Disc slip: Difference between revisions

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==Overview==
==Overview==
[[Intervertebral disk slip]] consists of 2 main parts, nucleus pulposus the central part, and annulus fibrosus the peripheral part. [[Intervertebral disc slip]] occurs when [[nucleus pulposus]] protrudes through [[annulus fibrosus]]. Most commonly [[disc slip]] is caused by degenerative changes and traumatic insults to the spine. Although, [[disc herniation]] can occur in any part of the [[vertebral column]] but [[lumbar disc slips]] are far more common than [[disc herniations]] in other parts of the spine. Males, obese, smokers and heavy weight lifters are at increased risk of developing [[disk slip]]. Clinical features of the disk slip vary depending upon the location and presence or absence of nerve impingement. Common clinical features include back pain, pain radiating to upper or lower extremity, motor weakness, numbness or tingling, absent deep tendon reflexes. MRI and CT scan have excellent sensitivity in diagnosing [[intervertebral disc slip]]. Conservative management starts with lifestyle modifications and medical therapy. Most of the patients get pain relief with conservative management. For severe or persistent cases surgical management can be used.


==Historical Perspective==
==Historical Perspective==
*[Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
*[[Intervertebral disc slip]] was first described by [[Virchow]], a [[german physician]], in [1857] in his publication related to disc pathologies. <ref name="pmid24752913">{{cite journal |vauthors=Truumees E |title=A history of lumbar disc herniation from Hippocrates to the 1990s |journal=Clin. Orthop. Relat. Res. |volume=473 |issue=6 |pages=1885–95 |date=June 2015 |pmid=24752913 |pmc=4418987 |doi=10.1007/s11999-014-3633-7 |url= |issn=}}</ref>
*In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
*In [1887], the first [[laminectomy]] was done by [[William MacEwen]] and [[Victor Horsely]] to treat [[lumbar disc slip]]. The first [[discectomy]] was done by surgeon [[Fedor Krause]] in 1908. <ref name="pmid19404576">{{cite journal |vauthors=Alemo S, Sayadipour A |title=Sources and patterns of pain in lumbar disc disease: revisiting Francis Murphey's theory |journal=Acta Neurochir (Wien) |volume=152 |issue=9 |pages=1555–8 |date=September 2010 |pmid=19404576 |doi=10.1007/s00701-009-0315-4 |url= |issn=}}</ref> <ref name="pmid8855462">{{cite journal |vauthors=Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, Singer DE |title=The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica |journal=Spine |volume=21 |issue=15 |pages=1777–86 |date=August 1996 |pmid=8855462 |doi=10.1097/00007632-199608010-00011 |url= |issn=}}</ref>
*In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
 
==Classification==
==Classification==
*[Disease name] may be classified according to [classification method] into [number] subtypes/groups:
*[[Intervertebral disc slip]] may be classified according to the extent of displacement of [[nucleus pulposus]] into 4 subtypes<ref name="urlDisc Herniation - Physiopedia">{{cite web |url=https://www.physio-pedia.com/Disc_Herniation#cite_note-12 |title=Disc Herniation - Physiopedia |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>:
:*[group1]
:*[[Bulging]]: Disc margins extend beyond vertebral endplate margins.
:*[group2]
:*[[Protrusion]]: Nucleus pulposus impinges on annulus fibrosus, posterior longitudinal ligament stays intact.
:*[group3]
:*[[Extrusion]]: Nucleus pulposus extrudes through the annulus fibrosus, posterior longitudinal ligament stays intact.
*Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].
:*[[Sequestration]]: Posterior longitudinal ligament is compromised. Nucleus pulposus extrudes through the annulus fibrosus and posterior longitudinal ligament into epidural space.
 
