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Spinal Disk Herniation

Spinal disk herniation Herniation Omphalocele (also known as herniated nucleus Nucleus Within a eukaryotic cell, a membrane-limited body which contains chromosomes and one or more nucleoli (cell nucleolus). The nuclear membrane consists of a double unit-type membrane which is perforated by a number of pores; the outermost membrane is continuous with the endoplasmic reticulum. A cell may contain more than one nucleus. The Cell: Organelles pulposus) describes the expulsion of the nucleus Nucleus Within a eukaryotic cell, a membrane-limited body which contains chromosomes and one or more nucleoli (cell nucleolus). The nuclear membrane consists of a double unit-type membrane which is perforated by a number of pores; the outermost membrane is continuous with the endoplasmic reticulum. A cell may contain more than one nucleus. The Cell: Organelles pulposus through a perforation Perforation A pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force. Esophagitis in the annulus fibrosus of the intervertebral disk. Spinal disk herniation Herniation Omphalocele is an important pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways syndrome with the potential for neurologic impairment and is most commonly caused by degenerative disk disease Disk Disease Examination of the Lower Limbs. Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor depends on the presence or absence of spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy or nerve root compression Compression Blunt Chest Trauma and the downstream neurologic sequelae (e.g., radicular pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, muscle weakness, sensory deficit Sensory Deficit Anterior Cord Syndrome, reflex deficit). Diagnosis is initially clinical and can be confirmed with diagnostic imaging (e.g., MRI). Management‌ ‌can range from conservative to surgical, depending on the situation.

Last updated: 29 Apr, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Spinal disk herniation Herniation Omphalocele is a condition wherein the gelatinous central portion of an intervertebral disk is forced through a weakened portion of the fibrocartilaginous outer part of the disk, often resulting in back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and/or nerve root irritation.

Spinal disks (intervertebral disks)

Structure:

  • Composed of an outer fibrous Fibrous Fibrocystic Change ring (annulus fibrosus) and a gelatinous center ( nucleus Nucleus Within a eukaryotic cell, a membrane-limited body which contains chromosomes and one or more nucleoli (cell nucleolus). The nuclear membrane consists of a double unit-type membrane which is perforated by a number of pores; the outermost membrane is continuous with the endoplasmic reticulum. A cell may contain more than one nucleus. The Cell: Organelles pulposus)
    • The annulus fibrosus is a semirigid fibroelastic structure that contains the nucleus Nucleus Within a eukaryotic cell, a membrane-limited body which contains chromosomes and one or more nucleoli (cell nucleolus). The nuclear membrane consists of a double unit-type membrane which is perforated by a number of pores; the outermost membrane is continuous with the endoplasmic reticulum. A cell may contain more than one nucleus. The Cell: Organelles pulposus and anchors the intervertebral disk to the adjacent vertebrae.
    • The nucleus Nucleus Within a eukaryotic cell, a membrane-limited body which contains chromosomes and one or more nucleoli (cell nucleolus). The nuclear membrane consists of a double unit-type membrane which is perforated by a number of pores; the outermost membrane is continuous with the endoplasmic reticulum. A cell may contain more than one nucleus. The Cell: Organelles pulposus is a gelatinous matrix of water and proteoglycans Proteoglycans Glycoproteins which have a very high polysaccharide content. Basics of Carbohydrates that allows the intervertebral disk to flex and deform with physiologic motion of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy.
  • Convex anteriorly, concave posteriorly

Function:

  • Deformable, shock-absorbing structures 
  • Deformability allows some freedom of motion between the bony elements of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy
  • Responsible for cushioning intervertebral articulations of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy

Anatomic relationships:

  • Outer ⅓ of the annulus fibrosus is innervated (potential pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways generator).
  • Annular Annular Dermatologic Examination fibers are continuous with periosteal fibers of the adjacent vertebra. 
  • Annular Annular Dermatologic Examination fibers are continuous with the cartilaginous vertebral end plates:
    • The vertebral end plate is a cartilaginous “cap” on the superior and inferior aspects of the bony vertebra.
    • Located between the bony vertebral elements and the intervertebral disk
  • Normally fills and is contained within the intervertebral disk space:
    • The space between the vertebral end plates defines the cranial and caudal limits of the intervertebral disk space.
    • The outer limits of the apophyses Apophyses Apophyseal Avulsion Fracture of the bony vertebral body Vertebral body Main portion of the vertebra which bears majority of the weight. Vertebral Column: Anatomy defines the peripheral limits of the intervertebral disk space. 
  • Continuous with and bordered anteriorly by the anterior longitudinal ligament:
    • Broad and thick fibrous Fibrous Fibrocystic Change structure, covers the entire anterior aspect of the spinal disk(s)
    • Provides structural support to the anterior spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy and anterior portion of the annulus fibrosus
    • Anterior herniations are rare owing to the width and structural integrity provided by this ligament
  • Continuous with and bordered posteriorly by the posterior longitudinal ligament:
    • Narrow; this fibrous Fibrous Fibrocystic Change structure (compared to the anterior longitudinal ligament), covers only the central concave portion of the spinal disk(s).
    • Forms the anterior border of the spinal canal Spinal Canal The cavity within the spinal column through which the spinal cord passes. Spinal Cord Injuries
    • Provides structural support to the posterior spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy and the central posterior portion of the annulus fibrosus 
    • Does not cover the posterolateral portion of the spinal disk(s), leaving the posterolateral aspect of the disk(s) most vulnerable to herniation Herniation Omphalocele

Epidemiology

  • Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency
    • Cervical radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis:
      • 107 in 100,000 men
      • 64 in 100,000 women
    • Thoracic radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis: 0.5%–4.5% of all disk ruptures (least common of all disk pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways syndromes)
    • Lumbar radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis:
      • 5–20 cases per 1000 adults annually
      • 66% of all disk pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways syndromes
  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of:
    • Acute low back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways: 37% 
    • Lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: 87%
  • Greatest prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in ages 30–50 years
  • Male:female ratio of 2:1
  • Note: < 5% of low back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways cases presenting to the primary care setting have a symptomatic disk herniation Herniation Omphalocele.

Etiology

  • Degenerative disk disease Disk Disease Examination of the Lower Limbs (most common cause)
  • Exceeding the limits of spinal range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs
  • Exceeding the limits of spinal load bearing
  • Trauma

Pathophysiology

Spinal disk degeneration (degenerative disk disease Disk Disease Examination of the Lower Limbs (DDD))

  • Loss of structural and functional integrity of the intervertebral disk(s)
  • May include any (multiple or all) of the following:

Annular Annular Dermatologic Examination tear

  • Annular Annular Dermatologic Examination fissure Fissure A crack or split that extends into the dermis Generalized and Localized Rashes if multiple tears present
  • Separation, avulsion, or breakage of annular Annular Dermatologic Examination fibers
  • May be traumatic or degenerative
  • May or may not be associated with leakage of the nucleus Nucleus Within a eukaryotic cell, a membrane-limited body which contains chromosomes and one or more nucleoli (cell nucleolus). The nuclear membrane consists of a double unit-type membrane which is perforated by a number of pores; the outermost membrane is continuous with the endoplasmic reticulum. A cell may contain more than one nucleus. The Cell: Organelles pulposus beyond annular Annular Dermatologic Examination margins
  • May produce discogenic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways regardless of leakage of nuclear contents

Spinal disk herniation Herniation Omphalocele

  • Displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms of disk contents ( annular Annular Dermatologic Examination, nuclear, cartilaginous, bony) beyond the limits of the normal disk space
  • Focal: < 25% of the disk circumference
  • Broad-based: 25%–50% of the disk circumference
  • Circumferential (also known as generalized disk bulge): > 50% of the disk circumference
  • Subcategories of herniation Herniation Omphalocele:
    • Spinal disk protrusion: 
      • A disk herniation Herniation Omphalocele wherein the x-axis dimensions are greater than the y-axis dimensions
      • Extends farther beyond the peripheral margins of the disk space horizontally than it does either cranially or caudally
      • Generally less advanced and smaller herniations
    • Spinal disk extrusion: 
      • A disk herniation Herniation Omphalocele wherein the y-axis dimensions are greater than the x-axis dimensions
      • Extends farther beyond the craniocaudal margins of the disk space than it does horizontally beyond the peripheral margins
      • Generally more advanced and larger herniations
    • Spinal disk sequestration: complete loss of continuity of herniated disk contents with the native disk
Stages of disk herniation

Continuum of spinal disk herniation Herniation Omphalocele

Image by Lecturio.

