk, declines progressively with age. The decline in the mechanical
properties of the nucleus pulposus is associated with the degree of proteoglycan
deterioration and the decrease in hydration, which lead to excessive regional peak
pressures within the disk. As the hyaluronan long chains shorten and swelling
pressure decreases as a result of this deterioration, the mechanical stiffness of the disk
decreases, which causes the annulus to bulge, with a corresponding loss of disk and
foramen height. [7] (See the image below.)
Hyaluronan long chains form a backbone for attracting electronegative or hydrophilic
branches, which hydrate the nucleus pulposus and cause a swelling pressure within
the annulus to allow it to stabilize the vertebrae and act as a shock absorber.
Deterioration within the intervertebral disk results in loss of these water-retaining
branches and eventually in the shortening of the chains.
The etiology of back pain for a particular individual cannot be determined, because of
the multiplicity of potential sources. Although periosteal disruption causes pain with
fractures, bone itself is devoid of pain receptors (eg, asymptomatic compression
fractures commonly are seen in the thoracic spine of elderly individuals with
osteoporosis). However, the degenerating intervertebral disk is known to have
neurovascular elements at the periphery, including pain fibers.
Disk deterioration and loss of disk height may shift the balance of weightbearing to
the facet joint; this mechanism has been hypothesized as a cause of LBP through the
facet joint capsule, as well as through other tissues attached to and between the
posterior bony elements.
When the annulus in animals is incised, a degenerative cascade is initiated that
mimics the natural aging process observed in humans, thus providing a model of disk
deterioration. [8] As the use of discography has increased for various clinical
applications, similar annular tears are seen routinely that are associated with the
degeneration of the intervertebral disk, even in patients who are asymptomatic.
Annular tears may simply be the result of aging and the degenerative cascade.
Pathology studies of young patients who died as a result of trauma reveal a surprising
degree of articular surface damage in the facet joints; magnetic resonance imaging
(MRI) routinely reveals disk deterioration in individuals in the second or third decade
of life. Injection of chymopapain into the intervertebral disk causes a repeatable and
predictable degenerative cascade in the facet joints, illustrating the coupling between
the disk and facet joints. Immobilization by facet fusion posteriorly leads to disk
deterioration; this avascular structure is solely dependent upon motion to facilitate the
diffusion of nutrients into it.
Whether the deterioration of the disk or that of the facet comes first has not been
determined; however, deterioration is known to occur in both.
Dehydration results from shortening of the hyaluronic chains, deterioration of the
state of aggregation, and decreases in the ratio of chondroitin sulfate to keratan
sulfate, leading to the disk bulging and disk height loss. The consistency of the
nuclear material undergoes a change from a homogeneous material to clumps, which
leads to the altered distribution of pressures within the disk and resistance to the flow
of nuclear material; the nuclear material thereby becomes mechanically unstable. [9]
The clumping of the degenerating nuclear material can be likened to a marble held
between two books—that is, it is difficult to contain.
These clumps may be lateral to the posterior longitudinal ligament and, therefore, may
have the least resistance to herniating through the corner of the intervertebral disk and
into the spinal canal or foramen. Surgical removal of the herniated fragments is
achieved by grasping them with a pituitary rongeur.
This method of surgical removal is not possible with normal, homogeneous material,
which is encountered when healthy interverterbral disks are excised anteriorly in
patients having surgery because of deformity or trauma. Using the pituitary rongeur
technique to perform a microdiscectomy on a herniated fragment necessitates a
preexisting state of deterioration; the weakened areas in the annulus provide a path of
least resistance for the nuclear material to egress.

