Disc Herniation

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Definition/Description

Lumbar disc herniation (LDH) is a common low back disorder. It is one of the most common diseases that produces low back pain and/or leg pain in adults.^, A herniated disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space. This herniation process begins from failure in the innermost annulus rings and progresses radially outward. The damage to the annulus of the disc appears to be associated with fully flexing the spine for a repeated or prolonged period of time. The nucleus loses its hydrostatic pressure and the annulus bulges outward during disc compression.

Other names used to describe this type of pathology are: prolapsed disc, herniated nucleus pulposus and discus protrusion.

Clinically Relevant Anatomy

The lumbar vertebrae are the largest segments of the vertebral column. The intervertebral discs lie between the vertebral bodies. The height of the disc is one-third of the vertebral body. The main function is to transmit forces from the bodyweight and muscle activity through the spinal column. Another important function is to provide flexibility.

In disc herniation, it’s the intervertebral disc that causes the problem. The disc consists of the annulus fibrosus (a complex series of fibrous rings) and the nucleus pulposus (a gelatinous core containing collagen fibers, elastin fibers and a hydrated gel). The vertebral canal is formed by the vertebral bodies, intervertebral discs and ligaments on the anterior wall and by the vertebral arches and ligaments on the lateral wall. The spinal cord lies in this vertebral canal.

A tear can occur within the annulus fibrosus. The material of the nucleus pulposus can track through this tear and into the intervertebral or vertebral foramen to impinge neural structure. A disc herniation can cause mechanical irritation of these structures which in turn can cause pain. This is presented as low back pain with possible radiculopathy if a nerve is affected. The disc can protrude posteriorly and impinge the roots of the lumbar nerves or it can protrude posterolaterally and impinge the descending root.

A disc has few blood vessels and some nerves. These nerves are mainly restricted to the outer lamellae of the annulus fibrosus. In the lumbar region, the level at which a disc herniates does not always correlate to the level of nerve root symptoms. When the herniation is in the posterolateral direction the affected nerve root is the one that exits at the level below the disk herniation. This is because the nerve root at the hernia-level has already exited the transverse foramen. A foraminal herniation on the other hand affects the nerve root that is situated at the same level.

There are four types of herniated discs described in Clinical Anatomy and Management of Back Pain (2006):

Bulging:extension of the disc margin beyond the margins of the adjacent vertebral endplates

Protrusion:the posterior longitudinal ligament remains intact but the nucleus pulposus impinges on the anulus fibrosus

Extrusion:the nuclear material emerges through the annular fibers but the posterior longitudinal ligament remains intact

Sequestration:the nuclear material emerges through the annular fibers and the posterior longitudinal ligament is disrupted. A portion of the nucleus pulposus has protruded into the epidural space

1. Bulging:extension of the disc margin beyond the margins of the adjacent vertebral endplates
2. Protrusion:the posterior longitudinal ligament remains intact but the nucleus pulposus impinges on the anulus fibrosus
3. Extrusion:the nuclear material emerges through the annular fibers but the posterior longitudinal ligament remains intact
4. Sequestration:the nuclear material emerges through the annular fibers and the posterior longitudinal ligament is disrupted. A portion of the nucleus pulposus has protruded into the epidural space

Epidemiology /Etiology

Disc herniation occur often as a result of age-related degeneration of the annulus fibrosis. However trauma, straining, torsion and lifting injury are also involved. Disc herniation are asymptomatic most of the time, and 75% of the intervertebral disc herniation recover spontaneously within 6 months. It can occur in any disc in the spine, but lumbar disc herniation and cervical disc herniation are the two most common forms.

In 95% of the lumbar disc herniation the L4-L5 and L5-S1 discs are affected. This causes lower back pain (lumbago) and possibly leg pain as well, in which case it is commonly referred to as sciatica. Lumbar disc herniation occurs 15 times more than cervical disc herniation, and is an important cause of lower back pain. The prevalence of a symptomatic herniated lumbar disc is about 1% to 3% with the highest prevalence among people aged 30 to 50 years, with a male to female ratio of 2:1. In individuals aged 25 to 55 years, about 95% of herniated discs occur at the lower lumbar spine (L4/5 and L5/S1 level); disc herniation above this level is more common in people aged over 55 years. Recurrent lumbar disc herniation (rLDH) is a common complication following primary discectomy. The systematic review of Huang W. etal. aimed to investigate the current evidence on risk factors for rLDH. Risk factors that had significant relation with rLDH were smoking (OR 1.99, 95% CI 1.53-2.58), disc protrusion (OR 1.79, 95% CI 1.15-2.79), and diabetes (OR 1.19, 95% CI 1.06-1.32). Gender, BMI, occupational work, level, and side of herniation did not correlate with rLDH significantly. Patients with these risk factors should be paid more attention for prevention of recurrence after primary surgery. More evidence provided by high-quality observational studies is still needed to further investigate risk factors for rLDH.

