Herniation of Intervertebral Disk

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Herniation of Intervertebral Disk

• By The toothless one J.Karl Pineda

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Background

• Lumbar disk disease is a frequent source of low
  back pain.
• Sciatica is defined as neuralgia along the course
  of the sciatic nerve.

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Pathophysiology

• The intervertebral disks act as shock absorbers
  and are found between the bodies of the
  vertebrae. They have a central area composed of a
  colloidal gel, called the nucleus pulposus, which
  is surrounded by a fibrous capsule, the annulus
  fibrosis. This structure is held together by the
  anterior longitudinal ligament, which is anterior
  to the vertebral bodies, and the posterior
  longitudinal ligament, which is posterior to the
  vertebral bodies and anterior to the spinal cord.
  The muscles of the trunk provide additional
  support.
• The most common site of disk herniation is at the
  L5-S1 interspace in the lumbosacral region. This
  is believed to be due to the thinning of the
  posterior longitudinal ligament as it extends
  caudally.
• Nomenclature specific to lumbar disk disease
• Disk bulge - Annular fibers intact
• Disk protrusion - Localized bulging with damage
  of some annular fibers
• Disk extrusion - Extended bulge with loss of
  annular fibers, but disk remains intact
• Disk sequestration - Fragment of disk broken off
  from the nucleus pulposus

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Frequency

• In the US Sciatica has been reported by various
  authors to occur in 1-10 of the population.
• Mortality/Morbidity Low back pain usually is
  self-limited and of short duration.
• Sex The male-to-female ratio is approximately
  11.
• Age The group most commonly affected is adults
  aged 25-45 years.

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Clinical Manifestation

• History The history may be sufficient to make
  presumptive diagnosis of a disk disorder or may
  guide the physician's usage of ancillary testing
  and consultations to further differentiate both
  the specific type of disk disease and potential
  other etiologies of the patient's back pain.
• Patients with disk disease usually are not able
  to give a precise time that the problem began
  because it usually is preceded by multiple
  episodes of less severe low back pain.
• Asking the patient the location of the pain is
  important.
• Pain that is localized to the lower back and
  gluteal area often is associated with disk
  disease.
• Pain associated with nerve root involvement
  commonly radiates down the leg, particularly
  below the level of the knee.
• Ask the patient about any unusual recent
  activity, especially if it involved the patient
  remaining in a flexed or rotated position. Find
  out if the patient experienced any recent trauma.
• Pain with flexion, rotation, or prolonged sitting
  or standing, and sharp (rather than dull) pain
  are suggestive of disk disease.
• The onset of pain may begin suddenly or gradually
  after injury.
• Typically, the pain is located bilaterally at the
  posterior belt line.
• The pain pattern usually is referred rather than
  radicular.
• Back motion, which includes sitting, standing,
  lifting, bending, and twisting, usually
  aggravates the pain it often is relieved with
  rest and a recumbent position.

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Clinical Manifestation

• Physical Nerve roots exit the spine below the
  intervertebral disks thus, herniation of a disk
  involves the nerve root below it.
• Observe the patient for abnormal gait, which is
  suggestive of a loss of the normal rhythm. Have
  ambulatory patients walk on their toes to test
  the function of S1.
• Observe the patient for abnormal posture, which
  is suggestive of splinting or guarding from pain.
• Test the patient's ability to dorsiflex the foot
  while sitting to test the L5 nerve root. Test for
  sensory loss that corresponds to a dermatomal
  area.
• Palpation of the lumbar spine and lower back is
  not helpful in the diagnosis of disk disease, but
  it should be done to rule out other causes of low
  back pain.
• A positive straight leg-raising test is
  indicative of nerve root involvement.
• This test is performed while the patient is lying
  supine with one leg either straight or flexed at
  the knee, with the sole of the foot flat on the
  stretcher. The other leg is kept straight and
  lifted by the examiner.
• If pain occurs when the leg is lifted between
  30-70 degrees from horizontal and travels down
  the leg until below the knee, the test is
  positive.
• Nerve root stretch tests are often negative.
• Patients may exhibit decreased lumbar range of
  motion (ROM).
• The usual motor, sensory, and reflex examinations
  (including perianal sensation and anal sphincter
  tone when appropriate) should be performed.
• A careful abdominal and vascular examination is
  mandatory in evaluation of these patients.

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Causes

• The normal aging process of the musculoskeletal
  system aggravates acute events.
• Risk factors
• Age
• Activity
• Smoking
• Obesity
• Vibration (eg, driving a car)
• Sedentary lifestyle
• Psychosocial factors

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Diagnostic Tests

• Laboratory tests generally are not helpful in the
  diagnosis of lumbar disk disease.
• Indications for screening laboratory examinations
  include a pain of a nonmechanical nature,
  atypical pain pattern, persistent symptoms, and
  age older than 50 years.
• Complete blood count (CBC) with differential
• Erythrocyte sedimentation rate (ESR)
• Alkaline and acid phosphatase
• Serum calcium
• Serum protein electrophoresis

