CASE WRITE-UP: 4

Topic: Lumbar Disc Herniation

BY

Zairul Anuar B Kamarul Bahrin (M.D USM)

CASE SUMMARY
Patients Name: En K.H.
Age / Sex / Race: 29 years / man / malay
Identification Number: 720804-05-5417
Date of first seen at Orthopedic clinic: 11 June 2001
The patient who is a taxi driver, was referred to the orthopedic clinic for a lower
backache for one year duration. The backache was associated with a radiating pain and
numbness of her right leg. An oral analgesic killer only provided a partial and temporary
relief. The leg pain was really bothering him as he could not stand for a long. The
problem started when he lifted a heavy box about a year ago. There was no urinary /
bowel problem. He was otherwise healthy.
A physical examination didnt show any remarkable sign except for the straight
leg raising which was reduced to about 45 on his right leg. He had an almost normal
range of back movement. No obvious muscle weakness and sensory deficit was detected
on his lower limb.
A plain radiograph of lumbosacral region showed a loss of normal lumbar
lordosis. There was no fracture or obvious spinal instability. The height of the disc space
appeared to be normal.
A presumptive diagnosis of an acute lumbar disc prolapse was made. A Magnetic
Resonance Imaging revealed a right posterolateral disc herniation which caused a
narrowing of the right intervertebral foramina between L5-S1 space.
He was advised to go for a surgical intervention. He underwent an open
discectomy on 14 September 2001. A bulged disc was removed at the level of L5-S1
space, which had been impinging on the nerve root at the posterolateral spinal canal
region. There was no early postoperative complication noted. He underwent back
physiotherapy / rehabilitation program as outpatient basis.
His backache was very much reduced. The sciatica resolved after two months
following the surgery and resumed his work as usual.

DISCUSSION
The case illustrated above is a common scenario for patient with acute herniated lumbar
disc
A normal adult disc is composed of a central nucleus pulposus and an outer annulus
fibrosus. The annulus fibrosus is made of a tough fibrous ring with different type of
mesh. Water made up 90-95% of its content. The remaining constituents are collagen and
proteoglycan. Collagen type 1 forms the periphery (outermost) of annulus whereas
collagen type 2 forms the innermost of annulus. There are numerous free nerve endings in
the outer layer of annulus fibrosus and the posterior longitudinal ligament. In the lumbar
spine, the anterior annulus is thicker and stronger than posterior annulus. However, a
strong posterior longitudinal ligament covers the weaker posterior annulus. The disc has
no blood supply (avascular). It receives its nutrition via a passive diffusion through the
end plates and the periphery annulus. The disc has no healing potential following
fissuring & fragmentation. The weight bearing point and the axis of rotation fall slightly
posterior to the midline of the disc.
The disc undergoes an aging process through a series of inevitable changes, which may
be accentuated in predisposed individual. The water and proteoglycan (negative charge)
content decrease. However, the collagen content and a keratin sulfate / chondroitin sulfate
ratio increase. The biological changes predisposes to the formation of intradiscal fissure
and fragmentation. This is followed by a progressive annular disruption. The inner
annular layer progressively become more superficial which ultimately results in a
complete annular tear. The disc material will then herniated into the spinal canal through
the weak area.
As fissuring and fragmentation take place and disrupts the annulus layer, patient will
experience an episodic backache often radiating to the back of thigh. Once the disc
material herniated into the canal, the intradiscal pressure and the pressure towards the
sensitive annular are relieved. Typically a sciatic pain replaces the back pain.

There are two basic mechanisms, which are believed to cause lower limb pain and
sciatica in a herniated disc.
a. Mechanical deformation secondary to either
i. Tension mechanism. In younger patient, the spinal nerve may be stretched over
the herniated disc or
ii. Compressive mechanism. In older patient where the nerve is compressed
between the herniated disc material and the rigid portion of spinal canal ie. lamina
or ligamentum flavum, posteriorly and the medial border of pedicle laterally.
Both mode of mechanism cause excessive pressure to the nerve may directly
injure the nerve, impair vascular drainage or initiate the inflammatory response and lead
to instertitial and periradicular fibrosis. The adhesion may block the CSF flow, may be
related to pain stimulation. Onozawa et al (2002) studied ectopic firing in an in vitro
model of the isolated dorsal root and clarified that the dorsal root ganglion is more
sensitive to mechanical compression than the dorsal root, that the threshold of mechanical
response of dorsal root ganglion is lowered by hypoxia, and that ectopic firing is induced
by some biochemical mediators. Nitric oxide was found to is strongly suggested to be
involved in radiculopathy symptoms ie.sciatica.
b. Nucleus pulposus induced effect.
Various substances may leak from the degenerative disc to the adjacent nerve
root, causing chemical radiculitis. The neurotoxicity, vascular impairment and
inflammatory mechanism may cause the pain. The resultant fibrosis may cause the
persistent pain despite adequate decompression.
Disc bulge is defined as a diffuse outpouching of the annulus fibrosus due to an early
disc degeneration and disc space collapse.

