Diagnosis

Spinal disc herniation

Etiology

Cause [qry]

• Progressive degeneration of the intervertebral disks with age

• Trauma

• Connective tissue disorders

• Congenital disorders (short pedicles)

Pathophysiology [qry]

1. The intervertebral disks is typically 7 to 10 mm thick and 4 cm in diameter and act as shock absorbers between the vertebrae

2. They have a central area composed of a colloidal gel (nucleus pulposus) which is surrounded by a fibrous capsule (annulus fibrosis)

3. This structure is held together by the anterior longitudinal ligament and the posterior longitudinal ligament

4. Mechanical degeneration

   • Thinning and weakening of the posterior longitudinal ligament

   • Alterations in capillaries, cell morphology, density within the nucleus pulposus

   • Formation of small clefts in the annulus fibrosus

   • Loss of disk height

5. Herniation of nucleus pulposus --> nerve compression and inflammatory response

6. Most common in the lumbar/cervical spine (biomechanical stress in flexible areas)

   • Posterolateral (lack of structural support from the longitudinal ligaments)

7. Clinical manifestation depend on the level and severity of compression

   • Back pain

   • Radiculopathy (nerve compression)

     • Sensory disturbances

     • Motor weakness

   • Myelopathy (spinal cord compression/dysfunction)

     • Bilateral affection of extremities

     • Coordination/balance

     • Bowel and bladder dysfunction

Risk factors [uq3][qry]

• Middle age (30-50 years)

• Activity

• Heavy lifting

• Cumulative occupational lumbar load from forward bending postures

• Smoking

• Obesity

• Vibration

• Sedentary lifestyle

• Psychosocial factors

Complications [qry]

• Chronic back pain

• Prolonged nerve damage

• Recurrence

• Complications of surgery: paralysis

Epidemiology

Incidence per 100.000 [nit][ssr][uq3][g4a][gcp][ibe]

Approach

• Neurology: motor, sensory, reflex, anal sphincter tone

• Vascular status

• Blood test: Sedimentation rate, ALP, calcium, serum protein electrophoresis

• MRI

• CT

Treatment

1. Cervical radiculopathy: [nit][yob]

   • Non-surgical treatment is the initial treatment of choice with good to excellent outcomes in up to 90% of patients:

     • Immobilization

     • Physiotherapy, traction, acupuncture, chiropractic manipulation

     • Medications: NSAIDs, acetaminophen, gabapentin, temporary low-dose opiates, systemic steroids, cervical steroid injection

   • Surgery: progressive neurologic deficits or signs of myelopathy

2. Lumbosacral radiculopathy: Mostly resolve spontaneously with conservative care [qry]

   • Non-surgical treatment is prefered:

     • NSAIDs

     • Physical therapy and structured exercise programs

   • Surgery:

     • Epidural corticosteroid injections are effective for short-term pain management

     • Diskectomy (surgical intervention is less effective after 1 year)

     • Chemonucleolysis

     • Spinal fusion

Differential diagnoses

Acute extremity ischemia, Angina pectoris, Aortic dissection, Cauda equina syndrome, Chronic limb ischemia, Compression fracture, Constipation, Discitis, Diverticulitis, Ependymoma, Epidural abscess, Epidural hematoma, Hemangioma, Herpes zoster, HIV, Lipoma, Lyme disease, Lymphoma, Metastatic bone tumors, Multiple myeloma, Neurofibroma, Osteoblastoma, Osteomyelitis, Osteosarcoma, Paraganglioma, Pelvic fracture, Pelvic inflammatory disease, Rheumatoid arthritis, Ruptured aortic aneurysm, Sickle cell disease, Spinal cord infection, Spinal cord injury, Spinal cord tumor, Spinal stenosis, Spondylolisthesis, Spondylolysis, Urolithiasis