Disc Herniation: Diagnosis and Management

• Lumbopelvic Pathology addresses the classification of low back pain and lumbopelvic pathologies.

Objectives

• Understand impairment-based classification of low back pain
• Demonstrate understanding of common Lumbopelvic pathologies

Pathology

• Pathology includes structural and functional deviations from the normal that constitute or characterize a disease.
• Pathology also covers the study of the essential nature of diseases and structural/functional changes they produce.
• Pathology does not always equal pain or limitation

Lumbar Clinical Practice Guideline

• Published in 2012 and updated in 2021
• Classifications for low back pain are impairment-based and not pathology based.
• Low back pain with mobility deficits are usually acute, subacute, or chronic.
• Low back pain with movement coordination impairments can be acute, subacute, or chronic.
• Low back pain with radiating pain can be acute, subacute, or chronic.
• Physical therapy diagnoses classifies low back pain

Overview of Pathology

• Serious/Systemic Pathology
• Bone Pathology
• Joint Pathology
• Disc Pathology
• Nerve Pathology
• Contractile Tissue Pathology

Serious/Systemic Pathology Overview

• Spondyloarthropathies
  • including Ankylosing Spondylitis
• Cauda Equina
• Abdominal Aortic Aneurysm (AAA)
• Cancer
• Fracture

Ankylosing Spondylitis

• Ankylosing Spondylitis is an inflammatory condition of the spine that can result in spinal fusion.
• Onset is commonly in early adulthood (80% of cases occur in those <40 years old), and it is more prevalent in men than women.
• The incidence rate is 0.2-0.5%.
• Symptoms include SI joint and lumbar pain, pain with inactivity that improves with movement, uveitis, and Achilles enthesitis
• Diagnosis is aided by X-rays which show sacroiliitis, and blood tests which check for HLA-B27.
• Treatment includes medication (anti-inflammatories) and exercise for mobility and strengthening.
• There is not a known cure.

Cauda Equina Syndrome

• Cauda Equina Syndrome involves compression of the cauda equina
• Causes can include trauma, disc protrusion, hemorrhage, and tumors
• Incidence is 0.005 to 0.03% of back pain cases.
• Signs and symptoms include urinary retention/incontinence, "Saddle Anesthesia", and loss of anal sphincter tone.
• Cauda Equina Syndrome is considered a medical emergency that requires quick decompression to avoid permanent damage.

Abdominal Aortic Aneurysm (AAA)

• AAA involves dilation of the abdominal aorta greater then 3 cm (1.2 inches).
• Symptoms include abdominal pain and backache
• Risk factors include being an older male (4-8% prevalence) versus older women (0.5-1.5% prevalence), age, smoking, and family history.
• Diagnosis can be achieved through palpation and imaging (Ultrasound, CT, MRI)

Compression Fracture

• Compression fractures most frequently occur at T8, T12, L1, and L5
• Trauma is a cause and has a higher correlation when significant in younger persons and minor in order persons
• Risk Factors include being post-menopausal, osteoporosis, and long-term corticosteroid use.
• Symptoms include site pain and limited motion
• Diagnosed via X-Ray
• Treatment options are conservative and involve time, kyphoplasty, and fusion

Tumors

• Primary tumors are rare, originate in spine, osteosarcoma, and multiple myeloma.
• Secondary tumors are common and metastasize from another area, such as breast, lung, thyroid, kidney, and prostate.
• Red flags include unexplained weight loss, pain not relieved with rest or position change, and night pain.

Bone Pathologies Overview:

• Spondylolysis
• Spondylolisthesis
• Schmorl's Nodes

Spondylolysis

• Spondylolysis is a fracture of the pars interarticularis without vertebral displacement.
• Occurs due to repeated or excessive end-range extension
  • Common in dancers and gymnasts
• Signs of Spondylolysis is pain which can present as either acute and/or chronic
  • Localized to the low back.
• Diagnosis includes X-rays and the Scotty Dog Collar Sign
• Treatment is conservative and involves flexion bias, bracing, and time.

Spondylolisthesis

• Spondylolisthesis is a pars fracture with anterior displacement of the vertebral body.
• Low back pain as a result of movement coordination impairments usually in the lumbar region, especially L5/S1.
• Etiology: congenital, arthritis, trauma, and stress fracture.
• Diagnosis made via X-ray.

Meyerding Scale

• Used in order to measure displacement/slippage
  • Grade 1 = 0 - 25%
  • Grade 2 = 25 - 50%
  • Grade 3 = 50 - 75%
  • Grade 4 = 75 - 100%
  • Spondyloptosis = >100%
• Symptoms include step-off deformity, neurological symptoms with higher grades, and pain.
• Treatment involves conservative therapy for low grades and injections.
• Surgery may be required for high grades.