A true disc herniation is defined as a focal outpouching of disc material secondary to

anatomic derangement limited to a specific circumferential region of the annulus.
Herniated disc can be classified into 2 broad categories:
1. Based on the herniated disc material related to posterior annulus and PLL and
continuity of the herniated disc to the remaining of the disc.
a. Protruded
Herniated disc is covered by an intact annulus but eccentrically displaced
(a contained type)
b. Extruded (75 % of cases)
Noncontained herniated disc material is in continuity with the disc space but
extending completely into the epidural space through the disrupted annulus.
c. Sequestrated (less than 5 %)
Noncontained herniated disc not in continuity with disc space and is a free
fragment of material in epidural space. No defect can be seen in the annulus.
(Eismont and Currier,1989).
The histological study of the excised herniated lumbar intervertebral disc revealed that,
most of the herniations of a lumbar intervertebral disc that occur before the age of 60
years were protrusions of the nucleus pulposus. A few cases of prolapsed anulus fibrosus
occurred after the age of 60 years old. A myxomatous degeneration of the annulus
fibrosus preceded and the of orientation of fibers was reversed in the ageing disc
(Yasuma et al, 1990).
2. Based on the anatomic location of the herniated disc along the circumference of the
annulus fibrosus:

Anterior : thus no neural compression is expected or

Posterior along the posterior annulus. The herniated disc can be Central (midline )
or Posterolaterally in disc space (the weakest portion of posterior annulus is on
either side of midline due to lack of reinforcement by PLL: ) or laterally
( foraminal ) or extraforaminal ( far lateral / lateral to the neural foramen ).

Central disc herniation may cause spinal stenosis and narrow one or both lateral recesses
affecting the forming nerve root at that level ( L5 roots at the L4-5 disc space as for
example ).
Posterolateral disc herniation affects the forming nerve root at the level of herniation ( at
the lateral recess zone).
Foraminal or extraforaminal herniation affects the exiting nerve root at the level neural
foramen or far lateral zone respectively. (e.g. L4 root at the L4-5 level).
The conus medularis is sacral end of the spinal cord at the level of L1-2 disc space
Below this the lumbar and sacral nerve roots extend caudally as the cauda equina within
the thecal sac. These lumbar nerve roots typically form and separate from the thecal sac
at the disc space level above the pedicle and travels caudally along the medial border of
the pedicle until it enters the neural foramen. The left and right spinal nerve exit below
their vertebral pedicle (L4 spinal nerve inferior to the L4 pedicle. The lateral border of
the forming spinal nerve is known as the shoulder of the nerve. The acute angle between
the formed spinal nerve and the continuity of thecal sac is known as nerve axilla.
The lateral recess zone is the region of the spinal canal between the lateral border of the
dural sac and a line connecting the medial border of the pedicles. The vertebral body and
disc form the anterior border and the posterior border is formed by anterior surface of the
superior articular process of the facet joint and the lateral expanse of the ligamentum
flavum. The lumbar nerve root forms in the lateral recess, generally at the level of disc
space.
The neural foramen is a space between adjacent pedicles through which the spinal nerves
pass segmentally. The upper / cephal half of the anterior border is made of the vertebral
body and the lower / caudal half is made of the intervertebral disc. The posterior border is
the facet joint, mainly the superior articular process of the lower vertebra.

