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  • Updated 03.14.2021
  • Released 07.30.1997
  • Expires For CME 03.14.2024

Lumbar disc disease

Introduction

Overview

Lumbar disc disease is considered a very important cause of lower back pain. In lumbar disc disease, back pain occurs due to a complex of factors in association with disc narrowing. Sciatica is radiating pain along the path of the sciatic nerve and usually is caused by disc herniation, leading to inflammation of a displaced nerve root but may also occur in other conditions, such as metastasis. 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. A metaanalysis indicated that genetic factors play a role in the pathogenesis of degenerative lumbar disc disease. A prior lumbar puncture is also associated with enhanced risk of degenerative disc disease. 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 discs in asymptomatic subjects as well. The prevalence of herniated discs increases with increasing age (peak is between 35 and 55 years). Medical management includes bed rest, analgesics, and muscle relaxants. Bed rest is widely advocated measure in treatment of lumbar disc disease, but its effectiveness remains unconfirmed. Corticosteroids are used, either orally or injected into the epidural space or near a spinal nerve, to get relief from pain. Lumbar surgery is indicated when the patient either has the cauda equina syndrome, progressive loss of motor strength, or has severe intractable pain. Lumbar total disc replacement is an effective treatment option for symptomatic single-level lower lumbar discopathy. Minimally invasive discectomy is also increasingly being performed as preferred surgical option for lumbar disc disease. Lumbar disc disease patients with knee osteoarthritis experience difficulty in daily activities due to knee pain after lumbar spinal surgery. Preoperative assessment for knee osteoarthritis is crucial. 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.

• Back pain occurs due to a complex of factors in association to disc narrowing.

• Sciatica is caused by disc herniation, leading to inflammation of a displaced nerve root but may also occur in other conditions, such as metastasis.

• A herniated disc 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) (05). 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 (48).The introduction of MRI in the 1980s 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 (30). 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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