9. Herniated Disc Dx

Question 1

How common are bulging discs?

Answer 1

More than half of adults have a bulging disc but it is clinically unimportant unless it contributes to canal stenosis

Question 2

Type of herniation where the base is broader than the depth

Answer 2

Protrusion

Question 3

What is the prevalence of herniated discs?

Answer 3

25% of adults under 60 have one but most are asymptomatic
1-5% are symptomatic in general population
2-3% are symptomatic in chiro setting
20% are symptomatic in orthopedic surgeon setting

Question 4

Type of disc herniation where the base is narrower than the depth

Answer 4

Extrusion

Question 5

When an extrusion separates from the disc

Answer 5

Sequestered disc

Question 6

When a sequestered disc moves up or down the spine, affecting different nerve roots

Answer 6

Wandering disc

Question 7

What is the difference between a contained and uncontained disc?

Answer 7

In a contained disc, the NP is behind the PLL or last layer of annular ring. An uncontained disc is no longer behind the PLL and is exposed, causing inflammation

Question 8

Which is more common, contained or uncontained disc?

Answer 8

Contained

Question 9

Which is more severe, contained or uncontained disc?

Answer 9

Uncontained, because it not only can cause compression but it also causes inflammation when NP is exposed

Question 10

What is the primary mechanism of disc injuries?

Answer 10

Compressive forces in repetitive flexion often with super-imposed forces

• possible genetic predisposition

Question 11

What are two non mechanical risk factors for developing disc problems?

Answer 11

• history of smoking

- genetic predisposition

Question 12

In general where does pain and paresthesia associated with radicular pain start?

Answer 12

Pain starts proximal ->distal

Paresthesia starts distal -> proximal

Question 13

Describe the progression of pain within the first few days of lumbar disc herniation

Answer 13

• sudden LBP with flexion
• subsides briefly but worsens in a few hours
• any movement is painful for a few days and pain is constant, deep, achy, dull and debilitating
• dull pain subsides but now sharp pain and paresthesia with forward flexion that begins to affect posterior thigh
• leg pain becomes worse than back
• sitting and bearing down difficult now but standing and walking are better

Question 14

What is the antalgic position associated with acute disc herniation?

Answer 14

• muscle splinting and posterior pelvic tilt to flatten lumbar lordosis and create more space retrodiscally

Question 15

What is the peak incidence for lumbar disc herniations?

Answer 15

30 - 55

• remember below 50

Question 16

Where do most herniation occur?

Answer 16

L4/L5 or L5/S1

Question 17

With a posterolateral disc herniation, what NR is most likely to be affected?

Answer 17

The nerve root that exits below the herniation

Ex: L4-L5 herniation will most likely cause L5 nerve root damage

Question 18

Patients with posterolateral disc herniations will have an antalgic lean to what side?

Answer 18

The opposite side of the herniation

Question 19

Radiculitis causes what?

Answer 19

NR irritation leading to:

• leg pain
• paresthesia
• hyperesthesia
• • SLR

Question 20

Radiculopahty causes what?

Answer 20

Compression of the DRG causing:
- SMR loss in lower extremity

More pressure = more loss

Question 21

How does the size of the spinal canal affect disc herniations and their prognosis?

Answer 21

Can increase severity of symptoms, worsen prognosis of conservative care and make surgery more difficult

Question 22

What is the difference between how sensory fiber and motor fibers respond to compression and irritation associated with disc hernations?

Answer 22

Sensory fibers are affected more rapidly but they also recover more rapidly than motor

Question 23

Which is more sensitive to compressive forces, NR or peripheral nerve?

Answer 23

NR

Question 24

How common is urinary retention, urgency and incontinence in the absence of cauda equina in disc hernations?

Answer 24

50%

This is about the same in spinal canal stenosis

Question 25

What is true sciatica?

Answer 25

Lesion in the peripheral nerve or at the L4-S1 nerve roots

Question 26

How is sciatica used in a more general and less accurate way?

Answer 26

Used to denote any pain beyond the knee in the distribution of the sciatic nerve even if it is deep referred pain