==Pathophysiology==
==Pathophysiology==
*The pathogenesis of [[disc slip]] is characterized by bulging of [[nucleus pulposus]] of the disk through the [[annulus pulposus]]. [[Nucleus pulposus]] is the central part of the [[intervertebral disc]] that contains [[proteoglycans]]. [[Proteoglycans]] cause water retention, thus [[nucleus pulposus]] is responsible for providing cushioning effect to [[vertebrae]]. [[Annulus fibrosis]] is the peripheral ring surrounding [[nucleus pulposus]] that is responsible for keeping [[nucleus pulposus]] in the center of the disk. Displaced fragments of [[nucleus pulposus]] can then compress the nerve roots passing behind the [[intervertebral disk space]]. Several underlying changes have been implicated in the development of [[slipped discs]] including decreased water content in [[nucleus pulposus]], increased activity of degradative processes including inflammatory mediators, [[apoptosis]], and [[matrix metalloproteinase]] enzyme leading to degeneration of [[intervertebral discs]]. Multiple genes have been considered responsible for [[intervertebral disc slip]]. It is also documented that axial overburdening of [[vertebral column]] may cause [[disc slip]].  
*The pathogenesis of [[disc slip]] is characterized by bulging of [[nucleus pulposus]] of the disk through the [[annulus pulposus]]. [[Nucleus pulposus]] is the central part of the [[intervertebral disc]] that contains [[proteoglycans]]. [[Proteoglycans]] cause water retention, thus [[nucleus pulposus]] is responsible for providing cushioning effect to [[vertebrae]]. [[Annulus fibrosis]] is the peripheral ring surrounding [[nucleus pulposus]] that is responsible for keeping [[nucleus pulposus]] in the center of the disk. Displaced fragments of [[nucleus pulposus]] can then compress the nerve roots passing behind the [[intervertebral disk space]]. Disc [[degeneration]] is the most common preceding factor in the development of [[disk slip]]. Several underlying changes have been implicated in the development of [[slipped discs]] including decreased water content in [[nucleus pulposus]], increased activity of degradative processes including inflammatory mediators, [[apoptosis]], and [[matrix metalloproteinase]] enzyme leading to degeneration of [[intervertebral discs]]. Role of multiple genes has also been implicated in [[intervertebral disc degeneration]] and consequent [[herniation]]. It is also documented that axial overburdening of [[vertebral column]] may cause [[disc slip]]. <ref name="pmid25024024">{{cite journal |vauthors=Kadow T, Sowa G, Vo N, Kang JD |title=Molecular basis of intervertebral disc degeneration and herniations: what are the important translational questions? |journal=[[Clinical Orthopaedics and Related Research]] |volume=473 |issue=6 |pages=1903–12 |date=June 2015 |pmid=25024024 |pmc=4418989 |doi=10.1007/s11999-014-3774-8 |url= |issn=}}</ref><ref name="pmid23537453">{{cite journal |vauthors=Mayer JE, Iatridis JC, Chan D, Qureshi SA, Gottesman O, Hecht AC |title=Genetic polymorphisms associated with intervertebral disc degeneration |journal=[[The Spine Journal : Official Journal of the North American Spine Society]] |volume=13 |issue=3 |pages=299–317 |date=March 2013 |pmid=23537453 |pmc=3655694 |doi=10.1016/j.spinee.2013.01.041 |url= |issn=}}</ref><ref name="pmid23932724">{{cite journal |vauthors=Colombier P, Clouet J, Hamel O, Lescaudron L, Guicheux J |title=The lumbar intervertebral disc: from embryonic development to degeneration |journal=[[Joint Bone Spine]] |volume=81 |issue=2 |pages=125–9 |date=March 2014 |pmid=23932724 |doi=10.1016/j.jbspin.2013.07.012 |url= |issn=}}</ref>
*[[Genes]] responsible for [[disc slip]] include [[genes]] coding for [[matrix metalloproteinases]], [[structural proteins]], [[Vitamin D receptor]], [[apoptosis factors]], [[growth factors]].
*[[Genes]] responsible for [[disc slip]] include [[genes]] coding for [[matrix metalloproteinases]], [[structural proteins]], [[Vitamin D receptor]], [[apoptosis factors]], [[growth factors]], [[collagen type I and IX]], [[interleukin 1]], [[interleukin 6]], [[asporin]], [[aggrecan]]. <ref name="pmid27917384">{{cite journal |vauthors=Martirosyan NL, Patel AA, Carotenuto A, Kalani MY, Belykh E, Walker CT, Preul MC, Theodore N |title=Genetic Alterations in Intervertebral Disc Disease |journal=[[Frontiers in Surgery]] |volume=3 |issue= |pages=59 |date=2016 |pmid=27917384 |pmc=5116693 |doi=10.3389/fsurg.2016.00059 |url= |issn=}}</ref><ref name="pmid23537453">{{cite journal |vauthors=Mayer JE, Iatridis JC, Chan D, Qureshi SA, Gottesman O, Hecht AC |title=Genetic polymorphisms associated with intervertebral disc degeneration |journal=[[The Spine Journal : Official Journal of the North American Spine Society]] |volume=13 |issue=3 |pages=299–317 |date=March 2013 |pmid=23537453 |pmc=3655694 |doi=10.1016/j.spinee.2013.01.041 |url= |issn=}}</ref>


==Causes==
==Causes==
[[Disc slip]] may be caused by age-related [[degenerative changes]], [[systemic inflammatory processes]], vertebral [[trauma]], sudden vertebral strain, twisted movement of the spine.
[[Disc slip]] may be caused by age-related [[degenerative changes]], [[systemic inflammatory processes]], vertebral [[trauma]], sudden vertebral strain, twisted movement of the spine, [[connective tissue disorders]]. <ref name="urlHerniated Disk in the Lower Back - OrthoInfo - AAOS">{{cite web |url=https://orthoinfo.aaos.org/en/diseases--conditions/herniated-disk-in-the-lower-back/ |title=Herniated Disk in the Lower Back - OrthoInfo - AAOS |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> <ref name="urlHerniated Disc – Symptoms, Causes, Prevention and Treatments">{{cite web |url=https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc |title=Herniated Disc – Symptoms, Causes, Prevention and Treatments |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


