Disc Herniation

Original Editors Fauve simoens, Nele Postal

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Search Strategy

Data base:
Pubmed/Web of Science/Google Scholar

Key words:
Disc herniation AND anatomy (AND vertebral column)
Disc AND anatomy
Disc herniation AND medical management
Disc herniation AND (physical)
Disc herniation AND surgery
Low back pain AND disc herniation AND prevention.
Disc herniation AND etiology
Disc herniation AND managment
Disc herniation AND radicular pain AND lumbar

Definition/Description

2. Definition/description
Lumbar disc herniation (LDH) is a common low back disorder It is one of most common diseases that produces low back pain and/or leg pain in adults.^{20, LOE 2B} A herniated disc is a displacement of disc material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disc space.^{30, LOE 1A} 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.^{15, LOE 3B}

Other names used to describe this type of pathology are: prolapsed disc, herniated nucleus pulposus and discus protrusion. ^{17, LOE 2A; 18, LOE 2B; 19, LOE 2B}

Clinically Relevant Anatomy

www.physio-pedia.com/Intervertebral_disc

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.^{9, LOE 2B}

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).^{9, LOE 2B} 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.^{10, LOE 5}

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.^{10, LOE 5} 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^{11, LOE 5}. The disc can protrude posteriorly and impinge the roots of the lumbar nerves or it can protrude posterolaterally and impinge the descending root.^{10, LOE 5}

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.^{9, LOE 2B} 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)¹²:

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 herniations are often asymptomatic, and 75% of the intervertebral disc herniations recover spontaneously within 6 months. In 95% of the lumbar disc herniations the L4-L5 and L5-S1 discs are most commonly affected. The cervical disc herniations are most locate at level C5-C6 and C6-C7. 

The most common direction for a disc herniation to occur is in the posterolateral direction, where the annulus fibrosis is thin and not supported by the anterior or posterior longitudinal ligament.   Chronic or sudden forcible hyperflexion or torsion can cause a disc hernia, but mostly there are no specific inciting events. Other possible causes can be a whiplash, poor posture, obesity smoking and occupational risks such as driving for a long time.

Characteristics/Clinical Presentation

Symptoms differ greatly depending on the position and the size of the herniated disc. If the herniated disc is not pressing on a nerve it is possible that the patient will experience no pain at all. When it’s pressing on a nerve, there may be a sharp pain, stiffness, tingling or weakness in the area of the body to which the nerve travels. (15),(6 LOE:5)
A herniated disc in the lumbar spine causes pain, burning, tingling and stiffness that radiates from the buttock into the leg and sometimes into the foot. It’s called sciatica.
See:http://www.physio-pedia.com/Sciatica
It may be more severe with standing, walking or sitting. Along with the leg pain, the patient may experience low back pain. (15), (5 LOE:5), (6 LOE:5)
A herniated disc in the cervical spine may include dull or sharp pain in the neck or between the shoulder blades, pain that radiates down the arm to the hand or fingers, or numbness or tingling in the shoulder or arm. The pain may increase with certain positions or movements of the neck. (15), (6 LOE:5)

Differential Diagnosis

• • Mechanical pain
  See: http://www.physio-pedia.com/Non_Specific_Low_Back_Pain
  • Discogenic pain(42 LOE2A)
  ◦ Symptoms: mainly low back pain
  • Myofascial pain(42 LOE2A)
  ◦ Symptoms: local and/or referred pain, sensory disturbances
  • Spondylosis/spondylolisthesis
  See: http://www.physio-pedia.com/Spondylolysis
  http://www.physio-pedia.com/Spondylolisthesis
  • Spinal/ lumbar stenosis(42 LOE2A)
  ◦ Symptoms: mild low back pain, multiradicular pain in one or both legs, mild motor deficits
  ◦ See: http://www.physio-pedia.com/Spinal_Stenosis
  • Cyst (42 LOE2A)
  ◦ symptoms: sensory disturbances, occasionally motor deficits
  • Hematoma(42 LOE2A)
  ◦ diagnosis by CT-scan
  • Discitis/osteomyelitis
  • Mass lesion/malignancy/neurinomas(42 LOE2A)
  ◦ difficult diagnosis when tumor is small in size
  ◦ symptoms: pain in hip and or thigh, atrophy of glutei en thigh muscles
  • Myocardial infarction
  • Aortic dissection(42 LOE2A)
  ◦ Aneurysm (aortic, iliac, abdominal)
  ◦ symptoms: low back pain, located leg pain
  
