Genesis Chiropractic Spine & Sports Center
7940 South University Blvd Suite 100, 
Centennial Co 80109
Phone (303) 927-6181 or (720) 515-8002
Email: GenesisSpineCenter@gmail.com
Genesis Chiropractic Spine & Sports Center      













Herniated Disc

General Information

 

Description:

  • Protrusion, extrusion, or sequestration of intervertebral disc from usual anatomic location, which may be asymptomatic, or which may result in radiculopathy or nonradicular pain

Also called:

  • Slipped disc
  • Prolapsed disc
  • Bulging disc
  • Ruptured disc
  • Herniation of nucleus pulposus (HNP)

Definitions:

  • Sciatica - type of radicular pain that originates in lower back and radiates down posterior or lateral thigh; etiology may be disc herniation or other cause

Incidence/Prevalence:

  • High rate of magnetic resonance imaging (MRI)- or computed tomography (CT)-detected disc herniation (20%-36%) among asymptomatic patient population
  • Prevalence of symptomatic herniated lumbar disc reported to be 1%-3% in Finland and Italy (Am Fam Physician 2006 Apr 1;73(7):1240)

Causes and Risk Factors

Causes:

  • Disc degeneration associated with normal aging
  • Recent trauma in children (Acta Paediatr 2010 Jan;99(1):19  

Pathogenesis:

  • Disc dehydration and increased collagen concentration associated with normal aging may disrupt annular fibers, predisposing disc to herniation of nucleus pulposus
  • Mechanisms of lumbosacral radicular pain include
    • Mechanical compression of nerve root by herniated material
    • Sensitization of nerve root by bioactive molecules, including inflammatory factors

Possible risk factors:

  • Factors associated with increased risk of sciatica include(1)
    • Sedentary lifestyle
    • Chronic cough
    • Pregnancy
    • Smoking
    • Frequent lifting of heavy objects

  • Family history of lumbar disc herniation may increase risk
    • Based on case-control study of 2,010 patients with lumbar disc herniation compared to 2,170 controls
    • Family history of lumbar disc herniation associated with increased risk (odds ratio [OR] 3.55, no p value reported)
    • Reference - Nan Fang Yi Ke Da Xue Xue Bao 2010 Nov;30(11):2488
  • genetic risk factor identified in case-control study, Trp3 allele in collagen IX alpha-3 protein gene present in 12% patients with sciatic pain and lumber disk disease and 5% controls (JAMA 2001 Apr 11;285(14):1843), editorial can be found in JAMA 2001 Apr 11;285(14):1886

  • Increased body mass index (BMI) associated with increased risk for lumbar disc herniation
    • Based on case-control study of 564 patients with lumbar disc herniation compared to 901 population controls
    • Structured personal interviews determined weight at different ages and other lifestyle factors
    • BMI ≥ 24.3 to < 29.21 associated with increased risk (OR 2.1, 95% CI 1.3-3.6)
    • Reference - Arthritis Res Ther 2010;12(5):R193 

  • Some cardiovascular risk factors appear associated with increased risk of symptomatic lumbar disc herniation
    • Based on prognostic cohort study
    • 98,407 female nurses without lumbar disc disease at enrollment were followed for 16 years
    • Physician-diagnosed and imaging-confirmed lumbar disc herniation in 2,727 (2.8%) nurses
    • Factors associated with increased risk of lumbar disc herniation included
      • Diabetes (adjusted relative risk [RR] 1.52, 95% CI 1.17-1.98)
      • Hypertension (adjusted RR 1.25, 95% CI 1.11-1.41)
      • High cholesterol (adjusted RR 1.26, 95% CI 1.1-1.44)
      • Having parent with myocardial infarction before age 60 (adjusted RR 1.13, 95% CI 1.02-1.26)
    • Reference - Spine J 2006 Nov-Dec;6(6):684

Factors not associated with increased risk:

  • Lifetime occupational driving patterns did not affect risk for lumbar disc degeneration in study of 45 twins with differing occupational driving patterns (Lancet 2002 Nov 2;360(9343):), commentary can be found in Lancet 2003 Feb 8;361(9356):531

Complications and Associated Conditions

Complications:

  • Acute cauda equina syndrome - neurologic emergency most often caused by large central disc herniation compressing low lumbar and sacral nerve roots
    • Saddle anesthesia
    • Changes in bowel or bladder habits (such as fecal incontinence or urinary retention)
    • Progressive leg weakness (possibly paraplegia)
  • Persistent, long-term back pain

Associated conditions:

  • Degenerative joint disease of the low back
  • Lumbar spinal stenosis
  • Degenerative spondylosis

History and Physical

History:

Chief concern (CC):

  • Pain typically in back and/or radiating into leg
  • Sensory loss, paraesthesias, or muscle weakness

History of present illness (HPI):

  • Radiating pain involving leg and/or low back, which may be described as
    • Sharp, dull, piercing, aching, burning, or throbbing
    • Severe and function-limiting
    • Worse when bending forward, sitting, coughing, sneezing, or straining
    • Relieved by lying down or walking
    • Worse in leg than in lower back
    • Only in leg and not in back at all

  • Nonradiating lumbar back pain possible
  • Sensory or motor abnormalities in lower extremities, including
    • Cold, tingling, pricking, or numbness
    • Loss of sensation
    • Muscle weakness
  • Patients with cognitive or neurologic impairment may not complain of pain or have typical pain behavior, but may have change in function
  • Ask about "red flag" findings that may indicate serious underlying pathology, or suggest cause other than lumbar disc herniation

Red Flag Symptoms and Findings with Associated Spinal Disorders:

 

Cauda Equina

Infection

Fracture

Cancer

Fecal incontinence

x

 

 

 

Saddle anesthesia

x

 

 

 

Urinary retention

x

 

 

 

Immunosuppression

 

x

 

 

IV drug use

 

x

 

 

Unexplained fever

 

x

 

 

Chronic steroid use

 

x

x

 

Osteoporosis

 

 

x

 

Significant trauma at any age

 

 

x

 

Age > 50 years

 

 

x

x

History of cancer

 

 

 

x

Unexplained weight loss, general malaise

 

 

 

x

Focal neurologic deficit in lower extremity

 

x

x

x

Progressive or disabling symptoms

 

x

x

x

Imaging is highly recommended for patients with positive red flag symptoms

Red Flag Symptoms and Findings with Associated Spinal Disorders:

  • Ask about
    • Pregnancy
    • Chronic cough

Past medical history (PMH):

  • In addition to identifying red flag findings, ask about
    • Infectious disorders (such as HIV, herpes zoster, epidural abscess, Lyme disease)
    • Structural deformities of spine
    • Mild trauma for patients ≥ 50 years old