The sympotamatic patient may present with:

a. Radiculopathy

Severe radiating lower extremity pain:

Low lumbar nerve: pain travels posterior in the thigh & leg radiating in the a
dermatome pattern; sole lateral foot (S1), dorsal aspect of the ankle and foot (L5).
Upper lumbar nerve: pain radiates to the anterior thigh (L2,3) ant knee and medial leg
(L 4).
The sciatica is commonly described as abrupt onset of sharp or stabbing pain.
More commonly constant but may vary in a severity with position and activity. The
patient is usually more comfortable stands than sit.
b. List to one side
Listing is away from the of pain in order to bring the compressed nerve root away
from the more poasterolateral disc herniation . Listing toward the side of leg pain may
indicate medial nerve compression from an axillary disc herniation.
c. Cauda Equina syndrome. It is caused by large central disc herniation at L4-5 or L3-4.
A low back pain, bilateral lower extremity pain, saddle anesthesia or dysthesia and motor
weakness in the leg are the usual presentation. The bowel and bladder incontinence may
occur. Such patient requires emergent imaging of spinal canal via MRI or CT myelogram
and emergent surgical intervention. Kostuik et al (1986) in a retrospective review of
31cases of cauda equina syndrome secondary to a central disc lesion identified two
modes of presentation. The first was an acute mode (10 patients) in which there were
abrupt, more severe symptoms and signs and a slightly poorer prognosis after
decompression, especially for the return of bladder function. The second mode of
presentation (21patients) was a gradual onset. All patients had urinary retention
preoperatively. Bladder function was the most seriously affected function preoperatively
and remained so postoperatively. The prognosis for return of motor function was good,
since 27 of the 31 patients who were operated on regained normal motor function.
Preoperatively all patients had sciatica. The average time to surgical decompression after
the patient was seen ranged from 1.1 days for the more acute lesions to 3.3 days for the
second group. There was no correlation of these times with return of function. Therefore,
even though early surgery is recommended, decompression does not have to be

performed in less than six hours if recovery is to occur, as has been suggested in the
pasted that decompression be done as soon as possible to allow maximum recovery and
minimize scar formation, which is known to be a sequel of prolonged neural
compression. The prognosis for motor recovery was the same after the two modes of
clinical presentation (majority within 6 weeks after surgery). However, recovery of
bladder function tended to be less in the patients with more acute symptoms. All but six
of thirty the patients who were operated on recovered
sensation completely within six months.
The radicular pain was most probably caused by nerve root compression by the
herniated nucleus pulposus as the leg pain was much greater compared to back pain.
However, when the leg pain is minimal and the back pain is predominant, precaution
should be taken before the condition can be diagnosed as a herniated intervertebral disc.
The leg pain worsened as the patients profession required him to sit and drive for long
hours.
As the acute episodes subsided, the degree of spasm diminishes remarkably. The
straight leg raise was still restricted to about 45 degree on the patients right leg. The
specific nerve root tension sign is elicited by slowly elevating the affected lower
extremity by the heel with the knee fully extended. Only reproduction or worsening of
radiating pain below the knee indicates a positive sign. Shiqing et al (1987) reported that
the distribution of pain on SLR allowed an accurate prediction of the location of the
lesion in 100 (88.5 per cent) of the 113 patients. A central protrusion tended to cause pain
in the back, lateral protrusions caused pain in the lower extremity, and intermediate
protrusions caused both (backache and leg pain).
Peripheral circulation, hip and knee joint motion have to be examined. An abdomen
examination: palpation followed by rectal tone and sensation is also important. Thorough
physical examination is important to avoid missing other cause of back pain or
radiculopathy. Among the common diseases that can mimic the disc disease includes
ankylosing spondylitis, multiple myeloma, vascular insufficiency, arthritis of the hip,
osteoporosis with stress fractures, extradural tumors, peripheral neuropathy, herpes zoster
and piriformis syndrome. The latter differential diagnosis is often overlooked. The

condition is usually derived from a clinical assessment. Durrani and Winnie suggested the
following diagnostic criteria for piriformis syndrome:

digital palpation of the piriformis muscle to reproduce sciatica

rectal or pelvic examination to rule out lateral pelvic wall tenderness and

reproduce sciatica

Freiberg and Pace signs

tonic external rotation of the affected lower extremity.

