II. Epidemiology
- Ages affected
- Disc Herniation rarely occurs before age 20 years
- Age 20-30 years: Up to one third have at least one degenerative lumbar disc
- Most common ages 30 to 50 years
- Most common spinal levels affected (95% of lumbar disc)
- Olympic athletes (worldwide, multiple sports)
- L5-S1 disc displacement in 58%
- Ong (2003) Br J Sports Med 37(3): 263-6 [PubMed]
III. Mechanism
- Progressive degeneration of disc nucleus pulposus
- Results from normal aging or repetitive Trauma
- Protrusion of disc (most commonly posterior-lateral)
- Herniation affects spinal root one level below
- Other Changes: Spondylosis (Chronic disc deterioration)
- Spur Formation
- Disc space narrowing
- Facet joint degeneration
IV. Symptoms
- See Low Back Pain
- Always inquire about Low Back Pain Red Flags (e.g. Cauda Equina Syndrome symptoms, fever, IVDA, Cancer)
- Usually insidious onset
- Acute Trauma may have preceded symptoms
-
Low Back Pain (deep aching)
- Aggravated by activity, coughing, sneezing or Valsalva Maneuver
- Provoked by prolonged sitting and forward bending
- Relieved by rest
- Localized to affected disc
- Intense Radicular Pain
- See Sciatica
- Referred pain to iliac crest or buttock
- Radiation of pain down posterior thigh and calf
- Pain may radiate into foot
-
Paresthesias
- Numbness or tingling in distal extremity
V. Signs
- Restricted low back range of motion
- Pain exacerbated by bending to affected side
- Local tenderness and Muscle guarding
- Painful gait
- Posturing to avoid pressure on disc
- Bent away from affected side
- Hip and knee flexed on affected side
- Nerve Root Tension Tests
-
Neurologic Examination
- Deep Tendon Reflexes
- L4 Nerve Root (L3-4 disc): Patellar Reflex
- S1 Nerve Root (L5-S1 disc): Achilles Reflex
- Motor Exam
- Sensory Exam
- L4 Nerve Root (L3-4 disc): Medial malleolus
- L5 Nerve Root (L4-5 disc): Dorsal third metatarsophalangeal joint
- S1 Nerve Root (L5-S1 disc): Lateral heel
- Deep Tendon Reflexes
- Radicular patterns by disc Herniation type
- Central DIsk Herniation
- Nerve root affected is ABOVE the disc
- Example: Central L3 disc Herniation causes findings above the L2-3 Nerve root
- Paracentral disk Herniation
- Nerve root affected is AT the disc
- Example: Paracentral L3 disc Herniation causes findings at the L2-3 Nerve root
- Lateral disk Herniation
- Nerve root affected is BELOW the disc (foraminal effects)
- Example: Lateral L3 disc Herniation causes findings at the L3-4 Nerve root
- Central DIsk Herniation
VI. Diagnosis
- Findings with strongest Positive Predictive Value for Lumbar Disc Disease
- Symptoms: Sciatica pain associated with:
- Pain in leg worse than back
- Typical Dermatomal Distribution of pain
- Pain provoked by Valsalva Maneuver
- Exam findings
- Crossed Straight Leg Raise positive
- Weak ankle dorsiflexion
- Absent ankle reflex
- Calf Muscle wasting (late finding)
- Symptoms: Sciatica pain associated with:
- Findings with strongest Negative Predictive Value for Lumbar Disc Disease
- No Sciatica
- Negative Straight Leg Raise
VII. Differential diagnosis
- See Sciatica
- See Low Back Pain Red Flags
- See Musculoskeletal Low Back Pain
- Lumbar spine Degenerative Joint Disease
- Lumbar Radiculopathy due to spine degeneration (osteophytes or bone spurs) typically follows a fixed or progressive course
- Contrast with Lumbar Disc Herniation which tends to improve as the disc Herniation resorbs
- Spinal Cord Tumor
- Consider especially in age under 20 or over 60 years
- Relentless pain aggravated or not relieved with rest
VIII. Imaging
- See Low Back Imaging
-
Lumbar Spine MRI has a 50% False Positive Rate (asymptomatic findings)
- Correlate pain and symptoms with MRI findings
IX. Management: Rehabilitation
X. Course
- Mild cases frequently resolve within 1-2 weeks
- Spontaneous recovery is the rule (90% in 6 weeks)
- Other cases may persist with moderate pain for 6 months
- Long-term outcomes are not improved with surgery (outcomes the same at 2 years)
XI. Complications
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Related Studies