The cervical disc herniation is most affected 8% of the time and most often at level C5-C6 and C6-C7. Intervertebral disc-related pain can be caused by structural abnormalities, such as disc degeneration or disc herniation; correspondingly, biochemical effects such as inflammation can also be the cause. Herniation of the nucleus pulposus is responsible for radiculopathy in approximately 20-25% of cases. Disc herniation can result from degeneration or are precipitated by traumatic incidents such as lifting, etc. The thoracic discs are affected only 1 - 2% of the time. The upper two cervical intervertebral spaces, the sacrum, and the coccyx have no discs and therefore excluded for the risk of disc herniation.

Tears are most frequent postero-lateral because of the absence of the anterior/posterior longitudinal ligament, where the annulus fibrosis is thin. Previously existing disc protrusion are often prior to disc herniation. The outermost layers of the fibrous ring are still intact and none of the central portion escapes beyond the outer layers. But with the amount of pressure rising on the disc, bulging is possible. Disc herniation is also referred to as a slipped disc, but medically not accepted as spinal discs cannot "slip" out of place because they are firmly attached to the vertebrae. The most common cause is degeneration of the intervertebral disc while trauma is a less common cause of disc herniation. Both degenerative disc disease and aging can result in disc degeneration. Type I collagen (sp1 site), type IX collagen, Vitamin D receptor, aggrecan, asporin, MMP3, interleukin -1 and interleukin-6 polymorphisms are candidate genes that are responsible for disc degeneration. Lumbar disc herniation is partly due to mutation in genes coding proteins which regulate the extracellular matrix (MMP2,THBS2).Chronic or suddenly forced hyperflexion or torsion can also cause a disc hernia, but mostly there are no specific inciting events. Other possible risk factors can be a whiplash, poor posture, obesity, heavy work, gender,smoking and occupational risks such as driving for a long time.

Characteristics/Clinical Presentation

Cervical disc herniation Cervical disc herniation causes referred pain to the head, face, neck, arms, shoulders and chest, and even in the low back. In the study of F. W. Gorham they describe how the pain pattern at each level is not consistent.

Fig1: Pain pattern cervical disc herniation

Laxmaiah Manchikanti, MD et al presented how cervical disc herniation radiates pain depending on the level where the herniation took place. The sensory, motor dysfunction and reflex changes as a result of compression of the nerve root of the cervical region is also given. Depending on whether primarily motor or sensory involvement is present, radicular pain is deep, dull, and achy or sharp, burning, and electric. Such radicular pain follows a dermatomal or myotomal pattern into the upper limb. Cervical radicular pain most commonly radiates to the interscapular region, although pain can be referred to the occiput, shoulder, or arm as well. Neck pain does not necessarily accompany radiculopathy and frequently is absent.

Table4: cervical disc herniation radiation Fig2: cervical disc herniation radiation

In a study using provocative discography for symptom mapping, Slipman et al showed that unilateral symptoms were found just as often as bilateral symptoms. Slight variation was noted for referred somatic pain originating from each disc level to the neck, shoulder, and upper thoracic region but with a great amount of overlap. Activities that increase intradiscal pressure (eg, lifting, Valsalva manoeuvre) intensify symptoms. Conversely, lying supine provides relief by decreasing intradiscal pressure. Vibrational stress from driving can also exacerbate discogenic pain. Yates et al showed that vibration and shock loading provided sufficient mechanical injury to exacerbate pre-existing herniation, whereas a flexed posture did not influence the distance of nucleus pulposus tracking.

Lumbar disc herniation occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum. Symptoms can affect the lower back, buttocks, thigh, anal/genital region (via the Perineal nerve), and may radiate into the foot and/or toe. The sciatic nerve is the most commonly affected nerve, causing symptoms of sciatica. The femoral nerve can also be affected and cause the patient to experience a numb, tingling feeling throughout one or both legs and even feet or even a burning feeling in the hips and legs. A hernia in the lumbar region often compresses the nerve root exiting at the level below the disk. Thus, a herniation of the L4/5 disc will compress the L5 nerve root.

