Lumbar disc disease

Ravindra Kumar Garg MD (Dr. Garg of King George's Medical University in Lucknow, India, has no relevant financial relationships to disclose.)
James G Greene MD PhD, editor. (Dr. Greene of Emory University School of Medicine has no relevant financial relationships to disclose.)
Originally released July 30, 1997; last updated June 7, 2016; expires June 7, 2019

This article includes discussion of lumbar disc disease, degenerative lumbar disorders, discogenic low back pain, lumbar degenerative disc disease, slipped disc, lumbar disc herniation, lumbar disc bulge, lumbar disc protrusion, lumbar disc extrusion, lumbar disc prolapse, herniated lumbar disk, low back pain, and lumbar spinal stenosis. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Lumbar disc disease is considered a very important cause of lower back pain. In lumbar disc disease, back pain (sciatica) occurs because a disc herniation irritates the displaced nerve root. A herniated disc fragment is in fact protrusion of the nucleus pulposus of the disc through the annulus fibrosus. Herniated disc, in severe cases, can produce dysfunction of the nerve. MR is the imaging method of choice of lumbar disc disease because of its capability of multiplanar imaging, excellent resolution, and absence of hazardous radiation. CT remains an efficient and accurate method of evaluating the spine. MRI often reveals herniated disks in asymptomatic subjects as well. The prevalence of herniated disks increases with increasing age. Medical management includes bed rest, analgesics, and muscle relaxants. The indications for surgical treatment of symptomatic lumbar disc disease are controversial. Definite indications include the cauda equina syndrome, progressive loss of motor strength, and severe intractable pain. In this article, the author discusses these controversies and reviews the latest information on epidemiology, pathophysiology, diagnostic studies, and management.

Key points

 

• Lumbar disc disease is a frequent cause of lower back pain (sciatica).

 

• Back pain occurs because a disc herniation irritates the displaced nerve root.

 

• A herniated disk is protrusion of the nucleus pulposus of the disc through the annulus fibrosus.

 

• MR is the imaging method of choice of lumbar disc disease.

 

• Medical management includes bed rest, analgesics, and muscle relaxants.

 

• Surgical treatment of symptomatic lumbar disc disease is controversial.

 

• Definite indications of surgery include the cauda equina syndrome, progressive motor loss, and intractable pain.

 

• Treatment failures are common.

Historical note and terminology

Egyptian, Greek, Roman, and Arabic text books mention sciatica pain considered to be often originating from the hip joint. Descriptions of lumbago and sciatica are available in many ancient books like the Bible and the writings of Hippocrates (460-370 BC) (Bhatt 2013). Laminectomy was performed for the first time in 1829, by Smith AG. Mixter and Barr published their original report of lumbar disc herniation in the New England Journal of Medicine as the cause of backache and leg pain (Mixter and Barr 1934).The introduction of MRI in the 1970s contributed tremendously in the understanding of lumbar disc disease.

Clinical terms in common usage are not uniformly defined, and they refer only to radiologic or pathologic description and do not imply specific disease entities. A disc bulge indicates a nonfocal contour abnormality beyond the normal margins of the intervertebral space. A disc protrusion is a focal contour abnormality where disc material is contained behind an intact annulus. Disc extrusion refers to extension of nuclear material through the annulus (disc rupture or herniation). The extent of disc extrusion may relate to the symptomatic potential of the disc: an intact annulus limits an associated inflammatory reaction, whereas an intact posterior longitudinal ligament limits the anatomic extent of herniation (Herzog 1996). Finally, a sequestered disc refers to disc material that is free in the epidural space, having lost contact with its parent disc.

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