Spinal Disk Herniation

Spinal disk herniation (also known as herniated nucleus pulposus) describes the expulsion of the nucleus pulposus through a perforation in the annulus fibrosus of the intervertebral disk. Spinal disk herniation is an important pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain syndrome with the potential for neurologic impairment and is most commonly caused by degenerative disk disease. Clinical presentation 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 or nerve root compression and the downstream neurologic sequelae (e.g., radicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, muscle weakness, sensory deficit, 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.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

Spinal disk herniation 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 Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain and/or nerve root irritation.

Spinal disks (intervertebral disks)

Structure:

  • Composed of an outer fibrous ring (annulus fibrosus) and a gelatinous center (nucleus pulposus)
    • The annulus fibrosus is a semirigid fibroelastic structure that contains the nucleus pulposus and anchors the intervertebral disk to the adjacent vertebrae.
    • The nucleus pulposus is a gelatinous matrix of water and proteoglycans that allows the intervertebral disk to flex and deform with physiologic motion of the spine.
  • Convex anteriorly, concave posteriorly

Function:

  • Deformable, shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of 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
  • Responsible for cushioning intervertebral articulations of the spine

Anatomic relationships:

  • Outer ⅓ of the annulus fibrosus is innervated (potential pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain generator).
  • Annular fibers are continuous with periosteal fibers of the adjacent vertebra. 
  • Annular 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 of the bony vertebral body defines the peripheral limits of the intervertebral disk space. 
  • Continuous with and bordered anteriorly by the anterior longitudinal ligament:
    • Broad and thick fibrous structure, covers the entire anterior aspect of the spinal disk(s)
    • Provides structural support to the anterior spine 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 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
    • Provides structural support to the posterior spine 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

Epidemiology

  • Incidence: 
    • Cervical radiculopathy:
      • 107 in 100,000 men
      • 64 in 100,000 women
    • Thoracic radiculopathy: 0.5%–4.5% of all disk ruptures (least common of all disk pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain syndromes)
    • Lumbar radiculopathy:
      • 5–20 cases per 1000 adults annually
      • 66% of all disk pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain syndromes
  • Prevalence of:
    • Acute low back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain: 37% 
    • Lifetime prevalence: 87%
  • Greatest prevalence in ages 30–50 years
  • Male:female ratio of 2:1

Etiology

  • Degenerative disk disease (most common cause)
  • Exceeding the limits of spinal range of motion
  • Exceeding the limits of spinal load bearing
  • Trauma

Pathophysiology

Spinal disk degeneration (degenerative disk disease (DDD))

  • Loss of structural and functional integrity of the intervertebral disk(s)
  • May include any (multiple or all) of the following:
    • Desiccation of the annulus fibrosus
    • Fibrosis/calcification of the annulus fibrosus
    • Loss of the intervertebral space (i.e., height)
    • Annular tear with or without herniation
    • Herniation of nuclear contents
    • Vertebral end plate defects
    • Osteophyte formation 

Annular tear

  • Annular fissure if multiple tears present
  • Separation, avulsion, or breakage of annular fibers
  • May be traumatic or degenerative
  • May or may not be associated with leakage of the nucleus pulposus beyond annular margins
  • May produce discogenic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain regardless of leakage of nuclear contents

Spinal disk herniation

  • Displacement of disk contents (annular, 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:
    • Spinal disk protrusion: 
      • A disk herniation 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 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

Image by Lecturio.