• 
  

Diagnostic Procedures

Physical 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 disk herniation in patients under the age of 35. For further explanations see: Straight Leg Raise test (35 LOE:2B)
Imagining
Imaging can be used to reveal disc herniations[2], 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. A CT-scan creates cross-sectional images of your spinal column and the structures around it. (6 LOE:5)
MRI Scans This test can be used to confirm the location of the herniated disk and to see which nerves 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. (6 LOE:5)
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. (6 LOE:5)

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

north american spine society score for neurologic symptoms

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.^{5, LOE 2A}
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^{5, LOE 2A} :

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. ^{4 (LOE 3B) ,7 (LOE 1A)} 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.^{7, LOE 1A}

Slump test: the sitting patient (with convex back) bents its 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.⁶

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).^{4, LOE 3B}

Lasègue’s test⁶: it’s an extension of the SLR: the therapist lowers the leg for 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.^{5, LOE 2A}

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 de diagnostic performance of these test is really poor. The sensitivity and specificity are really low.^{5, LOE 2A}

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.^{5, LOE 2A}

Reflexes: weakness or absence of the Achilles tendon reflex possibly refers to S1 radiculopathy^{5, LOE 2A}

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.^{5, LOE 2A}

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.^{5,LOE 2A}

Manual testing and sensory testing^{5,LOE 2A ,6, LOE 1A}: looks for hypoaesthesia, hypoalgesia, tingling or numbness. One example for 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.^{5, LOE 2A}

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

Only a small percentage of patients with lumbar disk herniations require surgery. Spine surgery is typically recommended only after a period of nonsurgical treatment has not relieved painful symptoms. Patients with sciatica due to a lumbar herniated disc are beneficial to early surgery. There is evidence for a better short-term relief of leg pain compared to conservative therapy. (23 LOE 1A) Patients with a lumbar disc herniation have a greater improvement after surgery than non-operatively patients. (27 LOE 2C)
The most common surgical procedure for a herniated disk in the lower back is a lumbar microdiskectomy. Microdisketomy involves removing the herniated part of the disk and any fragments that are putting pressure on the spinal nerve.[9]

Physical Therapy Management

Physical therapy often plays a major role in herniated disc recovery. Its methods not only offer immediate pain relief and decreases disability (26 LOE 1B), but they also teach you how to condition your body to prevent further injury.(10, LOE:5) No evidence has been found for the effectiveness of conservative treatment compared with surgery for treatment of cervical disc herniation. (22) Microdiscectomy for management of lumbar disc herniation in patients with associated radiculopathy is more effective than conservative management. There is moderate evidence that favours stabilization exercise over no treatment, manipulation over sham manipulation and the addition of mechanical traction to medication and electrotherapy. There was no evidence found for traction, laser or ultrasound. (24 LOE 1A) Conservative treatment has been compared with a surgical treatment (lumbar discectomy) regarding return to sport by athletes. No significant difference has been found the two groups of treatment, but the athletes no longer perform at the prior level of participation in both groups. (26 LOE 1B)

Many studies have shown that a combination of different techniques will form the optimal treatment. Exercise and ergonomic programs should be considered as important components of the therapy.(34 LOE 2A)

Deep Tissue Massage: There are more than 100 types of massage, but deep tissue massage is an ideal option if you have a herniated disc because it uses a great deal of pressure to relieve deep muscle tension and spasms, which develop to prevent muscle motion at the affected area.