Natural History
Much has been written concerning the process of spinal deterioration or spondylosis,
which occurs over a lifetime.Intervertebral disk deterioration leads to decreased
stiffness of the disk, as well as diminished stability, resulting in episodic pain that is
common and may be temporarily severe. However, continued deterioration ultimately
leads to restabilization of the spine by collagenization, which stiffens the disk.
Patients in their 50s and 60s customarily have stiffer spines but less pain than patients
in their 30s and 40s who are undergoing initiation of the degenerative cascade.
Patients who ask if they have to live with this pain "for the rest of their lives" can be
reassured to some extent by this natural history. Furthermore, spontaneous recovery
from an acute pain episode routinely occurs, so any treatment must be demonstrated
as effective by positively altering the expected course without treatment.
In general practice, the overall incidence of herniated nucleus pulposus (HNP) in
patients who have new LBP onset is less than 2%. Therefore, most of these patients
have deterioration of the intervertebral disk and dysfunction of the functional
segmental unit. They will have LBP, and some will have associated leg pain but
without sciatica (an intractable, radiating pain, below the knee) or radiculopathy. A
disk fragment that is no longer contained within the annulus but is displaced into the
spinal canal has decreased hydration and deteriorated proteoglycan that can be
expected to undergo further deterioration and consequent annular desiccation,
essentially like a grape being transformed into a raisin.
Spontaneous resolution of sciatica may result from shrinkage of a herniated fragment,
aided by macrophages and the evoked inflammatory reaction, but practitioners too
often attribute this clinical improvement to their favorite treatments. Intractable
symptoms of sciatica from intervertebral disk displacements may benefit dramatically
from surgical intervention. Within 20 years of Mixter and Barr's 1934 report,
Friedenberg compared operative treatment with nonoperative
treatment.12,13 Nonoperative treatment yielded 3 groups of results: pain free,
occasional residual pain, and disabling pain. Proportions of these groups remained
similar after 5 years. Friedenberg concluded that even recurrent severe episodes may
resolve without surgery; the problem was and remains patient selection.
Weber presented a randomized, controlled study (marred by dropouts in the surgery
control group because of severe pain) and concluded that patient results were the
same whether treated operatively or conservatively, except that those who were
treated operatively had better results at 1 year.14 The Spine Patient Outcomes
Research Trial (SPORT) observational cohort is similarly limited in its conclusions by
crossovers: 50% of the surgery arm had surgery within 3 months and 30% of the
nonsurgical group had surgery, but at long-term follow-up, both groups again were
not statistically different.15
Natural History
Much has been written concerning the process of spinal deterioration or spondylosis,
which occurs over a lifetime.Intervertebral disk deterioration leads to decreased
stiffness of the disk, as well as diminished stability, resulting in episodic pain that is
common and may be temporarily severe. However, continued deterioration ultimately
leads to restabilization of the spine by collagenization, which stiffens the disk.
Patients in their 50s and 60s customarily have stiffer spines but less pain than patients
in their 30s and 40s who are undergoing initiation of the degenerative cascade.
Patients who ask if they have to live with this pain "for the rest of their lives" can be
reassured to some extent by this natural history. Furthermore, spontaneous recovery
from an acute pain episode routinely occurs, so any treatment must be demonstrated
as effective by positively altering the expected course without treatment.
In general practice, the overall incidence of herniated nucleus pulposus (HNP) in
patients who have new LBP onset is less than 2%. Therefore, most of these patients
have deterioration of the intervertebral disk and dysfunction of the functional
segmental unit. They will have LBP, and some will have associated leg pain but
without sciatica (an intractable, radiating pain, below the knee) or radiculopathy. A
disk fragment that is no longer contained within the annulus but is displaced into the
spinal canal has decreased hydration and deteriorated proteoglycan that can be
expected to undergo further deterioration and consequent annular desiccation,
essentially like a grape being transformed into a raisin.
Spontaneous resolution of sciatica may result from shrinkage of a herniated fragment,
aided by macrophages and the evoked inflammatory reaction, but practitioners too
often attribute this clinical improvement to their favorite treatments. Intractable
symptoms of sciatica from intervertebral disk displacements may benefit dramatically
from surgical intervention. Within 20 years of Mixter and Barr's 1934 report,
Friedenberg compared operative treatment with nonoperative
12,13
treatment. Nonoperative treatment yielded 3 groups of results: pain free,
occasional residual pain, and disabling pain. Proportions of these groups remained
similar after 5 years. Friedenberg concluded that even recurrent severe episodes may
resolve without surgery; the problem was and remains patient selection.
Weber presented a randomized, controlled study (marred by dropouts in the surgery
control group because of severe pain) and concluded that patient results were the
same whether treated operatively or conservatively, except that those who were
treated operatively had better results at 1 year.14 The Spine Patient Outcomes
Research Trial (SPORT) observational cohort is similarly limited in its conclusions by
crossovers: 50% of the surgery arm had surgery within 3 months and 30% of the
nonsurgical group had surgery, but at long-term follow-up, both groups again were
not statistically different.15
Prognosis
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. Many reports in the literature have described specific cytokines
elevated, but not comprehensively; endplate changes are observed but no clear
correlation identified to this point. Various nuclear replacements that reduce
postoperative loss of disc height restoring compressive loading are being studied. [13]
With a discectomy, patients with dominant leg pain have excellent results, with 85-
90% returning to full function. However, as many as 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. [14]
The remaining concern of recurrent herniation is small, though it is correlated with
obesity. [15] Efforts to minimize this complication have included annulus
repair [16] and injecting hemostatic materials or bioactive molecules. Etanercept was
shown in a small study to be of no benefit for sciatica, although the addition of
butorphanol with corticosteroid was helpful with an epidural injection. [17]
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. Studies have shown that degenerated discs have different growth
factors and other molecules; thus, even introducing mesenchymal stem cells requires
significant further research and development. [18]
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.
Tomasino et al presented radiologic and clinical outcome data on patients who
underwent single-level anterior cervical discectomy and fusion (ACDF) for cervical
spondylosis and/or disc herniation using bioabsorbable plates for
instrumentation. [19] Overall, at 19.5 months postoperatively, 83% of the patients had
favorable outcomes based on the Odom criteria.
The authors found that absorbable instrumentation provides better stability than the
absence of a plate but that graft subsidence and deformity rates may be higher than
those associated with metal implants. In this study, the fusion rate and outcome were
found to be comparable to the results achieved with metallic plates, and the authors
concluded that the use of bioabsorbable plates is a reasonable alternative to metal,
avoiding the need for lifelong metallic implants.
Buchowski et al performed a cross-sectional analysis of two large prospective,
randomized multicenter trials to evaluate the efficacy of cervical disc arthroplasty for
myelopathy with a single-level abnormality localized to the disc space. [20] The authors
found that patients in both the arthroplasty and arthrodesis groups had improvement
following surgery, with improvement being similar and with no worsening of
myelopathy occurring in the arthroplasty group.
The authors noted that although the findings at 2 years postoperatively suggest that
arthroplasty is equivalent to arthrodesis in these cases, they did not evaluate the
treatment of retrovertebral compression as occurs with ossification of the posterior
longitudinal ligament. [20]
Carragee et al compared progression of common degenerative findings between
lumbar discs injected 10 years earlier with those same disc levels in matched subjects
who were not exposed to discography. [21] The authors found that in all graded or
measured parameters, discs exposed to puncture and injection had greater progression
of degenerative findings than the control (noninjected) discs. Progression of disc
degeneration was 35% in the discography group, compared to 14% in the control
group, with 55 new disc herniations occurring in the discography group and 22 in the
control group.
The study also found significantly greater loss of disc height and signal intensity in
the discography discs. The authors noted, therefore, that careful consideration of risk
and benefit are necessary in regard to disc injection. [21]
McGirt et al performed a prospective cohort study with standardized postoperative
lumbar imaging with computed tomography (CT) and magnetic resonance imaging
(MRI) every 3 months for a year, then annually, to assess same-level recurrent disc
herniation. [22] Improvement in all outcome measures was observed 6 weeks after
surgery. At 3 months after surgery, 18% loss of disc height was observed, which
progressed to 26% by 2 years. In 11 (10.2%) patients, revision discectomy was
required at a mean of 10.5 months after surgery.