Annular 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, extension, side bending, rotation)
      • 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 of the annulus include:
    • Desiccation of the annulus fibrosus
    • Fibrosis/calcification of the annulus fibrosus
    • Loss of the intervertebral space (i.e., height)
    • Annular tear with or without herniation
    • Herniation of nuclear contents
  • Tears in the annulus fibrosus under high exertion lead to: 
    • Prolapse of the nucleus pulposus
    • Disk herniation 
    • The herniated disk can shift medially, mediolaterally, or laterally and affects structures in its vicinity.
  • This herniation causes: 
    • Discogenic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain (local pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain from nerve fibers of the annulus)
    • Myelocompression (also known as myelopathy; compression of the 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 itself):
      • Conus medullaris syndrome
      • Cauda equina syndrome
    • Irritation/compression of the respective spinal nerve roots:
      • Radiculitis: dermatomal radicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain/sensory change only
      • Radiculopathy: dermatomal radicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain + myotomal motor manifestation (weakness, depressed reflexes)

Clinical Presentation

Related terminology

  • Dermatome: a predictable area of sensory innervation (receptive field) associated with a given spinal nerve
  • Myotome: a predictable area of motor innervation (muscles, muscle groups, and related deep tendon reflexes (DTRs)) associated with a given spinal nerve
  • Discogenic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain: localized (axial, midline) pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain associated with the disruption of fibers in the annulus fibrosus:
    • Localized, sharp or dull, does not radiate
    • Exacerbated by coughing, straining, or sneezing
    • Generally worse with flexion (compressed disk elements) and relieved with extension (offloads disk elements)
    • Pain reproduced with provocative diskography
    • Not all degenerated disks are painful.
    • Discogenic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain may be isolated or accompanied by radicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or referred pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain.
    • Localized (axial pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain) may also emanate from nondisk structures ( pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain from these areas generally does not refer or radiate to distant areas):
      • Ligamentous structures
      • Tendinous structures
      • Facet joints
  • Referred pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Predictable region of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain distribution associated with a given pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 (usually not past the knee) including the iliotibial band and trochanteric bursa.
      • 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain to the ipsilateral groin, including genital organs. 
  • Radicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain: pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or uncomfortable sensory disturbance in the dermatomal distribution of the associated spinal nerve root(s) due to irritation or compression
    • Pain is distant from the site of the disk abnormality.
    • Generally in the distribution of the dermatome of the affected nerve root(s)
    • Pain is generally neuropathic in nature (i.e., burning, painful numbness, tingling, stinging, lancinating (electric, shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock-like)).
  • Radicular syndrome (also known as nerve root compression or radiculopathy): describes the collection of symptoms that are triggered by mechanical irritation or compression of a spinal nerve root by the abnormal presence of disk contents
    • Essentially radicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain plus motor manifestations
    • Motor manifestations may include:
      • Myotomal weakness
      • Reflex depression related to the affected myotome
      • Muscle spasm in the muscles of the myotome

History

Question the individual about the pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain characteristics (e.g., sharp, dull, boring) and accompanying symptoms (e.g., referred pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, radiating pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, sensory changes, motor changes), as well as previous illnesses, which may serve as warning signals for specific causes of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with an urgent call for action.

Pain location and related areas:

  • Neck:
    • Localized cervical spine pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain: also known as cervicalgia
    • Cervical spine pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain generally refers pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain to the head and/or shoulders.
    • Cervical nerve root irritation/compression will radiate pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain into the upper-extremity dermatomes.
    • Isolated cervical nerve root dermatomal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain: also known as cervical radiculitis
    • Cervical radiculitis may be a component of cervical radiculopathy.
  • Thorax:
    • Localized thoracic spine pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain also known as thoracalgia
    • Thoracic spinal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain generally refers pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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.
    • Thoracic nerve root irritation/compression radiates into the associated dermatomes of the intercostal nerve(s).
    • Isolated intercostal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain radiation also known as intercostalgia
  • Low back:
    • Localized low back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain: also known as lumbago
    • Lumbar spinal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain generally refers pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain to the buttocks, pelvic region (including hips and/or groin), or lower extremities.
    • Isolated lumbar spinal nerve root pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain: also known as lumbar radiculitis
    • Lumbar radiculitis may be a component of lumbar radiculopathy.

