Lumbar Disk Disorders Disease

BASICS

DESCRIPTION

Many patients with low back pain have lumbar disk disease and involvement of surrounding spinal ligaments, muscles and skeleton. Over time may progress to disk degeneration, disk herniation, spinal narrowing and arthritic proliferation of the facet joint. Management is based on symptoms and disability, because the distinction between the normal aging of the spine and pathological findings are hard to distinguish.

Non-radicular low back pain (acute and chronic) - low back pain remaining near belt-line caused by soft tissue or disk injury
Radicular low back pain (acute and chronic) - neuropathic pain is to a greater degree in the buttocks, hips or legs rather than the back. There may or may not be signs of weakness, numbness, or loss of reflex. In younger patients, the source of the pain is likely to be mechanical compression or chemical irritation of a nerve root.
Spinal stenosis is more likely to be the etiology of radicular pain in patients over 55 years
System(s) affected: Musculoskeletal, Nervous
Genetics: N/A
Incidence/Prevalence in USA:
- One of the most frequent complaints for which adults seek medical attention and second to the common cold for most time off work
- Lifetime prevalence of low back pain is 60-90%. The annual incidence is 5%. Among patients with acute back pain, 1% have nerve root symptoms.
- 95% of diseased disks are localized to L4-5 and L5-S1
- Less than 2% of patients with low back pain have infections, neoplasms, or inflammatory spondyloarthropathies
Predominant age: 25-45 years, first episode in 20's and 30's, infrequent before 20 years or after age 65
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

Variable pain; usually dull, originating in back, extending below knee
Pain may radiate (often unilaterally) in nerve root distribution
Back pain decreases at night. Bedrest usually improves symptoms at least temporarily.
Pain increases with sitting, standing
Constitutional symptoms absent
Sciatica can occur without back pain
Often sensory aberrations in extremities, paresthesia and numbness
Occasionally muscle group weakness
Most disk ruptures are posterolateral and press upon lumbar nerve root with radiating pain
Lumbar scoliosis possible, trunk tilted toward or away from affected side, depending on location of extrusion
Paraspinal muscle spasm

CAUSES

Trauma, major or minor
Frequent lifting of objects weighing 25 pounds (11.3 kg) or more, especially if lifted with arms extended and knees straight, and body twisted
Vibration; e.g., driving motor vehicles

RISK FACTORS

Normal aging process after age 20 years
Cigarette smoking
Narrow lumbar vertebral canal (for prolapsed disk)
Stress, muscle tension
Obesity

DIAGNOSIS

LABORATORY

ESR - usually normal

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Difficult to distinguish normal aging process of disk degeneration from specific lesions causing low back pain and sciatica

SPECIAL TESTS

Electromyography - useful to exclude peripheral neuritis

IMAGING

Lumbosacral plain films - rarely indicated just to initiate a conservative management program; indicated to rule out tumor or structural abnormality although presence of latter may not confirm source of pain
Lumbosacral oblique views - controversial
Magnetic resonance now preferred over CT scan and myelogram (for surgical candidate evaluation). Notes: disk herniation found in 20-35% and disk bulging in 56% of asymptomatic adults under 60 years.

DIAGNOSTIC PROCEDURES

Sciatic stretch test - in supine position, elevation of affected leg (to 15-30% for severe, 30-60% milder) elicits pain. Tip: can compare to sitting position to look for learned behavior.
Laségue's sign - patient is supine, hip flexed, dorsiflexion of ankle accentuates sciatic pain or muscle spasm in posterior thigh
Cross straight-leg-raising - elevating normal leg produces sciatica down other leg
Doorbell sign - (insensitive) deep palpation of the spinous process over protruded disk reproduces sciatica
Femoral stretch (for L2-3) - in prone position, affected leg is extended from knee reproducing pain along femoral nerve
Faber's test - (positive only for hip pain) in supine position, flexion, abduction and external rotation produces pain
Neurologic assessment of lower extremities and perineum - usually locates level of lesion. Test gait, reflexes, motor strength, muscle atrophy; pulses and abdominal bruits; rectal sphincter.

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient for majority. Inpatient for severe disability and/or surgery.