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)
Conversely, cold therapy (also called cryotherapy) slows circulation. This reduces inflammation, muscle spasms and pain. Your physical therapist may place an ice pack on the target area, give you an ice massage, or even use a spray known as fluoromethane to cool inflamed tissues.

Hydrotherapy: As the name suggests, hydrotherapy involves water. As a passive treatment, hydrotherapy may involve simply sitting in a whirlpool bath or warm shower. Hydrotherapy gently relieves pain and relaxes muscles.

Transcutaneous electrical nerve stimulation (TENS): A TENS machine uses an electrical current to stimulate your muscles. It sounds intense, but it really isn't painful. Electrodes taped to your skin send a tiny electrical current to key points on the nerve pathway. TENS reduces muscle spasms and is generally believed to trigger the release of endorphins, which are your body's natural pain killers.

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. (34 LOE 2A)
By gently pulling apart the bones, the intent is to reduce the disc herniation. The analogy is much like a flat tire "disappearing" when you put a jack under the car and take pressure off the tire. It can be performed in the cervical or lumbar spine.[14] Lumbar traction may be performed in prone position as in 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. (34 LOA 2A)
A recent study has shown that traction therapy has positive effects on pain, disability and SLR on patients with intervertebral disc herniation.(35 LOE 2B)

Core stability: Many people don't realize how important a strong core is to their spinal health. Your core (abdominal) muscles help your back muscles support your spine. When your core muscles are weak, it puts extra pressure on your back muscles. Your physical therapist may teach you core stabilizing exercises to strengthen your back.
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. Core stability exercises could be performed in water as well, there is no difference between the environments (land or water). (31 LOE 3B)
See: http://www.physiopedia.com/The_effectiveness_of_core_stability_exercise_with_regards_to_general_exercise_in_the_management_of_chronic_non_specific_low_back_pain - Core_Stability

Flexibility: Learning proper stretching and flexibility techniques will prepare you for aerobic and strength exercises. Flexibility helps your body move easier by warding off stiffness(10 LOE:5)

Muscle strengthening: Strong muscles are a great support system for your spine and better handle pain

Lumbar stabilizing exercises: (LSE) (16 LOE 2A) (36 LOE 3B)
There is evidence that SLE increases lumbar stability and improve ADL activity in patients with lumbar disc herniation.
Exercises

LSE reduces the pain intensity and improves the functional capacity in young male patients with lumbar disc herniation.

Note: See ‘Rehabilitation interventions with postoperative lumbar disc hernia’ for further explanation and examples of LSE.
See: http://www.physio-pedia.com/Exercises_for_Lumbar_Instability

TCM: Traditional Chinese Medicine for low back pain (17 LOE 1B,18 LOE 1B)
- 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.
- Acupressure
- Cupping

Spinal manipulative therapy (SMT) and mobilization (MOB) (19 LOE 1A) Acute low back pain short-term pain relief
Chronic low back pain, SMT has an effect similar to NSAID.
See: http://www.physio-pedia.com/Spinal_Manipulation

Rehabilitation interventions with postoperative lumbar disc hernia
The first thing to do when patients come out of the surgery, is to give 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. [11][12][13][14]

An immediate rehabilitation program is recommended in patients with microiskectomy. Exercise therapy with a cognitive intervention is an effective treatment. This treatment is considered as an alternative to vertebral fusion in patients who underwent LDH surgery with symptom recurrence after the first surgery. (21) Patients who participated in a comprehensive rehabilitation program after lumbar disc herniation surgery have better long-term health benefits than those who didn’t follow any intervention, but this can not be superior to ham therapy. (25 LOE 1B)

