What Is a Herniated Nucleus Pulposus?

Intervertebral disc herniation is one of the more common spinal diseases in clinical practice. Mainly because the various components of the intervertebral disc (nucleus pulposus, fibrous rings, cartilage plates), especially the nucleus pulposus, have different degrees of degenerative lesions. Under the influence of external factors, the fibrous rings of the intervertebral discs rupture, and the nucleus pulposus tissue is ruptured Protruded (or prolapsed) in the posterior (lateral) side or in the spinal canal, causing adjacent tissues such as spinal nerve roots and spinal cord to be stimulated or oppressed, causing neck, shoulder, lumbar and leg pain, numbness and a series of clinical symptom. According to the location of the disease, it is divided into cervical disc herniation, thoracic disc herniation, and lumbar disc herniation.

Basic Information

nickname

Herniated disc

English name

intervertebral disc displacement

Visiting department

orthopedics

Multiple groups

Young people

Common locations

Cervical disc, thoracic disc, lumbar disc

Common causes

Intervertebral disc degeneration, chronic strain, trauma, and congenital abnormalities

Common symptoms

Neck, shoulder, waist and leg pain, numbness

Contagious

no

Causes of herniated discs

Increased abdominal pressure

Such as severe cough, forced defecation during constipation, and so on.

2. Improper waist posture

When the waist is in the flexed position, if it is suddenly rotated, it is easy to induce the nucleus pulposus.

3. Sudden weight loading

When not fully prepared, the load on the waist suddenly increases, and it is easy to cause the nucleus pulposus to protrude.

4. Waist injury

Acute trauma can affect fibrous rings, cartilage plates and other structures, and promote the degeneration of the nucleus pulposus.

5. Occupational factors

If the driver of the car is in a sitting and bumpy state for a long time, it is easy to induce a disc herniation.

Disc herniation classification

According to the location of the disease, it can be divided into cervical disc herniation, thoracic disc herniation, and lumbar disc herniation.

Cervical disc herniation

Cervical intervertebral disc herniation refers to those who have suffered from a series of symptoms caused by cervical ring and spinal cord compression caused by acute or repeated minor injury to the fibrous ring. These include swelling, protrusion and prolapse of the nucleus pulposus, which represent different stages of cervical spondylosis. However, in clinical practice, sudden cervical disc herniation (prolapse) is often encountered, and paralysis is the first symptom.

2. Thoracic disc herniation

Thoracic disc herniation is more common in adults between 40 and 50 years of age than patients with lumbar disc herniation. There are more males than females, but there is no significant racial difference. The common incidence is T ₈ L ₁ , with T ₁₁ T ₁₂ , T ₁₂ L _{1 is} most common. Because of its varied clinical manifestations, its diagnosis is also difficult. In recent years, due to the application of some advanced diagnostic methods, such as CT, MRI, especially MRI, this disease can be diagnosed early.

3. Lumbar disc herniation

Lumbar disc herniation is one of the more common diseases, mainly due to the various degrees of degenerative changes in the various parts of the lumbar disc (nucleus pulposus, fibrous rings and cartilage plates), especially the nucleus pulposus, under the influence of external forces. The fibrous ring of the intervertebral disc is ruptured, and the nucleus pulposus tissue protrudes (or prolapses) from the rupture to the back or in the spinal canal, causing adjacent spinal nerve roots to be stimulated or oppressed, resulting in pain in the waist, numbness and pain in one or two lower limbs Wait for a series of clinical symptoms. Lumbar disc herniation has the highest incidence of lumbar 4-5 and lumbar 5- 1.

Clinical manifestations of herniated disc

Cervical disc herniation

Clinical manifestations depend primarily on the tissue being oppressed. According to the different imaging positions, the disease can be divided into the following three types: central type, lateral type and paracentral type.

(1) Central type Compression of the cervical spinal cord is the main manifestation. This type of protrusion was previously thought to be rare. With the development of diagnostic technology, especially after the advent of MRI technology, central cervical disc herniation is no longer rare. Due to the compression of the spinal cord, incomplete or complete paralysis of the extremities and abnormal urination may occur; at the same time, the tendon reflexes of the extremities appear hyperactive. Pathological reflex signs can be positive and appear to be diminished or disappear according to the protruding plane.

(2) Lateral type is mainly root pain. The main symptoms are neck pain and limited movement, like falling on the pillow, and the pain can radiate to the shoulder or occipital area; there is pain and numbness in one upper limb. During the seizure period, patients can be asymptomatic. Examination revealed that the head and neck were often in an upright position with limited movement. The spinous process of the lower cervical spine and the scapular region may have tenderness. If the head is back and side to the affected side, the pressure on the top of the head can cause neck and shoulder pain and radiate to the hand. Pulling the affected upper limb can cause pain. Sensory disturbances vary depending on the plane of the disc herniation.

