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Herniated Nucleus Propulsus Lumbar

 

synonyms:Herniated Nucleus Propulsus, herniated disc

Herniated Disc ICD-9

Herniated Disc Etiology / Epidemiology / Natural History

  • Lumbar HNP occurs with flexion, axial compression and rotation.
  • Associated with weightlifting, rowing, football, hockey, rugby, bowling.
  • Tumor necrosis factor-alph, produced by chondrocyte like cells in the nucleus pulposus may be the key chemical mediator for nerve root pain.
  • Mean age = 35 yrs.

Herniated Disc Anatomy

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Herniated Disc Clinical Evaluation

  • Low back, buttock, thigh pain, paresthesias, numbness, weakness in a dermatomal distribution.
  • Decreased lumbar and pelvic flexibility, May demonstrate sciatic shift.
  • Hyporeflexia
  • Straight-leg raise: ipsilateral, concordant leg pain at 35° to 70° of elevation in supine or sitting postions. Indicates L4-5 or L5-S1 disk herniation. High sensitivity, low specificity.
  • Contralateral Straight-leg raise: concordant leg pain with contralateral leg elevations.
  • Femoral stretch test: anterior thight pain with hip extension and knee flexion with the patient in the lateral or prone postion. Indicates L1-4 disk herniation.
  • Pain often increased by coughing, sneezing, Valsava.
  • Sensory motor exam of the perineum including a rectal exam is indicated if any question of bowel/bladder dysfunction exists to rule out Cauda Equina Syndrome.

Herniated Disc Xray / Diagnositc Tests

  • A/P, lateral, flexion/extension views of effected spinal level (cervical, lumbar, thoracic) indicated. Often normal or normal degenerative changes.
  • MRI: best demonstrates acute herniation. Gadolinium enhancement indicated for patients with history of prior surgery.

Herniated Disc Classification / Treatment

  • Short period of rest followed by activity limitations, NSAIDS, Physical therapy, muscle relaxants, Narcotics, progressive activity. Consider rigid brace in 15° of lordosis to increase mobilization.
  • Systemic glucocorticoids may have some short term benefit, but no lasting benefit. (Finckh A, Spine 2006;31:377).
  • Epidural Steroid injection / Selective nerve root injections (Riew KD, JBJS 2006;88A:1722).
  • 90% resolve withing 3 months.
  • Consider partial discectomy. (Weber H, Spine 1983;8:131), (Weinstein JN, JAMA 2006;296:2441), (Atlas SJ, Spine 2005;30:927).

Herniated Disc Associated Injuries / Differential Diagnosis

  • Cauda Equina Syndrome
  • Lumbar degenerative disc disease
  • Lumbar spinal stenosis

Herniated Disc Complications

  • Recurrent Herniation: 5%-10%

Herniated Disc Follow-up Care

Herniated Disc Review References

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