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Diagnostic Tests

• Radiographic studies are very helpful in the
  diagnosis of lumbar disk disease, but several
  important caveats should be taken into account
  with the use of these tests.
• Most patients with pain from lumbar disk disease
  will have resolution of their symptoms with
  conservative treatment.
• For an otherwise healthy individual, unless the
  patient is immobilized completely by the pain and
  requires admission, or the pain has been present
  for more than 6 weeks, diagnostic studies are not
  recommended. Elderly patients or those with a
  history of cancer or chronic infection (including
  tuberculosis), trauma, or osteoporosis should
  have imaging performed as part of their routine
  workup during initial presentation.
• MRI is the imaging modality of choice in
  evaluating patients with lumbar disk disease.
  Studies have shown that as many as 60 of people
  without back symptoms have disk bulges and
  protrusions on MRI. Therefore, these findings may
  not correlate with the patient's symptoms.

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Diagnostic Tests

• CT scanning is useful for diagnosing disk disease
  but is less sensitive than MRI. CT scanning of
  the abdomen can help to evaluate and rule out
  other etiologies of pain such as aortic aneurysm,
  ureteral calculi, and intra-abdominal causes.
  Combining CT scan with myelography can increase
  the sensitivity of the modality for spinal cord
  pathology.
• Myelography may provide a definitive diagnosis on
  its own, but this is an invasive test requiring a
  lumbar puncture and the use of contrast material.
• Plain films of the lumbar spine generally are not
  helpful in the diagnosis of lumbar disk disease,
  except to rule out other diseases and to evaluate
  for possible skeletal etiology as the cause of
  the patient's symptoms. They should be performed
  in patients who are elderly or those with a
  history of cancer or chronic infection (including
  tuberculosis), trauma, or osteoporosis.
• Bone scan (scintigraphy)
• Technetium-99m labeled phosphorus indicates
  active mineralization of bone.
• A bone scan is indicated to rule out tumors,
  trauma, or infection.

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MRI image of herniated disk
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Treatment

• Prehospital Care Little is needed in the way of
  prehospital care. Appropriate spinal
  immobilization should be considered if the
  patient has evidence of trauma otherwise, simple
  transportation in the position of comfort is all
  that is indicated.
• Emergency Department Care
• Patients should lie in a position in which they
  are most comfortable.
• Muscle relaxants are of limited use and clinical
  studies have not proven their efficacy. This
  class includes benzodiazepines, methocarbamol,
  and cyclobenzaprine. Patients should be warned
  that all of these drugs are sedating.
• Opioids provide very effective acute pain relief,
  but they should not be used in patients with
  chronic pain.
• Salicylates, acetaminophen, and nonsteroidal
  anti-inflammatory drugs (NSAIDs) all have been
  used in the treatment of pain from lumbar disk
  disease, but none of these has been shown to be
  superior to the others. Acetaminophen lacks
  anti-inflammatory activity.

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Drugs to take

• Ibuprofen (Ibuprin, Advil, Motrin) -- Usually DOC
  for treatment of mild to moderately severe pain
  if no contraindications

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Drugs to take

• Ketoprofen (Oruvail, Orudis, Actron) -- Used for
  relief of mild to moderately severe pain and
  inflammation. Administer small dosages initially
  to patients with small body size, to the elderly,
  and to those with renal or liver disease. Doses
  higher than 75 mg do not increase therapeutic
  effects. Administer high doses with caution and
  closely observe patient for response.

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Drugs to take

• Flurbiprofen (Ansaid) -- May inhibit enzyme
  cyclooxygenase, which in turn inhibits
  prostaglandin biosynthesis. These effects may be
  mechanism of its analgesic, antipyretic, and
  anti-inflammatory activities.

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More drugs to take

• Naproxen (Anaprox, Naprelan, Naprosyn) -- Used
  for relief of mild to moderately severe pain.
  Inhibits inflammatory reactions and pain by
  decreasing activity of enzyme cyclooxygenase,
  causing decrease in prostaglandin synthesis.

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Herniated disk is not fun
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Interventions
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Interventions

• Prescribe medication on schedule and document
  effectiveness
• Use distraction
• Heat or ice application
• Moving by log rolling and repositioning every 2
  hours (if not contraindicated by maintaining
  traction)
• High protein, iron and vitamin enriched diet

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Interventions

• Observe dressing for bleeding or cerebrospinal
  fluid leakage
• Antiembolic stockings if ordered
• Document IO
• It is important to monitor the patient for
  evidence of respiratory and paralytic ileus as
  complications may occur in laminectomy patients
• Move by log rolling

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Interventions

• Spend as little time as possible in sitting
  position
• Braces or corsets if prescribed are applied
  before patient gets out of bed
• Encourage ADL
• No lifting or carrying anything heavier than 5
  pounds for at least 8 weeks
• Avoid twisting motions of the trunk
• Reinforce importance of follow-up visit to
  physician

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Prognosis

• With conservative treatment, some patients will
  receive relief of symptoms
• If neurological pathology develops, surgical
  intervention is needed
• Prognosis is usually quite favorable

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Herniated disks can be a hairy situation
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Randy, Mike, Glen, Jay, Mr. Dave