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Lumbar Herniated Nucleus Pulposus

  • Philip K. Louie
  • Gregory D. LopezEmail author
Chapter

Abstract

This chapter will discuss the pathophysiology, exam, diagnosis, and management of lumbar disc herniation (LDH). In brief, LDH is a common pathology that affects a significant percentage of the population. The natural history of LDH is favorable, and excellent results have been obtained following conservative management. Anti-inflammatory medications, physical therapy, and epidural steroid injections make up the mainstay of nonoperative treatment. However, large-scale SPORT suggests that patients managed with discectomy may have a more favorable outcome when compared to conservative treatment. A “mini-open” technique is the most common modality of discectomy performed; however, minimally invasive approaches are gaining popularity. The use of a tubular retractor system typifies the modern minimally invasive approach. A number of randomized controlled trials comparing open discectomy to minimally invasive microdiscectomy have been performed, demonstrating that both techniques are equally effective at relieving pain and have comparable reherniation rates. Overall complication rates are similar between open and minimally invasive approaches; however, the number of incidental durotomies is higher with minimally invasive approaches, likely reflective of the learning curve. Minimally invasive approaches offer the potential benefit of less soft tissue trauma and faster recovery; however, they are technically demanding. Excellent results can be obtained with either a minimally invasive or open approach.

Keywords

Lumbar herniated disc Herniated nucleus pulposus Tubular retractor system Mini-open technique Microdiscectomy 