Anesthetic block in the piriformis muscle, imaging examination around the

piriformis muscle ( MRI ), and an electrophysiological method using H reflex

Nakamura et al (2002) evaluated the recorded action potentials from the lumbar spine
after stimulation of the peroneal nerve in patients with piriformis syndrome. The
measurement was used to support the diagnosis of piriformis sundrome. However the
objective test needs to be subjected for further clinical trial.
The diagnosis of herniated lumbar disc was almost certain by clinical judgment. The
radiological modalities for the evaluation of low back pain includes a plain radiograph,
myelography, computed tomography and magnetic resonance imaging ( Holtas S, 1993).
Magnetic resonance imaging provides the best imaging of the disc and neural tissues. A
sagittal MR images are useful for assessment of neural foramen and spinal canal. It is
important to correlate the clinical symptoms and signs to the finding of MR image. It
showed a posterolateral disc herniation which cause a narrowing at the right
intervertebral foramina between L5-S1 space. This correlated well with the initial clinical
assessment
Most patients with radiculopathy and documented lumbar disc herniation will have a
spontaneous resolution of symptoms without intervention over time in up to 90 % of
cases. These patients who will recover spontaneously will do so within the first 6-12
weeks. Reports of serial CT and MRI reviews in documented lumbar disc herniation have
shown a significant overall decrease in size of the herniated material over time,
presumably due to dehydration of the disc fragments and possibly due to resolution of the
herniation by an inflammatory responses (Haro H et al, 1996).
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The surgeon should be aware several important accepted concepts when treating a patient
with lumbar disc herniation (Mc Culloch, 1996):

More than 90% of patient with clinical signs and symptoms related to herniated
disc improves with a conservative treatment.

Only 2-4% of patients with herniated disc require surgical intervention.

A magnetic resonance imaging will reveal a herniated disc in about 20% of

asymptomatic patients age less than 60 years old.

A surgical intervention will improve the short-term outcomes for patients with
sciatica (satisfactory outcome in 90% of cases), but long-term outcome shows
little difference between those treated surgically and those treated conservatively.

Thus, it is worthwhile trying a good nonoperative treatment plan for most patient with
acute lumbar herniated disc. The initial goal is to control symptoms. Most patient respond
to nonsteroidal anti-inflammatory drugs (NSAIDs). Bed rest may be useful for 1 to 2
days but not longer. Once symptoms are controlled, start an activation rehabilitation
program. Such a program should include both an aerobic conditioning component and
trunk muscle strengthening.
Both trunk flexors and extensors should be strengthened. If the patient demonstrates good
progress, he or she can resume full activities at approximately 3 months after onset,
assuming that there is full compliance with an activation program. Physical therapy
should be used judiciously. The exercises should be fitted to the symptoms and not forced
as an absolute group of activities. Patients with acute back and thigh pain eased by
passive extension of the spine in the prone position can benefit from extension exercises
rather than flexion exercises. Improvement in symptoms with extension is indicative of a
good prognosis with conservative care. On the other hand, patients whose pain is
increased by passive extension may be improved by flexion exercises. These exercises
should not be forced in the face of increased pain. This may avoid further disc extrusion.
Malmivaara et al. compared the efficacy of bed rest alone, back extension exercises, and
continuation of ordinary activities as tolerated in the treatment of acute back pain. They

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concluded that continuation of ordinary activities within the limits permitted by pain led
to a more rapid recovery (Sprengler,1988).
The epidural a long-acting steroid with an epidural anesthetic injection is an
excellent method of symptomatic treatment of back and leg pain from discogenic disease
and other sources. Most studies show 60% to 85% short-term success rate that falls to
30% to 40% long-term (6-month) good result rate. The local effect of the steroids has
been shown to last at least three weeks at a therapeutic level. In a well-controlled study,
Berman et al found that the best results were obtained in patients with subacute or
chronic leg pain with no prior surgery. They also found that the worst results were in
patients with motor or reflex abnormalities (12% to 14% good results). However the
procedure is contraindicated in the presence of infection, neurological disease (such as
multiple sclerosis), hemorrhagic or bleeding disorder, cauda equina syndrome, and a
rapidly progressive neural deficit (Holmes, 1979).

There are a few indications for surgical intervention in patients with lumbar disc
herniation. This includes patients with a:

Cauda equina syndrome

Progressive motor weakness

The surgical intervention is also indicated in selected patient who has failed a trial of
three months of nonoperative treatment. Some centers consider the persistent of pain for
at least six weeks extending below the knee as failure of conservative treatment. The pain
should have been decreased by rest, anti-inflammatory medication, or even epidural
steroids but should have recurred to the initial levels after a minimum of 6 to 8 weeks of
conservative care (Eismont and Currier, 1989).

