Disc Herniation

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Original Editors Fauve simoens, Nele Postal

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Search Strategy

Information relating to physical therapy management and more specific 'rehabilitation interventions with postoperative lumbar disc hernia' was collected through article databases such as pubmed and web of knowledge. Th combination of key words such as postoperative lumbar disc herniation, exercises therapie, exercise programme, postoperative intervention, rehabilitation en physical therapy were used to find articles with usefull information about this section. Most of the used articles were published in 2007 - 2009.

Definition/Description

The 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 withe fully flexing the spine for a repeated or prolonged period of time. The nucleus loses his hydrostatic pressure and the annullus bulges outward during disc compression. 

Clinically Relevant Anatomy

There are many structures surrounding a discus intervertebralis: annulus fibrosus, anterior longitudinal ligament, posterior longitudinal ligament, nerve roots, nerves and muscles. A discus 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.

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 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.
In the cervical region the herniated disc compresses the nerve actually exiting at that 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.

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

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Differential Diagnosis

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Diagnostic Procedures

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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

Examination

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Medical Management

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Physical Therapy Management

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.

Most studies start their rehabilitation program 4-6 weeks postsurgery. In the meantime, the patients were followed on the above mentioned instructions. 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.

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. Keeping this in mind it is self-evident that the endurance of these muscles have to be trained too. Endurance of the muscles participating in the core stability are 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.
A few studies mention stretching of shortened muscles, such as Hamstrings and Quadriceps. Hip flexion restriction seem 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. 
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.

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. A high intensity program gains faster results as a low intensity program, but the results are the same in the end. 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.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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