  Table5: lumbar disc herniation radiation Fig3: lumbar disc herniation radiation

Figure 3 illustrates the clinical features of posterolateral lumbar intervertebral disc herniation. Straight leg raising or cross straight leg raising and motor examination may be crucial in the assessment of disc herniation. Table 5 shows the diagnostic features for various levels of nerve root involvement. Kamran Sahrakar et al review shows how most lumbar disc herniation (lumbar disc diseases) are preceded by bouts of varying degrees and duration of back pain. In many cases, an inciting event cannot be identified. Pain eventually may radiate into the leg. It may be characterized as less achy, burning, or similar to an electrical shock and is often described as a shooting or stabbing pain. The distribution of the leg pain is somewhat dependent on the level of nerve root irritation. Higher herniation (third or fourth lumbar levels) can radiate into the groin or anterior thigh. Lower radiculopathies (first sacral level) cause pain in the calf and bottom of the foot. Fifth lumbar radiculopathy, which occurs most commonly, causes lateral and anterior thigh and leg pain. Often, accompanying numbness or tingling occurs with a distribution similar to the pain. Accompanying muscle weakness may be unrecognized if the pain is incapacitating. The pain usually improves when the patient is in the supine position with the legs slightly elevated. Patients are more comfortable when changing positions. Short walks can bring relief. Long walks or extended sitting (especially driving) can aggravate the pain. It may be more severe with standing or sitting. Along with the leg pain, the patient may experience low back pain.

Lateral and medial disc herniation Jung Hwan Lee etal. describes how lateral disc herniation (foraminal and extra foraminal) has clinical characteristics that are different from those of medial disc herniation (central and subarticular), including older age, more frequent radicular pain, and neurologic deficits. This is supposedly because lateral disc herniation mechanically irritates or compresses the exiting nerve root or dorsal root ganglion inside of a narrow canal more directly than medial disc herniation. The lateral group showed significantly larger proportion of patients with radiating leg pain and multiple levels of disc herniations than the medial group. No significant differences were found in terms of gender proportions, duration of pain, pre-treatment NRS, severity of disc herniation, and presence of leg muscles’ weakness. The proportion of patients who underwent surgery was not significantly different between both groups. However, the proportion of patients who accomplished successful pain reduction after treatment was significantly smaller in the lateral than the medial group. Table6: Comparison of Clinical and Radiological Characteristics Between Lateral and Medial Disc Herniation

Differential Diagnosis

• Mechanical pain     

• Discogenic pain : Symptoms mainly include low back pain
• Myofascial pain: leads to local and/or referred pain, sensory disturbances
• Spondylosis/spondylolisthesis       

• Spinal/ lumbar stenosis: leads to mild low back pain, multiradicular pain in one or both legs, mild motor deficits       

• Cyst : leads to sensory disturbances, occasionally motor deficits
• Hematoma: diagnosis can be made by CT-scan
• Discitis/osteomyelitis
• Mass lesion/malignancy/neurinomas: difficult to diagnose when tumor is small in size. Symptoms mainly include pain in hip and/or thigh and atrophy of glutei and thigh muscles.
• Aortic dissection: leads to an aneurysm (of the aortic/iliac/abdominal arterie). Symptoms include low back pain, located leg pain.
• Epidural abscess: can cause symptoms resembling those associated with radicular pain possibly due to a disc herniation in the lumbarspinal column.
• Tumour: if the sequestered disc is unusually large (rare condition), it is possible to confuse it with a tumour on MRI examination. In this case, surgery will need to be performed to confirm diagnosis.
• Hodgkin’s disease: in the advanced stage it can lead to masses taking up space in the spinal column (although this is very rare), in their turn causing symptoms linked to disc herniation (such as the cauda equina syndrome).
• Other non-discogenic conditions resulting in sciatica:       

1.            Lumbar nerve root schwannoma
2.            Facet hypertrophy
3.           Pelvic endometriosis
4.           Herpes zoster infection          
   
   These conditions all result in compression or inflammation along the course of the sciatic nerve or lumbosacral roots

Diagnostic Procedures

Neurological examination

• Straight Leg Raise Test: The SLR test is a test done during the physical examination. This test is a very accurate predictor of a disc herniation in patients under the age of 35. In patients older than 60 a suppression in the positivity of the tests can be found.

• Crossed Lasègue
• Sensory loss: can be tested with light touch or a pin prick followed by classification on a three-point scale.
• Anesthesia linked to dermatomes
• Muscle weakness: testing of muscle groups and rating them om a five-point scale. Examples: testing of dorsiflexion ankle, hip abductors, flexion knee
• Knee tendon reflex
• Achilles tendon reflex
• Finger-ground distance in centimeter
• Scoliosis: this is a mechanism developed by patients to avoid pain. In patients with a disc herniation the same scoliosis pattern can be found, starting with a short curve at the lumbosacral region and a long curve in the thoracic or thoracolumbar region in the other direction. The herniation can be found in most cases in the direction of the first curve and on the other side of the accompanying trunk shift. To differentiate between a structural scoliosis and a scoliotic posture, the Adams forward bend test can be used
• Femoral nerve stretch test: found to be positive if the patient experienced radiating pain

