Neurosurgery notes/Spine/Spinal Degenerative Diseases/Lumbar degenerative disease/Lumbar disc herniation (LDH)

Lumbar disc herniation (LDH)

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Lumbar degenerative disease
  • General
    • Lumbar disc herniation (LDH) is focal displacement of disc material beyond the margin of the adjacent vertebral body.
    • LDH and radiculopathy is the most common indication for spinal surgery.
  • Numbers
    • Prevalence of symptomatic LDH is approximately 3%,
    • most commonly affecting the 30 to 50-year-old age group.
  • Aetiology
    • Age related changes to the disc;
      • Occupational factors (frequent heavy lifting, twisting, and exposure to vibration)
    • Traumatic herniation
      • uncommon.
    • Genetic predisposition predispose to LDH.
  • Natural history
    • Natural history of massive disc herniation (n=15) Cribb et al 2007
      • Repeat MR scanning after a mean 24 months (5 to 56)
      • A dramatic resolution of the herniation in 14 patients.
      • No patient developed a cauda equina syndrome.
      • The mean percentage of the canal occupied by disc on an axial MR scan
        • was 66% (55% to 80%).
        • The reduction in size of the herniation on MRI was a mean of 80% (68% to 100%).
    • Kevin Tsang group 2023 systemic review n360
      • Mean time to follow-up imaging was 11.5 months.
      • Factor predictors of regression
        • Disc type
            • Disc type
            Probabilities of spontaneous regression
            Bulging
            13.3%
            Protruded
            52.5%
            Extruded
            70.4%
            Sequestered
            93.0%
          • Extruded and sequestered fragments have a greater tendency to completely resolve by six months, possibly due to engulfment by macrophages.
            • Disc definition
            Herniated disc
            A localized displacement of nucleus, cartilage, fragmented apophyseal vertebral bone, and/or annular tissue beyond the intervertebral disc space
            Disc bulge
            A disc which extends beyond the edges of the disc space, over greater than 50% (180°) of the circumference of the disc and usually less than 3 mm beyond the edges of the vertebral body apophyses
            Disc extrusion
            A herniated disc where the base of the herniation (transverse dimension) is smaller than the AP dimension
            Disc protrusion
            A herniated disc where the base of the herniation (transverse dimension) is wider than the AP dimension; > 25% but < 50% (180°) of disc herniation
            Central disc
            A disc that extrudes or protrudes in the midline
            Paracentral disc
            A disc that extrudes or protrudes just off the midline but still in the spinal canal (i.e. right central or left central)
            Neural foraminal disc
            A disc that extrudes or protrudes into the neural foramen
            Far lateral disc
            A disc that extrudes or protrudes anterolateral to the neural foramen outside of the spinal canal
            Sequestered disc
            A subtype of extruded disc that has broken away from the from the site of extrusion (i.e. free disc material in canal)
            Migrated disc
            A subtype of extruded disc that extends in the craniocaudal plane but still maintains continuity with the disc
             
            notion image
             
        • Larger Herniation volume
        • Transligamentous herniation
        • Higher Komori types
  • Pathology
    • The location of the herniation determines which nerve root is involved
      • Exiting nerve
      • Transiting nerve
    • Protrusion is
      • Central
      • Lateral recess
      • Foraminal
      • Extraforaminal
    • Herniation is contained by or traverses the posterior longitudinal ligament, the following terms are used:
      • a disc protrusion involves deformation of but not rupture of the annulus,
      • an extruded disc breaches the annulus with nuclear continuity,
      • a sequestered disc is a free nuclear fragment.
  • Clinical features
    • Radicular pain
      • Due to combination of
        • mechanical compression
          • Compression alone results in numbness but is not painful.
          • Compression results in
            • oligaemia,
            • oedema,
            • inflammation.
          • Reduced CSF and blood flow reduce nutritional supply and the ability to remove noxious chemicals.
          • A history of acute back pain may precede radicular symptoms.
        • chemical irritation.
      • Repeatable
        • a positive Lasegue sign
        • reversed Lasegue sign (upper lumbar compression),
        • crossed Lasegue sign (large discs)
    • Dermatomal pain
    • Paraesthesia
    • Numbness
    • Symptoms increased by
      • Sitting
      • Standing
      • Valsalva manoeuvres
    • Myotomal weakness
    • Hyporeflexia
    • A reduced range of motion
    • Antalgic gait
    • Pain on compression of the spine
  • Radiology
    • MRI is the standard investigation, while high- resolution computed tomography (CT) or myelography can be used when MRI is contraindicated.
    • Neurophysiology may help exclude peripheral nerve lesions.
      • The possibility of a peripheral nerve lesion should be considered in cases of foot drop and disconcordant neurology.
  • Management
    • General
      • WFNS 2024 recommendation
        • Surgery for lumbar disc herniation is recommended for failure of conservative treatment, severe motor deficit, progressive neurological impairment, CES.
        • Earlier surgery in lumbar disc herniation is suggested in case of major motor deficit and is associated with faster recovery and might improve motor outcomes.
        • Although minimally invasive procedures have short term advantages, there is insufficient evidence to make a recommendation for or against the choice of a specific surgical procedure for LDH.
        • Sequestrectomy and standard microdiscectomy have similar clinical results in terms of pain control, recurrence rate, functional outcome, and complications at short/medium term.
        • Lumbar fusion is not recommended as a routine treatment following primary discectomy in patients with isolated herniated lumbar discs causing radiculopathy.
          • Lumbar fusion may be considered in patients with herniated discs who have evidence of significant chronic axial back pain, have severe degenerative changes, or have instability associated with radiculopathy caused by herniated lumbar discs.
      • NICE recommendation
        • Offer surgery at least after 6-8 months of non surgical treatment
      Conservative
      • In the absence of cauda equina syndrome or an acute foot drop treatment is normally conservative.
      • Reassurance is the key, specifically a short period of bed rest (three days), optimal analgesia including anti- inflammatories followed by physiotherapy is utilized.
      • Symptoms resolve over three months in the majority.
        • Unrelenting severe sciatica with sensorimotor symptoms may take a different course and early surgery is reasonable.
      • Epidural and transforaminal blockade with corticosteroid is an adjunct rather than a definitive treatment.
        • NERVES trial:

