Skip to main content
Top
Published in: Current Reviews in Musculoskeletal Medicine 4/2017

01-12-2017 | Treatment of Lumbar Degenerative Pathology (HJ Kim and G Mundis, section editors)

Lumbar Disc Herniation

Authors: Raj M. Amin, Nicholas S. Andrade, Brian J. Neuman

Published in: Current Reviews in Musculoskeletal Medicine | Issue 4/2017

Login to get access

Abstract

Purpose of Review

Substantial advancements have been made in the cause, diagnosis, imaging, and treatment options available for patients with lumbar disc herniation (LDH). We examined the current evidence and highlight the concepts on the frontline of discovery in LDH.

Recent Findings

There are a myriad of novel etiologies of LDH detailed in recent literature including inflammatory factors and infectious microbes. In the clinical setting, recent data focuses on improvements in computer tomography as a diagnostic tool and non-traditional injection options including tumor necrosis alpha inhibitors and platelet-rich plasma. Operative treatment outcomes have focused on minimally invasive endoscopic approaches and demonstrated robust 5-year post-operative outcomes.

Summary

Advances in the molecular etiology of LDH will continue to drive novel treatment options. The role of endoscopic treatment for LDH will continue to evolve. Further research into10-year outcomes will be necessary as this surgical approach continues to gain widespread popularity.
Literature
13.
go back to reference • Hoffman H, Choi AW, Chang V, et al. Aquaporin-1 expression in herniated human lumbar intervertebral discs. Glob Spine J. 2017;7(2):133–40. https://doi.org/10.1177/2192568217694007. This new-found association between aquaporin-1 expression and radiologic findings in lumbar disc herniation provides a new avenue of investigation regarding the etiology of herniation symptoms CrossRef • Hoffman H, Choi AW, Chang V, et al. Aquaporin-1 expression in herniated human lumbar intervertebral discs. Glob Spine J. 2017;7(2):133–40. https://​doi.​org/​10.​1177/​2192568217694007​. This new-found association between aquaporin-1 expression and radiologic findings in lumbar disc herniation provides a new avenue of investigation regarding the etiology of herniation symptoms CrossRef
17.
go back to reference • Paul CPL, de Graaf M, Bisschop A, et al. Static axial overloading primes lumbar caprine intervertebral discs for posterior herniation. PLoS One. 2017:1–23. The specific association of static axial overloading with posterior herniation provides a link between certain lifestyle behaviors and a particular herniation subtype. Behavioral changes may be able to reduce the incidence of posterior herniations. • Paul CPL, de Graaf M, Bisschop A, et al. Static axial overloading primes lumbar caprine intervertebral discs for posterior herniation. PLoS One. 2017:1–23. The specific association of static axial overloading with posterior herniation provides a link between certain lifestyle behaviors and a particular herniation subtype. Behavioral changes may be able to reduce the incidence of posterior herniations.
18.
go back to reference Kobayashi S, Takeno K, Yayama T, Baba H. Pathomechanisms of sciatica in lumbar disc herniation effect of periradicular adhesive tissue on electrophysiological values by an intraoperative straight leg raising test. Spine (Phila Pa 1976). 2010;35(22):2004–14.CrossRef Kobayashi S, Takeno K, Yayama T, Baba H. Pathomechanisms of sciatica in lumbar disc herniation effect of periradicular adhesive tissue on electrophysiological values by an intraoperative straight leg raising test. Spine (Phila Pa 1976). 2010;35(22):2004–14.CrossRef
19.
go back to reference O’Donnell J, O’Donnell A. Prostaglandin E2 content in herniated lumbar disc disease. O’Donnell J, O’Donnell A. Prostaglandin E2 content in herniated lumbar disc disease.
20.
go back to reference Willburger R, Wittenberg R. Prostaglandin release from lumbar disc and facet joint tissue. Spine (Phila Pa 1976). 1994;19. Willburger R, Wittenberg R. Prostaglandin release from lumbar disc and facet joint tissue. Spine (Phila Pa 1976). 1994;19.
22.
