Herniated Nucleus Pulposus Treatment & Management

Updated: May 20, 2019
  • Author: Deepak Gautam, MBBS, MS(Orth); Chief Editor: Jeffrey A Goldstein, MD  more...
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Treatment

Conservative Treatment

Spontaneous improvement of low back discomfort has allowed ineffective treatments to perpetuate, because benefits have been ascribed to them when they are prescribed while the patient is still symptomatic but otherwise improving.

Hippocrates expected improvement in sciatica in 40 days, and the customary and contemporary guideline is 6 weeks. An often-quoted study suggested near-resolution improvement of 90% of patients within 6 weeks, but this study has been faulted because the criterion for patient recovery was failure to return to the observing physician. [28]  The prevalence of back problems is consistent with the failure of a subgroup of patients to improve and to have periodic recurrent episodes of disability.

Analysis of the effectiveness of treatments and attempts to restrict treatment to those modalities that have demonstrated efficacy are evidence-based medical practice. Bed rest has a long history of use but has not been shown to be effective beyond the initial 1 or 2 days; after this period, it is counterproductive. All conservative treatments are essentially efforts to reduce inflammation. Therefore, only a very short period of rest is appropriate; anti-inflammatories are of some benefit (because the pain is from inflammation of the nerve), and warm, moist heat or modalities may help. Tumor necrosis factor (TNF)-α antagonism has been experimentally shown to decrease inflammatory events in preclinical models. [29]

Activities should be resumed as early as the patient can tolerate. Exercise and physical therapy mobilize muscles and joints to facilitate the removal of edema and promote recovery. Muscle relaxants may offer symptomatic relief of the acute muscle spasms, but only in the early stages; however, all are centrally acting, they do not directly relax skeletal muscle, and they are also sedating.

For back pain without radiculopathy, chiropractic care has high patient satisfaction when performed within the first 6 weeks, and it has been shown to have good efficacy acutely from an evidence-based standpoint. [30]  Injections (eg, epidural) may be particularly helpful in patients with radiculopathy by providing symptomatic relief, which allows the patient to increase activities and helps facilitate rehabilitation. [31, 32]  Any nuclear material that is herniated may shrink as the proteoglycan deteriorates, loses its water-retaining ability, and turns from a grapelike object to a raisinlike object.

Arbitrary time schedules for improvement are inappropriate in any patient who continues to improve and whose function is relatively maintained. Traction in the acute setting may help muscle spasms, but it does not reduce the herniated nucleus pulposus (HNP) and has no good evidence of efficacy. The use of traction does not justify hospital admission; this is not cost-effective, and traction can be administered on an outpatient basis.

Long-term use of physical therapy modalities is no more effective than hot showers or hot packs are at home. A transcutaneous electrical nerve stimulation (TENS) unit may be subjectively helpful in some patients with chronic conditions. Patients should be encouraged essentially to compensate for intervertebral disk incompetence, to the extent possible, by means of muscular stabilization, as well as to maintain flexibility by initiating lifelong exercise regimens that include aerobic conditioning (particularly swimming, which allows gravity relief).

It is important to assess the body mechanics of every patient who is disabled from work. All patients should be educated about body mechanics and informed of the risk factors for faulty body mechanics, so that applications can be incorporated into individual work settings, including appropriate seating (eg, lumbar support). The lumbar facet joints are oriented relatively vertically, thus allowing forward flexion, but they impact each other when a person bends and then rotates. Repetitive bending and twisting have been noted to be epidemiologic problems in workers and may be associated with chronic pain and disability. [33]  Attention to lifting techniques and ergonomic modification at workstations may be appropriate.

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Surgical Intervention

The classic presentation of an HNP includes the complaint of sciatica, with associated objective neurologic findings of weakness, reflex change, and dermatomal numbness. Various surgical procedures have been reported, which havev the common goal of decompressing the neural elements to relieve the leg pain. These procedures are most appropriate for patients with minimal or tolerable back pain who have an essentially intact and clinically stable disk. However, the hope of permanently relieving the back pain is a fantasy—a false hope.

The most common procedure for a herniated or ruptured intervertebral disk is a microdiskectomy, in which a small incision is made, aided by an operating microscope, and a hemilaminotomy is performed to remove the disk fragment that is impinging on the nerves.

Many patients who undergo microdiskectomy can be discharged with minimal soreness and complete relief of leg pain after overnight admission and observation. Same-day procedures are in the process of cautious development. Patients with dominant back pain have a different problem, even if HNP is present, and would require stabilization by fusion if unresponsive to well-managed appropriate therapy or arthroplasty (if there is an isolated level with good facet joints).

Minimally invasive techniques have not replaced this standard microdiskectomy procedure but can be summarized in two broad categories: central decompression of the disk and directed fragmentectomy. Outpatient treatment has been reported. [34]

Central decompression of the disk can be performed chemically or enzymatically with chymopapain, by laser or plasma (ionized gas) ablation and vaporization, or mechanically by aspiration and suction with a shaver such as the nucleotome or percutaneous lateral decompression (arthroscopic microdiskectomy).

The Food and Drug Administration (FDA) initially released and then withheld chymopapain for injection into lumbar disks because of adverse allergic reactions in patients; skin tests subsequently were used to determine sensitivity. However, the procedure continued to induce severe muscle spasms that could be far worse than those of an open operation and thus necessitated hospitalization and bedrest for up to 50% of patients. [35]

This morbidity must be considered a contradiction to the assertion by proponents that the enzyme is limited to the disk in the chemical digestion of the nucleus pulposus, because the muscles are severely affected, which would not be expected if the enzyme were contained. In addition, severe scarring in the spinal canal is noted routinely after this procedure.

The nucleotome and laser central decompressions have been shown only to equal placebo in effectiveness, and their use has declined. Superiority has not been demonstrated; patient selection is crucial, and the learning curve is steep. [36]

Further development of alternatives, such as nucleoplasty, and efforts to reduce disk pressure remain under study. The incidence of recurent herniation is small but may be irreducible. Efforts to seal the anulus are under investigation.

Directed fragmentectomy is similar to open microdiskectomy and has demonstrated greater effectiveness than placebo. This procedure uses an arthroscopic approach and a probe that directs a flexible pituitary rongeur from the center of the intervertebral disk toward the posterior anulus. Endoscopic techniques for performing a directed fragmentectomy and minimizing disruption of normal structures continue in development, but superiority has not been demonstrated despite the theoretical advantages of this minimally invasive approach.

With respect to the cervical spine, HNP customarily is treated anteriorly, because the pathology is anterior and manipulation of the cervical cord is not tolerated by the patient. The posterior approach is reserved for disk herniation that is confined to the foramen and for foraminal stenosis. An alternative to the anterior cervical spine approach is minimal disk excision; clinical stability following this procedure is dependent upon the residual disk, which is also true in cases where there is lumbar spine involvement with back pain. Removal of neural compression dramatically relieves radiculopathy; however, residual axial neck pain may result in significant impairment.

Anterior cervical interbody fusion is another intervention. Proponents of diskectomy alone assert equivalent results, but the adequacy of follow-up in those case reports is a significant concern. Patients with more severe disk degeneration, particularly myelopathy, would more uniformly undergo fusion. Anterior instrumentation is being used more commonly, and interbody cages are under consideration as a means of attaining more rapid rehabilitation and more consistent results. Multilevel disk replacement has been suggested as being at least similar to fusion. [37]

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