eMedicine Specialties > Neurosurgery > Spine

Lumbar Disc Disease

Author: Kamran Sahrakar, MD, FACS, Clinical Professor, Department of Neurosurgery, University of California at San Francisco
Coauthor(s): Martin Melicharek, MD, Assistant Clinical Professor, Department of Neurosurgery, University of California at Davis
Contributor Information and Disclosures

Updated: Oct 23, 2008

Introduction

Lumbar disc disease accounts for a large amount of lost productivity in the workforce. Accurate diagnosis can be difficult and often requires interpretation. Treatment is controversial. Surgical treatment can be technically simple and professionally gratifying for the surgeon. Treatment failures are not uncommon, are often related to posttraumatic or work-related injuries, and may result in litigation. As a consequence, this disease can generate distrust of physicians on the part of patients and vice versa.

This article clarifies some important guidelines for the diagnosis and treatment of lumbar disc disease.

History of the Procedure

The first published report of lumbar disc herniation with radiculopathy was written by Mixter and Barr in 1934. Surgical treatment was not widespread until the 1950s. Today, lumbar discectomy is one of the most commonly performed elective operations in the United States.

Problem

Lumbar disc disease is a rather encompassing term. For example, some physicians include back pain alone as a symptom of disc disease. Others make the diagnosis without evidence of disc disease on MRI. The discussion of this article is limited to well-defined lumbar disc herniation. The pathophysiology, clinical presentation, radiographic diagnosis, treatment, and outcome are discussed.

Frequency

Although most people experience back pain during their lifetime, only a fraction experience lumbar radiculopathy or sciatica as a consequence of root compression or irritation.

Almost 5% of males and 2.5% of females experience sciatica at some time in their lifetime.

Etiology

A herniated disk fragment comes from the nucleus pulposus of the disc (a remnant of the embryonic notochord). In the normal condition, this nucleus is in the disk center securely contained by the annulus fibrosus.

When a fragment of nucleus herniates, it irritates and/or compresses the adjacent nerve root. This can cause the pain syndrome known as sciatica and, in severe cases, dysfunction of the nerve.

Presentation

Most lumbar disc herniations (lumbar disc diseases) are preceded by bouts of varying degrees and duration of back pain. In many cases, an inciting event cannot be identified. Pain eventually may radiate into the leg. It may be characterized as less achy, burning, or similar to an electrical shock and is often described as a shooting or stabbing pain. The distribution of the leg pain is somewhat dependent on the level of nerve root irritation. Higher herniations (third or fourth lumbar levels) can radiate into the groin or anterior thigh. Lower radiculopathies (first sacral level) cause pain in the calf and bottom of the foot.

Fifth lumbar radiculopathy, which occurs most commonly, causes lateral and anterior thigh and leg pain. Often, accompanying numbness or tingling occurs with a distribution similar to the pain. Accompanying muscle weakness may be unrecognized if the pain is incapacitating. The pain usually improves when the patient is in the supine position with the legs slightly elevated. Patients are more comfortable when changing positions. Short walks can bring relief. Long walks or extended sitting (especially driving) can aggravate the pain.

On examination, patients may be neurologically normal, may have a profound radiculopathy, or may even demonstrate a cauda equina syndrome. A positive straight-leg raising sign is almost always present. However, a crossed straight-leg raising sign may be even more predictive of a lumbar disc herniation (lumbar disc disease). The back may appear scoliotic. Gait is often abnormal. Muscle weakness may be revealed particularly when testing walking on heels and toes.

Indications

The indications for surgical treatment of symptomatic lumbar disc disease are not clearly delineated. Nevertheless, situations exist in which most spine surgeons would probably agree on operative intervention. These situations include the following:

  • A patient with cauda equina syndrome
  • A patient demonstrating progressive neurologic deficit during a period of observation
  • A patient with persistent bothersome sciatic pain, despite conservative management, for a period of 6-12 weeks (a time period that varies from surgeon to surgeon)

Notably missing from this list is a patient presenting with a profound motor deficit of varying duration. In the absence of pain, whether such patients benefit from surgery is unclear. No consensus has been reached concerning how urgent surgery is for a patient who presents with a clinical picture of painful disk herniation. Unfortunately, the decision to operate emergently is often based on fear of legal repercussions rather than on scientific evidence of actual patient benefit.