Cervical, thoracic, or lumbar pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in combination with any of the clinical scenarios below are a “red flag” and require early investigation and treatment to prevent significant morbidity.

Table: Clinical scenarios with possible diagnoses
Clinical scenario Possible diagnosis
Severe trauma (due to motor vehicle accidents, 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, weight loss, anorexia), and increased pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in supine position; severe nocturnal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain Tumor
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, loss of appetite, and fatigue), a history of infection and associated general illness; drug abuse; immune suppression; strong pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain at night Infection
Pain radiating into the legs accompanied by paresthesia or weakness; cauda equina syndrome: sudden bladder or rectal dysfunction, perianal and perineal loss of sensation; marked/increasing neurologic deficit; cessation of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with increasing paralysis leading to complete loss of function of the reference muscle (nerve root death) Herniated disk
Sudden onset of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or weakness after lumbar puncture, intrathecal injection, epidural steroid injection, or spinal anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. 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

Physical examination

Inspection:

  • Lordosis: excessive backward curvature of a spinal area (generally cervical or lumbar) 
  • Kyphosis: excessive forward curvature of the spine (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 from the midline
  • Step off: generally a focal anterior deviation (single segment) from the normal alignment of the spinous processes related to spondylolysis ( 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 (forward slippage of a bony vertebral segment on its caudal neighbor
  • Asymmetry of paraspinal musculature

Palpation:

  • Paraspinal muscle abnormalities (i.e., hypertonicity, atrophy)
  • 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 ( 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 (forward slippage of a bony vertebral segment on its caudal neighbor)
  • Crepitus

Provocative maneuvers:

  • Spurling test (also known as cervical compression test) for cervical disk herniation:
    • The individual bends (extension, flexion, side bending, rotation) 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain.
  • 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 raise test) for lumbar disk herniation:
    • 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 off the table to 30–45 degrees.
    • Positive test reproduces localized, referred, or radicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain.
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 test (Lasègue test)

Image by Lecturio.

Evaluation of radicular symptoms:

  • Sensory: Identify areas of referred pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and/or radicular pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain/sensory disturbance.
  • Motor: Identify areas of myotomal weakness and/or reflex depression.
Table: Important cervical radicular syndromes
Syndrome Paresis Pain radiation, paresthesia, abnormal sensitivity Weakened reflexes
C5 Deltoideus Lateral shoulder Biceps reflex
C6 Biceps brachii, musculus brachioradialis 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 extending to the thumb Biceps reflex, radial reflex
C7 Triceps brachii 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 extending to 2nd–4th fingers Triceps reflex, biceps reflex
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 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, 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 extending to 5th finger Not applicable
Table: Important lumbar radicular syndromes
Syndrome Paresis Pain radiation, paresthesia, sensitivity 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 toward the knee Adductor reflex, perhaps patellar reflex
L4 Quadriceps, musculus tibialis anterior 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 Patellar reflex
L5 Extensor hallucis longus (lifts big toe), perhaps musculus tibialis anterior and posterior, musculus gluteus medius 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, 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 extending to big toe Tibialis posterior reflex
S1 Triceps surae (plantar flexion, test perhaps through standing on toes), musculus gluteus maximus, musculus biceps femoris 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, 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 Achilles reflex
S2–S4 Bladder 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, anal region (cauda syndrome: breech presentation) Anal reflex

Evaluation of myelopathy:

  • Look for signs of upper motor neuron disease.
  • Pertinent history/exam findings:
    • Spasticity
    • Hyperactive reflexes
    • Weakness
    • Trömner sign (upper-limb involvement)
    • Babinski sign (lower-limb involvement)
  • Urinary/fecal incontinence

Evaluation of conus medullaris/cauda equina syndromes:

  • Back pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with bilateral radicular signs/symptoms
  • Sensory changes/weakness of both lower extremities
  • Bladder/bowel dysfunction (autonomic disruption)
  • Saddle anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts or decreased sensation in the perineum 
  • Sexual dysfunction
Saddle anesthesia

