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Lumbar (Intervertebral) Disk Disorders

  • Author: Jere F Baldwin, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Feb 18, 2016
 

Practice Essentials

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 [1] or gradual onset after injury

See Clinical Presentation for more detail.

Diagnosis

Examination in a patient with suspected lumbar (intervertebral) disk disease may feature the following:

  • Abnormal gait
  • Abnormal postures
  • 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.

Testing

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

Imaging studies

The following radiologic studies may be used to evaluate lumbar disk disease:

  • Magnetic resonance imaging: Imaging modality of choice [2]
  • 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.

Management

Most patients with pain from lumbar disk disease have resolution of their symptoms with conservative treatment.

Pharmacotherapy

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:

  • Ibuprofen
  • Ketoprofen
  • Flurbiprofen
  • Naproxen

Surgical option

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:

  • Discectomy
  • Spinal fusion
  • Injection of chymopapain

See Treatment and Medication for more detail.

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Background

Lumbar disk disease is a frequent source of low back pain. Sciatica is defined as neuralgia along the course of the sciatic nerve.

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Pathophysiology

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
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Frequency

Sciatica has been reported by various authors to occur in 1-10% of the population.

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Mortality/Morbidity

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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Contributor Information and Disclosures
Author

Jere F Baldwin, MD Medical Director, Department of Emergency Medicine, Mercy Hospital Port Huron

Jere F Baldwin, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Emergency Physicians, American Medical Association, Michigan State Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey Horwitz, DO Director, Assistant Clinical Professor, Department of Emergency Medicine, North Shore University Hospital at Forest Hills

Jeffrey Horwitz, DO is a member of the following medical societies: Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Mark S Slabinski, MD, FACEP, FAAEM Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Ohio State Medical Association

Disclosure: Nothing to disclose.

References
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