Annular Annular Dermatologic Examination disruption

  • A healthy annulus fibrosus is fibroelastic in structure:
    • Rigid enough to withstand the shear forces of physiologic spinal motion
    • Flexible enough to deform to the physiologic limits of spinal motion
  • Mechanisms that compromise the integrity of the annulus fibrosus include:
    •  Nonphysiologic shear forces:
      • Excessive or repetitive motion (e.g., flexion Flexion Examination of the Upper Limbs, extension Extension Examination of the Upper Limbs, side bending, rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays)
      • Excessive or repetitive load bearing (e.g., heavy lifting, obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity)
      • Trauma
    • Degenerative progression:
      • Can be part of the normal aging process 
      • Can be accelerated by lifestyle factors  
  • Degenerative changes Degenerative Changes Spinal Stenosis of the annulus include:
  • Tears in the annulus fibrosus under high exertion lead to: 
    • Prolapse of the nucleus Nucleus Within a eukaryotic cell, a membrane-limited body which contains chromosomes and one or more nucleoli (cell nucleolus). The nuclear membrane consists of a double unit-type membrane which is perforated by a number of pores; the outermost membrane is continuous with the endoplasmic reticulum. A cell may contain more than one nucleus. The Cell: Organelles pulposus
    • Disk herniation Herniation Omphalocele 
    • The herniated disk can shift medially, mediolaterally, or laterally and affects structures in its vicinity.
  • This herniation Herniation Omphalocele causes: 

Clinical Presentation

Related terminology

  • Dermatome: a predictable area of sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology innervation (receptive field) associated with a given spinal nerve
  • Myotome Myotome Development of the Limbs: a predictable area of motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology innervation (muscles, muscle groups, and related deep tendon reflexes Deep Tendon Reflexes Neurological Examination (DTRs)) associated with a given spinal nerve
  • Discogenic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways: localized ( axial Axial Computed Tomography (CT), midline) pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways associated with the disruption of fibers in the annulus fibrosus:
    • Localized, sharp or dull, does not radiate
    • Exacerbated by coughing, straining, or sneezing Sneezing The sudden, forceful, involuntary expulsion of air from the nose and mouth caused by irritation to the mucous membranes of the upper respiratory tract. Rhinovirus
    • Generally worse with flexion Flexion Examination of the Upper Limbs (compressed disk elements) and relieved with extension Extension Examination of the Upper Limbs (offloads disk elements)
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways reproduced with provocative diskography
    • Not all degenerated disks are painful.
    • Discogenic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways may be isolated or accompanied by radicular pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or referred pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
    • Localized ( axial Axial Computed Tomography (CT) pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways) may also emanate from nondisk structures ( pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways from these areas generally does not refer or radiate to distant areas):
      • Ligamentous structures
      • Tendinous structures
      • Facet joints
  • Referred pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Predictable region of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways distribution associated with a given pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways generator (e.g., herniated disk)
    • Remote from the site of tissue damage
    • Nondermatomal location
    • Example:
      • Sacroiliac (SI) joint inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation may refer pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways predictably to the ipsilateral posterolateral thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy (usually not past the knee) including the iliotibial band Iliotibial band Thigh: Anatomy and trochanteric bursa Trochanteric bursa Hip Joint: Anatomy.
      • Femoroacetabular joint inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation may refer pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways to the ipsilateral groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination, including genital organs. 
  • Radicular pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways: pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or uncomfortable sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology disturbance in the dermatomal Dermatomal Dermatologic Examination distribution of the associated spinal nerve root(s) due to irritation or compression Compression Blunt Chest Trauma
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is distant from the site of the disk abnormality.
    • Generally in the distribution of the dermatome of the affected nerve root(s)
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways is generally neuropathic in nature (i.e., burning, painful numbness, tingling Tingling Posterior Cord Syndrome, stinging, lancinating (electric, shock-like)).
  • Radicular syndrome (also known as nerve root compression Compression Blunt Chest Trauma or radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis): describes the collection of symptoms that are triggered by mechanical irritation or compression Compression Blunt Chest Trauma of a spinal nerve root by the abnormal presence of disk contents

History

Question the individual about the pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways characteristics (e.g., sharp, dull, boring) and accompanying symptoms (e.g., referred pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, radiating pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology changes, motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology changes), as well as previous illnesses, which may serve as warning signals for specific causes of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with an urgent call for action.

Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways location and related areas:

  • Neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess:
    • Localized cervical spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways: also known as cervicalgia
    • Cervical spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways generally refers pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways to the head and/or shoulders.
    • Cervical nerve root irritation/ compression Compression Blunt Chest Trauma will radiate pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways into the upper-extremity dermatomes Dermatomes Spinal Cord: Anatomy.
    • Isolated cervical nerve root dermatomal Dermatomal Dermatologic Examination pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways: also known as cervical radiculitis Radiculitis Ankylosing Spondylitis
    • Cervical radiculitis Radiculitis Ankylosing Spondylitis may be a component of cervical radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis.
  • Thorax:
    • Localized thoracic spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways also known as thoracalgia
    • Thoracic spinal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways generally refers pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways to the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall: Anatomy.
    • Thoracic nerve root irritation/ compression Compression Blunt Chest Trauma radiates into the associated dermatomes Dermatomes Spinal Cord: Anatomy of the intercostal nerve(s).
    • Isolated intercostal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma also known as intercostalgia
  • Low back:
    • Localized low back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways: also known as lumbago
    • Lumbar spinal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways generally refers pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways to the buttocks, pelvic region (including hips and/or groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination), or lower extremities.
    • Isolated lumbar spinal nerve root pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways: also known as lumbar radiculitis Radiculitis Ankylosing Spondylitis
    • Lumbar radiculitis Radiculitis Ankylosing Spondylitis may be a component of lumbar radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis.

Cervical, thoracic, or lumbar pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in combination with any of the clinical scenarios below are a “red flag” and require early investigation and treatment to prevent significant morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status.

Table: Clinical scenarios with possible diagnoses
Clinical scenario Possible diagnosis
Severe trauma (due to motor vehicle accidents Motor Vehicle Accidents Spinal Cord Injuries, fall from a great height, and sports injury), and minor trauma in elderly or individuals potentially affected by osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis; systemic steroid therapy Vertebral fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
Advanced age, history of tumors, and generalized symptoms ( fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia, weight loss Weight loss Decrease in existing body weight. Bariatric Surgery, anorexia Anorexia The lack or loss of appetite accompanied by an aversion to food and the inability to eat. It is the defining characteristic of the disorder anorexia nervosa. Anorexia Nervosa), and increased pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in supine position; severe nocturnal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways Tumor Tumor Inflammation
Generalized symptoms (acute fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, chills Chills The sudden sensation of being cold. It may be accompanied by shivering. Fever, loss of appetite, and fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia), a history of infection and associated general illness; drug abuse; immune suppression Suppression Defense Mechanisms; strong pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at night Infection
Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways radiating into the legs accompanied by paresthesia or weakness; cauda equina Cauda Equina The lower part of the spinal cord consisting of the lumbar, sacral, and coccygeal nerve roots. Spinal Cord Injuries syndrome: sudden bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess or rectal dysfunction, perianal and perineal loss of sensation; marked/increasing neurologic deficit; cessation of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with increasing paralysis leading to complete loss of function Loss of Function Inflammation of the reference muscle (nerve root death) Herniated disk
Sudden onset of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or weakness after lumbar puncture Lumbar Puncture Febrile Infant, intrathecal injection, epidural steroid injection, or spinal anesthesia Spinal anesthesia Procedure in which an anesthetic is injected directly into the spinal cord. Anesthesiology: History and Basic Concepts, especially in individuals taking anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants or those with thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia or other bleeding dyscrasia Spinal hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception

Physical examination

Inspection Inspection Dermatologic Examination:

  • Lordosis: excessive backward curvature of a spinal area (generally cervical or lumbar) 
  • Kyphosis Kyphosis Deformities of the spine characterized by an exaggerated convexity of the vertebral column. The forward bending of the thoracic region usually is more than 40 degrees. This deformity sometimes is called round back or hunchback. Osteoporosis: excessive forward curvature of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy (generally thoracic)
  • Scoliosis Scoliosis Scoliosis is a structural alteration of the vertebral column characterized by a lateral spinal curvature of greater than 10 degrees in the coronal plane. Scoliosis can be classified as idiopathic (in most cases) or secondary to underlying conditions. Scoliosis: lateral deviation of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy from the midline
  • Step off: generally a focal anterior deviation (single segment) from the normal alignment of the spinous processes related to spondylolysis Spondylolysis Deficient development or degeneration of a portion of the vertebra, usually in the pars interarticularis (the bone bridge between the superior and inferior facet joints of the lumbar vertebrae) leading to spondylolisthesis. Imaging of the Spine and Spinal Cord ( fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the bony vertebral pars intraarticularis) and/or spondylolisthesis Spondylolisthesis Displacement of a vertebra forward in relation to the vertebra below Back Pain (forward slippage of a bony vertebral segment on its caudal neighbor)
  • Asymmetry Asymmetry Examination of the Upper Limbs of paraspinal musculature