go back to reference Kraychete DC, Rioko KS, Adriana Macado I, Bacellar O, Carvalho EM. Serum cytokine levels in patients with chronic low back pain due to herniated disc: analytical cross-sectional study. Sao Paulo Med J. 2010;128(5):259–62.CrossRefPubMed Kraychete DC, Rioko KS, Adriana Macado I, Bacellar O, Carvalho EM. Serum cytokine levels in patients with chronic low back pain due to herniated disc: analytical cross-sectional study. Sao Paulo Med J. 2010;128(5):259–62.CrossRefPubMed
23.
go back to reference • Liu Y, Wei J, Zhao Y, Zhang Y, Han Y, Chen B. Follistatin-like protein 1 promotes inflammatory reactions in nucleus pulposus cells by interacting with the MAPK and NF κ B signaling pathways. Oncotarget. 2017. The discovered involvement of FSTL1 in the nucleus pulposus inflammatory pathway elaborates on upstream pathways that lead to COX-2 upregulation, and provides a possible avenue for the development of non-operative treatment of inflammation-related symptoms in patients. • Liu Y, Wei J, Zhao Y, Zhang Y, Han Y, Chen B. Follistatin-like protein 1 promotes inflammatory reactions in nucleus pulposus cells by interacting with the MAPK and NF κ B signaling pathways. Oncotarget. 2017. The discovered involvement of FSTL1 in the nucleus pulposus inflammatory pathway elaborates on upstream pathways that lead to COX-2 upregulation, and provides a possible avenue for the development of non-operative treatment of inflammation-related symptoms in patients.
24.
go back to reference • Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy. Eur Spine J. 2013;22(4):697–707. https://doi.org/10.1007/s00586-013-2675-y. Improvement of lower back pain after long-term antibiotic treatment provides strong support for a role of P. acnes in symptom etiology. Moreover, it suggests another possible non-operative treatment to explore: anti-anaerobe antibiotics CrossRefPubMedPubMedCentral • Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy. Eur Spine J. 2013;22(4):697–707. https://​doi.​org/​10.​1007/​s00586-013-2675-y. Improvement of lower back pain after long-term antibiotic treatment provides strong support for a role of P. acnes in symptom etiology. Moreover, it suggests another possible non-operative treatment to explore: anti-anaerobe antibiotics CrossRefPubMedPubMedCentral
31.
go back to reference • Kobayashi Y, Sekiguchi M, Konno S. Effect of an acid-sensing ion channels inhibitor on pain-related behavior by nucleus pulposus applied on the nerve root in rats. Spine (Phila Pa 1976). 2017. https://doi.org/10.1097/BRS.0b013e318173298b. Improved pain symptoms with blockade of ASICs solidifies the role of acidity in sciatica etiology. Furthermore, ASICS may be a novel target for non-operative treatment of pain in lumbar disc herniation. • Kobayashi Y, Sekiguchi M, Konno S. Effect of an acid-sensing ion channels inhibitor on pain-related behavior by nucleus pulposus applied on the nerve root in rats. Spine (Phila Pa 1976). 2017. https://​doi.​org/​10.​1097/​BRS.​0b013e318173298b​. Improved pain symptoms with blockade of ASICs solidifies the role of acidity in sciatica etiology. Furthermore, ASICS may be a novel target for non-operative treatment of pain in lumbar disc herniation.
34.
go back to reference Vucetic N, Svennson O. Physical signs in lumbar disc hernia. Clin Orthop Relat Res. 1996. Vucetic N, Svennson O. Physical signs in lumbar disc hernia. Clin Orthop Relat Res. 1996.
35.
go back to reference Nachemson A. Disc pressure measurements. Spine (Phila Pa 1976). 1981;6(1). Nachemson A. Disc pressure measurements. Spine (Phila Pa 1976). 1981;6(1).
38.
go back to reference • Krishnan V, Rajasekaran S, Aiyer SN. Clinical and radiological factors related to the presence of motor deficit in lumbar disc prolapse: a prospective analysis of 70 consecutive cases with neurological deficit. Eur Spine J. 2017. https://doi.org/10.1007/s00586-017-5019-5. This is the first time that a risk profile with good sensitivity and specificity for cauda equina syndrome has been established for lumbar disc herniation patients. Those who meet criteria can be better monitored to prevent permanent motor deficit in these patients . • Krishnan V, Rajasekaran S, Aiyer SN. Clinical and radiological factors related to the presence of motor deficit in lumbar disc prolapse: a prospective analysis of 70 consecutive cases with neurological deficit. Eur Spine J. 2017. https://​doi.​org/​10.​1007/​s00586-017-5019-5. This is the first time that a risk profile with good sensitivity and specificity for cauda equina syndrome has been established for lumbar disc herniation patients. Those who meet criteria can be better monitored to prevent permanent motor deficit in these patients .