            • Bottom line:

            • TFESI (Transforaminal steroid injections) should be considered as a first invasive treatment option
            • Surgery is unlikely to be a cost-effective alternative to TFESI
      Surgery
      • Indications
        • Absolute
          • Severe paresis
          • Cauda equina syndrome
        • Relative
          • Non- responsive severe sciatica
          • persistent symptoms for greater than >6 wks following optimal conservative management
      • Evidence
        • Class 1 evidence supports improved short- term outcome with surgery.
        • The efficacy of surgery in comparison to conservative treatment declines over time.
      • Operative techniques
        • Open techniques
          • interlaminar approach and lumbar microdiscectomy.
        • Percutaneous techniques
          • Endoscopic discectomy
          • Chemonucleolysis
          • automated percutaneous lumbar discectomy
      Outcome
      • SPORTS

          • Bottom line

          • Surgery improves pain and function faster than non-surgery
          • However due to cross over the randomized group's surgical benefit is lost
          • Looking at the observational group surgical benefits tend to stay significant even at the 8 year mark
      • Peul 2008
          • Early surgery (< 2 weeks) achieved more rapid relief of sciatica than conservative care, but outcomes were similar by one year and these did not change during the second year.
      • Rothoerl 2002, Nygaard 2000, Ng 2004, Braybooke 2006, Bailey 2016
        • Longer wait to surgery poorer outcome in short term but no difference in long term
      • Marshall reply
        • Mild motor paresis is very common in lumbar disc herniation, occurring in approximately 50% of cases;
        • Mild to moderate paresis will recover after surgery in 75% of cases, and most of this will occur during the first year;
        • Even where cases of mild to moderate weakness fail to improve, there is little detriment to late function and quality of life;
        • Marked extensor weakness, including complete foot-drop, occurs in 5% to 10% of cases, and there is a potential for recovery in approximately half, with or without treatment;
        • In those with severe extensor weakness, especially painless footdrop, discectomy does not improve the outcome;
        • Improvement in symptoms after discectomy:
          • pain relief --> motor function --> sensation
          • Persistence of minor dermatomal sensory deficit is common and usually trivial;
        • Except for the cauda equina syndrome and with clearly evolving motor weakness, unrelenting radicular pain (sciatica and cruralgia) must be considered to be the main indication for discectomy.
      • M. Mariconda (n=180) Long term outcome (20 yrs) after lumbar discectomy
        • Short form-36 summary scores were similar to the aged-matched normative values.
        • No disability or minimum disability on the Oswestry disability index was reported by 136 patients (75.6%), and 162 (90%) were satisfied with their operation
        • most important predictors of patients’ self-reported positive outcome were male gender and higher educational level.
        • No association was detected between muscle recovery and outcome.
          • Those with a persistent motor deficit will have little long-term disability or impaired quality of life as long as their pain has been relieved.
        • motor paresis recovers in 75% of cases, and that the reflexes revert to normal in 60%.
      • Jönsson and Strömqvist et al 1995 (n=187)
        • Severe weakness of the extensor hallucis longus was present in 11% of cases
        • Treated by lumbar discectomy
        • 70% to 75% showed recovery (one-third complete and two-thirds partial) after operation.
        • Recovery occurred mainly during the first 4 months after surgery.
      • Patient characteristics associated with improved treatment effects with surgical intervention for lumbar disc herniation:
        • Age > 41 years,
        • Absence of joint problems
        • A high school education or less
        • No worker’s compensation
        • Duration of symptoms for over 6 months
        • Being married
        • Worsening symptom trend at baseline
        • Mental Component Score (MCS) of < 35
  • Those with ongoing worker’s compensation who underwent lumbar fusion have a significant increase in disability, opiate use, and poor return to work status