Most studies start their rehabilitation program 4-6 weeks postsurgery. In the meantime, the patients were followed on the above mentioned instructions.[14] Unlike, the most important goals of the rehabilitation of other peripheral joints, namely: regaining strength and range of motion; the most important goal of the rehabilitation of the low back is to improve the patients’ health. Regaining strength and range of motion are commonly used wrong as most important goals of the low back rehabilitation because of the influence from the athletic world and sport rehabilitation. These goals increase the risk for more back problems. [1]

During back rehabilitation of postoperative disc hernia it is important to regain core stability first. The ‘corset‘ of the lumbar spine -formed by the abdominal and back muscles- has to be rebuild. Maintaining this corset is important during various movements, activities and several situations. [11][12][1][13][14] Keeping this in mind it is self-evident that the endurance of these muscles has to be trained too. Endurance of the muscles participating in the core stability is educated in a neutral position of the upper body/back due to start with short term repetitions that shift into long term repetitions. The exercises that are given in the beginning are subsequently performed in different positions and with several arm and leg movements.[1][13]

Examples of these exercises are dynamic lumbar stabilization 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 microdisectomy: (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

Other examples of lumbar stabilization and dynamic lumbar strengthening exercises: (38 LOE 2A)

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)

A few studies mention stretching of shortened muscles, such as Hamstrings and Quadriceps. [11][12] Hip flexion restriction seems not to be linked with any back pain and maybe unnecessary if the goal is just solving back problems. Eventually if Hamstrings and Quadriceps are shortened, restricted functioning of the hip may occur. For this reason, stretching is necessary to regain full function of the hip. [1]
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]
Various studies have shown that a treatment with accompaniment of a physical therapist or a multi-disciplinary treatment have a positive effect on the regularity of doing the exercises and the rapidity of return-to-work. [11][13][14] A high intensity program gains faster results as a low intensity program, but the results are the same in the end.[13] During the rehabilitation the patients have to be supported to restart and preserve their daily activities; active coping has to be stimulated. Guiding and instructing the patients are of great importance during the treatment/rehabilitation. [11][1][14]

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.

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)

References

1. 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)
2. Freeman, Brian JC, et al. "Randomized, double-blind, placebo-controlled, trial of transforaminal epidural etanercept for the treatment of symptomatic lumbar disc herniation." Spine 38.23 (2013): 1986-1994. (Level of evidence: 1B)
3. Pirbudak, Lütfiye, et al. "The effect of tramadol and tramadol+ gabapentin combination in patients with lumbar disc herniation after epidural steroid injection." Turkish journal of medical sciences 45.6 (2015): 1214-1219. (Level of evidence: 1B)
4. Majlesi, Javid, et al. "The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation." JCR: Journal of Clinical Rheumatology 14.2 (2008): 87-91. (Level of evidence: 3B)
5. Van Der Windt, Daniëlle AWM, et al. "Physical examination for lumbar radiculopathy due to disc herniation in patients with low‐back pain." The Cochrane Library (2010). (Level of evidence: 2A)
6. Kreiner, D. Scott, et al. "An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy." The Spine Journal 14.1 (2014): 180-191. (Level of evidence: 1A)
7. Scaia, Vincent, David Baxter, and Chad Cook. "The pain provocation-based straight leg raise test for diagnosis of lumbar disc herniation, lumbar radiculopathy, and/or sciatica: a systematic review of clinical utility." Journal of back and musculoskeletal rehabilitation 25.4 (2012): 215-223. (Level of evidence: 1A)
8. Manchikanti, Laxmaiah, et al. "Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials." Surgical neurology international 6 (2015). (Level of evidence: 1A)
9. Raj, P. Prithvi. "Intervertebral Disc: Anatomy‐Physiology‐Pathophysiology‐Treatment." Pain Practice 8.1 (2008): 18-44. (Level of evidence: 2B)
10. Drake, Richard, A. Wayne Vogl, and Adam WM Mitchell. Gray's anatomy for students. Elsevier Health Sciences, 2014.
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