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|Description |Inflammation of a nerve root in the lumbar region of the spine due to compression | |

| |by an extruding disk. | |

|Pathology (organ, cell, system)|Grossly, cracks develop in the disc, which shrinks and buckles out. There is |UpToDate Online: Lumbosacral |

| |narrowing of the disc space. |Radiculopathy |

| |Microscopically, there are changes in disk proteoglycan composition. | |

|Pathophysiology |There are two foramina underneath an individual lumbar vertebrae. The spinal nerve|UpToDate Online: Lumbosacral |

| |roots pass through these foramina. These foramina are bordered anteriorly by the |Radiculopathy |

| |intervertebral disc, which separates the vertebral bodies. The disc consistes of an| |

| |outer annulus fibrosus and an inner nucleus pulposus, which has the consistency of | |

| |tooth paste and provides the disc with its shock absorbing qualities. | |

| |Age-related: There are age related changes in the disk, including altered | |

| |proteoglycan composition and disk space narrowing. The annulus fibrosus becomes | |

| |fibrotic and develops fissures. As the disk space narrows, the inner nucleus | |

| |pulposus may buckle out and compress a nerve root, leading to radiculopathy. | |

| |Traumatic: herniation may occur secondary to heavy lifting while bent at the waist.| |

| |Most disk herniations occur at the L4-L5 and L5-S1 levels. | |

|Differential Diagnosis |Spinal stenosis: Symptoms are exacerbated by standing in an erect posture (back |UpToDate Online: Lumbosacral |

| |extension). Flexion relieves symptoms. This is most commonly caused by |Radiculopathy |

| |degenerative spondylosis. | |

| |Cauda equine syndrome: may present with radiculopathy, but would also expect | |

| |bowell/bladder incontenance. | |

| |There are multiple etiologies for nerve root compression leading to radiculopathy. | |

| |These include metastases and spinal abscesses. | |

| |Sacroiliitis may also cause lower back pain with radiculopathy. | |

|Epidemiology |Prevalence is equal in men and women. Lifetime prevalence is around 3-5% in |UpToDate Online: Lumbosacral |

| |adults. Incidence increases with age. Men typically develop symptoms in their |Radiculopathy |

| |40’s, while women are typically affected between 50 and 60. |Lumbosacral adiculopathy. |

| | |Tarulli AW; Raynor EM. Neurol |

| | |Clin. 2007 May;25(2):387-405. |

|Etiology |This disease is caused by the nucleus pulposis extruding through the annulus |UpToDate Online: Lumbosacral |

| |fibrosis and impinging upon nerve roots. What causes this herniation? Disk space |Radiculopathy |

| |narrowing and changes in disk structure have been noted with age. Fissures develop| |

| |in the annulus fibrosus. This provides a mechanism for nucleus pulposis | |

| |herniation. | |

|Clinical manifestations |Patients present with lower back pain, stiffness, and radiculopathy due to |UpToDate Online: Lumbosacral |

| |compression of the nerve root by the herniated disk. |Radiculopathy |

| |Sciatica is a common term that refers to pain along the sciatic nerve in | |

| |radiculopathy. | |

| |Forward flexion (sitting, lifting, going up stairs) exacerbates pain. (This is key| |

| |to differentiate from spinal stenosis). Anything that increases intraspinal | |

| |pressure such as coughing will exacerbate symptoms. | |

| |L5 radiculopathy is the most common, which presents with back pain radiating down | |

| |the lateral side of the lower leg. There may be weakness of hip flexion, knee | |

| |extension, and hip abduction. Knee reflexes may be reduced given the weakness. | |

| |Sensation may be affected from the anterior thigh down to the medial lower leg. | |

| |It should be noted that these findings are neither sensitive nor specific for disc | |

| |herniation; many herniated disks are not symptomatic. Lower back pain and | |

| |radiculopathy have a broad differential and are not specific for disk herniation. | |

| |The straight leg raise test is a sensitive but not specific test to diagnose | |

| |radiculopathy due to disc herniation. Raising the patients leg (symptomatic side) | |

| |from the supine position will increase dural tension in the lumbar levels and may | |

| |reproduce radicular pain. | |

|Late presentation, |Symptoms will resolve in most instances of untreated disease. |UpToDate Online: Lumbosacral |

|complications |While rare, there are instances in the literature of disk herniation progressing to|Radiculopathy |

| |cord compression/cauda equine syndrome. |Spine (Phila Pa 1976). 2009 Nov |

| | |15;34(24):2711-3. |

| | |Cauda equina syndrome caused by a |

| | |complete traumatic lumbar disc |

| | |complex extrusion without |

| | |alterations of facet joints. |

| | |González-Bonet LG, Mollá-Torró JV.|

| | |Department of Neurosurgery, |

| | |Hospital de La Ribera, Alzira, |

| | |Valencia, Spain. |

|Nutritional factors |The main nutritional risk factor is a diet predisposing to obesity. Obesity and |Spine 2009 Dec 1;34(25):E918-22. |

| |increased lumbar loads are key risk factors for disk herniation. Weight loss |Risk factors for lumbar |

| |and/or a normal BMI are important to minimize risk. |intervertebral disc herniation in |

