CLASSICAL DISC HERNIATION

By Dr. Anupreet Bassi

Director and Spine Consultant
Dr J L Bassi Hospital and Research Institute
 Definition of Disc Herniation
Localized displacement of disc
material beyond the normal margins of
the intervertebral disc space* resulting
in pain, weakness, numbness or other
neurological symptom in a myotomal
or dermatomal distribution

*Fardon DF, Milette PC, Combined Task Forces of the North American Spine Society ASoSR, American
Society of N. Nomenclature and classification of lumbar disc pathology. Recommendations of the
Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and
American Society of Neuroradiology. Spine (Phila Pa 1976). Mar 1 2001;26(5):E93-E113
CAUSES
 Degeneration
 Trauma
 Both minor and major
 Conn tissue
 Short pedicles
Pathophysiology of acute disc
 Acute Disc Herniation

Release of PG,Interlukin 6,nitrous oxide

From NUC.PUL.

Nerve root compression Chemical inflamation

Chemical radiculitis

PAIN
 XX 2750460
 40 Y F C/O Right leg pain (buttock to calf – Post.) with
numbness in same area since 2.5 months after lifting
weight
 SYMPTOMS
 Sudden pain when picking up heavy object- initially slight but
worsens and can impair movement.
 Repeated attacks occur suddenly e.g. sneezing or coughing
 Pain after a prolonged sustained position
 Central or referred symptoms- not always clearly defined
 Proximal worse than distal
 Pain diminishes when lying down with knees supported or
hanging in a specific position
 May have Cauda equina
SIGNS
 Young, healthy patient
 Lateral tilt of the pelvis / List
 Increased lumbar lordosis
 Gluteal / calf area sensitive to palpation
 Protective muscle spasm
 Sitting, straining, driving, Valsalva,
coughing and sneezing painful
 Decreased intervertebral movements
 Walking Limp
 Straight leg painful
 WHAT ARE THE RELEVANT
QUESTIONS?
Any Red Flags
Aggravating / decreasing factors
Other neurological manifestation
Any systemic signs
Comorbidities
Occupation
Family & Financial Hx
Associated risk factors
 Examination
 Ambulation / Gait
 Local tenderness area
 Manual muscle power testing
 Sensory testing – 50 - 60 %
 Supine straight Leg Raise Test / Lasegue Test Level 1 Evidence
 Cross SLR
 Restricted ROM
 Reflex testing
 Cough Impulse
Insufficient Evidence
 Femoral Nerve Stretch Test
 Gore Sign
 Bell Test
When to get investigations done?
 X-ray
 MRI
 Myelography
 CT
 Electrodiagnostic study
 Post voidal residual urine volume scan
Examination – Walking with limp, Power 5/5 SLR right positive 40
degree (Braggard +ve) Spasm in glutei area, sens thigh, rest normal

L3

L4

Right L5-S1 disc

herniation
 Treatment
 In the absence of reliable evidence relating to the
natural history of lumbar disc herniation with
radiculopathy, it is the work group’s opinion that the
majority of patients will improve independent of
treatment. Disc herniations will often
shrink/regress over time. Many, but not all, papers
have demonstrated a clinical improvement with
decreased size of disc herniations.

North American Spine Society Guidelines 2012

Multiple Treatments
 Main course of action
 Home Exercises mainly extension based
 Physiotherapy
 Local heat therapy
 Precautions
 NSAIDS – COX 2 vs Non Selec COX inhibitors
 Pregabalin / Gabapentin
 B-Complex
 Calcium / Vitamin E to decrease cramps
 Steroids
 TCAs
 Opioids
 TNF alpha inhibitors
 ADVICE
 Avoid sitting positions (driving or bathing)
 Sit with knees lower than hips and use lumbar cushion
 Avoid sustained positions
 Avoid rotation movements when picking up objects
 Avoid sudden, jerky movements (sporting activities)
 Do not pick up heavy objects
 Swimming is good exercise- strengthens erector spinae
 Wear a brace during activities which aggravate backache
 After significant strengthening exercises normal activities can be
resumed
 3 Months passed – No Significant pain
relief

Block or Surgery
• Significant pain with • Significant pain with
conservative failure conservative and block failure
3-6 months
• Bowel / Bladder Involvement
• Neurological deficit especially
acute and significant