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The aim of surgery is:

To decompress the neural tissue

To provide pain relieve
To achieve segmental spinal stability
To replicate function of the natural disc
To preserve normal range of motion.
An appropriate patient selection is important prior disc surgery. The patient was already
suffering the leg pain for almost a year. The discectomy can be done as an elective case.
The limited open approach and discectomy (with or without a loupe magnification)
is an established procedure of proven efficacy. An adequate surgical exposure is
necessary. A small laminotomy with exposure of the lamina above and below to the level
of herniated disc is often adequate. However, a complete laminectomy may be necessary
in patient with a large herniated disc and who presented with a neurologic deficit. An
incision is made in the annulus fibrosus. The central and lateral part of the nucleus
pulposus is removed as much as possible. The nerve root should be easily displaced 1 cm
medially after the removal of herniated disc. Should the root remain fixed, additional
exploration of the foramina and the vertebral canal is necessary. The use of a loupe
magnification help to improve the visualization and handling of the nerve roots so that
iatrogenic irreversible neural injury can be avoided (Holmes, 1979).
Microsurgery lumbar discectomy is essentially similar to standard open discectomy
apart from limited but adequate illumination and magnification (with the use of
microscope). The procedure is technically demanding. Postacchini et al (2002)
conducted a prospective study involving 116 patients with motor deficits associated with
herniation of a lumbar disc that underwent microdiscectomy. They were studied during
the first six months and at a mean of 6.4 years after surgery. The muscle, which most
frequently had severe or very severe weakness, was extensor hallucis longus, followed in
order by triceps surae, extensor digitorum communis, tibialis anterior, and others. At the
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latest follow-up examination, 76% of patients had complete recovery of strength.

Persistent weakness was found in 16% of patients who had a mild preoperative deficit
and in 39% of those with severe or very severe weakness. Muscle strength was graded 4
in all patients with persistent weakness, except for four with a very severe preoperative
deficit affecting the L5 or S1 nerve root. Excluding this last group, the degree of recovery
of motor function was inversely related to the preoperative severity and duration of
muscle weakness.
Chemonucleolysis with chymopapain injection is another option to shrink the protruded
disc. An enzyme that is used will react with the central nucleus as a primary substrate
without necessarily affecting the protruded portion of the disc. However, the enzymatic
reaction is difficult to standardize with a set dosage because of wide varieties in the
composition of the substrate among patients. The procedure is not so popular because of
its higher failure rate. Rand et al showed improvement in only 66% of the patients using
chymopapain as compared to 85% to 90% in open discectomy. It is contraindicated in
sequestrated disc, patients who are allergic to papaya or its derivatives, previous surgical
treatment of the lumbar spine (Revel 1993).
Percutaneous Lumbar Discectomy is designed to mechanically decompress a herniated
lumbar disc through a posterolaterally-inserted cannula. Several technical challenges for
the posterolateral endoscopic procedure can be encountered (Yeong et al,2001):

A safe and effective access is limited to a narrow channel.

There is no or little working space (as compared with the procedure for knee and
shoulder joints)

The creation of intradiscal workspace is needed before intracanal disc fragment

extraction.

A herniated fragment is accessible only when the operating instrument is placed in

the optimal trajectory.

Delamarter et al (1995) reported microdiscectomy results of excellent, good, and fair in

99% of 184 patients. As with microsurgical discectomy and chemonucleolysis, it is
contraindicated in patients with a spinal stenosis (Eismont, 1989).
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Conclusion
The limited open approach and discectomy was an appropriate decision made by the
surgeon as the diagnosis was confirmed by a magnetic resonance image. The offending
herniated disc can be removed with certainty. The surgical procedure is relatively safe as
compared to other techniques with predictable surgical outcome. However, both the
surgeon and the patient must realize that disc surgery is not a cure but may only provide a
symptomatic relief. It neither stops the pathological processes that allowed the herniation
to occur nor return the patient the back to its previous state. The patient must still practice
a good posture and body mechanics after surgery. Activities that involves a repetitive
bending, twisting, and lifting with the spine in flexion may have to be curtailed or
eliminated. Some permanent modification in the patients life-style may be necessary if a
prolonged relief is to be expected.

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