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination:

  • Paraspinal muscle Paraspinal muscle Deep muscles in the back whose function is to extend and rotate the spine and maintain posture. It consists splenius, semispinalis, multifidus, rotatores, interspinales, intertransversarii and sacrospinalis. Parapharyngeal Abscess abnormalities (i.e., hypertonicity Hypertonicity Volume Depletion and Dehydration, atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation)
  • Areas of tenderness (e.g., spinous process, intervertebral disk space, paraspinal muscles)
  • Step off: generally a focal anterior deviation (single segment) from the normal alignment of the spinous processes related to spondylolysis Spondylolysis Deficient development or degeneration of a portion of the vertebra, usually in the pars interarticularis (the bone bridge between the superior and inferior facet joints of the lumbar vertebrae) leading to spondylolisthesis. Imaging of the Spine and Spinal Cord ( fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures of the bony vertebral pars intraarticularis) and/or spondylolisthesis Spondylolisthesis Displacement of a vertebra forward in relation to the vertebra below Back Pain (forward slippage of a bony vertebral segment on its caudal neighbor)
  • Crepitus Crepitus Osteoarthritis

Provocative maneuvers:

  • Spurling test (also known as cervical compression Compression Blunt Chest Trauma test) for cervical disk herniation Herniation Omphalocele:
    • The individual bends ( extension Extension Examination of the Upper Limbs, flexion Flexion Examination of the Upper Limbs, side bending, rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays) the head toward the painful side. 
    • The physician applies caudal pressure to the top of the head. 
    • Positive test reproduces localized, referred, or radicular pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
  • Lasègue test (also known as straight leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy raise test) for lumbar disk herniation Herniation Omphalocele:
    • With the individual supine, physician passively lifts each leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy off the table to 30–45 degrees.
    • Positive test reproduces localized, referred, or radicular pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.
Straight leg test (lasègue test)

Straight leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy test (Lasègue test)

Image by Lecturio.

Evaluation of radicular symptoms:

  • Sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology: Identify areas of referred pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and/or radicular pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways/ sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology disturbance.
  • Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology: Identify areas of myotomal weakness and/or reflex depression.
Table: Important cervical radicular syndromes
Syndrome Paresis Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma, paresthesia, abnormal sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques Weakened reflexes
C5 Deltoideus Lateral shoulder Biceps reflex Biceps Reflex Neurological Examination
C6 Biceps Biceps Arm: Anatomy brachii, musculus brachioradialis Brachioradialis Forearm: Anatomy Radial arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy extending to the thumb Biceps reflex Biceps Reflex Neurological Examination, radial reflex
C7 Triceps brachii Triceps brachii Elbow Joint: Anatomy Regio antebrachii dorsalis, dorsal hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy extending to 2nd–4th fingers Triceps reflex, biceps reflex Biceps Reflex Neurological Examination
C8 Small hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy muscles Ulnar arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy, lateral hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy extending to 5th finger Not applicable
Table: Important lumbar radicular syndromes
Syndrome Paresis Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma, paresthesia, sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques disturbance Weakened reflexes
L3 Deltoideus Transverse anterior aspect of the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy toward the knee Adductor reflex, perhaps patellar reflex
L4 Quadriceps, musculus tibialis anterior Tibialis anterior Leg: Anatomy Anterior and medial lower leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy Patellar reflex
L5 Extensor hallucis longus Extensor hallucis longus Leg: Anatomy (lifts big toe), perhaps musculus tibialis anterior Tibialis anterior Leg: Anatomy and posterior, musculus gluteus medius Gluteus medius Gluteal Region: Anatomy Lateral and anterior lower leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy, dorsal foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy extending to big toe Tibialis posterior Tibialis posterior Leg: Anatomy reflex
S1 S1 Heart Sounds Triceps surae ( plantar flexion Plantar Flexion Chronic Apophyseal Injury, test perhaps through standing on toes), musculus gluteus maximus Gluteus maximus Gluteal Region: Anatomy, musculus biceps femoris Biceps femoris Thigh: Anatomy Posterior and lateral thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy, lateral foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy Achilles reflex Achilles Reflex Examination of the Lower Limbs
S2 S2 Heart Sounds S4 S4 Heart Sounds Bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess and rectal dysfunction (neurologic emergency, see cauda syndrome) Posterior thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh: Anatomy, anal region (cauda syndrome: breech presentation Breech presentation A malpresentation of the fetus at near term or during obstetric labor with the fetal cephalic pole in the fundus of the uterus. There are three types of breech: the complete breech with flexed hips and knees; the incomplete breech with one or both hips partially or fully extended; the frank breech with flexed hips and extended knees. Fetal Malpresentation and Malposition) Anal reflex