49.
go back to reference • Manchikanti L, Pampati V, Benyamin RM, Hirsch JA. Cost utility analysis of lumbar interlaminar epidural injections in the treatment of lumbar disc herniation, central spinal stenosis, and axial or discogenic low back pain. Pain Physician. 2017:219–228. The finding of strong QALY benefit in patients receiving intralaminar epidural injections supports the continued use of this non-operative treatment option. • Manchikanti L, Pampati V, Benyamin RM, Hirsch JA. Cost utility analysis of lumbar interlaminar epidural injections in the treatment of lumbar disc herniation, central spinal stenosis, and axial or discogenic low back pain. Pain Physician. 2017:219–228. The finding of strong QALY benefit in patients receiving intralaminar epidural injections supports the continued use of this non-operative treatment option.
51.
go back to reference Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336:1634–40.CrossRefPubMed Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336:1634–40.CrossRefPubMed
53.
go back to reference • Altun I, Yuksel KZ. Impact of position on efficacy of caudal epidural injection for low back pain and radicular leg pain due to central spinal stenosis and lumbar disc hernia. J Korean Neurosurg Soc. 2017;60(2):205–10. Highlights benefits of performing injections in the lateral decubitus position as opposed to prone position. This provides patients with better relief at follow-up CrossRefPubMedPubMedCentral • Altun I, Yuksel KZ. Impact of position on efficacy of caudal epidural injection for low back pain and radicular leg pain due to central spinal stenosis and lumbar disc hernia. J Korean Neurosurg Soc. 2017;60(2):205–10. Highlights benefits of performing injections in the lateral decubitus position as opposed to prone position. This provides patients with better relief at follow-up CrossRefPubMedPubMedCentral
54.
go back to reference Kim J, Hur JW, Ph D, et al. Surgery versus nerve blocks for lumbar disc herniation: quantitative analysis of radiological factors as a predictor for successful outcomes. J Korean Neurosurg Soc. 2016;59(5):478–84.CrossRefPubMedPubMedCentral Kim J, Hur JW, Ph D, et al. Surgery versus nerve blocks for lumbar disc herniation: quantitative analysis of radiological factors as a predictor for successful outcomes. J Korean Neurosurg Soc. 2016;59(5):478–84.CrossRefPubMedPubMedCentral
59.
go back to reference Zhong M, Liu JT, Jiang H, Mi W, Yu P-FCL, Xue RR. Incidence of spontaneous resorption of lumbar disc herniation: a meta-analysis. Pain Physician. 2017;6:45–52. Zhong M, Liu JT, Jiang H, Mi W, Yu P-FCL, Xue RR. Incidence of spontaneous resorption of lumbar disc herniation: a meta-analysis. Pain Physician. 2017;6:45–52.
61.
go back to reference Jewell DV, Riddle DL. Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica. Phys Ther. 2005;85(11):1139–50.PubMed Jewell DV, Riddle DL. Interventions that increase or decrease the likelihood of a meaningful improvement in physical health in patients with sciatica. Phys Ther. 2005;85(11):1139–50.PubMed
63.
go back to reference Wang S, Rui Y, Tan Q, Wang C. Enhancing intervertebral disc repair and regeneration through biology: platelet-rich plasma as an alternative strategy. Arthritis Res Ther. 2013;15. Wang S, Rui Y, Tan Q, Wang C. Enhancing intervertebral disc repair and regeneration through biology: platelet-rich plasma as an alternative strategy. Arthritis Res Ther. 2013;15.
65.