==Differentiating [[intervertebral disc slip]] from other Diseases==
==Differentiating [[intervertebral disc slip]] from other Diseases==
*[[Disc slip]] must be differentiated from other diseases that cause [[radicular pain]], [[sensory deficits]], and [[motor weakness]], such as:
*[[Disc slip]] must be differentiated from other diseases that cause [[radicular pain]], [[sensory deficits]], and [[motor weakness]], such as<ref name="urlHerniated Disc – Symptoms, Causes, Prevention and Treatments">{{cite web |url=https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc |title=Herniated Disc – Symptoms, Causes, Prevention and Treatments |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> <ref name="urlDisc Herniation - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK441822/ |title=Disc Herniation - StatPearls - NCBI Bookshelf |author= Dydyk AM, Ngnitewe Massa R, Mesfin FB|authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>:
:*[[Spinal tumors]]
:*[[Spinal tumors]]
:*[[Spinal abscess]]
:*[[Spinal abscess]]
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:*[[Spinal stenosis]]
:*[[Spinal stenosis]]
:*[[Arthritis]]
:*[[Arthritis]]
:*[[Spinal cysts]]
:*[[Epidural hematoma]]


==Epidemiology and Demographics==
==Epidemiology and Demographics==
* The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
* The incidence of [[intervertebral disc slip]] is estimated to be [5-20] cases per 1000 individuals annually. In case of lumbar disc slips, 95% of the herniations in patients aged between 25 to 55 occur at L4-L5 or L5-S1 level. In case of cervical spine, C6-C7 disc is most commonly herniated.<ref name="pmid30929479">{{cite journal |vauthors=Fjeld OR, Grøvle L, Helgeland J, Småstuen MC, Solberg TK, Zwart JA, Grotle M |title=Complications, reoperations, readmissions, and length of hospital stay in 34 639 surgical cases of lumbar disc herniation |journal=[[The Bone & Joint Journal]] |volume=101-B |issue=4 |pages=470–477 |date=April 2019 |pmid=30929479 |doi=10.1302/0301-620X.101B4.BJJ-2018-1184.R1 |url= |issn=}}</ref> <ref name="pmid19445754">{{cite journal |vauthors=Jordan J, Konstantinou K, O'Dowd J |title=Herniated lumbar disc |journal=[[BMJ Clinical Evidence]] |volume=2009 |issue= |pages= |date=March 2009 |pmid=19445754 |pmc=2907819 |doi= |url= |issn=}}</ref>
* In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].
   
   
===Age===
===Age===
*Patients of all age groups may develop [disease name].
*[Disease name] is more commonly observed among patients aged [age range] years old.
*[Disease name] is more commonly observed among [elderly patients/young patients/children].
   
   
*[[Intervertebral disc slip]] is more commonly observed among patients aged [[30 to 50]] years old.
===Gender===
===Gender===
   
   
*[[Males]] are more commonly affected with [[intervertebral disc slip]] than [[females]].
*[[Males]] are more commonly affected with [[intervertebral disc slip]] than [[females]].<ref name="pmid30929479">{{cite journal |vauthors=Fjeld OR, Grøvle L, Helgeland J, Småstuen MC, Solberg TK, Zwart JA, Grotle M |title=Complications, reoperations, readmissions, and length of hospital stay in 34 639 surgical cases of lumbar disc herniation |journal=[[The Bone & Joint Journal]] |volume=101-B |issue=4 |pages=470–477 |date=April 2019 |pmid=30929479 |doi=10.1302/0301-620X.101B4.BJJ-2018-1184.R1 |url= |issn=}}</ref>


===Race===
===Race===
*There is no racial predilection for [disease name].
*There is no racial predilection for [[intervertebral disc slip]].
*[Disease name] usually affects individuals of the [race 1] race.
*[Race 2] individuals are less likely to develop [disease name].


==Risk Factors==
==Risk Factors==
*Common risk factors in the development of [[intervertebral disc slip]] are  [[male gender]], [[excessive body weight]], [[smoking]], [[sedentary life style]], [[abrupt increase in physical activity]], [[heavy weight lifting]], [[poor posture]], [[poor nutrition]].
*Common risk factors in the development of [[intervertebral disc slip]] are  [[male gender]], [[excessive body weight]], [[smoking]], [[sedentary life style]], [[abrupt increase in physical activity]], [[heavy weight lifting]], [[poor posture]], [[poor nutrition]]. <ref name="urlHerniated Disk in the Lower Back - OrthoInfo - AAOS">{{cite web |url=https://orthoinfo.aaos.org/en/diseases--conditions/herniated-disk-in-the-lower-back/ |title=Herniated Disk in the Lower Back - OrthoInfo - AAOS |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> <ref name="urlLumbar Disk Disease (Herniated Disk) | Johns Hopkins Medicine">{{cite web |url=https://www.hopkinsmedicine.org/health/conditions-and-diseases/lumbar-disc-disease-herniated-disc |title=Lumbar Disk Disease (Herniated Disk) &#124; Johns Hopkins Medicine |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