Evaluation of myelopathy:

  • Look for signs of upper motor neuron disease Motor neuron disease Diseases characterized by a selective degeneration of the motor neurons of the spinal cord, brainstem, or motor cortex. Clinical subtypes are distinguished by the major site of degeneration. In amyotrophic lateral sclerosis there is involvement of upper, lower, and brainstem motor neurons. In progressive muscular atrophy and related syndromes the motor neurons in the spinal cord are primarily affected. With progressive bulbar palsy, the initial degeneration occurs in the brainstem. In primary lateral sclerosis, the cortical neurons are affected in isolation. Amyotrophic Lateral Sclerosis.
  • Pertinent history/exam findings:
    • Spasticity
    • Hyperactive reflexes
    • Weakness
    • Trömner sign (upper-limb involvement)
    • Babinski sign Babinski sign A reflex found in normal infants consisting of dorsiflexion of the hallux and abduction of the other toes in response to cutaneous stimulation of the plantar surface of the foot. In adults, it is used as a diagnostic criterion, and if present is a neurologic manifestation of dysfunction in the central nervous system. Posterior Cord Syndrome (lower-limb involvement)
  • Urinary/ fecal incontinence Fecal incontinence Failure of voluntary control of the anal sphincters, with involuntary passage of feces and flatus. Pediatric Constipation

Evaluation of conus medullaris Conus Medullaris Spinal Cord Injuries/ cauda equina Cauda Equina The lower part of the spinal cord consisting of the lumbar, sacral, and coccygeal nerve roots. Spinal Cord Injuries syndromes:

  • Back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with bilateral radicular signs/symptoms
  • Sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology changes/weakness of both lower extremities
  • Bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess/bowel dysfunction (autonomic disruption)
  • Saddle anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts or decreased sensation in the perineum Perineum The body region lying between the genital area and the anus on the surface of the trunk, and to the shallow compartment lying deep to this area that is inferior to the pelvic diaphragm. The surface area is between the vulva and the anus in the female, and between the scrotum and the anus in the male. Vagina, Vulva, and Pelvic Floor: Anatomy 
  • Sexual dysfunction Sexual dysfunction Physiological disturbances in normal sexual performance in either the male or the female. Sexual Physiology
Saddle anesthesia

Sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology area affected in “saddle anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts

Image by Lecturio.

Diagnosis

Diagnosis is usually suspected with a thorough history and physical examination and often confirmed with diagnostic imaging (e.g., MRI).

MRI

Right-central disk bulge

Disk bulge:
Axial Axial Computed Tomography (CT) (A) and sagittal Sagittal Computed Tomography (CT) (B) T2-weighted images T2-Weighted Images Imaging of the Head and Brain reveal a focal right-central disk bulge at L4–L5 that slightly indents the thecal sac and extends into the right nerve root canal (white arrow in A, black arrow in B). A more focal protrusion and associated annular Annular Dermatologic Examination tear is present at L5– S1 S1 Heart Sounds (white arrow in B).

Image: “Disc Bulge” by Department of Chiropractic, D’Youville College, 320 Porter Avenue, Buffalo, NY, 14201, USA. License: CC BY 2.0

CT scan

  • Preferred study to visualize bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types structures
  • Can also show calcified herniated disks. 
  • Relatively more accessible than MRI
  • Alternative if individual cannot undergo MRI
  • CT myelography can be performed to visualize herniated disk.

X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays

  • Most accessible method 
  • Used to assess for structural instability:
    • Spondylolysis Spondylolysis Deficient development or degeneration of a portion of the vertebra, usually in the pars interarticularis (the bone bridge between the superior and inferior facet joints of the lumbar vertebrae) leading to spondylolisthesis. Imaging of the Spine and Spinal Cord
    • Spondylolisthesis Spondylolisthesis Displacement of a vertebra forward in relation to the vertebra below Back Pain
  • May be needed as an initial imaging method to authorize CT and/or MRI
  • Provocative diskography:
    • Injection of contrast media Contrast Media Substances used to allow enhanced visualization of tissues. Computed Tomography (CT) directly into the disk for disk visualization
    • May be performed under fluoroscopy Fluoroscopy Production of an image when x-rays strike a fluorescent screen. X-rays or CT guidance
    • Reproduction of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways on injection confirms the presence of discogenic pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.