According to the authors, patients who had larger anular defects and removal of
smaller disc volumes had increased risk of recurrent disc herniation, and those who
had greater disc volumes removed had more progressive disc height loss by 6 months
after surgery. The authors suggested, based on the findings, that in cases of larger
anular defects or less aggressive disc removal, concern for recurrent herniation should
be increased and that, in such cases, effective anular repair may behelpful. [22]
Fish et al performed a retrospective single-center study to analyze whether MRI
findings could be used to predict therapeutic responses to cervical epidural steroid
injections (CESI) in patients with cervical radiculopathy. [23] Patients were categorized
by the presence or absence of four types of cervical MRI findings: disc herniation,
nerve root compromise, neuroforaminal stenosis, and central canal stenosis.
The authors found that only the presence, versus the absence, of central canal stenosis
was associated with significantly superior therapeutic response to CESI. They
therefore concluded that the MRI finding of central canal stenosis is a potential
indication that CESI may be merited. [23]
Hirsch et al did a systematic review of the literature to determine the effectiveness of
automated percutaneous lumbar discectomy (APLD). [24]According to the authors,
based on United States Preventive Services Task Force (USPSTF) criteria, the
indicated evidence for APLD is level II-2 for short- and long-term relief, indicating
that APLD may provide appropriate relief in properly selected patients with contained
lumbar disc prolapse. However, the authors noted that there is a paucity of
randomized, controlled trials in the literature covering this subject.
Dasenbrock et al performed a meta-analysis of six trials of 837 patients comparing
open discectomy with minimally invasive discectomy and found similar visual
analogue scale (VAS) scores at short and long-term follow-up. Results showed no
significant difference in relief of leg pain between the two approaches. Reoperation
was more common with limited (tubular) exposure but not statistically significant, and
total complications did not differ. [25]

History
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
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, both-legs or Milgram test) are available but
cloud the issue, because the sciatic nerve root tension or straight-leg 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 (the Kemp 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.

Diagnostic Considerations
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.

Approach Considerations
After plain radiographs are obtained, further imaging studies (eg, magnetic resonance
imaging [MRI], computed tomography [CT], and 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, in that 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, including piriformis 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. [26] However, large numbers of patients have reported
significant relief after facet joint injections for nonspecific low back pain (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.

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.

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.

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.

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).

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.

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).

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.

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. Multilevel disc
replacement has been suggested as at least similar to fusion. [36]

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