== Natural History, Complications and Prognosis==
== Natural History, Complications and Prognosis==
*The majority of patients with [disease name] remain asymptomatic for [duration/years].  
*Two-third of patients with [[lumbar disc herniation]] improve within 6 months as herniated disk tends to regress over time. After 6 weeks, only around 10% of the patients have persistent pain to consider surgery. <ref name="urlHerniated Lumbar Disk - Clinical Evidence Handbook - American Family Physician">{{cite web |url=https://www.aafp.org/afp/2006/0401/p1240.html#afp20060401p1240-b12 |title=Herniated Lumbar Disk - Clinical Evidence Handbook - American Family Physician |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
*Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
*If left untreated, patients with [[intervertebral disc slip]] may develop [[chronic back pain]], [[permanent nerve damage]], [[persistent motor weakness]], [[persistent sensory deficits]], [[Cauda equina syndrome]]. <ref name="urlLumbar Disk Disease (Herniated Disk) | Johns Hopkins Medicine">{{cite web |url=https://www.hopkinsmedicine.org/health/conditions-and-diseases/lumbar-disc-disease-herniated-disc |title=Lumbar Disk Disease (Herniated Disk) &#124; Johns Hopkins Medicine |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> <ref name="urlSlipped (Herniated) Disc: Symptoms, Causes, and Effects">{{cite web |url=https://www.healthline.com/health/herniated-disk |title=Slipped (Herniated) Disc: Symptoms, Causes, and Effects |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
*If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
*Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
*Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].


== Diagnosis ==
== Diagnosis ==
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=== History and Symptoms ===
=== History and Symptoms ===
*Symptoms of [[Intervertebral disc slip]] depend upon the site and extent of the slipped disc and are present in the are supplied by the compressed nerve. They may include the following:
*Symptoms of [[Intervertebral disc slip]] depend upon the site and extent of the slipped disc and are present in the are supplied by the compressed nerve. They may include the following<ref name="urlHerniated Disc – Symptoms, Causes, Prevention and Treatments">{{cite web |url=https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc |title=Herniated Disc – Symptoms, Causes, Prevention and Treatments |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="urlHerniated disk - Symptoms and causes - Mayo Clinic">{{cite web |url=https://www.mayoclinic.org/diseases-conditions/herniated-disk/symptoms-causes/syc-20354095 |title=Herniated disk - Symptoms and causes - Mayo Clinic |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>:
====Lumbar disc slip====
====Lumbar disc slip====
:*[[Lower back pain]]
:*[[Lower back pain]]
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:*[[loss of bowel or bladder control]]
:*[[loss of bowel or bladder control]]
:*[[pain aggravation with walking, standing or sitting]]
:*[[pain aggravation with walking, standing or sitting]]
====Cervical disc slip====
====Cervical or thoracic disc slip====
:*[[Neck pain]]
:*[[Neck pain]]
:*[[pain between shoulder girdles]]
:*[[pain between shoulder girdles]]
:*[[pain radiating down the arm to the hand or fingers]]
:*[[pain radiating down the arm to the hand or fingers]]
:*[[numbness]]/[[tingling]] in the arm or shoulder
:*[[numbness]]/[[tingling]] in the forearm, arm or shoulder
:*[[increase in pain with neck movements]].
:*[[increase in pain with neck movements]].
:*[[weakness in the muscles of hand or forearm]]


=== Physical Examination ===
=== Physical Examination ===
*Physical examination findings depend upon the nerve root compressed and maybe remarkable for:
*Physical examination findings depend upon the nerve root compressed and maybe remarkable for<ref name="urlDisc Herniation - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK441822/ |title=Disc Herniation - StatPearls - NCBI Bookshelf |author= Dydyk AM, Ngnitewe Massa R, Mesfin FB|authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>:
:*[[motor weakness]] of the [[muscles]] supplied by that [[nerve root]]
:*[[C5 nerve]]: [[numbness]] in lateral arm, weakened shoulder [[abduction]], [[external rotation]], [[forearm supination]] and [[elbow flexion]], abnormal [[biceps reflex]] and [[brachioradialis reflex]].
:*[[loss of sensation]] in the [[dermatome]] innervated by that [[nerve]]
:*[[C6 nerve]]: [[numbness]] in thumb, index finger, lateral foream, weakened shoulder [[abduction]], [[external rotation]], [[forearm supination]], [[forearm pronation]] and [[elbow flexion]], abnormal [[biceps reflex]] and [[brachioradialis reflex]]. 
:*Absent [[deep tendon reflexes]]
:*[[C7 nerve]]: [[numbness]] in palm, index and middle fingers, weakened [[wrist flexion]], [[radial extension]], and [[forearm pronation]], abnormal triceps reflex.
:*positive[[straight leg raise test]] in lumbar radiculopathy
:*[[C8 nerve]]: [[numbness]] in medial forearm and hand, weakened distal finger [[flexion]], [[extension]], [[abduction]], [[adduction]], [[distal thumb flexion]] and [[wrist extension]]. Normal reflexes
:*[[T1 nerve]]: [[numbness]] in anterior and medial forearm, weakened finger [[adduction]], [[abduction]], thumb [[abduction]] and distal [[thumb flexion]]. Normal [[deep tendon reflexes]]
:*[[L1 nerve]]: altered sensation in [[inguinal region]], weakened hip flexion.
:*[[L2,L3,L4 nerves]]: altered sensation in medial leg and anterior thigh, weakened hip [[fexion]], [[adduction]], knee [[extension]], abnormal patellar reflex.
:*[[L5 nerve]]: altered sensation in lateral calf, dorsal for and space between 1st and 2nd toe, weakened hip [[abduction]], knee [[flexion]], foot [[dorsiflexion]], [[toe flexion and extension]], [[foot eversion]] and [[inversion]]. Abnormal semitendinosus or semimembranosus reflex.
:*[[S1 nerve]]: altered sensation on posterior calf, lateral or plantar foot, weakened hip extension, knee flexion, foot plantar flexion, loss of bowel or bladder control, sexual dysfunction.
:*[[S2-S4 nerves]]: altered sensation on medial side of buttock, perianal and perineal region, absence of wink and bulbocavernosus reflex.
:*positive [[straight leg raise test]] in lumbar radiculopathy.