GENERAL MEASURES

Conservative treatment is recommended for the first 6 weeks. Most herniated disks resorb over time, particularly large and extruded disks. For persistent pain and neurological deficits, consider evaluation for surgery. Surgery should not be delayed more than 6 months because of risk of chronic disability.
Initial: minimize bedrest, ordinary activities as tolerated, local heat, pelvic traction, sedation, physical therapy (90% response)
Manipulation therapy contraindicated with sciatica
For chronic non-radicular pain: improve physical fitness with low impact aerobic exercise. Manipulation and physical therapy have shown benefit.
Transcutaneous electrical nerve stimulation (TENS): very short-term benefit

SURGICAL MEASURES

Gram positive antimicrobial prophylaxis recommended for all techniques
Procedures available
- Standard diskectomy
- Microsurgical diskectomy - Open and micro techniques achieve highest relief of symptoms
- Percutaneous diskectomy - Other minimally invasive diskectomies are percutaneous suction, percutaneous laser, micro-endoscopic, and arthroscopic disk decompression. Success is critical to patient selection
- Chemonucleolysis - lower rate of benefit and occasional severe complications
- Spinal fusion (arthrodesis) - indicated for spinal instability
Absolute indications for diskectomy
- Cauda equina syndrome
- Progressive neurological deficit despite conservative treatment
Relative indications for diskectomy
- Intolerable pain
- Multiple episodes of radiculopathy
- Severe postural tilt
- Persistent dysfunctional pain - these patients have been reported to improve more rapidly postoperatively but long term results show no difference from nonoperative treatment
- Static neurological deficit - no reported difference between operative or nonoperative treatment for improvement in weakness or sensory disturbance
Epidural steroid injection remains controversial

ACTIVITY

After pain is controlled (2-4 days), begin progressive walking program. Short walks initially 4 times a day and lengthen as tolerated.
Return to work as soon as possible with avoidance of high risk activities, e.g., heavy lifting, vibration, smoking

DIET

Weight reduction if appropriate

PATIENT EDUCATION

Good posture, proper body mechanics, physical fitness, physical therapy if appropriate

FOLLOW UP

PREVENTION/AVOIDANCE

Modification of jobs to reduce exposure to known risk factors
Selection of workers by such means as strength testing for certain jobs
Avoid smoking
Lessen obesity

POSSIBLE COMPLICATIONS

Foot drop with weakness of anterior tibial, posterior tibial and peroneal muscles
Loss of ankle jerk
Bladder and rectal sphincter weakness with retention or incontinence
Limitation of movement and restricted activity
Narcotic addiction

EXPECTED COURSE AND PROGNOSIS

Acute low back pain (90%) and/or radiculopathy (60-80%) can be expected to recover spontaneously with conservative therapy
Chronic nonradicular low back pain - most patients respond to conservative management such as manipulation, fitness, weight reduction, and education regarding back care
Chronic radicular pain - good selection of surgical candidates have found satisfactory results (80% in long-term studies)

MISCELLANEOUS

ASSOCIATED CONDITIONS

Poor physical conditioning/posture
Obesity
Osteoarthritis
Osteoporosis
Depression, other psychiatric disorders

AGE-RELATED FACTORS

Pediatric: Scoliosis, onset age 10 years, rarely symptomatic until adulthood. Detect difference in leg length.
Geriatric: Usually multifactorial lesions of spine. Degenerative spondylolisthesis (especially in women), spinal stenosis, and neurogenic claudication are more likely.
Others: N/A

PREGNANCY

Commonly associated with low back pain and/or sciatica. Treatment is conservative.

OTHER NOTES

Features which predict best surgical outcome (90-95% improvement when all three exist)
- Definable neurological deficit
- Pathology in imaging which correlates with deficit
- Positive nerve root tension signs
Adverse psychosocial factors to resolving back pain
- Sciatica with predominant back symptoms
- Pending litigation or compensation
- Depressed or hostile patient
- Low IQ or poorly educated may not be able to participate in assessment or decision
- Prolonged use of narcotics or alcohol

ABBREVIATIONS

N/A

Clinical Investigations

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