References

  1. 1.
    Ambrossi GLG, McGirt MJ, Sciubba DM, Witham TF, Wolinsky J-P, Gokaslan ZL, Long DM. Recurrent lumbar disc herniation after single-level lumbar discectomy: incidence and health care cost analysis. Neurosurgery. 2009;65:574–8; discussion 578.PubMedCrossRefGoogle Scholar
  2. 2.
    Pugely AJ, Gao Y, Martin CT, Callaghan JJ, Weinstein SL, Marsh JL. The effect of resident participation on short-term outcomes after orthopaedic surgery. Clin Orthop Relat Res. 2014;472:2290–300.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Carragee EJ, Golish SR. In: Rao RD, Smuck M, editors. Orthopaedic knowledge update 4: spine. Rosemont: Amer Academy of Orthopaedic; 2012. [ISBN 13: 978-0892037377].Google Scholar
  4. 4.
    Ma D, Liang Y, Wang D, Liu Z, Zhang W, Ma T, Zhang L, Lu X, Cai Z. Trend of the incidence of lumbar disc herniation: decreasing with aging in the elderly. Clin Interv Aging. 2013;8:1047–50.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. J Neurosurg. 1964;21:74–81.CrossRefGoogle Scholar
  6. 6.
    Postacchini F, Postacchini R. Operative management of lumbar disc herniation : the evolution of knowledge and surgical techniques in the last century. Acta Neurochir Suppl. 2011;108:17–21.PubMedCrossRefGoogle Scholar
  7. 7.
    Caspar W. A new surgical procedure for lumbar disc herniation causing less tissue damage through a microsurgical approach. In: Lumbar disc adult hydrocephalus. Berlin/Heidelberg: Springer; 1977. p. 74–80.CrossRefGoogle Scholar
  8. 8.
    Foley KT. Microendoscopic discectomy. Tech Neurosurg. 1997;3:301–7.Google Scholar
  9. 9.
    Clark AJ, Safaee MM, Khan NR, Brown MT, Foley KT. Tubular microdiscectomy: techniques, complication avoidance, and review of the literature. Neurosurg Focus. 2017;43:E7.PubMedCrossRefGoogle Scholar
  10. 10.
    Arts M, Brand R, van der Kallen B, Lycklama à Nijeholt G, Peul W. Does minimally invasive lumbar disc surgery result in less muscle injury than conventional surgery? A randomized controlled trial. Eur Spine J. 2011;20:51–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Grunhagen T, Shirazi-Adl A, Fairbank JCT, Urban JPG. Intervertebral disk nutrition: a review of factors influencing concentrations of nutrients and metabolites. Orthop Clin North Am. 2011;42:465–77–vii.PubMedCrossRefGoogle Scholar
  12. 12.
    White AA III, Panjabi MM. Clinical biomechanics of the spine. 2nd ed. Philadelphia: Lippincott; 1990.Google Scholar
  13. 13.
    Takegami K, An HS, Kumano F, Chiba K, Thonar EJ, Singh K, Masuda K. Osteogenic protein-1 is most effective in stimulating nucleus pulposus and annulus fibrosus cells to repair their matrix after chondroitinase ABC-induced in vitro chemonucleolysis. Spine J. 2005;5:231–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Takatalo J, Karppinen J, Niinimäki J, Taimela S, Näyhä S, Järvelin M-R, Kyllönen E, Tervonen O. Prevalence of degenerative imaging findings in lumbar magnetic resonance imaging among young adults. Spine. 2009;34:1716–21.PubMedCrossRefGoogle Scholar
  15. 15.
    Stefanakis M, Al-Abbasi M, Harding I, Pollintine P, Dolan P, Tarlton J, Adams MA. Annulus fissures are mechanically and chemically conducive to the ingrowth of nerves and blood vessels. Spine. 2012;37:1883–91.PubMedCrossRefGoogle Scholar
  16. 16.
    Bobechko WP, Hirsch C. Auto-immune response to nucleus pulposus in the rabbit. J Bone Joint Surg Br. 1965;47:574–80.PubMedCrossRefGoogle Scholar
  17. 17.
    Gertzbein SD, Tait JH, Devlin SR. The stimulation of lymphocytes by nucleus pulposus in patients with degenerative disk disease of the lumbar spine. Clin Orthop Relat Res. 1977:149–54.Google Scholar
  18. 18.
    Saal JA, Saal JS, Herzog RJ. The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine. 1990;15:683–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Kang JD, Georgescu HI, McIntyre-Larkin L, Stefanovic-Racic M, Donaldson WF, Evans CH. Herniated lumbar intervertebral discs spontaneously produce matrix metalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2. Spine. 1996;21:271–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Olmarker K, Rydevik B, Nordborg C. Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equina nerve roots. Spine. 1993;18:1425–32.PubMedCrossRefGoogle Scholar
  21. 21.
    Rajasekaran S, Bajaj N, Tubaki V, Kanna RM, Shetty AP. ISSLS prize winner: the anatomy of failure in lumbar disc herniation: an in vivo, multimodal, prospective study of 181 subjects. Spine. 2013;38:1491–500.PubMedCrossRefGoogle Scholar
  22. 22.
    Fardon DF, Williams AL, Dohring EJ, Murtagh FR, Gabriel Rothman SL, Sze GK. Lumbar disc nomenclature: version 2.0: recommendations of the combined task forces of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology. Spine J. 2014;14:2525–45.PubMedCrossRefGoogle Scholar
  23. 23.
    Li Y, Fredrickson V, Resnick DK. How should we grade lumbar disc herniation and nerve root compression? A systematic review. Clin Orthop Relat Res. 2015;473:1896–902.PubMedCrossRefGoogle Scholar
  24. 24.
    Hsu K, Zucherman J, Shea W, Kaiser J, White A, Schofferman J, Amelon C. High lumbar disc degeneration. Incidence and etiology. Spine. 1990;15:679–82.PubMedCrossRefGoogle Scholar
  25. 25.
    Daghighi MH, Pouriesa M, Maleki M, Fouladi DF, Pezeshki MZ, Mazaheri Khameneh R, Bazzazi AM. Migration patterns of herniated disc fragments: a study on 1,020 patients with extruded lumbar disc herniation. Spine J. 2014;14:1970–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14:180–91.PubMedCrossRefGoogle Scholar
  27. 27.
    Radcliff K, Hilibrand A, Lurie JD, Tosteson TD, Delasotta L, Rihn J, Zhao W, Vaccaro A, Albert TJ, Weinstein JN. The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial. J Bone Joint Surg Am. 2012;94:1353–8.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Hughes SPF, Freemont AJ, Hukins DWL, McGregor AH, Roberts S. The pathogenesis of degeneration of the intervertebral disc and emerging therapies in the management of back pain. J Bone Joint Surg Br. 2012;94:1298–304.PubMedCrossRefGoogle Scholar