=== Laboratory Findings ===
=== Laboratory Findings ===
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===CT scan===
===CT scan===
CT scan may be helpful in the diagnosis of [[intervertebral disc slip]]. Like MRI, CT scan also provides a detailed view of the spinal canal and its contents, thus it can detect disc slip along with its extent and location.Findings on CT scan suggestive of [[intervertebral disc slip]] include [[bulging of intervertebral disc]], [[nerve root compression]], and [[spinal cord compression]].
CT scan may be helpful in the diagnosis of [[intervertebral disc slip]]. Like MRI, CT scan also provides a detailed view of the spinal canal and its contents, thus it can detect disc slip along with its extent and location.Findings on CT scan suggestive of [[intervertebral disc slip]] include [[bulging of intervertebral disc]], [[nerve root compression]], and [[spinal cord compression]]. <ref name="urlHerniated Disc – Symptoms, Causes, Prevention and Treatments">{{cite web |url=https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc |title=Herniated Disc – Symptoms, Causes, Prevention and Treatments |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> <ref name="urlHerniated Lumbar Disc, low back, ruptured disc, bulging disc | Mayfield Brain & Spine, Cincinnati, Ohio">{{cite web |url=https://mayfieldclinic.com/pe-hldisc.htm#:~:text=A%20herniated%20disc%20occurs%20when,or%20compresses%20a%20spinal%20nerve. |title=Herniated Lumbar Disc, low back, ruptured disc, bulging disc &#124; Mayfield Brain & Spine, Cincinnati, Ohio |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


===MRI===
===MRI===
MRI may be helpful in the diagnosis of [[intervertebral disc slip]], as it is considered the gold standard for the diagnosis of this disorder. MRI has an excellent capacity to visualize all the soft tissues including the spinal cord, and nerve roots thus it can easily detect bulging intervertebral disc and also if there is any compression of nerve root or spinal cord. MRI is also very helpful in ruling out other differentials.
MRI may be helpful in the diagnosis of [[intervertebral disc slip]], as it is considered the gold standard for the diagnosis of this disorder. MRI has an excellent capacity to visualize all the soft tissues including the spinal cord, and nerve roots thus it can easily detect bulging intervertebral disc and also if there is any compression of nerve root or spinal cord. MRI is also very helpful in ruling out other differentials.<ref name="urlHerniated Lumbar Disc, low back, ruptured disc, bulging disc | Mayfield Brain & Spine, Cincinnati, Ohio">{{cite web |url=https://mayfieldclinic.com/pe-hldisc.htm#:~:text=A%20herniated%20disc%20occurs%20when,or%20compresses%20a%20spinal%20nerve. |title=Herniated Lumbar Disc, low back, ruptured disc, bulging disc &#124; Mayfield Brain & Spine, Cincinnati, Ohio |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="urlHerniated Disc – Symptoms, Causes, Prevention and Treatments">{{cite web |url=https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc |title=Herniated Disc – Symptoms, Causes, Prevention and Treatments |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


===Other Imaging Findings===
===Other Imaging Findings===
[[Myelogram]] may be helpful in the diagnosis of [[intervertebral disc slip]]. It is a modified x-ray technique in which the spinal canal is visualized after injection of a contrast material. It can show if a [[slipped disk]] is compressing a [[nerve root]] or [[spinal cord]]
[[Myelogram]] may be helpful in the diagnosis of [[intervertebral disc slip]]. It is a modified x-ray technique in which the spinal canal is visualized after injection of a contrast material. It can show if a [[slipped disk]] is compressing a [[nerve root]] or [[spinal cord]]<ref name="urlHerniated Disc – Symptoms, Causes, Prevention and Treatments">{{cite web |url=https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc |title=Herniated Disc – Symptoms, Causes, Prevention and Treatments |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


===Other Diagnostic Studies===
===Other Diagnostic Studies===
[[Electromyogram]] and [[nerve conduction studies]] may be helpful in the diagnosis of [[intervertebral disc slip]]. These tests assess the response of nerve or muscle to electric stimulation. They can reveal if there is any nerve damage or compression as a consequence of slipped disk.
[[Electromyogram]] and [[nerve conduction studies]] may be helpful in the diagnosis of [[intervertebral disc slip]]. These tests assess the response of nerve or muscle to electric stimulation. They can reveal if there is any nerve damage or compression as a consequence of slipped disk.<ref name="urlHerniated Disc – Symptoms, Causes, Prevention and Treatments">{{cite web |url=https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc |title=Herniated Disc – Symptoms, Causes, Prevention and Treatments |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="urlHerniated Lumbar Disc, low back, ruptured disc, bulging disc | Mayfield Brain & Spine, Cincinnati, Ohio">{{cite web |url=https://mayfieldclinic.com/pe-hldisc.htm#:~:text=A%20herniated%20disc%20occurs%20when,or%20compresses%20a%20spinal%20nerve. |title=Herniated Lumbar Disc, low back, ruptured disc, bulging disc &#124; Mayfield Brain & Spine, Cincinnati, Ohio |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