Imaging
Imaging can be used to reveal disc herniation, note that most disc herniations are asymptomatic:

• Plain X-rays: don't detect herniated disks, but they may be performed to rule out other causes of back pain, such as an infection, tumor, spinal alignment issues or a broken bone.
• CT-scan: creates cross-sectional images of your spinal column and the structures around it.
• MRI Scans: can be used to confirm the level of the herniated disc, the location of the herniation within that level (axial and left/right), the morphology of the hernia and finally to see which nerve(s) are affected.
• Myelogram: A dye is injected into the spinal fluid, and then X-rays are taken. This test can show pressure on your spinal cord or nerves due to multiple herniated disks or other conditions.
• Nerve tests: Electromyograms and nerve conduction studies measure how well electrical impulses are moving along nerve tissue. This can help pinpoint the location of the nerve damage.
• 3T MRM (3-Tesla Magnetic Resonance Myelogram): appropriate imaging technique to diagnose far lateral disc herniations in particular. Preferable to disco-CT because of its non-invasive method.
• Discography and disco-CT: can be used to diagnose intradural lumbar disc herniation (very rare) preoperatively. Leakage of the contrast substance into the intradural space can be seen in the images.
  
  

Outcome Measures

If the disc herniation is symptomatic different outcome measures can be used:
Short Form-36 bodily pain (SF-36 BP)
Physical function scale (PF scores)
Oswestry disability index
Roland-Morris disability index
VAS-score: one of leg pain and one of back pain
North American Spine Society Score for neurologic symptoms

McGill pain Questionnaire: this questionnaire looks at the location, intensity, quality and pattern of the pain as well as alleviating and aggrevating factors.

Sciatica Frequency and Bothersome Index (SFBI): patients rate their leg pain, numbness/tingling in the leg, foot or groin, weakness in the leg/foot and back/leg pain while sitting and the frequency with which these symptoms occur on a scale of 0 (= not bothersome) to 6 (= extremely bothersome).

Prolo scale: measures the functional and economic status of the patient after undergoing surgery according to the surgeon and/or nurse involved in research.

Maine – Seattle Back Questionnaire: a score between 0 and 12 is given to items concerning the back.

Numeric Rating Scale: used to rate pain (such as pain in the lower back, sciatic pain…) on a scale from 0 (“no pain”) to 10 (“worst pain imaginable”). Patients are asked to rate their current pain intensity.

Patient Global Impression of Change (PGIC).

Examination

Patients with low back pain and sciatica can have radiculopathy due to lower lumbar disc herniation. The following tests can be used for the examination and to conclude if the radiant pain is caused by disc herniation.
See cervical/lumbar radiculopathy for the examination that can be used to assess if the radiant pain is caused by disc herniation.

www.physio-pedia.com/Lumbar_Radiculopathy

www.physio-pedia.com/Cervical_Radiculopathy

Physical examination of lumbar radiculopathy due to disc herniation

Straight Leg Raise (SLR); specificity (0,89) and sensitivity (0,52)

The patient is in supine position and the examiner raises the leg (on the symptomatic side). The knee stays fully extended. When the angle at the hip in which the SLR is reached differs in comparison to the other leg, or when pain is produced during the test, the test is considered to be positive.

Slump test:

The sitting patient (with convex back) bends his head forward and stretches his leg out with the toes pointing upward. The purpose is to stretch the neural structures within the vertebral canal and foramen.

The SLR (0,52) is less sensitive than the slump test (0,84), but the specificity of the SLR (0,89) was slightly higher than the slump test (0,83).

Lasègue’s test: it’s an extension of the SLR: the therapist lowers the leg to an extent of five to ten degrees. Then, the foot is passively dorsiflexed. The test is considered to be positive when the ipsilateral leg pain (sciatica below the knee) occurs upon elevation.

Crossed Lasegue test (XSLR)⁶

This test is considered to be positive when the pain (sciatica) can be reproduced upon passive extension of the contra-lateral leg.5, LOE 2A 

Scoliosis: the therapist is going to evaluate this parameter using visual inspection. Scoliosis might be a potential indicator of lumbar disc herniation. Research has proven that the diagnostic performance of this test is really poor. The sensitivity and specificity are really low.

Muscle weakness or paresis

The examiner measures strength during ankle dorsiflexion or extension of the big toe (without or against resistance).
Dorsal flexion impaired --> L4 radiculopathy
Toe extension impaired --> L5 radiculopathy
If the possible range at the symptomatic side differs from the non-symptomatic side, then the test is considered to be positive.

Reflexes

Weakness or absence of the Achilles tendon reflex possibly refers to S1 radiculopathy

Forward flexion test: the purpose is to bend forward in standing position. There is no consensus regarding the criteria that have to be considered in order to determine if the radiant pain is caused by disc herniation. Some studies use limitation of forward flexion as main criteria, while others use back/leg pain as the primary indicator.

