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herniated disc

Etiology: (risk factors) 1) aging 2) genetic factors 3) obesity 4) lack of exercise 5) ergonomic a) prolonged periods of sitting b) lifting or pulling heavy objects c) heavy physical exertion d) repetitive motions e) exposure to constant vibration 6) smoking 7) history of back injury 8) back surgery Pathology: - generally involves lumbar spine - > 90% at L4-L5 or L5-S1 - herniation of the central gelatinous material (nucleus pulposus) of an intervertebral disc through its fibrous outer covering (anulus fibrosis) - impingement on nerve root Genetics: - susceptibility to lumbar disk herniation may be associated with a) defects in COL9A3 b) polymorphisms in THBS2 [7] Clinical manifestations: 1) acute pain a) acute back pain - deep back muscle pain, muscle spasms - pain varies with changes in position b) radicular pain, sciatica - most frequent cause of sciatica [8] - straight leg raising has good sensitivity [3] c) pain during urination may be noted 2) abnormal posture 3) limitation of spine movement 4) numbness or weakness in one or both legs & feet 5) diminished reflexes 6) cauda equina syndrome - loss of bowel & bladder control 7) may be asymptomatic [8] Radiology: - MRI of lumbar spine in patients with persistent sciatica (4-6 weeks), & epidural glucocorticoid injections or spinal surgery being considered [8] Differential diagnosis: - lumbar spinal stenosis Management: 1) patients with severe or progressive neurologic deficits require a referral for surgery [8] 2) acetaminophen or NSAIDs as needed 3) epidural steroid injections (weekly x 3) - do not reduce need for surgery [8] 4) pulsed radiofrequency, delivered into the back with a thin needle (anesthesia not required) - relief of back pain & sciatica pain >= 1 year [9] 5) 1-2 days of bedrest maximum 6) supervised exercise 7) discectomy a) probably management of choice b) indications for elective surgery: - congruent clinical & MRI findings - no improvement within 6 weeks [8] c) surgery may still be effective after 6 months of symptoms [5] 8) observation & discectomy with similar outcomes [2] - disc herniations often shrink - without surgery, pain decreases in ~87% of patients within 3 months [8] 9) outcomes of non-surgical management similiar in older vs younger patients [4]

General

disc disease hernia

Database Correlations

OMIM 603932

References

  1. Buttermann GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. J Bone Joint Surg Am. 2004 Apr;86-A(4):670-9. PMID: 15069129
  2. Weinstein JN et al, Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): A randomized trial. JAMA 2006, 296:2441 PMID: 17119140 - Weinstein JN et al, Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006, 296:2451 PMID: 17119141 - Flum DR Interpreting surgical trials with subjective outcomes. JAMA 2006, 296:2483 PMID: 17119146
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 18. American College of Physicians, Philadelphia 2009, 2018,
  4. Suri P et al. Nonsurgical treatment of lumbar disk herniation: Are outcomes different in older adults? J Am Geriatr Soc 2011 Mar; 59:423. PMID: 21391933
  5. Rihn JA et al. Duration of symptoms resulting from lumbar disc herniation: Effect on treatment outcomes. Analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am 2011 Oct 19; 93:1906. PMID: 22012528
  6. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  7. OMIM :accession 603932
  8. Deyo RA, Mirza SK CLINICAL PRACTICE. Herniated Lumbar Intervertebral Disk. N Engl J Med 2016; 374:1763-1772. May 5, 2016 PMID: 27144851
  9. Susman E Radiofrequency Pulses End Back Pain - Probes guided to herniated disk appears to enhance pain relief and healing. MedPage Today. Nov 30, 2018 https://www.medpagetoday.com/meetingcoverage/rsna/76612 - Napoli A, et al T Guided Pulsed Radiofrequency in Patients with Acute Low Back Pain and Sciatica: 1 Year Follow-Up versus Image-Guided Injection Only as Control Group, Radiological Society of North America (RSNA) 2018.
  10. American Association of Neurological Surgeons http://www.neurosurgerytoday.org/what/patient_e_herniated.asp