== Treatment ==
== Treatment ==
Patients are instructed to follow certain lifestyle modifications before any pharmacologic treatment is done. They include maintenance of activity level that is painless, physiotherapy, avoidance of any activity that incites pain, avoidance from lifting heavy weights, weight control, use of spinal support.   
Certain non-pharmacologic treatments and lifestyle modifications can be used before any pharmacologic treatment is done. They include maintenance of activity level that is painless, physiotherapy, avoidance of any activity that incites pain, avoidance from lifting heavy weights, weight control, use of spinal support, spinal massage, spinal manipulation, spinal [[traction]], heat or ice application.  <ref name="urlHerniated Disc – Symptoms, Causes, Prevention and Treatments">{{cite web |url=https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc |title=Herniated Disc – Symptoms, Causes, Prevention and Treatments |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="urlHerniated Disk in the Lower Back - OrthoInfo - AAOS">{{cite web |url=https://orthoinfo.aaos.org/en/diseases--conditions/herniated-disk-in-the-lower-back/ |title=Herniated Disk in the Lower Back - OrthoInfo - AAOS |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
=== Medical Therapy ===
=== Medical Therapy ===
*The mainstay of medical therapy for [[intervertebral disc slip]] are [[analgesic]] medications like [[NSAIDS]] or [[acetaminophen]], [[muscle relaxants]], [[steroids]]. A [[steroid]] injection in the [[epidural space]] may also be administered to provide pain relief.
*The medical treatment options for pain relief in [[intervertebral disc slip]] are [[analgesic]] medications like [[NSAIDS]] or [[acetaminophen]], [[muscle relaxants]], [[steroids]] and [[anti depressants]]. A [[steroid]] injection in the [[epidural space]] may also be administered to provide pain relief. <ref name="urlHerniated Disc – Symptoms, Causes, Prevention and Treatments">{{cite web |url=https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc |title=Herniated Disc – Symptoms, Causes, Prevention and Treatments |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref><ref name="urlHerniated Disk in the Lower Back - OrthoInfo - AAOS">{{cite web |url=https://orthoinfo.aaos.org/en/diseases--conditions/herniated-disk-in-the-lower-back/ |title=Herniated Disk in the Lower Back - OrthoInfo - AAOS |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


=== Surgery ===
=== Surgery ===


*[[Discectomy]] can be performed for patients with [[intervertebral disc slip]] who do not improve with medical management and lifestyle modifications. It can also be performed in patients with profound muscular weakness or poor bowel or bladder control due to nerve compression. [[Discectomy]] is of 2 types. [[Microsurgical discectomy]] involves a small incision in the center of the back followed by microdissection to reach the [[herniated disk]]. Then the part of the disk impinging on the [[nerve root]] is removed. [[Microendoscopic discectomy]] involves an incision at the back. In order to reach the [[vertebra]], [[dilators]] are used. Then an [[endoscope]] is used to access and remove the [[herniated disk]]. [[Microendoscopic discectomy]] causes lesser tissue damage than [[microsurgical discectomy]].
*[[Discectomy]] can be performed for patients with [[intervertebral disc slip]] who do not improve with medical management and lifestyle modifications. It can also be performed in patients with persistent or progressive neurologic deficit due to nerve compression. [[Discectomy]] is of 2 types. [[Microsurgical discectomy]] involves a small incision in the center of the back followed by microdissection to reach the [[herniated disk]]. Then the part of the disk impinging on the [[nerve root]] is removed. [[Microendoscopic discectomy]] involves an incision at the back. In order to reach the [[vertebra]], [[dilators]] are used. Then an [[endoscope]] is used to access and remove the [[herniated disk]]. [[Microendoscopic discectomy]] causes lesser tissue damage than [[microsurgical discectomy]]. Other options like [[laser discectomy]] are also available but their efficacy is not fully proven. In selective cases, [[discectomy]] can be combined with [[laminectomy]] and [[spinal fusion]]<ref name="urlHerniated Lumbar Disc, low back, ruptured disc, bulging disc | Mayfield Brain & Spine, Cincinnati, Ohio">{{cite web |url=https://mayfieldclinic.com/pe-hldisc.htm#:~:text=A%20herniated%20disc%20occurs%20when,or%20compresses%20a%20spinal%20nerve. |title=Herniated Lumbar Disc, low back, ruptured disc, bulging disc &#124; Mayfield Brain & Spine, Cincinnati, Ohio |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref> <ref name="urlSlipped (Herniated) Disc: Symptoms, Causes, and Effects">{{cite web |url=https://www.healthline.com/health/herniated-disk#treatment |title=Slipped (Herniated) Disc: Symptoms, Causes, and Effects |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
 