Schmorl's Nodes

• Involves disc herniation through the vertebral endplate into the body of the vertebrae
• It is usually asymptomatic

Joint Pathology Overview:

• Low back pain with mobility deficits according to CPG.
• Degenerative Joint Disease (DJD) Facet arthropathy, Spondylosis, and Osteoarthritis (OA) are all different words for the same thing.
• Genetic and lifestyle factors, and trauma all contribute towards joint pathologies/conditions.
• Arthritic changes includes Osteophytes, Cartilage loss, and Thickening of the capsule

Facet Joint Signs/Symptoms

• Pain stiffness can be relieved with movement.
• ROM is limited.
• Closed positions are often the most uncomfortable such as standing and walking.
• The population most affected tend to be older.
• Conservative care is one treatment alongside mobility work and manual therapy. Another treatment pathway is injections, and radiofrequency ablation.

SI Joint

• Usually related to hypermobility.
  • More pertinent in Peripartum women vs men.
  • Hypermobile people
  • Connective tissue disorders
  • CPG: with low back pain with movement coordination impairments
• Symptoms include stiff, sharp, tingling, pain that's localized and/or generalized, sitting inactivity, shifting weight to affected side, or lifting & running.
• Treatments include conservative care with bracing work and manual therapy. Strengthening, injections, RFA, or surgery is also common.

Disc Pathology Overview

• Estimated prevalence of pain related to disc herniation is 1.6-13.4% (Wong et al 2023).
• DDD involves 88-96% in patients 60-80 y/o that have disc degeneration.
• Numbers increase every decade of life starting at age 20.
• Disc herniation: 69-84% of asymptomatic patients between 60-80 y/o are said to bulge the disk.

Degenerative Disc Disease (DDD)

• Decrease in proteoglycans decreases water imbibition into nucleus
• Decreased vertical height
• Increased facet joint loading
• Ligamentous laxity: bulging into spinal canal causing stenosis
• Loss of nutrients, strong genetic link, and lifestyle factors all lead to DDD.

Disc Herniation

• Posterolateral is most common
• Degeneration causes breakdown of inner rings and no outer ring deformation
• Prolapse causes bulging with normal annular margin and outer rings intact
• Extrusion is nuclear material escapes but is still one piece. Portions typically extrude out of broken annulus.
• Finally, during sequestration the nuclear material breaks free from disc causing the annular material to break free.
• Low back pain with radiating pain and related signs/symptoms. Back and radiating pain causes +/- neurological signs which include (Bend/twist > standing/walking with nerve mechanosensitivity.)
• Treatment pathway is to start with time and directional, and if that fails use treatment such as Surgery.

Can disc herniations heal without surgery?

• YES

Nerve Pathology Overview

• CPG - Low back pain with radiating pain
• Radiculopathy
• Stenosis
• Nerve Entrapment
  • Nerve Mechanosensitivity
  • "Double Crush" Syndrome

Radiculopathy

• Prevalence rate is 3-5%, with age a major risk factor.
  • Men: 40s
  • Women: 50-60s
• Includes degenerative spondyloarthropathies, disc herniation, and spondylolisthesis as factors.
• True neurological deficits are present. Signs/Symptoms
  • Pain: dermatomes, myotomes & reflexes.
  • Pain associated with the nerve root.
  • Decreased ROM nerve mechanosensitivity.
• Treatment: Conservative, injection & surgery

Central Stenosis

• Stenosis includes narrowing of a canal or tube.
  • Narrowing of spinal cord space
  • "Buckling"/thickening of PLL & ligamentum flavum.
• Symptoms
  • Bilateral LE symptoms, +/- true neurological signs, neurogenic claudication & upper motor neuron deficits.
• Treatment: conservative care and direction specific treatments, combined with injections and/or surgery.

Foraminal Stenosis

• Narrowing of foramen
• Facet hypertrophy
• Disc pathology
• Unilateral symptoms are common.
• Additional symptoms include neurogenic Claudication, Lower Motor Neuron deficits and +/- true neurological signs.
• Treatment encompasses direction-specific conservative care, injections, and surgery.

Nerve Entrapment

• Theory: Minor injury to nerve, connective tissue causes:
• Adherence/ "tethering"
• Shortening.
• Loss of Elasticity
• Results in pain, paresthesia along affected nerve. Often, nerves are sensitized to pressure (stretch, compression) and prevalence varies based on body area.
  Symptoms include pain and paresthesia along nerve, or deficits to the motor system.
• Be wary of "Double Crush"
• Compression and irritation of nerves along two distinct areas.

Nerve Treatment

• Nerves require space, movement, cardiovascular to thrive.

Contractile Pathology

• CPG - Low back pain with mobility deficits can be overlooked here as a pain generator. Muscle strain is typically the result of acute or chronic overuse leading to myofascial pain. Similarly, muscle spasm is a potential contributor to protective mechanisms in the spine by causing a contractile or nerve-injury response within a joint or disc. Treatment and management may vary.
• Symptoms may manifest as sharp pain within/around lumbar musculature accompanied by limited ROM upon assessment. Treatment typically takes different forms - ranging anywhere from time, conservative care of joint systems, and therapeutic trigger point injections (amongst other things).