Hyperextension test: the patient needs to passively mobilise the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pain deteriorates.

Manual testing and sensory testing

Look for hypoaesthesia, hypoalgesia, tingling or numbness. One example of testing: the patient closes his eyes and the examiner strikes the skin bilaterally and simultaneously. The patient is asked if he feels any differences between the left and right side. The test is considered to be positive when there is a dermatomal distribution. Although, the diagnostic performance of sensitivity and specificity is poor.

Medical Management

Over-the-counter pain medications such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve, others) can be used when the pain is mild to moderate.^{13 (LOE:5)} 

Narcotics, like codeine or oxycodone-acetaminophen, can be useful when the pain doesn’t alleviate with over-the-counter pain medications. There are some possible side effects such as nausea, sedation, confusion and constipation. ^{13 (LOE: 5)}

Nerve pain medications: drugs such as gabapentin (Neurontin, Gralise, Horizant), pregabalin (Lyrica), duloxetine (Cymbalta), tramadol (Ultram) and amitriptyline often help relieve pain. These drugs have a milder set of side effects than do narcotic medications. Therefore they're being increasingly used as first line prescription medications for people who have herniated disks.^{13 (LOE:5)}
Patients with disc herniation who receive treatment with tramadol (75mg/day) or tramadol (75mg/day) combined with gabapentin (900mg/day) had decreased VAS (visual analogue scale) and ODI values (Oswestry Disablity Index) and increased SLET values (Straight Leg Elevation Test).^{3 (LOE:1B)}

Muscle relaxers. Muscle relaxants may be prescribed if you have muscle spasms. Sedation and dizziness are common side effects of these medications.^{11,13 (LOE: 5)}

Cortisone injections. Inflammation-suppressing Therapeutic Corticosteroid Injection may be given directly into the area around the spinal nerves. Spinal imaging can help guide the needle more safely. Occasionally a course of oral steroids may be tried to reduce swelling and inflammation.^{13 (LOE: 5)}

Epidural steroid injection (ESI) is an effective alternative to reduce the inflammation of the nerve root.^{3 (LOE 1B)}
Clinically significant reductions in the mean daily worst leg and back pain were observed due to two transforminal injections (etanercept 0,5mg). More than half of the subjects experienced a 50% to 100% pain relief for at least three to six months after receiving a transforminal injection. These epidural etanercept (0,5mg) should offer patients with symptomatic lumbar disc herniation and sciatica a safe and effective non-operative treatment. ^{2(LOE: 1B)}
There is strong evidence for caudal, lumbar interlaminar and lumbar transforaminal injections in the management of lumbar disc herniation. Steroids should be more effective compared with local anesthethic alone. The studie concludes that there was superiority of epidural steroid injections with local anesthetic over local anesthetics.^{8 (LOE: 1A )}

Surgical Treatment

Lumbar disc herniation epidural injections: Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, Manchikanti et al found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement.

Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months). The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores. ^{(55, LOE 1A)}

Disc herniation surgery:

Surgery mostly consists of a discectomy with or without fusion of bones. The research of Jacobs W. et al concluded that there is no difference in pain relief between the different fusion techniques. ^{(77, LOE:1B)}

Scott L. et al concluded in his systematic review for lumbar disc herniation surgery that on short term (6-24 months) after discectomy 3% to 34% of the patients reported recurrent back/ leg pain. On long term after discectomy 5% to 36% patients reported recurrent back/ leg pain. In this study 0% to 23% of the patients reported a reoperation for recurrent disc herniation. 6% has a reoperation on the same level. The reoperation consisted of 5% fusion and 95% discectomy.

7% reported postoperative complications such as wound hematoma, wound infection, cerebrospinal fluid leak, deep venous thrombosis, and new neurologic deficit.

The clinically important decline in low back disability compared to baseline after 3 months is only 3%. The clinically important worsening compared to the 3 months levels: after 1 year: 22%, after 2 years: 26% ^{(56, LOE: 1A)}

Jacobs WCH et al. concluded in his review that when patients have lumbar disc herniation that causes sciatica they have a faster pain relief when a fast-surgical operation is performed instead of prolonged conservative treatment. At 1 year of follow-up and 2 years of follow-up 95% of patients in both treatment groups had experienced satisfactory recovery. So surgery might not be beneficial on long term follow-up. ^{(78, LOE: 1B)}