=== Prevention ===
=== Prevention ===
   
   
*Effective measures for the primary prevention of [[intervertebral disc slip]] include [[maintaining a normal body weight]], [[regular excercise]], and [[good posture]].
*Effective measures for the primary prevention of [[intervertebral disc slip]] include [[maintaining a normal body weight]], [[regular exercise]], [[smoking cessation]] and [[good posture]]. <ref name="urlLumbar Disk Disease (Herniated Disk) | Johns Hopkins Medicine">{{cite web |url=https://www.hopkinsmedicine.org/health/conditions-and-diseases/lumbar-disc-disease-herniated-disc |title=Lumbar Disk Disease (Herniated Disk) &#124; Johns Hopkins Medicine |author= |authorlink= |coauthors= |date= |format= |work= |publisher= |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>


==References==
==References==

Latest revision as of 18:48, 14 September 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ahmad Muneeb, MBBS[2] Synonyms and keywords: Intervertebral Disc Displacements; Disc Displacements, Intervertebral; Disc Displacement, Intervertebral; Intervertebral Disk Displacements; Disk Displacements, Intervertebral; Disk Displacement, Intervertebral; Intervertebral Disk Displacement; Disks, Prolapsed; Slipped Disk; Disk Prolapse; Discs, Slipped; Herniated Disks; Slipped Discs; Herniated Disc; Disks, Slipped; Disk, Prolapsed; Prolapsed Disk; Disc, Slipped; Prolapses, Disk; Slipped Disc; Discs, Prolapsed; Discs, Herniated; Prolapsed Discs; Disks, Herniated; Disk, Herniated; Herniated Disk; Prolapse, Disk; Disk Prolapses; Prolapsed Disc; Disc, Herniated; Disc, Prolapsed; Slipped Disks; Disk, Slipped; Herniated Discs; Prolapsed Disks

Overview

Intervertebral disk slip consists of 2 main parts, nucleus pulposus the central part, and annulus fibrosus the peripheral part. Intervertebral disc slip occurs when nucleus pulposus protrudes through annulus fibrosus. Most commonly disc slip is caused by degenerative changes and traumatic insults to the spine. Although, disc herniation can occur in any part of the vertebral column but lumbar disc slips are far more common than disc herniations in other parts of the spine. Males, obese, smokers and heavy weight lifters are at increased risk of developing disk slip. Clinical features of the disk slip vary depending upon the location and presence or absence of nerve impingement. Common clinical features include back pain, pain radiating to upper or lower extremity, motor weakness, numbness or tingling, absent deep tendon reflexes. MRI and CT scan have excellent sensitivity in diagnosing intervertebral disc slip. Conservative management starts with lifestyle modifications and medical therapy. Most of the patients get pain relief with conservative management. For severe or persistent cases surgical management can be used.

Historical Perspective

Classification

  • Bulging: Disc margins extend beyond vertebral endplate margins.
  • Protrusion: Nucleus pulposus impinges on annulus fibrosus, posterior longitudinal ligament stays intact.
  • Extrusion: Nucleus pulposus extrudes through the annulus fibrosus, posterior longitudinal ligament stays intact.
  • Sequestration: Posterior longitudinal ligament is compromised. Nucleus pulposus extrudes through the annulus fibrosus and posterior longitudinal ligament into epidural space.

Pathophysiology

Causes

Disc slip may be caused by age-related degenerative changes, systemic inflammatory processes, vertebral trauma, sudden vertebral strain, twisted movement of the spine, connective tissue disorders. [9] [10]

Differentiating intervertebral disc slip from other Diseases

Epidemiology and Demographics

  • The incidence of intervertebral disc slip is estimated to be [5-20] cases per 1000 individuals annually. In case of lumbar disc slips, 95% of the herniations in patients aged between 25 to 55 occur at L4-L5 or L5-S1 level. In case of cervical spine, C6-C7 disc is most commonly herniated.[12] [13]

Age

Gender

Race

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

There are no specific diagnostic criteria for intervertebral disc slip.

History and Symptoms

  • Symptoms of Intervertebral disc slip depend upon the site and extent of the slipped disc and are present in the are supplied by the compressed nerve. They may include the following[10][17]:

Lumbar disc slip

Cervical or thoracic disc slip

Physical Examination

  • Physical examination findings depend upon the nerve root compressed and maybe remarkable for[11]:

Laboratory Findings

Electrocardiogram

There are no ECG findings associated with intervertebral disc slip.

X-ray

There are no x-ray findings associated with intervertebral disc slip. However, an x-ray may be helpful in detecting other etiologies causing similar symptoms like fractures, abscesses, tumors, bony spurs etc.

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with intervertebral disc slip.

