Lumbar disc herniation

Considerable genetic predisposition to early onset in some families.

Most patients experience back pain during their lifetime, only a small number have lumbar radiculopathy or sciatica as a consequence of root compression or irritation.

Approximately 5% of men and 2.5% of females experience sciatica at some point.

Lifetime prevalence exceeds 10%.

A fragment of nucleus pulposus disc.

The nucleus pulposus is the center of the disc and is normally contained by the annulus fibrosus.

A herniated nucleus pulposus can irritate and compress the adjacent nerve root and causes pain, ref2242ed to as sciatica.

About 90% of all lumbar disc herniation occur at the L4-5 and L5-S1 levels, and are about equal in frequency.

L3-4 herniation are infrequent.

In severe cases nerve dysfunction occurs.

Often an inciting event is not identified.

Most herniation preceded by bouts of back pain.

Acute lumbar radiculopathy is characterized by radiating leg pain in the lumbar nerve root distribution.

Pains associated with lumbar disc herniation may be aching, burning, electric shock like discomfort, shooting, or sharp pain, with pain eventually radiating to the leg.

Distribution of the leg pain is dependent upon the level of the root irritation.

At the third or fourth lumbar levels can radiate into the groin or anterior thigh.

L5 radiculopathy causes lateral and anterior thigh and leg pain.

L5 radiculopathy occurs most commonly.

Of S1 may cause pain in the calf and bottom of the foot.

Pain usually improves in the supine position, with the legs slightly elevated.

Patients more comfortable when changing positions.

Relief often brought on by short walks and aggravated by prolonged walks and extended sitting.

May be associated with normal neurological examination, a radiculopathy or a cauda equina syndrome.

Usually associated with a positive straight leg raising test.

A crossed straight leg raising may be an even more predictable test.

Muscle weakness may be present as well as an impaired gait.

Spontaneous recovery occurs in most patients.

In patients who have prolonged disease invasive procedures such as epidural steroid injections and lumbar dissectomy are commonly performed.

Epidural steroid injections are invasive, generally require preprocedure magnetic resonance imaging and expose patients to fluoroscopic radiation.

Lumbar diskectomy is the most common surgical procedure performed for patients having back and leg pain.

There is up to a 15 fold variation in regional surgical rate for lumbar disc surgery in the U.S.

Surgery indicated in he presence of a cauda equina syndrome, the presence of progressive neurologic deficit, persistence of sciatic pain over a period of 6-12 weeks of conservative therapy.

Transcutaneous lumbar diskectomy overall success rate 83%.

Lumbar disc surgery was evaluated by The Spine Patient Outcomes Research Trial (SPORT), a randomized trial enrolling 501 surgical candidates with confirmed imaging lumbar herniated discs and persistent signs and symptoms for at least 6 weeks treated with standard open diskectomy versus nonoperative treatment individualized for the patient: both groups of patients improved substantially over a 2 year period.

SPORT study revealed that relief of leg pain most consistent and apparent improvement with surgery, and little evidence of harm from surgical or no surgical management.

SPORT study revealed that the most common complication was a dural tear, occurring in 4% of patients

SPORT study revealed surgical patients sere consistently improved by surgery for all outcomes and at all time periods, but the differences were small and not statically significant except for secondary measures of sciatica severity and self-rated improvement.

For patients with acute radiculopathy due to a herniated lumbar disc, a short course of oral steroids results in modest improved function but no improvement in pain (Goldberg H et al).

Most cases of acute radiculopathy improve within several months indicated that approximately two thirds of herniated lumbar discs undergo significant (greater than 50%) resorption within one year.

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