  29. 29.
    Shih P, Smith TR, Fessler RG, Song JK. Minimally invasive discectomy for the treatment of disc herniation causing cauda equina syndrome. J Clin Neurosci. 2011;18:1219–23.PubMedCrossRefGoogle Scholar
  30. 30.
    van der Windt DA, Simons E, Riphagen II, et al. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010;138:CD007431.Google Scholar
  31. 31.
    Weiner BL, Zibis A. In: Wiesel SW, editor. Lumbar discectomy. Operative techniques in orthopaedic surgery. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2015. [ISBN 13: 9781451193145].Google Scholar
  32. 32.
    Lee JH, Lee S-H. Physical examination, magnetic resonance image, and electrodiagnostic study in patients with lumbosacral disc herniation or spinal stenosis. J Rehabil Med. 2012;44:845–50.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Hahne AJ, Ford JJ, McMeeken JM. Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review. Spine. 2010;35:E488–504.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Oosterhuis T, Costa LOP, Maher CG, de Vet HCW, van Tulder MW, Ostelo RWJG. Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev. 2014;9:CD003007.Google Scholar
  35. 35.
    Manchikanti L, Falco FJE, Pampati V, Cash KA, Benyamin RM, Hirsch JA. Cost utility analysis of caudal epidural injections in the treatment of lumbar disc herniation, axial or discogenic low back pain, central spinal stenosis, and post lumbar surgery syndrome. Pain Physician. 2013;16:E129–43.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Manchikanti L, Benyamin RM, Falco FJE, Kaye AD, Hirsch JA. Do epidural injections provide short- and long-term relief for lumbar disc herniation? A systematic review. Clin Orthop Relat Res. 2015;473:1940–56.PubMedCrossRefGoogle Scholar
  37. 37.
    Radcliff KE, Kepler CK, Jakoi A, Sidhu GS, Rihn J, Vaccaro AR, Albert TJ, Hilibrand AS. Adjacent segment disease in the lumbar spine following different treatment interventions. Spine J. 2013;13:1339–49.PubMedCrossRefGoogle Scholar
  38. 38.
    Abdi S, Datta S, Lucas LF. Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications. Pain Physician. 2005;8:127–43.PubMedGoogle Scholar
  39. 39.
    Centers for Disease Control and Prevention (CDC). Multistate outbreak of fungal infection associated with injection of methylprednisolone acetate solution from a single compounding pharmacy—United States, 2012. MMWR Morb Mortal Wkly Rep. 2012;61:839–42.Google Scholar
  40. 40.
    Bromage PR, Benumof JL. Paraplegia following intracord injection during attempted epidural anesthesia under general anesthesia. Reg Anesth Pain Med. 1998;23:104–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Freeman BJC, Ludbrook GL, Hall S, Cousins M, Mitchell B, Jaros M, Wyand M, Gorman JR. Randomized, double-blind, placebo-controlled, trial of transforaminal epidural etanercept for the treatment of symptomatic lumbar disc herniation. Spine. 2013;38:1986–94.PubMedCrossRefGoogle Scholar
  42. 42.
    Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine. 1983;8:131–40.PubMedCrossRefGoogle Scholar
  43. 43.
    Lurie JD, Tosteson TD, Tosteson ANA, Zhao W, Morgan TS, Abdu WA, Herkowitz H, Weinstein JN. Surgical versus non-operative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial (SPORT). Spine. 2014;39:3–16.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Rubin DB. On the limitations of comparative effectiveness research. Stat Med. 2010;29:1991–5.PubMedCrossRefGoogle Scholar
  45. 45.
    Javid MJ, Nordby EJ. Lumbar chymopapain nucleolysis. Neurosurg Clini N Am. 1996;7:17–27.CrossRefGoogle Scholar
  46. 46.
    Meinert CL. Clinical trials: design, conduct, and analysis. 2nd ed. New York: Oxford University Press; 2012. [ISBN 13: 978-0195387889].Google Scholar
  47. 47.
    Wittenberg RH, Oppel S, Rubenthaler FA, Steffen R. Five-year results from chemonucleolysis with chymopapain or collagenase: a prospective randomized study. Spine. 2001;26:1835–41.PubMedCrossRefGoogle Scholar
  48. 48.
    Mathews HH, Long BH. Minimally invasive techniques for the treatment of intervertebral disk herniation. J Am Acad Orthop Surg. 2002;10:80–5.PubMedCrossRefGoogle Scholar
  49. 49.
    Quigley MR, Maroon JC. Automated percutaneous discectomy. Neurosurg Clin N Am. 1996;7:29–35.PubMedCrossRefGoogle Scholar
  50. 50.
    Smith JS, Eichholz KM, Shafizadeh S, Ogden AT, O’Toole JE, Fessler RG. Minimally invasive thoracic microendoscopic diskectomy: surgical technique and case series. World Neurosurg. 2013;80:421–7.PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Perez-Cruet MJ, Foley KT, Isaacs RE, Rice-Wyllie L, Wellington R, Smith MM, Fessler RG. Microendoscopic lumbar discectomy: technical note. Neurosurgery. 2002;51:S129–36.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Dasenbrock HH, Juraschek SP, Schultz LR, Witham TF, Sciubba DM, Wolinsky J-P, Gokaslan ZL, Bydon A. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. J Neurosurg Spine. 2012;16:452–62.PubMedPubMedCentralCrossRefGoogle Scholar
  53. 53.
    Than KD, Wang AC, Etame AB, La Marca F, Park P. Postoperative management of incidental durotomy in minimally invasive lumbar spinal surgery. Minim Invasive Neurosurg. 2008;51:263–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Rasouli MR, Rahimi-Movaghar V, Shokraneh F, Moradi-Lakeh M, Chou R. Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev. 2014;20:CD010328.Google Scholar
  55. 55.
    Virk SS, Diwan A, Phillips FM, Sandhu H, Khan SN. What is the rate of revision discectomies after primary discectomy on a national scale. Clin Orthop Relat Res. 2017;33:273.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryRush University Medical CenterChicagoUSA

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