| | |Chinese population: a case-control|

| | |study. |

| | |Zhang YG, Sun Z, Zhang Z, Liu J, |

| | |Guo X. |

|Radiographic evidence |XRAY – Very insensitive for the diagnosis of disc herniation (poor soft tissue |UpToDate Online: Lumbosacral |

| |resolution), but helpful for narrowing the differential and ruling out tumors, |Radiculopathy |

| |infections, and fractures. | |

| |MRI is a sensitive modality that identifies most pathology that would indicate | |

| |surgical intervention. T2 MRI may show the extension of a disk (black disk | |

| |separating gray vertebral bodies) protruding from the disk space. A black disk | |

| |indicates a lack of water and proteoglycan, which is consistent with degenerative | |

| |disk disease. | |

| |CT: Better soft tissue resolution than Xray, but inferior to MRI. This can also | |

| |show the shape and contents of the spinal canal as well as the surrounding soft | |

| |tissue. | |

|Laboratory evidence |EMG may be used to distinguish weakness secondary to pain-related reduced effort |UpToDate Online: Lumbosacral |

| |from neurogenic weakness, which may be observed in nerve root compression. |Radiculopathy |

| |There are no true laboratory abnormalities that aid in establishing a diagnosis of | |

| |disk herniation, although normal lab values may help to rule out other possible | |

| |etiologies of lower back pain. | |

|Psychosocial impact of disease |Lower back pain is commonly associated with depression. The pain can be persistent| |

| |and may generate limitations in a patient’s daily activities. While a causal | |

| |relationship has not been established, mental side-effects of chronic pain can be | |

| |substantial. While the physical limitations of chronic lower back pain and | |

| |radiculopathy may be easily appreciated, the mental side-effects should not be | |

| |overlooked. | |

|Risk factors |Family history, lumbar load (and obesity), and patients who worked longer hours |Spine 2009 Dec 1;34(25):E918-22. |

| |with a larger “time urgency” were found to be at increased risk for disk |Risk factors for lumbar |

| |herniation. |intervertebral disc herniation in |

| |Physical exercise and sleeping on a hard bed were isolated as potential protective |Chinese population: a case-control|

| |factors. |study. |

| | |Zhang YG, Sun Z, Zhang Z, Liu J, |

| | |Guo X. |

|Prevention |Lumbar support, hard sleeping surface, and physical activity had been shown to be |Spine 2009 Dec 1;34(25):E918-22. |

| |protective factors. These are simple cost-effective interventions. Maintaining a |Risk factors for lumbar |

| |normal BMI is also important for minimizing lumbar load. |intervertebral disc herniation in |

| | |Chinese population: a case-control|

| | |study. |

| | |Zhang YG, Sun Z, Zhang Z, Liu J, |

| | |Guo X. |

|Treatment options |Conservative management in these patients may involve NSAIDS, brief rest period |UpToDate Online: Lumbosacral |

| |following by physical therapy, oral steroids, epidural cortisone injections, lumbar|Radiculopathy |

| |back support, and weight loss. |Vroomen PC, de Krom MC, Knottnerus|

| |Spinal manipulation/chiropractic treatment is contraindicated. |JA (Feb 2002). "Predicting the |

| |Surgery should only be considered after pain has proven refractory to conservative |outcome of sciatica at short-term |

| |management. Surgery is also indicated in the event of bowell/bladder incontenance |follow-up". Br J Gen Pract 52 |

| |and neurological deficits. |(475): 119–23. |

| |There are several surgical treatment options, including laminectomy, discectomy, | |

| |and chemonucleolysis. In chemonucleolysis, the disk is chemically dissolved. In | |

| |discectomy, the nucleus pulposus is removed to decompress the affected nerves. In | |

| |laminectomy, the lamina of the vertebra is removed to increase the size of the | |

| |spinal canal to decompress spinal nerves. This is also a common treatment for | |

| |spinal stenosis. | |

|Outcomes of treatment |Most herniated disks will heal without treatment. It has been shown in one study |Vroomen PC, de Krom MC, Knottnerus|

| |that 73% of patients displayed reasonable to major improvement without surgery. |JA (Feb 2002). "Predicting the |

| |The Hague Spine Intervention Prognostic Study Group found that rates of pain relief|outcome of sciatica at short-term |

| |and of perceived recovery were faster for patients assigned to early surgery, |follow-up". Br J Gen Pract 52 |

| |although 1 year outcomes were similar for conservative treatment plus eventual |(475): 119–23. |

| |surgery as needed versus early surgery. | |

|Potential |One study of lumbar microdiscectomy found complication rates of 6.7% when the |Can J Neurol Sci. 2010 |

|Complications of treatment |procedure was performed by surgeons who did not specialize in spinal surgery versus|Jan;37(1):49-53. |

| |7.3% in spine specialists, a statistically insignificant difference. 71% of |Admission and acute complication |

| |complications were dural tear, 4% urinary retention, and 25% were transient or |rate for outpatient lumbar |

| |permanent new radiculopathy. There were no incidences of vascular injury. |microdiscectomy. |

| | |Fallah A, Massicotte EM, Fehlings |

| | |MG, Lewis SJ, Rampersaud YR, |

| | |Ebrahim S, Bernstein M. |

| | | |

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