II. Epidemiology

  1. Ages affected
    1. Most common ages 30 to 50 years
    2. Rarely occurs before age 20 years
  2. Most common spinal levels affected (95% of lumbar disc)
    1. Vertebral level L4-5
    2. Vertebral level L5-S1

III. Mechanism

  1. Progressive degeneration of disc nucleus pulposus
    1. Results from normal aging or repetitive Trauma
  2. Protrusion of disc (most commonly posterior-lateral)
    1. Herniation affects spinal root one level below
  3. Other Changes: Spondylosis (Chronic disc deterioration)
    1. Spur Formation
    2. Disc space narrowing
    3. Facet joint degeneration

IV. Complications

V. Symptoms

  1. Usually insidious onset
    1. Acute Trauma may have preceded symptoms
  2. Low Back Pain (deep aching)
    1. Aggravated by activity, coughing, and sneezing
    2. Relieved by rest
    3. Localized to affected disc
  3. Intense Radicular Pain
    1. See Sciatica
    2. Referred pain to iliac crest or buttock
    3. Radiation of pain down posterior thigh and calf
    4. Pain may radiate into foot
  4. Paresthesias
    1. Numbness or tingling in distal extremity

VI. Signs

  1. Restricted low back range of motion
  2. Pain exacerbated by bending to affected side
  3. Local tenderness and muscle guarding
  4. Posturing to avoid pressure on disc
    1. Bent away from affected side
    2. Hip and knee flexed on affected side
  5. Nerve Root Tension Tests
    1. Straight Leg Raise
  6. Neurologic Examination
    1. Deep Tendon Reflexes
      1. L4 Nerve Root (L3-4 disc): Patellar Reflex
      2. S1 Nerve Root (L5-S1 disc): Achilles Reflex
    2. Motor Exam
      1. L4 Nerve Root (L3-4 disc): Ankle dorsiflexion
      2. L5 Nerve Root (L4-5 disc): Great toe dorsiflexion (extensor hallucis longus)
      3. S1 Nerve Root (L5-S1 disc): Ankle plantar flexion (gastrocnemius-soleus complex)
    3. Sensory Exam
      1. L4 Nerve Root (L3-4 disc): Medial malleolus
      2. L5 Nerve Root (L4-5 disc): Dorsal third metatarsophalangeal joint
      3. S1 Nerve Root (L5-S1 disc): Lateral heel
  7. Radicular patterns by disc Herniation type
    1. Central DIsk Herniation
      1. Nerve root affected is ABOVE the disc
      2. Example: Central L3 disc Herniation causes findings above the L2-3 Nerve root
    2. Paracentral disk Herniation
      1. Nerve root affected is AT the disc
      2. Example: Paracentral L3 disc Herniation causes findings at the L2-3 Nerve root
    3. Lateral disk Herniation
      1. Nerve root affected is BELOW the disc (foraminal effects)
      2. Example: Lateral L3 disc Herniation causes findings at the L3-4 Nerve root

VII. Diagnosis

  1. Findings with strongest Positive Predictive Value for Lumbar Disc Disease
    1. Symptoms: Sciatica pain associated with:
      1. Pain in leg worse than back
      2. Typical dermatomal distribution of pain
      3. Pain provoked by Valsalva Maneuver
    2. Exam findings
      1. Crossed Straight Leg Raise positive
      2. Weak ankle dorsiflexion
      3. Absent ankle reflex
      4. Calf muscle wasting (late finding)
  2. Findings with strongest Negative Predictive Value for Lumbar Disc Disease
    1. No Sciatica
    2. Negative Straight Leg Raise

VIII. Differential diagnosis

  1. See Sciatica
  2. See Low Back Pain Red Flags
  3. See Musculoskeletal Low Back Pain
  4. Lumbar spine Degenerative Joint Disease
    1. Lumbar Radiculopathy due to spine degeneration (osteophytes or bone spurs) typically follows a fixed or progressive course
    2. Contrast with Lumbar Disc Herniation which tends to improve as the disc Herniation resorbs
  5. Spinal Cord Tumor
    1. Consider especially in age under 20 or over 60 years
    2. Relentless pain aggravated or not relieved with rest

IX. Imaging

XI. Course

  1. Mild cases frequently resolve within 1-2 weeks
  2. Spontaneous recovery is the rule (90% in 6 weeks)
  3. Other cases may persist with moderate pain for 6 months
  4. Long-term outcomes are not improved with surgery (outcomes the same at 2 years)

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Ontology: Prolapsed lumbar disc (C0281899)

Concepts Acquired Abnormality (T020)
SnomedCT 156632000, 202708005
English Prolapse lumb intervert disc, Prolapsed lumbar disc, Lumbar disc herniation, bulging lumbar disc, herniated lumbar disc, extruded lumbar intervertebral disc (diagnosis), herniated lumbar intervertebral disc, extruded lumbar intervertebral disc, extruded lumbar disc, bulging of lumbar intervertebral disc (diagnosis), herniated lumbar intervertebral disc (diagnosis), bulging of lumbar intervertebral disc, Slipped lumbar disc, herniated lumbar disk, herniated lumbar nucleus pulposus, lumbar disc prolapse, prolapsed lumbar disc, discs lumbar prolapsed, lumbar herniated disk, disc lumbar prolapse, prolapsed disc lumbar, disk herniated lumbar, herniated disk lumbar, disc lumbar prolapsed, Prolapsed lumbar intervertebral disc, Prolapsed lumbar intervertebral disc (disorder)
Dutch tussenwervelschijf dislocatie lumbaal, hernia van lendewervel, prolaps tussenwervelschijf lumbaal
French Hernie discale lombaire, Disque lombaire prolabé, Hernie du disque lombaire
German Vorfall einer Bandscheibe, verlagerte lumbale Bandscheibe, Lendenwirbelhernie
Italian Ernia di disco lombare, Ernia del disco lombare, Disco lombare prolassato
Portuguese Disco lombar deslocado, Disco lombar prolapsado, Herniação do disco lombar
Spanish Hernia discal lumbar, Disco lumbar prolapsado, prolapso de disco intervertebral lumbar (trastorno), prolapso de disco intervertebral lumbar
Japanese 腰部椎間板すべり症, 腰部椎間板脱出, 腰椎椎間板ヘルニア, ヨウツイツイカンバンヘルニア, ヨウブツイカンバンスベリショウ, ヨウブツイカンバンダッシュツ
Czech Herniace lumbální destičky, Vyhřezlá bederní ploténka, Prolaps bederní ploténky
Hungarian Lumbalis discus herniatio, Félrecsúszott lumbális discus, Lumbalis prolabált discus

Ontology: Lumbar disc lesion (C0549374)

Concepts Disease or Syndrome (T047)
SnomedCT 156629003, 268076000, 274137005
Dutch tussenwervelschijflaesie lumbaal
French Lésion d'un disque lombaire, Discopathie lombaire, LESION DISQUE LOMBAIRE
German lumbale Bandscheibenschaedigung, DISKUSSCHAEDIGUNG IM LENDENBEREIC
Italian Lesione del disco lombare
Portuguese Lesão de disco lombar, Lesão do disco lombar, LESAO DO DISCO LOMBAR
Spanish Lesión de disco lumbar, lesión de disco lumbar (trastorno), lesión de disco lumbar
English Lumbar disc lesion, LUMBAR DISC LESION, Disc lesion lumbar, Lumbar disc lesion (disorder)
Japanese 腰部椎間板病変, ヨウブツイカンバンビョウヘン
Czech Léze bederní ploténky
Hungarian Lumbalis discus laesio