Management

Conservative management

  • Analgesics (e.g., NSAIDs NSAIDS Primary vs Secondary Headaches) and muscle relaxants (e.g., cyclobenzaprine Cyclobenzaprine Spasmolytics)
    • If nonopioid analgesics prove ineffective, weak opioid Opioid Compounds with activity like opiate alkaloids, acting at opioid receptors. Properties include induction of analgesia or narcosis. Constipation analgesics may be prescribed. 
    • Treatment should follow the stepped care recommended by the WHO.
  • Consider activity restrictions and/or bracing if neurologic signs/symptoms present.
  • Physical therapy Physical Therapy Becker Muscular Dystrophy as tolerated as symptoms improve
  • High-velocity osteopathic and/or chiropractic treatment is contraindicated.
  • Interventional pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways management procedures may be palliative: epidural steroid injection at the affected spinal segment(s)
    • Transforaminal approach: epidural space Epidural space Space between the dura mater and the walls of the vertebral canal. Epidural Hemorrhage accessed laterally, directly at the intervertebral neural foramen of the affected nerve root(s)
    • Interlaminar approach: epidural space Epidural space Space between the dura mater and the walls of the vertebral canal. Epidural Hemorrhage accessed posteriorly, at the intervertebral interlaminar space below the affected nerve root(s)
    • Caudal approach: epidural space Epidural space Space between the dura mater and the walls of the vertebral canal. Epidural Hemorrhage accessed caudally, remote from the affected nerve root(s) at the sacral hiatus

Surgical management

Surgical management is reserved for individuals whose condition does not respond to conservative treatment and/or in whom persistent or rapidly worsening neurologic deficits Neurologic Deficits High-Risk Headaches are present.

  • Absolute indications:
    • Bowel/ bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess dysfunction
    • Conus–cauda syndrome
    • Significant paresis
    • Signs of myelopathy
  • Relative indications:
    • Spinal disk sequestration
    • Failure of conservative therapy (persisting pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways syndrome for weeks despite conservative therapy)
  • Procedures:
    • Spinal disk material can be removed via:
      • Laminectomy Laminectomy A surgical procedure that entails removing all (laminectomy) or part (laminotomy) of selected vertebral lamina to relieve pressure on the spinal cord and/or spinal nerve roots. Vertebral lamina is the thin flattened posterior wall of vertebral arch that forms the vertebral foramen through which pass the spinal cord and nerve roots. Neurosurgery
      • Diskectomy
      • More advanced spinal surgical techniques are beyond the scope of this document.
Microdiskectomy technique

Microdiskectomy technique

Image by Lecturio.

Complications

  • Chronic back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
  • Significant loss of work and disability Disability Determination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits. ABCDE Assessment in severe cases
  • Remnant nerve damage due to nerve root compression Compression Blunt Chest Trauma
  • Repeated intervention

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • 85% of cases will resolve within 8–12 weeks with no treatment.
  • Conservative therapy can ameliorate up to 80% of cases.
  • Success with conservative therapy is comparable to that with surgical intervention, following appropriate monitoring and observation.
  • The rate of recidivism is rather high.

