Lumbar (Intervertebral) Disk Disorders 

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

Overview

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.

Background

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

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

Frequency

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

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.

 

Presentation

History

The history may be sufficient to make presumptive diagnosis of a disk disorder, or it may guide the physician's usage of ancillary testing and consultations to further differentiate both the specific type of disk disease and potential other etiologies of the patient's back pain.

Patients with disk disease usually are not able to give a precise time that the problem began because it usually is preceded by multiple episodes of less severe low back pain.

Asking the patient the location of the pain is important. Pain that is localized to the lower back and gluteal area often is associated with disk disease. Pain associated with nerve root involvement commonly radiates down the leg, particularly below the level of the knee.

Ask the patient about any unusual recent activity, especially if it involved the patient remaining in a flexed or rotated position. Find out if the patient experienced any recent trauma. Pain with flexion, rotation, or prolonged sitting or standing, and sharp (rather than dull) pain are suggestive of disk disease.

The onset of pain may begin suddenly[1] or gradually after injury. Typically, the pain is located bilaterally at the posterior belt line. The pain pattern usually is referred rather than radicular. Back motion, which includes sitting, standing, lifting, bending, and twisting, usually aggravates the pain; it often is relieved with rest and a recumbent position.

Physical

Nerve roots exit the spine below the intervertebral disks; thus, herniation of a disk involves the nerve root below it.

Observe the patient for abnormal gait, which is suggestive of a loss of the normal rhythm. Have ambulatory patients walk on their toes to test the function of S1.

Observe the patient for abnormal posture, which is suggestive of splinting or guarding from pain.

Test the patient's ability to dorsiflex the foot while sitting to test the L5 nerve root. Test for sensory loss that corresponds to a dermatomal area.

Palpation of the lumbar spine and lower back is not helpful in the diagnosis of disk disease, but it should be done to rule out other causes of low back pain.

A positive straight leg raising test is indicative of nerve root involvement. This test is performed while the patient is lying supine with one leg either straight or flexed at the knee, with the sole of the foot flat on the stretcher. The other leg is kept straight and lifted by the examiner. If pain occurs when the leg is lifted between 30-70 degrees from horizontal and travels down the leg until below the knee, the test is positive.

Nerve root stretch test results are often negative.

Patients may exhibit decreased lumbar range of motion (ROM).

The usual motor, sensory, and reflex examinations (including perianal sensation and anal sphincter tone when appropriate) should be performed.

A careful abdominal and vascular examination is mandatory in evaluation of these patients.

Causes

The normal aging process of the musculoskeletal system aggravates acute events.[3]

Risk factors include the following:

  • Age

  • Activity

  • Smoking

  • Obesity

  • Vibration (eg, driving a car)

  • Sedentary lifestyle

  • Psychosocial factors

 

DDx

 

Workup

Approach Considerations

Workup(active tab)

Laboratory Studies

Laboratory tests generally are not helpful in the diagnosis of lumbar disk disease.

Indications for screening laboratory examinations include pain of a nonmechanical nature, atypical pain pattern, persistent symptoms, and age older than 50 years.

  • Complete blood count (CBC) with differential

  • Erythrocyte sedimentation rate (ESR)

  • Alkaline and acid phosphatase level

  • Serum calcium level

  • Serum protein electrophoresis

Imaging Studies

Radiographic studies are very helpful in the diagnosis of lumbar disk disease,[4] but several important caveats should be taken into account with the use of these tests.[5]

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

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. Elderly patients or those with a history of cancer or chronic infection (including tuberculosis), trauma, or osteoporosis should have imaging studies performed as part of their routine workup during initial presentation.

MRI is the imaging modality of choice in evaluating patients with lumbar disk disease.[2] Studies have shown that as many as 60% of people without back symptoms have disk bulges and protrusions on MRI.[6] Therefore, these findings may not correlate with the patient's symptoms.[7]

In a study of 283 patients with sciatica with confirmed disc herniation, MRI assessment of nerve root compression and extrusion of a herniated disc was associated with less leg pain at 1-year follow-up. However, according to the study, MRI findings seemed not to be helpful in determining which patients would do better with early surgery versus prolonged conservative care.[7]

CT scanning is useful for diagnosing disk disease but is less sensitive than MRI. CT scanning of the abdomen can help to evaluate and rule out other etiologies of pain such as aortic aneurysm, ureteral calculi, and intra-abdominal causes. Combining CT scan with myelography can increase the sensitivity of the modality for spinal cord pathology.