Minimally invasive procedures, including percutaneous therapies under local anaesthesia, are increasingly gaining attention. The review of Rasoul MR et al. showed that minimally invasive discectomy (MID) may be inferior to open discectomy in terms of relief of leg pain, low back pain and re-hospitalisation. However, differences in pain relief appeared to be small and may not be clinically important. The potential advantages of MID are a lower risk of surgical site and other infections, a shorter hospital stay. More research is needed. ^{(57, LOE 1A)}

Cervical disc herniation surgery: In the meta-analysis of Yan Hu et al. cervical disc arthroplasty was shown superior over anterior discectomy and fusion for the treatment of symptomatic cervical disc disease in terms of overall success, NDI success, neurological success, implant/surgery-related serious adverse events, secondary procedure, functional outcomes, patient satisfaction and recommendation, and superior adjacent segment degeneration. ^{(58, LOE: 1A)}

Physical Therapy Management

Physical therapy often plays a major role in herniated disc recovery. Physiotherapy does not only offer pain relief and decreases disability ^{23, LOE 1B}, but it also contributes to protecting the body to prevent further injury. ^{24, LOE 5} No evidence has been found for the effectiveness of conservative treatment compared with surgery for treatment of cervical disc herniation.^{25, LOE 1A} Different studies have shown that a combination of different techniques will form the optimal treatment for a herniated disc. There is contradictory and insufficient evidence with respect to the use of traction, ultrasound and low-level laser therapy.^{1, LOE 1A} Exercise and ergonomic programs should be considered as very important components of this combined therapy.^{17, LOE 2A}

The physical therapy management for patients with disc herniation can be divided into two main groups: patients with or without surgery. In case of surgery, revalidation programmes start regularly 4-6 weeks post-surgery. ^{28, LOE 1A}

Some patients with a herniated disc undergo an operation to reduce their symptoms. After this operation they might follow physiotherapy to support their rehabilitation. A comparison among rehabilitation programmes that start four to six weeks post-surgery with exercises versus no treatment shows that exercise programmes are more effective than no treatment in terms of short-term follow-up for pain. They also investigated the difference between high-intensity exercise programmes and low-intensity exercise programmes. There was low-quality evidence shown that high-intensity exercise programmes are slightly more effective for pain and in terms of functional status in the short term compared with low-intensity exercise programmes. However long-term follow-up results for both pain and functional status showed no significant differences between groups. Research shows no significant differences between supervised exercise programmes and home exercise programmes in terms of short-term pain relief. ^{29, LOE 1A}

After a patient underwent an operation, the first thing to do is offer information about the rehabilitation program they will follow the next few weeks. The patients are instructed and accompanied in daily activities such as: coming out of bed, going to the bathroom and clothing. Besides all this the patients have to pay attention on the ergonomics of the back throughout back school.^{28, LOE 1A; 35, LOE 2A; 36, LOE 2B; 37, LOE 2A}

Stretching: There is low-quality evidence found to suggest that adding hyperextension to an intensive exercise programme might not be more effective than intensive exercise alone for functional status or pain outcomes. There were also no clinically relevant or statistically significant differences found in disability and pain between combined strength training and stretching, and strength training alone.^{29, LOE 1A}

Behavioural graded activity programme: A global perceived recovery was better after a standard physiotherapy programme than after a behavioural graded activity programme in the short term, however no differences were noted in the long term.^{29, LOE 1A}

Ultrasound and shock wave therapies: Ultrasound is used to penetrate the tissues and transmitting heat deep into the tissues. The aim of ultrasound is to increase local metabolism and blood circulation, enhance the flexibility of connective tissue, and accelerate tissue regeneration, potentially reducing pain and stiffness, while improving mobility. Shock wave applies vibration at a low frequency to the tissues (10, 50, 100, or 250 Hz). This causes an oscillatory pressure to decrease pain. The available evidence does not support the effectiveness of both therapy strategies for treating a herniated disc.^{31, LOE 1B}

Transcutaneous electrical nerve stimulation (TENS): TENS uses an electrical current to stimulate the patients muscles. Electrodes on the skin send a tiny electrical current to key points on the nerve pathway. It is generally believed to trigger the release of endorphins, which are the body's natural pain killers and reduce muscle spasms. For this reason, TENS therapy contribute to pain relief and improvement of function and mobility of the lumbosacral spine.^{33, LOE 2A}

Manipulative treatment: Manipulative treatment on lumbar disc herniation appears to be safe, effective, and it seems to be better than other therapies. However high-quality evidence is needed to be further investigated.^{32, LOE 1A}

Stabilisation exercises/core stability: A strong core is important to the health of the spine. The core (abdominal) muscles help the back muscles support the spine. When your core muscles are weak, it puts extra pressure on your back muscles. So it is important to teach core stabilizing exercises to strengthen your back. It is also very important to train the endurance of these muscles. A core stability program decreases pain level, improves functional status, increases health-related quality of life and static endurance of trunk muscles in lumbar disc herniation patients.^{34, LOE 3B} Individual high-quality trials found moderate evidence that stabilisation exercises are more effective than no treatment.^{26, LOE 1A}

