Lumbar Disc Herniation

Areesak Chotivichit, M.D.

Associate Professor
Orthopaedic surgery
Siriral Hospital

Thaispineclinic.com
 Anatomy
Outer anulus fibrosus
(type I collagen)
Inner anulus fibrosus
(type II collagen)
Central nucleus
pulposus (type II
collagen,
proteoglycans)
[type X found in
degenerated disc]
 Disc degeneration
Anulus: 25
concentric lamellae of
collagen fibers,
angles 60 vertically แสดงความเสือ่ มของหมอนรองกระดูก
[120 to other fibers.]
Degeneration
Well hydrated
proteoglycan > อายุ 50 อายุ20 อายุ50

desiccated
fibrocartilaginous
annulus fissuring
Disc degeneration

multifactors
 Mechanism of pain:
Radicular pain: nerve root, dorsal root ganglion
Mechanical deformation
Inflammatory response> auto immune
Axial pain: muscles, disc, facets, dorsal root
ganglion
Mechanical
Inflammation
[*dorsal root ganglion can cause both pain*]
 Anatomy

pain Nerve supply

 Imaging and classification
MRI is the gold standard especially T2
weighted.
– 22% and 36% of MRI in asymptomatic pt had
disc herniation (<60, >60 yo)
– Contained [protrusion] / noncontained disc[
extrusion = subligamentous or
– transligamentous relative to PLL,
sequestration = free fragment]
 Conservative Rx.
works most of the time!
The life time prevalence for surgical
intervention = 1-3%
90% have gradual resolution within 3
months.
Most of the non contained will be resorbed
* MRI >not always indicated in the first 6
weeks*
Rx. Bed rest 2-3 days, meds, PT [no traction]
Epidural steroid, selective nerve blocks
 Surgical Rx.
Discectomy yields faster resolution of the
symptoms
Outcomes at 4 years were equal both
conservative and surgery
Isolated back pain in the absence of
radicular signs and symptoms is
contraindicated to discectomy [except for
the large central herniation]
 Indications:
Definite:
– progressive neurological deficit [not static]
– cauda equina
– profound neurological deficit
Relative:
– persistent radiculopathy > 6 weeks
– recurrent episode of incapacitating sciatica
– persistent motor deficit with tension sign and pain
– pseudoclaudication [+ stenosis]
*DISCECTOMY IS NOT FOR BACK PAIN*
25 yo female with Lt. sciatica for 6 months
 T2

T1 T2
 Technique:
If transligamentous extrusion or sequestered
disc, take the fragment out and check the defect
at the annulus. If the defect is smaller than 3 mm
(only a Penfield 4 can get in) then no further
removal of the disc content. If not sure, do as in
the 2.
If contained disc, make a slid (oblique) just
enough to get the punch in and remove only
loosed fragment of the nucleus. Irrigation with
syringe and Medicut [no 18] help loosen up
some of the degenerated fragment out.
 Recurrence
Carragee EJ JBJS Am 2003 Jan; 85-A (17): 102-8
All Pts Frag- Frag- Frag- No-frag
fiss defect cont cont
No 180 89 33 42 16
Recur % 11.7 1.1 27.3 11.9 37.5
Doc 8.9 1.1 27.3 9.5 12.5
rehern %
Reop % 6.1 1.1 21.2 4.8 6.3
Non fragment contained disc had highest recurrent rate
but only 1/3 had documented reherniation. Only ½ of
these required reoperation.
 Recurrence
Gaston P.
– JBJS Br. 2003 May;85(4):535-7
Reoperation after microdiscectomy in 993 patients
= 4.9% at 5 years and = 7.9% at 10 years (K-M
survival analysis)
Morgan- Hough CV .
– JBJS Br. 2003 Aug;85(6):871-4
Revision rate after 553 discectomy = 7.9% (most
were contained disc) 16 years fw
Osterman H: Spine 2003March 15;28(6): 621-7
– 14% of 35309 pts with discectomy had at least one
reoperation(1987-1998)
– Pts with one reoperation had a 25% cummulative risk
of further spinal surgery in 10 years
– If the first reoperation was spinal fusion ,risk of having
further surgery = 5%

* Many patients have life after discectomy*

 Alternative Rx.
Automated percutaneus lumbar discectomy
– Banaldi G. Neuroradiology 2003 Oct; 45(10)
735-43
Good result of 67% at 6 months (1350 pts down to
1047)
Epidural steroid / selective nerve block
– Wang JC: J spinal disopder tech.2002 Aug;
15(4): 269-72
77% success delayed surgery 12-24
months
 Alternatives
Radiofrequency
nucleoplasty
– Wetzel FT : Spine 2002
Nov 15;27(22): 2621-6
review of articles :
60-70% had improvement
of pain
Degradation of results
with time 3-6 months
Follow up period 6- 24
months
Number of patients were
small ( < 100)
 Alternatives
Fusion + discectomy [posterior or PLIF or
TLIF]:
– for a primary herniated lumbar disc is far over beyond
a standard of care [subject the patients to take higher
risk for complications ,cost and adjacent
degeneration. [TO BE COMDEMED]
Lumbar disc arthroplasty
– [so called ‘expanded indication’]:
– for a primary herniated lumbar disc is far over beyond
a standard of care [subject the patients to take higher
risk for complications and cost. [TO BE COMDEMED]
 Special sites for herniation
Foraminal disc :
– compress the root at the level above [L4-5 >
root 4] Require postero-lateral approach
through intertransverse lig. Can cause severe
pain due to dorsal root ganglion compression.
Far out lateral disc:
– same as foraminal disc.
Foraminal disc
High lumbar
herniation(L2,3) :
– usually occur in older
patient. The disc is
quite far up from the
interlaminaspace
especially if it migrates
up to the pedicle level.
A hemilaminectomy
might require.
Degenerative disc
herniation (hard disc)
if associates with
lateral recess or
foraminal stenosis, it
should be removed
[may need curette or
high speed burr]
Hard disc bulging
associate with
degenerative
spondylolithesis usually
do not require discectomy
in the lower lumbar area
because the lamina is
decompressed in a
lordotic spine except
obvious compression
seen [then fusion is
necessary]
 Differential [in elderly]
Lateral recess
stenosis from the
osteophyte of the
superior facet
Facet subluxation in
spondylosis can
impinge the nerve in
the foramen
 Complications

Perioperative:
– wrong level, wrong side, incidental durotomy,
nerve root injury = 0.2%, infection =1 %
Late:
– disc space infection [disabling back pain at 3-
6 weeks], instability