Herniated Disc Management

Jason C. Eck, DO, MSOrthopedic Spine Surgeon

Southeastern Spine and NeurosurgeryChattanooga, TN

Disclosures

• No financial disclosures

Herniated Disc

• Abnormal rupture of the soft central portion of the disc (nucleus pulposus) through the surrounding outer ring (annulus fibrosus). • About 95% of all disc herniation

cases, the L4-L5 or L5-S1 disc levels are involved

Herniated Disc

• Causes:• Trauma or injury to the disc• Disc degeneration• Congenital predisposition

Herniated Disc

• Classifications• Central

• Often associated with back pain only• May present with cauda equina syndrome

• Posterolateral• Most common (90-95%)• PLL is weakest here• Affects the traversing nerve root

• L4-L5 affects L5 nerve root• Foraminal

• Less common (5-10%)• Affects exiting nerve root

• L4/L5 affects L4 nerve root• Axillary

• Can affect both exiting and descending nerve roots

Herniated Disc

• Manifestations• Axial LBP

• May be discogenic or mechanical• Radicular pain

• Buttock and leg symptoms• Often worse with sitting• Worse with coughing, Valsalva,

sneezing• Cauda equina syndrome

• Bilateral leg pain• LE weakness• Saddle anesthesia• Bowel and bladder symptoms

Treatment

• Nonoperative• Rest• Medication

• NSAID’s• PO steroids• Steroid injections• Muscle relaxants• Nerve stabilizers

• PT• 90% improve without surgery

Treatment

• Surgical indications• Persistent pain lasting >6wks and

failing nonsurgical options• Progressive neurologic deficit• Intractable pain• Cauda equina symptoms

Treatment

• Surgery• Microdiscectomy

• Most common• MIS approach• Outpatient

• Fusion• Recurrent HNP• Instability• Calcified HNP

• Arthroplasty

Treatment

• Post op• Ambulating as tolerated• Minimize Bending/Lifting/Twisting

for ~6 weeks• Most gradually return to function• PT if needed

Treatment

• Risks of surgery• Infection• Recurrent HNP• Durotomy• Nerve injury• Vascular injury• Discitis• Medical complications

Questions??