Link 'Core stability': http://www.physio-pedia.com/Core_stability
Link ‘Exercises for lumbar instability’: http://www.physiopedia.com/Exercises_for_Lumbar_Instability

Traction: The goal of traction is to reduce the effects of gravity on the spine. This technique is often used to relief the patient’s pain in order to facilitate the progression to an exercise program.^{17, LOE 2A} By gently pulling apart the bones, the intent is to reduce the disc herniation. It can be performed in the cervical or lumbar spine.^{28, LOE 1A} Lumbar traction may be performed in prone or supine position. When applying this kind of treatment, it is recommended to place the patient in a flexed position as it tends to open the neuroforamin and to stretch the posterior elements of the back. To unload the intervertebral disc more effectively it is preferable to let the patient lay in a prone position with a correct amount of lordosis in the lower back. Usually traction will be performed with a force equal to 50% of the patient’s body weight. The total duration of the treatment should be 15 minutes with use of an intermittent force pattern of 20 to 30 seconds on and 10 to 15 seconds off. ^{17 LOA 2A}
A recent study has shown that traction therapy has positive effects on pain, disability and SLR on patients with intervertebral disc herniation.^{18, LOE 2B} Also one trial found some additional benefit from adding mechanical traction to medication and electrotherapy.^{30, LOE 1A}

Aquatic vertical traction: In patients with low back pain and signs of nerve root compression this method had greater effects on spinal height, the relieving of pain, lowering the centralisation response and lowering the intensity of pain than the assuming of a supine flexing position on land. ^{75, LOE 2B}

Hot and cold therapies offer their own set of benefits, and your physical therapist may alternate between them to get the best results. Your physical therapist may use heat to increase blood flow to the target area. Blood helps heal the area by delivering extra oxygen and nutrients. Blood also removes waste byproducts from muscle spasms.^{10 LOE:5}

Cryotherapy can be used to suppress the metabolism of the tissue after joint surgery, because of the decrease in tissue temperature. This leads to a lessening of pain, edema and postoperative bleeding, and also helps postoperative recovery of range of motion much more rapidly. For patients who underwent one level microendoscopic discectomy for lumbar disc herniation the Icing System CF3000 can be used as it can be used to cool the spine when in a supine position or when lying on the side. ^{76, LOE 2B}

Muscle strengthening: Strong muscles are a great support system for your spine and better handle pain. If core stability is totally regained and fully under control, strength and power can be trained. But only when this is necessary for the patients functioning/activities. This power needs to be avoided during the core stability exercises because of the combination of its two components: force and velocity. This combination forms a higher risk to gain back problems and back pain.^{1 LOE 1B}

Traditional Chinese Medicine for low back pain (TMC): TCM has been demonstrated to be effective. Reviews have demonstrated that acupressure, acupuncture and cupping can be efficacious in pain and disability for chronic low back pain included disc herniation. ^{17 LOE 2A,18 LOE 1B}

Spinal manipulative therapy (SMT) and mobilization (MOB): It leads to short-term pain relief when suffering from acute low back pain. When looking at chronic low back pain, SMT has an effect similar to NSAID. ^{19 LOE 1A}
LINK: http://www.physio-pedia.com/Spinal_Manipulation

Dynamic lumbar stabilization exercises: Exercises which include techniques such as dynamic abdominal girdle and methods for finding and maintaining neutral lumbar position during daily activities. The emphasis is here placed on the multifidus and the transversus abdominis muscle. The multifidus plays a role in the protection of the lumbar region against involuntary movements and torsion forces as it contributes to spine stabilisation. On the other side the transversus abdominis assists to lumbar stability through increased abdominal pressure by acting like a belt around the abdomen. ^{37 LOE 2B}

Following program can be used as a protocol for rehabilitation following a lumbar microdiscectomy: ^{37 LOE 2B}
▪ Duration of rehabilitation program: 4 weeks
▪ Frequency: every day
▪ Duration of one session: approximately 60 minutes
▪ Treatment: dynamic lumbar stabilization exercises + home exercises
▪ Exercises:
Prior to the DLS training session patients are provided with instruction or technique to ensure and protect a neutral spine position. During the first 15 minutes of each session stretching of back extensors, hip flexors, hamstrings and Achilles tendon should be performed.
DLS consists of:
- Quadratus exercises
- Abdominal strengthening
- Bridging with ball
- Straightening of external abdominal oblique muscle
- Lifting one leg in crawling position
- Lifting crossed arms and legs in crawling position
- Lunges