CT scan

CT scan may be helpful in the diagnosis of intervertebral disc slip. Like MRI, CT scan also provides a detailed view of the spinal canal and its contents, thus it can detect disc slip along with its extent and location.Findings on CT scan suggestive of intervertebral disc slip include bulging of intervertebral disc, nerve root compression, and spinal cord compression. [10] [18]

MRI

MRI may be helpful in the diagnosis of intervertebral disc slip, as it is considered the gold standard for the diagnosis of this disorder. MRI has an excellent capacity to visualize all the soft tissues including the spinal cord, and nerve roots thus it can easily detect bulging intervertebral disc and also if there is any compression of nerve root or spinal cord. MRI is also very helpful in ruling out other differentials.[18][10]

Other Imaging Findings

Myelogram may be helpful in the diagnosis of intervertebral disc slip. It is a modified x-ray technique in which the spinal canal is visualized after injection of a contrast material. It can show if a slipped disk is compressing a nerve root or spinal cord[10]

Other Diagnostic Studies

Electromyogram and nerve conduction studies may be helpful in the diagnosis of intervertebral disc slip. These tests assess the response of nerve or muscle to electric stimulation. They can reveal if there is any nerve damage or compression as a consequence of slipped disk.[10][18]

Treatment

Certain non-pharmacologic treatments and lifestyle modifications can be used before any pharmacologic treatment is done. They include maintenance of activity level that is painless, physiotherapy, avoidance of any activity that incites pain, avoidance from lifting heavy weights, weight control, use of spinal support, spinal massage, spinal manipulation, spinal traction, heat or ice application. [10][9]

Medical Therapy

Surgery

Prevention

References

  1. ↑ Truumees E (June 2015). "A history of lumbar disc herniation from Hippocrates to the 1990s". Clin. Orthop. Relat. Res. 473 (6): 1885–95. doi:10.1007/s11999-014-3633-7. PMC 4418987. PMID 24752913.
  2. ↑ Alemo S, Sayadipour A (September 2010). "Sources and patterns of pain in lumbar disc disease: revisiting Francis Murphey's theory". Acta Neurochir (Wien). 152 (9): 1555–8. doi:10.1007/s00701-009-0315-4. PMID 19404576.
  3. ↑ Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, Singer DE (August 1996). "The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica". Spine. 21 (15): 1777–86. doi:10.1097/00007632-199608010-00011. PMID 8855462.
  4. ↑ "Disc Herniation - Physiopedia".
  5. ↑ Kadow T, Sowa G, Vo N, Kang JD (June 2015). "Molecular basis of intervertebral disc degeneration and herniations: what are the important translational questions?". Clinical Orthopaedics and Related Research. 473 (6): 1903–12. doi:10.1007/s11999-014-3774-8. PMC 4418989. PMID 25024024.
  6. ↑ 6.0 6.1 Mayer JE, Iatridis JC, Chan D, Qureshi SA, Gottesman O, Hecht AC (March 2013). "Genetic polymorphisms associated with intervertebral disc degeneration". The Spine Journal : Official Journal of the North American Spine Society. 13 (3): 299–317. doi:10.1016/j.spinee.2013.01.041. PMC 3655694. PMID 23537453.
  7. ↑ Colombier P, Clouet J, Hamel O, Lescaudron L, Guicheux J (March 2014). "The lumbar intervertebral disc: from embryonic development to degeneration". Joint Bone Spine. 81 (2): 125–9. doi:10.1016/j.jbspin.2013.07.012. PMID 23932724.
  8. ↑ Martirosyan NL, Patel AA, Carotenuto A, Kalani MY, Belykh E, Walker CT, Preul MC, Theodore N (2016). "Genetic Alterations in Intervertebral Disc Disease". Frontiers in Surgery. 3: 59. doi:10.3389/fsurg.2016.00059. PMC 5116693. PMID 27917384.
  9. ↑ 9.0 9.1 9.2 9.3 "Herniated Disk in the Lower Back - OrthoInfo - AAOS".
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 "Herniated Disc – Symptoms, Causes, Prevention and Treatments".
  11. ↑ 11.0 11.1 Dydyk AM, Ngnitewe Massa R, Mesfin FB. "Disc Herniation - StatPearls - NCBI Bookshelf".
  12. ↑ 12.0 12.1 Fjeld OR, Grøvle L, Helgeland J, Småstuen MC, Solberg TK, Zwart JA, Grotle M (April 2019). "Complications, reoperations, readmissions, and length of hospital stay in 34 639 surgical cases of lumbar disc herniation". The Bone & Joint Journal. 101-B (4): 470–477. doi:10.1302/0301-620X.101B4.BJJ-2018-1184.R1. PMID 30929479.
  13. ↑ Jordan J, Konstantinou K, O'Dowd J (March 2009). "Herniated lumbar disc". BMJ Clinical Evidence. 2009. PMC 2907819. PMID 19445754.
  14. ↑ 14.0 14.1 14.2 "Lumbar Disk Disease (Herniated Disk) | Johns Hopkins Medicine".
  15. ↑ "Herniated Lumbar Disk - Clinical Evidence Handbook - American Family Physician".
  16. ↑ 16.0 16.1 "Slipped (Herniated) Disc: Symptoms, Causes, and Effects".
  17. ↑ "Herniated disk - Symptoms and causes - Mayo Clinic".
  18. ↑ 18.0 18.1 18.2 18.3 "Herniated Lumbar Disc, low back, ruptured disc, bulging disc | Mayfield Brain & Spine, Cincinnati, Ohio".

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