Lumbar (Intervertebral) Disk Disorders
- Author: Jere F Baldwin, MD; Chief Editor: Trevor John Mills, MD, MPH more...
Lumbar (intervertebral) disk disease is a frequent source of low back pain. Bulging, protruding, extruding, or sequestered disks can result in lumbar disk disease.
Signs and symptoms
Signs and symptoms of lumbar disk disease include the following:
Sharp (rather than dull) pain
Typically, bilateral pain located at the posterior belt line
Referred pain rather than radicular
Usually preceded by multiple episodes of less severe low back pain
Localized to the lower back and gluteal area
Pain with flexion, rotation, or prolonged sitting or standing
Pain relieved in a recumbent position
Pain of sudden onset  or gradual onset after injury
See Clinical Presentation for more detail.
Examination in a patient with suspected lumbar (intervertebral) disk disease may feature the following:
Decreased lumbar range of motion
Positive straight leg raising test: Indicative of nerve root involvement
Usually negative nerve root stretch test results
Perform the usual motor, sensory, and reflex examinations (including perianal sensation and anal sphincter tone when appropriate). It is also mandatory to perform a careful abdominal and vascular examination.
Laboratory tests are generally not helpful in the diagnosis of lumbar disk disease. For an otherwise healthy individual, unless the patient is immobilized completely by the pain and requires admission or the pain has been present for more than 6 weeks, diagnostic studies are not recommended.
Indications for screening laboratory tests such as the following include pain of a nonmechanical nature, atypical pain pattern, persistent symptoms, and age older than 50 years:
Complete blood count with differential
Erythrocyte sedimentation rate
Alkaline and acid phosphatase levels
Serum calcium level
Serum protein electrophoresis
The following radiologic studies may be used to evaluate lumbar disk disease:
Magnetic resonance imaging: Imaging modality of choice 
Computed tomography scanning: Useful but less sensitive than MRI
Myelography: May provide definitive diagnosis itself, but technique is invasive
Plain lumbar films: Generally not helpful in the diagnosis, except to rule out other diseases and to evaluate for possible skeletal etiology as the cause of the patient's symptoms
Bone scanning: To rule out tumors, trauma, or infection
See Workup for more detail.
Most patients with pain from lumbar disk disease have resolution of their symptoms with conservative treatment.
Salicylates, acetaminophen, and nonsteroidal anti-inflammatory drugs appear about equally effective for the treatment of pain from lumbar disk disease. Opioids provide very effective acute pain relief, but they should not be used in patients with chronic pain. Muscle relaxants such as benzodiazepines, methocarbamol, and cyclobenzaprine are not only of limited use but also sedating.
Nonsteroidal anti-inflammatory drugs such as the following may be used in patients with lumbar (intervertebral) disk disorders to reduce pain and inflammation:
Patients with lumbar disk disorders who have not had a response with 6 weeks of conservative therapy may consider surgical intervention, such as the following:
Injection of chymopapain
Lumbar disk disease is a frequent source of low back pain. Sciatica is defined as neuralgia along the course of the sciatic nerve.
The intervertebral disks act as shock absorbers and are found between the bodies of the vertebrae. They have a central area composed of a colloidal gel, called the nucleus pulposus, which is surrounded by a fibrous capsule, the annulus fibrosis. This structure is held together by the anterior longitudinal ligament, which is anterior to the vertebral bodies, and the posterior longitudinal ligament, which is posterior to the vertebral bodies and anterior to the spinal cord. The muscles of the trunk provide additional support.
The most common site of disk herniation is at the L5-S1 interspace in the lumbosacral region. This is believed to be due to the thinning of the posterior longitudinal ligament as it extends caudally.
Nomenclature specific to lumbar disk disease is as follows:
Disk bulge - Annular fibers intact
Disk protrusion - Localized bulging with damage of some annular fibers
Disk extrusion - Extended bulge with loss of annular fibers, but disk remains intact
Disk sequestration - Fragment of disk broken off from the nucleus pulposus
Sciatica has been reported by various authors to occur in 1-10% of the population.
Low back pain usually is self-limited and of short duration. The male-to-female ratio is approximately 1:1. The group most commonly affected is adults aged 25-45 years.
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