Home exercises: should be added to the treatment. These should be performed every day.
Modalities: 5 repeats during the first week up to 10-15 repeats in the following weeks

Aerobic training: On the other side, a study has been conducted to analyse the effect of an aerobic training program on post-operative patients. One month after the surgery, the patients received a supervised treadmill exercise next to the home exercise program. The treadmill exercise consisted of a walk of 30 minutes on the treadmill without inclination five times a week with tolerated speed during four weeks. The speed of walking was increased once the patient’s tolerability was considered as high enough. The conclusion is that aerobic exercise-based rehabilitation program in combination with home exercises starting one month after first-time single-level lumbar microdiscectomy has a positive effect on functionality than only a home exercise program. However the authors of the study point out that more studies should be conducted concerning aerobic exercise programs in post-operative patients. ^{41 LOE: 2B}

Lumbar tender point deep massage: When used in combination with lumbar traction, this method resulted in a higher pain threshold, less muscle hardness and less intense pain in patients with chronic non-specific lower back pain than lumbar traction on its own.^{74, LOE 1b}

Conservative therapy for cervical spine ^{(79, LOE 1B)}  According to the systematic review of Gross A.:

-  Cervical manipulation VS inactive control (subacute- chronic): gives immediate pain relief but not on short term follow-up.

-  Cervical manipulation VS cervical mobilization (acute- chronic): decline in pain, better QoL and GPE

-  Cervical manipulation VS medication: (acute- subacute): better function of neck, more decline in pain

-  Cervical manipulation Vs massage (chronic): decline in pain, better function

This concludes that cervical manipulation may give better results in decline in pain and better function than inactive control, cervical mobilization, medication and massage.

The systematic review Bronfort did on spinal manipulative therapy (SMT)concluded that for chronic neck pain that SMT and mobilization may give more pain reduction then a general practitioner management on short term follow-up but similar pain relief like high-technology rehabilitative exercise in the short and long term. In a mix of acute and chronic patients there is limited evidence that SMT, in both the short and long term, is inferior to physical therapy. (80, LOE 1B)

Resources

http://www.isass.org/h/patient_resources_spine_conditions.html

http://orthoinfo.aaos.org/topic.cfm?topic=a00534

https://my.clevelandclinic.org/health/diseases_conditions/hic_Herniated_Disc

https://www.spine.org/Portals/0/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniation.pdf

Drake, Richard, A. Wayne Vogl, and Adam WM Mitchell. Gray's anatomy for students. Elsevier Health Sciences, 2014.

Clinical Bottomline

Intervertebral disc herniation is one of most common diseases that produces low back pain and/or leg pain in adults.^{20, LOE 2B} It often occurs as a result of age-related degeneration of the annulus fibrosis. Disc herniation are most of the time asymptomatic and 75% of the intervertebral disc herniation recover spontaneously within 6 months.^{21 , LOE 3b}

Disc herniation can occur at different levels in the spine. A herniated disc affects most commonly the lumbar discs between vertebra L4-L5 and L5-S1. Cervical disc herniation are more rare than lumbar disc degeneration. The cervical disc herniation is most locate at level C5-C6 and C6-C7.^{22, LOE 3B}

Recent Related Research (from Pubmed)

Wong, J. J., et al. "Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration." European Journal of Pain (2016). (Level of evidence: 1A)
Huang, Weimin, et al. "Risk Factors for Recurrent Lumbar Disc Herniation: A Systematic Review and Meta-Analysis." Medicine 95.2 (2016). (Level of evidence: 1A)

Lee, Sungjoon, et al. "A 20-Year-Old Retained Surgical Gauze Mimicking a Spinal Tumor: A Case Report." Korean Journal of Spine 13.3 (2016): 160-163. (Level of evidence: 3B)

Jeon, Joon Bok, et al. "The Factors That Affect Improvement of Neurogenic Bladder by Severe Lumbar Disc Herniation in Operation." Korean Journal of Spine 13.3 (2016): 124-128. (Level of evidence: 1B)

Yeo, Chang Gi, et al. "Three-Years Outcome of Microdiscectomy via Paramedian Approach for Lumbar Foraminal or Extraforaminal Disc Herniations in Elderly Patients over 65 Years Old." Korean Journal of Spine13.3 (2016): 107-113.

ALBAYRAK, Serdal, et al. "Dural Tear: A Feared Complication of Lumbar Discectomy." Turk Neurosurg (2016): 1
van Helvoirt, Hans, et al. "Transforaminal epidural steroid injections influence Mechanical Diagnosis and Therapy (MDT) pain response classification in candidates for lumbar herniated disc surgery." Journal of back and musculoskeletal rehabilitation 29.2 (2016): 351-359. (Level of evidence: 2B)

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