Differential Diagnosis

  • Low-back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways due to mechanical causes (e.g., poor posture)
  • Diskal cyst: uncommon lesion of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy. Diskal cyst is an extrathecal cyst that communicates with the adjacent intervertebral disk through an annular Annular Dermatologic Examination fissure Fissure A crack or split that extends into the dermis Generalized and Localized Rashes. The cysts Cysts Any fluid-filled closed cavity or sac that is lined by an epithelium. Cysts can be of normal, abnormal, non-neoplastic, or neoplastic tissues. Fibrocystic Change can compress the nerve root, resulting in radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis
  • Degenerative spinal stenosis Spinal stenosis Spinal stenosis is the progressive narrowing of the central spinal canal, intervertebral foramen, and lateral recess, leading to compression of the nerve root. Spinal stenosis can occur in the cervical, thoracic, and lumbar spine and is commonly caused by degenerative bone disease (mostly affecting the elderly). Spinal Stenosis: narrowing of the vertebral canal that compresses spinal nerves Spinal nerves The 31 paired peripheral nerves formed by the union of the dorsal and ventral spinal roots from each spinal cord segment. The spinal nerve plexuses and the spinal roots are also included. Spinal Cord: Anatomy and may cause leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and difficulty walking. Degenerative spinal stenosis Spinal stenosis Spinal stenosis is the progressive narrowing of the central spinal canal, intervertebral foramen, and lateral recess, leading to compression of the nerve root. Spinal stenosis can occur in the cervical, thoracic, and lumbar spine and is commonly caused by degenerative bone disease (mostly affecting the elderly). Spinal Stenosis is usually caused by the development of osteophytes on the vertebra. The symptoms of degenerative lumbar stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS) commonly occur in elderly adults and can be treated conservatively with pain-relieving agents or aggressively with decompressive surgery.
  • Metastasis Metastasis The transfer of a neoplasm from one organ or part of the body to another remote from the primary site. Grading, Staging, and Metastasis: spread of a tumor Tumor Inflammation from its primary site to nearby or distant places. Some malignancies, such as prostate cancer Prostate cancer Prostate cancer is one of the most common cancers affecting men. In the United States, the lifetime risk of being diagnosed with prostate cancer is approximately 11%, and the lifetime risk of death is 2.5%. Prostate cancer is a slow-growing cancer that takes years, or even decades, to develop into advanced disease. Prostate Cancer, can metastasize to the vertebral bodies and mimic lumbago owing to radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis
  • Pseudoradicular syndrome: Back pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways that appears radicular and radiates into arms and legs but is not immediately caused by nerve root compression Compression Blunt Chest Trauma is called pseudoradicular syndrome. Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways does not typically radiate strictly as in radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis, and instead, it may appear as paresthesia, without a strong correlation Correlation Determination of whether or not two variables are correlated. This means to study whether an increase or decrease in one variable corresponds to an increase or decrease in the other variable. Causality, Validity, and Reliability with dermatomes Dermatomes Spinal Cord: Anatomy. Pseudoradicular syndrome is usually orthopedic, perhaps mediated by facet syndrome or iliosacral joint syndrome, suggesting joint distortions (blockages), which are attributed to degenerative changes Degenerative Changes Spinal Stenosis or poor posture.
  • Peripheral nerve lesions: peripheral nerve lesions or plexus lesions can mimic nerve root damage clinically. In addition to accurate analysis of clinical symptoms, neurography can be used to facilitate the diagnosis.
  • Inflammatory radiculitis Radiculitis Ankylosing Spondylitis: radiculitis Radiculitis Ankylosing Spondylitis caused by either a bacterial or a viral infection (mainly borreliosis and herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox) and autoimmune or cryptogenic inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation should be considered in the differential diagnosis. Aside from spinal disk herniation Herniation Omphalocele, localized demand for space ( tumor Tumor Inflammation, bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types metastases) can cause radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis. Also, degenerative spinal changes, spinal abscesses, or spondylodiskitis should be considered, as well as the possibility of diabetic radiculopathy Radiculopathy Disease involving a spinal nerve root which may result from compression related to intervertebral disk displacement; spinal cord injuries; spinal diseases; and other conditions. Clinical manifestations include radicular pain, weakness, and sensory loss referable to structures innervated by the involved nerve root. Rheumatoid Arthritis.

References

  1. Appel, B. (2001). Nomenclature and classification of lumbar disc pathology. The Spine Journal, 14(2), 147–151. https://doi.org/10.1177/197140090101400208
  2. Deyo, R.. (2016). Herniated lumbar intervertebral disk. Retrieved October 29, 2021, from https://www.nejm.org/doi/full/10.1056/NEJMcp1512658
  3. Dydyk, A. (2021). Disc herniation. StatPearls. Retrieved October 29, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK441822/
  4. Hsu, P. (2021). Acute lumbosacral radiculopathy: pathophysiology, clinical features, and diagnosis. UpToDate. Retrieved October 29, 2021, from https://www.uptodate.com/contents/acute-lumbosacral-radiculopathy-pathophysiology-clinical-features-and-diagnosis
  5. Kerry Levin, K. (2021). Acute lumbosacral radiculopathy: treatment and prognosis. Retrieved October 29, 2021, from https://www.uptodate.com/contents/acute-lumbosacral-radiculopathy-treatment-and-prognosis

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