go back to reference Levi D, Horn S, Tyszko S, Levin J, Hecht-Leavitt C, Walko E. Intradiscal platelet-rich plasma injection for chronic discogenic low back pain: preliminary results from a prospective trial. Pain Med. 2015:pnv053. https://doi.org/10.1093/pm/pnv053. Levi D, Horn S, Tyszko S, Levin J, Hecht-Leavitt C, Walko E. Intradiscal platelet-rich plasma injection for chronic discogenic low back pain: preliminary results from a prospective trial. Pain Med. 2015:pnv053. https://​doi.​org/​10.​1093/​pm/​pnv053.
70.
go back to reference Osterman H, Seitsalo S, Karppinen J, Malmivaara A. Effectiveness of microdiscectomy for lumbar disc herniation. Spine (Phila Pa 1976). 2006;31(21):2409–14.CrossRef Osterman H, Seitsalo S, Karppinen J, Malmivaara A. Effectiveness of microdiscectomy for lumbar disc herniation. Spine (Phila Pa 1976). 2006;31(21):2409–14.CrossRef
71.
go back to reference Ademi Z, Gloy V, Glinz D, et al. Cost-effectiveness of primarily surgical versus primarily conservative treatment of acute and subacute radiculopathies due to intervertebral disc herniation from the Swiss perspective. Swiss Med Wkly. 2016:1–14. https://doi.org/10.4414/smw.2016.14382. Ademi Z, Gloy V, Glinz D, et al. Cost-effectiveness of primarily surgical versus primarily conservative treatment of acute and subacute radiculopathies due to intervertebral disc herniation from the Swiss perspective. Swiss Med Wkly. 2016:1–14. https://​doi.​org/​10.​4414/​smw.​2016.​14382.
72.
go back to reference • Oba H, Takahashi J, Tsutsumimoto T, et al. Predictors of improvement in low back pain after lumbar decompression surgery: prospective study of 140 patients. J Orthop Sci. 2017:6–11. https://doi.org/10.1016/j.jos.2017.03.011. The identification of pre-operative factors that are associated with improved discectomy outcomes may aid in selecting patients who are most likely to improve from surgical intervention. • Oba H, Takahashi J, Tsutsumimoto T, et al. Predictors of improvement in low back pain after lumbar decompression surgery: prospective study of 140 patients. J Orthop Sci. 2017:6–11. https://​doi.​org/​10.​1016/​j.​jos.​2017.​03.​011. The identification of pre-operative factors that are associated with improved discectomy outcomes may aid in selecting patients who are most likely to improve from surgical intervention.
80.
83.
go back to reference Li Z, Hou S, Shang W, Song K, Zhao H. Modified percutaneous lumbar foraminoplasty and percutaneous endoscopic lumbar discectomy: instrument design, technique notes, and 5 years follow-up. Pain Physician. 2017;20:85–98. Li Z, Hou S, Shang W, Song K, Zhao H. Modified percutaneous lumbar foraminoplasty and percutaneous endoscopic lumbar discectomy: instrument design, technique notes, and 5 years follow-up. Pain Physician. 2017;20:85–98.
84.
go back to reference • Tu Z, Li YW, Wang B, et al. Clinical outcome of full-endoscopic interlaminar discectomy for single-level lumbar disc herniation: a minimum of 5-year follow-up. Pain Physician. 2017;(3):425–430. Demonstrates good outcomes for interlaminar discectomy conducted entirely endoscopically. There is high potential for successfully minimally invasive surgery for single-level disc herniation. • Tu Z, Li YW, Wang B, et al. Clinical outcome of full-endoscopic interlaminar discectomy for single-level lumbar disc herniation: a minimum of 5-year follow-up. Pain Physician. 2017;(3):425–430. Demonstrates good outcomes for interlaminar discectomy conducted entirely endoscopically. There is high potential for successfully minimally invasive surgery for single-level disc herniation.
85.
go back to reference Eun SS, Lee SH, Sabal LA. Long-term follow-up results of percutaneous endoscopic lumbar discectomy. Pain Physician. 2016;19:1161–6. Eun SS, Lee SH, Sabal LA. Long-term follow-up results of percutaneous endoscopic lumbar discectomy. Pain Physician. 2016;19:1161–6.
88.
go back to reference Choi K, Kim J, Lee C. Outcome of decompression alone for foraminal/extraforaminal entrapment of L5 nerve root through Wiltse paraspinal approach. Clin Spine Surg. 2016:1–7. Choi K, Kim J, Lee C. Outcome of decompression alone for foraminal/extraforaminal entrapment of L5 nerve root through Wiltse paraspinal approach. Clin Spine Surg. 2016:1–7.
89.
go back to reference Wiltse L, Spencer C. New uses and refinements of the paraspinal approach to the lumbar spine. Spine (Phila Pa 1976). 1988;13(6). Wiltse L, Spencer C. New uses and refinements of the paraspinal approach to the lumbar spine. Spine (Phila Pa 1976). 1988;13(6).