Concepts | Disease or Syndrome (T047) |
ICD10 | M54.17 |
SnomedCT | 2415007 |
English | lumbosacral root lesions (diagnosis), lumbosacral root lesions, nerve root and plexus disorder lumbosacral root lesions, Radiculopathy, lumbosacral region, lumbosacral radiculopathy, lumbosacral root lesion, radiculopathy of lumbosacral region (diagnosis), radiculopathy of lumbosacral region, Lumbosacral radiculopathy (disorder), Lumbosacral radiculopathy, Lumbosacral root lesion, lesion; lumbosacral, root, Lumbosacral radiculopathy, NOS, Lumbosacral root lesion, NOS |
Dutch | lesie; lumbosacraal, wortel |
Spanish | lesión de la raíz lumbosacra (trastorno), lesión de la raíz lumbosacra, radiculopatía lumbosacra |
Ontology: Prolapsed lumbar disc (C0281899)
Concepts | Acquired Abnormality (T020) |
SnomedCT | 156632000, 202708005 |
English | Prolapse lumb intervert disc, Prolapsed lumbar disc, Lumbar disc herniation, bulging lumbar disc, herniated lumbar disc, extruded lumbar intervertebral disc (diagnosis), herniated lumbar intervertebral disc, extruded lumbar intervertebral disc, extruded lumbar disc, bulging of lumbar intervertebral disc (diagnosis), herniated lumbar intervertebral disc (diagnosis), bulging of lumbar intervertebral disc, Slipped lumbar disc, herniated lumbar disk, herniated lumbar nucleus pulposus, lumbar disc prolapse, prolapsed lumbar disc, discs lumbar prolapsed, lumbar herniated disk, disc lumbar prolapse, prolapsed disc lumbar, disk herniated lumbar, herniated disk lumbar, disc lumbar prolapsed, Prolapsed lumbar intervertebral disc, Prolapsed lumbar intervertebral disc (disorder) |
Dutch | tussenwervelschijf dislocatie lumbaal, hernia van lendewervel, prolaps tussenwervelschijf lumbaal |
French | Hernie discale lombaire, Disque lombaire prolabé, Hernie du disque lombaire |
German | Vorfall einer Bandscheibe, verlagerte lumbale Bandscheibe, Lendenwirbelhernie |
Italian | Ernia di disco lombare, Ernia del disco lombare, Disco lombare prolassato |
Portuguese | Disco lombar deslocado, Disco lombar prolapsado, Herniação do disco lombar |
Spanish | Hernia discal lumbar, Disco lumbar prolapsado, prolapso de disco intervertebral lumbar (trastorno), prolapso de disco intervertebral lumbar |
Japanese | 腰部椎間板すべり症, 腰部椎間板脱出, 腰椎椎間板ヘルニア, ヨウツイツイカンバンヘルニア, ヨウブツイカンバンスベリショウ, ヨウブツイカンバンダッシュツ |
Czech | Herniace lumbální destičky, Vyhřezlá bederní ploténka, Prolaps bederní ploténky |
Hungarian | Lumbalis discus herniatio, Félrecsúszott lumbális discus, Lumbalis prolabált discus |
Ontology: Lumbar disc lesion (C0549374)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 156629003, 268076000, 274137005 |
Dutch | tussenwervelschijflaesie lumbaal |
French | Lésion d'un disque lombaire, Discopathie lombaire, LESION DISQUE LOMBAIRE |
German | lumbale Bandscheibenschaedigung, DISKUSSCHAEDIGUNG IM LENDENBEREIC |
Italian | Lesione del disco lombare |
Portuguese | Lesão de disco lombar, Lesão do disco lombar, LESAO DO DISCO LOMBAR |
Spanish | Lesión de disco lumbar, lesión de disco lumbar (trastorno), lesión de disco lumbar |
English | Lumbar disc lesion, LUMBAR DISC LESION, Disc lesion lumbar, Lumbar disc lesion (disorder) |
Japanese | 腰部椎間板病変, ヨウブツイカンバンビョウヘン |
Czech | Léze bederní ploténky |
Hungarian | Lumbalis discus laesio |
Ontology: Lumbar radiculopathy (C1263855)
Concepts | Disease or Syndrome (T047) |
ICD10 | M54.16 |
SnomedCT | 2415007, 128196005 |
Italian | Radicolopatia lombare |
Japanese | 腰髄神経根障害, ヨウズイシンケイコンショウガイ |
English | Lumbar radiculopathy, NOS, lumbar radiculopathy, lumbar radiculopathy (diagnosis), Radiculopathy, lumbar region, radiculopathy lumbar, Lumbar radiculopathy, Lumbar radiculopathy (disorder), lumbar; radiculitis, radiculitis; lumbar |
Czech | Lumbální radikulopatie |
Hungarian | Lumbalis radiculopathia |
Dutch | lumbalis; radiculitis, radiculitis; lumbalis, lumbale radiculopathie |
Spanish | radiculopatía lumbar (trastorno), radiculopatía lumbar, Radiculopatía lumbar |
Portuguese | Radiculopatia lombar |
French | Radiculopathie lombaire |
German | Radikulopathie der Lendenwirbel |