Relevant Anatomy

A disc herniation (lumbar disc disease) most frequently irritates the displaced nerve root. One of the more difficult concepts for beginning medical students to grasp is the anatomic relationship of the fifth lumbar (L5) nerve root to the L4-5 disc herniation.

Equally important to understand is the concept of the far lateral or foraminal disc herniation in which the root above the disc herniation is irritated.

With very large herniations, the entire cauda equina can be compressed and functionally compromised. This causes saddle anesthesia and can cause urinary retention and incontinence.

Contraindications

Any claim of absolute contraindications for lumbar disc disease would invariably be challenged. Most spine surgeons adhere to some guidelines, including the following:

  • A patient with unrelenting back pain: Patients who have back pain after a bout of sciatica has resolved are not good candidates for operative treatment. Often, these patients are the most insistent and difficult to manage. Occasionally, these are patients whose back pain improved after discectomy for a large central disc herniation.
  • A patient with an incomplete workup: When diagnosis is uncertain, postpone surgery. Disc herniations are so ubiquitous that being cavalier in diagnosis is easy. Ensure the completeness of the workup prior to proceeding with the operation. All surgeons can recall several cases in which a diabetic plexopathy or an epidural metastasis was missed.
  • A patient not provided adequate conservative treatment: Spine surgeons rarely commit a patient with a short period of sciatica and without bedrest and a steroid trial to an operation that will permanently alter the patient's back mechanics and strength.

More on Lumbar Disc Disease

Overview: Lumbar Disc Disease
Workup: Lumbar Disc Disease
Treatment: Lumbar Disc Disease
Follow-up: Lumbar Disc Disease
References
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References

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  2. Mirzai H, Tekin I, Yaman O, et al. The results of nucleoplasty in patients with lumbar herniated disc: a prospective clinical study of 52 consecutive patients. Spine J. Jan-Feb 2007;7(1):88-92; discussion 92-3. [Medline].

  3. Celik SE, Celik S, Kara A, et al. Lumbar facet joint angle and its importance on joint violation in lumbar microdiscectomy. Neurosurgery. Jan 2008;62(1):168-72; discussion 172-3. [Medline].

  4. Eugene J. Carragee, MD, Anthony O. et al. A Prospective Controlled Study of Limited VersusSubtotal Posterior Discectomy: Short-Term Outcomesin Patients With Herniated Lumbar Intervertebral Discsand Large Posterior Anular Defect. Spine. 2006;31:653-657.

  5. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. Nov 22 2006;296(20):2441-50. [Medline].

  6. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. Nov 22 2006;296(20):2451-9. [Medline].

  7. Mazanec D, Okereke L. Interpreting the Spine Patient Outcomes Research Trial. Medical vs surgical treatment of lumbar disk herniation: implications for future trials. Cleve Clin J Med. Aug 2007;74(8):577-83. [Medline].

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  11. Loupasis GA, Stamos K, Katonis PG, et al. Seven- to 20-year outcome of lumbar discectomy. Spine. Nov 15 1999;24(22):2313-7. [Medline].

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Further Reading

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Keywords

lumbar, degenerative disc disease, lumbar disc disease, lumbar degenerative disc disease, lumbar disk disease, degenerative disc, lumbar spine disc disease, lumbar disc herniation, sciatica, radiculopathy, lumbar discectomy, back pain, cauda equina syndrome, lumbar spine, spinal disc, back disc, disease disc, lumbar fusion, disc fusion, degenerative spine, spine surgery, spine

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Contributor Information and Disclosures

Author

Kamran Sahrakar, MD, FACS, Clinical Professor, Department of Neurosurgery, University of California at San Francisco
Kamran Sahrakar, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Medical Association, California Medical Association, Florida Medical Association, and Nevada State Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Martin Melicharek, MD, Assistant Clinical Professor, Department of Neurosurgery, University of California at Davis
Martin Melicharek, MD is a member of the following medical societies: American Association of Neurological Surgeons, California Medical Association, and Ohio State Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Michael G Nosko, MD, PhD, Chief, Division of Neurosurgery, Director of Neurovascular Surgery, Medical Director of Neuroscience Unit, Associate Professor, Department of Surgery, University of Medicine and Dentistry at New Jersey
Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

 
 
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