Sensory area affected in “saddle anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. 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

  • Method of choice to confirm spinal disk herniation because of its better soft tissue visualization. 
  • Axial and sagittal views
  • Used for planning of interventional pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain procedures and surgery
  • Many cases of disk herniation can be asymptomatic and found incidentally on routine imaging for other causes.
Right-central disk bulge

Disk bulge:
Axial (A) and sagittal (B) T2-weighted images 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 tear is present at L5–S1 (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. Structure of Bones 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
    • Spondylolisthesis
  • May be needed as an initial imaging method to authorize CT and/or MRI
  • Provocative diskography:
    • Injection of contrast media directly into the disk for disk visualization
    • May be performed under fluoroscopy or CT guidance
    • Reproduction of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain on injection confirms the presence of discogenic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain.

Management

Conservative management

  • Analgesics (e.g., NSAIDs) and muscle relaxants (e.g., cyclobenzaprine)
    • If nonopioid analgesics prove ineffective, weak opioid analgesics Opioid analgesics Opiates are drugs that are derived from the sap of the opium poppy. Opiates have been used since antiquity for the relief of acute severe pain. Opioids are synthetic opiates with properties that are substantially similar to those of opiates. Opioid 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 as tolerated as symptoms improve
  • High-velocity osteopathic and/or chiropractic treatment is contraindicated.
  • Interventional pain management Pain Management Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a subjective experience. Acute pain lasts < 3 months and typically has a specific, identifiable cause. Pain Management procedures may be palliative: epidural steroid injection at the affected spinal segment(s)
    • Transforaminal approach: epidural space accessed laterally, directly at the intervertebral neural foramen of the affected nerve root(s)
    • Interlaminar approach: epidural space accessed posteriorly, at the intervertebral interlaminar space below the affected nerve root(s)
    • Caudal approach: epidural space 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 are present.

  • Absolute indications:
    • Bowel/bladder dysfunction
    • Conus–cauda syndrome
    • Significant paresis
    • Signs of myelopathy
  • Relative indications:
    • Spinal disk sequestration
    • Failure of conservative therapy (persisting pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain syndrome for weeks despite conservative therapy)
  • Procedures:
    • Spinal disk material can be removed via:
      • Laminectomy
      • Diskectomy
      • More advanced spinal surgical techniques are beyond the scope of this document.
Microdiskectomy technique

Microdiskectomy technique

Image by Lecturio.

Complications

  • Chronic back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain
  • Significant loss of work and disability in severe cases
  • Remnant nerve damage due to nerve root compression
  • Repeated intervention

Prognosis

  • 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 Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain due to mechanical causes (e.g., poor posture)
  • Diskal cyst: uncommon lesion of the spine. Diskal cyst is an extrathecal cyst that communicates with the adjacent intervertebral disk through an annular fissure. The cysts can compress the nerve root, resulting in radiculopathy. 
  • 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 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 pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 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 commonly occur in elderly adults and can be treated conservatively with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain-relieving agents or aggressively with decompressive surgery.
  • Metastasis: spread of a tumor 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. 
  • Pseudoradicular syndrome: Back pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain that appears radicular and radiates into arms and legs but is not immediately caused by nerve root compression is called pseudoradicular syndrome. Pain does not typically radiate strictly as in radiculopathy, and instead, it may appear as paresthesia, without a strong correlation with dermatomes. Pseudoradicular syndrome is usually orthopedic, perhaps mediated by facet syndrome or iliosacral joint syndrome, suggesting joint distortions (blockages), which are attributed to degenerative changes 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 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, localized demand for space (tumor, 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. Structure of Bones metastases) can cause radiculopathy. Also, degenerative spinal changes, spinal abscesses, or spondylodiskitis should be considered, as well as the possibility of diabetic radiculopathy.

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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