Myelography may provide a definitive diagnosis on its own, but this is an invasive test requiring a lumbar puncture and the use of contrast material.

Plain films of the lumbar spine generally are not helpful in the diagnosis of lumbar disk disease, except to rule out other diseases and to evaluate for possible skeletal etiology as the cause of the patient's symptoms. They should be performed in patients who are elderly or those with a history of cancer or chronic infection (including tuberculosis), trauma, or osteoporosis.

Technetium-99m labeled phosphorus indicates active mineralization of bone. A bone scan is indicated to rule out tumors, trauma, or infection.

 

Treatment

Prehospital Care

Little is needed in the way of prehospital care. Appropriate spinal immobilization should be considered if the patient has evidence of trauma; otherwise, simple transportation in the position of comfort is all that is indicated.

Emergency Department Care

Patients should lie in a position in which they are most comfortable.

Muscle relaxants are of limited use, and clinical studies have not proven their efficacy. This class includes benzodiazepines, methocarbamol, and cyclobenzaprine. Patients should be warned that all of these drugs are sedating. Opioids provide very effective acute pain relief, but they should not be used in patients with chronic pain. Salicylates, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) all have been used in the treatment of pain from lumbar disk disease, but none of these has been shown to be superior to the others. Acetaminophen lacks anti-inflammatory activity.[8, 9]

Of 76 patients who presented to an emergency department with low back pain, 42 (55%) had resolution or return of pain to baseline with conservative management; 18 (24%) had improvement with intervention (epidural steroid injection or kyphoplasty); 8 (10%) improved with surgery; and 8 had persistent pain (11%).[10]

 

Medication

Medication Summary

The goals of therapy are to reduce pain and inflammation.[11]

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Class Summary

These agents are used most commonly for the relief of mild to moderately severe pain. Although effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen usually is the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain if no contraindications.

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small body size, to elderly persons, and to those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.

Flurbiprofen (Ansaid)

May inhibit enzyme cyclooxygenase, which, in turn, inhibits prostaglandin biosynthesis. These effects may be mechanism of its analgesic, antipyretic, and anti-inflammatory activities.

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, causing decrease in prostaglandin synthesis.

 

Follow-up

Further Outpatient Care

Patients should lie in a position in which they are most comfortable.

Bed rest is not recommended most of the time. The exception is for patients whose pain is so severe that they cannot ambulate. Prolonged immobilization may worsen pain and extend recovery time. Strict bed rest should never exceed 2 days. Patients should be encouraged to begin limited activity as soon as possible.

Whether spinal manipulation (ie, chiropractic care) improves the rate of recovery in patients with disk disease is controversial.

Multiple surgical techniques have been used in patients with disk herniation who have not responded to 6 weeks of conservative therapy. These techniques include diskectomy, spinal fusion, and injection of chymopapain. Newer techniques continue to be developed.[12, 13, 14, 15]

The Spine Patient Outcomes Research Trial (SPORT) in 2006 failed to find any statistical superiority of surgical treatment versus conservative treatment for lumbar disk herniation.[16, 17] This occurred because the study design allowed crossover of treatment based on the patients' preference. These findings suggest that, in most cases, there is no clear reason to advocate for surgery apart. Patient choice appears to be the most important predictive factor.

Further Inpatient Care

Inpatient care generally is not required, except for those rare cases of intractable pain or in cases in which the social situation does not allow adequate home care. Further inpatient care mostly consists of continued analgesics, physical therapy, and possible consultation with a spine specialist.

Deterrence/Prevention

Prevention includes the following:

  • Smoking cessation

  • Weight reduction

  • Improve general physical condition

  • Avoid aggravating factors

Complications

Complications include the following:

  • Incorrect diagnosis

  • Chronic low back pain

  • Narcotic addiction

  • Persistent psychosocial problems

Prognosis

Most patients can resume normal activities.

Patient Education

For excellent patient education resources, see eMedicineHealth's patient education article Low Back Pain.