90.
go back to reference Habiba S, Nygaard ØP, Brox JI, Hellum C, Austevoll IM, Solberg TK. Risk factors for surgical site infections among 1,772 patients operated on for lumbar disc herniation: a multicentre observational registry-based study. Spine (Phila Pa 1976). 2017; https://doi.org/10.1007/s00701-017-3184-2. Habiba S, Nygaard ØP, Brox JI, Hellum C, Austevoll IM, Solberg TK. Risk factors for surgical site infections among 1,772 patients operated on for lumbar disc herniation: a multicentre observational registry-based study. Spine (Phila Pa 1976). 2017; https://​doi.​org/​10.​1007/​s00701-017-3184-2.
92.
go back to reference Kotil K. Closed drainage versus non-drainage for single-level lumbar disc surgery: relationship between epidural hematoma and fibrosis. Asian Spine J. 2016;10(6):1072–8.CrossRefPubMedPubMedCentral Kotil K. Closed drainage versus non-drainage for single-level lumbar disc surgery: relationship between epidural hematoma and fibrosis. Asian Spine J. 2016;10(6):1072–8.CrossRefPubMedPubMedCentral
95.
go back to reference Shin B-J. Risk factors for recurrent lumbar disc herniations. Asian Spine J. 2014;8(2). Shin B-J. Risk factors for recurrent lumbar disc herniations. Asian Spine J. 2014;8(2).
97.
go back to reference Cinotti G, Roysam GS, Eisenstein SM, Postacchini F. Ipsilateral recurrent lumbar disc herniation. A prospective, controlled study. J Bone Jt Surg. 1993;80-B:825–32. Cinotti G, Roysam GS, Eisenstein SM, Postacchini F. Ipsilateral recurrent lumbar disc herniation. A prospective, controlled study. J Bone Jt Surg. 1993;80-B:825–32.
98.
go back to reference Kim K, Park S, Kim Y. Disc height and segmental motion as risk factors for recurrent lumbar disc herniation. Spine (Phila Pa 1976). 2009;34(24):2674–8.CrossRef Kim K, Park S, Kim Y. Disc height and segmental motion as risk factors for recurrent lumbar disc herniation. Spine (Phila Pa 1976). 2009;34(24):2674–8.CrossRef
100.
go back to reference Hegarty D, Shorten G. Multivariate prognostic modeling of persistent pain following lumbar discectomy. Pain Physician. 2012;15(5):421.PubMed Hegarty D, Shorten G. Multivariate prognostic modeling of persistent pain following lumbar discectomy. Pain Physician. 2012;15(5):421.PubMed
101.
go back to reference Carragee EJ, Han MY, Yang B, Kim DH, Kraemer H, Billys J. Activity restrictions after posterior lumbar discectomy: a prospective study of outcomes in 152 cases with no postoperative restrictions. Spine (Phila Pa 1976). 1999;24(22):2346–51.CrossRef Carragee EJ, Han MY, Yang B, Kim DH, Kraemer H, Billys J. Activity restrictions after posterior lumbar discectomy: a prospective study of outcomes in 152 cases with no postoperative restrictions. Spine (Phila Pa 1976). 1999;24(22):2346–51.CrossRef
Metadata
Title
Lumbar Disc Herniation
Authors
Raj M. Amin
Nicholas S. Andrade
Brian J. Neuman
Publication date
01-12-2017
Publisher
Springer US
Published in
Current Reviews in Musculoskeletal Medicine / Issue 4/2017
Electronic ISSN: 1935-9748
DOI
https://doi.org/10.1007/s12178-017-9441-4

Other articles of this Issue 4/2017

Current Reviews in Musculoskeletal Medicine 4/2017 Go to the issue

Management of Anterior Shoulder Instability (X Li, section editor)

Return to Sports After Shoulder Stabilization Surgery for Anterior Shoulder Instability

Treatment of Lumbar Degenerative Pathology (HJ Kim and G Mundis, section editors)

Interbody Fusion Techniques in the Surgical Management of Degenerative Lumbar Spondylolisthesis

Treatment of Lumbar Degenerative Pathology (HJ Kim and G Mundis, section editors)

Degenerative Scoliosis

Treatment of Lumbar Degenerative Pathology (HJ Kim and G Mundis, section editors)

Minimally invasive techniques for lumbar decompressions and fusions

Management of Anterior Shoulder Instability (X Li, section editor)

Current Concepts in Rehabilitation for Traumatic Anterior Shoulder Instability

Treatment of Lumbar Degenerative Pathology (HJ Kim and G Mundis, section editors)

Treatment for Degenerative Lumbar Spondylolisthesis: Current Concepts and New Evidence