Herniated Nucleus Pulposus Class d

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Definition Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in the surrounding annulus fibrosus. The tear causes pain; when the disk impinges on an adjacent nerve root, a segmental radiculopathy with paresthesias and weakness in the distribution of the affected root results.

Spinal vertebrae are separated by cartilaginous disks consisting of an outer annulus fibrosus and an inner nucleus pulposus. When degenerative changes (with or without trauma) result in protrusion or rupture of the nucleus through the annulus fibrosus in the lumbosacral or cervical area, the nucleus is displaced posterolaterally or posteriorly into the extradural space.

Radiculopathy occurs when the herniated nucleus compresses or irritates the nerve root. Posterior protrusion may compress the cord or cauda equina, especially in a congenitally narrow spinal canal ( spinal stenosis). In the lumbar area, > 80% of disk ruptures affect L5 or S1 nerve roots; in the cervical area, C6 and C7 are most commonly affected.

Symptoms and Signs Herniated disks often cause no symptoms, or they may cause symptoms and signs in the distribution of affected nerve roots. Pain usually develops suddenly, and back pain is typically relieved by bed rest. In contrast, nerve root pain caused by an epidural tumor or abscess begins more insidiously, and back pain is worsened by bed rest. In patients with lumbosacral herniation, straight-leg raises stretch the lower lumbar roots and exacerbate back or leg pain (bilateral if disk herniation is central); straightening the knee while sitting also causes pain.

Cervical herniation causes pain during neck flexion or tilting Cervical herniation causes pain during neck flexion or tilting. Cervical cord compression, if chronic, manifests with spastic paresis of the lower limbs and, if acute, causes quadriparesis. Cauda equina compression often results in urine retention or incontinence due to loss of sphincter function.

Diagnosis MRI or CT scan identify the cause and precise level of the lesion. Rarely (ie, when MRI is contraindicated and CT is inconclusive), CT myelography is necessary. Electrodiagnostic testing may help identify the involved root. Because an asymptomatic herniated disk is common, the clinician must carefully correlate symptoms with MRI abnormalities before invasive procedures are considered.

Treatment Conservative treatment initially Invasive procedures if neurologic deficits are progressive or severe Immediate surgical evaluation if the spinal cord is compressed Because a herniated disk desiccates and shrinks over time, symptoms tend to abate regardless of treatment. Up to 85% of patients with back pain— regardless of cause—recover without surgery within 6 wk.

Conservative treatment Treatment of a herniated disk should be conservative, unless neurologic deficits are progressive or severe. Heavy or vigorous physical activity is restricted, but ambulation and light activity (eg, lifting objects < 2.5 to 5 kg [≈ 5 to 10 lb] using correct techniques) are permitted as tolerated; prolonged bed rest (including traction) is contraindicated. Acetaminophen, NSAIDs, or other analgesics should be used as needed to relieve pain

If symptoms are not relieved with non opioid analgesics, corticosteroids can be given systematically or as an epidural injection; however, analgesia tends to be modest and temporary. Methylprednisolone may be given, tapered over a 6 days, starting with 24 mg daily and decreased by 4 mg a day. Physical therapy and home exercises can improve posture and strengthen back muscles and thus reduce spinal movements that further irritate or compress the nerve root.

SOURCE http://www.merckmanuals.com/professional/neurologic- disorders/peripheral-nervous-system-and-motor-unit- disorders/herniated-nucleus-pulposus

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