Lumbar Disc Herniation


Nerve Root Anatomy


  • Central prolapse: back pain only
  • Posterolateral (MC): PLL weakest
  • Foramina (far lateral or extraforaminal): l4/5 hit l4
  • Axillary: hits both roots
  • Protrusion: bulging nucleus contained within annul
  • Sub-anular extrusion: annular extrusion: annulus intact but fragment above or below disc
  • Trans-anular disc herniation: fragment ruptured through annulus but maintains continuity within disc space
  • Sequestration: disc material herniates through annulus and is no longer continuous with disc space

Provocative Tests


Non Operative Treatment

Operative Treatment

  • Surgery proves greater improvements in pain and disability in the 1st 2 years vs nonsurgical improvements
    • microscopic discectomy just as effective as open discectomy
  • Laminectomy and discectomy (microdiscectomy):
    • disabling pain >6 months, progressive and significant weakness, caudal equine syndrome – return to medium to high intensity activities at 4-6 weeks
  • Outcomes better with surgery
    • Positive predictors of good outcome:
      • leg pain chief complaint
      • +SLR
      • corresponding weakness and MRI
      • absence of joint problems, age >41
    • Negative:
      • WC
      • smoking
  • Far lateral microdiscectomy:
    • Far lateral herniation, use paraspinal approach of Wilts
  • Complications:
    • Dural tear, recurrent HNP, disci tis, vascular catastropher: breaking through anterior annulus and injuring vena cava/aorta
  • Revision surgery has equal outcomes as primary surgery that is – equal pain and equal function