(3) Paracentral type In addition to the lateral symptoms and signs, there are also different degrees of unilateral spinal cord compression symptoms, namely Brown-Sequard syndrome. Spinal cord compression is often obscured by severe root pain.

2. Thoracic disc herniation

There are various manifestations of thoracic disc herniation. There is no specific manifestation that can be used for diagnosis. Its symptoms and signs are determined by the disc herniation, including the segment, size, direction, time of compression, and degree of blood vessel damage. And the size of the spinal canal. In symptomatic patients, the lesions often progress progressively.

Patients often experience chest and back pain first, followed by sensory disturbances, weakness and dysfunction. The spine may have mild scoliosis and localized vertebral pain, tenderness, and tenderness.

3. Lumbar disc herniation

(1) Back pain is the first symptom that occurs in most patients, with an incidence of about 91%. Because the outer layer of the fibrous ring and the posterior longitudinal ligament are stimulated by the nucleus pulposus, the sinus vertebral nerves cause lower back pain, which may sometimes be accompanied by hip pain.

(2) Radiation pain in lower limbs Although high lumbar disc herniation (lumbars 2 to 3, waists 3 to 4) can cause femoral neuralgia, it is rare in clinical practice, less than 5%. The vast majority of patients have a lumbar 4 to 5 and a lumbar 5 to sacral 1 with prominent sciatica. Typical sciatica is radiating pain from the lower back to the buttocks, the back of the thighs, the outside of the lower legs, and down to the feet. The pain can be exacerbated by increased abdominal pressure such as sneezing and coughing. The limbs with radiating pain are mostly on one side, and only a few of the central or paracentral nucleus pulposus show bilateral lower limb symptoms.

(3) Symptoms of the cauda equina Nerve nucleus or prolapse that protrudes to the rear, and free intervertebral disc tissue compresses the cauda equina, which is mainly manifested as dysuria, dysuria, and perineal and perianal abnormalities. In severe cases, symptoms such as uncontrollable bowel movements and incomplete paralysis of the lower limbs may occur, which are rare in clinical practice.

Intervertebral disc herniation

Cervical disc herniation

(1) X-ray examination Routine radiographs of the cervical spine are taken in the normal, lateral and dynamic positions. The cervical lordosis is reduced or disappeared; the affected intervertebral space is narrowed and there may be degenerative changes. In young cases or patients with acute traumatic prominence, the intervertebral space can be found without abnormality, but the affected segment instability can be seen on the cervical lateral dynamic radiograph, and a more obvious trapezoidal change (false subluxation) appears.

(2) CT examination CT examination is helpful to the diagnosis of this disease. In recent years, many scholars have advocated the use of myelography and CT examination (CTM) in the diagnosis of cervical disc herniation, and believe that the value of CTM in the diagnosis of lateral cervical disc herniation is significantly greater than that of MRI; The rate of magnetic resonance imaging technology will be more beneficial to patients.

(3) MRI examination MRI examination is of great value in the diagnosis of cervical disc herniation. Its accuracy is significantly higher than that of CT examination and myelography. It can be directly observed on the MRI film that the intervertebral disc protrudes backward into the spinal canal, and the signal intensity of the disc herniation component and the residual nucleus pulposus is basically the same. In the case of a central cervical disc herniation, it can be seen that the protruding intervertebral disc significantly compresses the cervical spine, making it locally flat or depressed, and the cervical spinal cord signal at the compression site is abnormal. In the lateral cervical disc herniation, it can be seen that the protruding intervertebral disc deforms the cervical spine by compression, the signal intensity changes, and the nerve root disappears or shifts backward.

2. Thoracic disc herniation

(1) Imaging examination X-ray examination The conventional thoracic spine X-ray and lateral radiography can show changes in disc degeneration: lipoid hyperplasia at the edge of the vertebral body, sclerosis, narrowing of the intervertebral space, calcification of the disc, small Hyperplasia and sclerosis of joints are common manifestations. The most important thing is calcification of the disc, especially the calcification that has penetrated into the spinal canal. Myelography A large-dose, water-soluble contrast agent for myelography and CT scan is a more accurate and excellent diagnostic method. CT examination CT can show prominent disc, CT can also show the spinal cord compression after myelography. MRI examination Suspected of this disease should be performed as soon as possible. MRI is the most effective measure for early diagnosis of this disease.

(2) Other inspections

Including EMG and somatosensory evoked potentials can also be helpful in the diagnosis of thoracic disc herniation.

3. Lumbar disc herniation

(1) Plain radiographs of the lumbar spine X-rays alone cannot directly reflect the presence of intervertebral disc herniation, but sometimes degenerative changes such as narrowing of the intervertebral space and hyperplasia of the vertebral body are sometimes seen on the radiographs, which is an indirect reminder. Some patients Scoliosis and scoliosis are possible. In addition, plain radiographs can detect the presence or absence of bone diseases such as tuberculosis and tumors, which is of important diagnostic significance.

(2) CT examination can clearly show the location, size, morphology of the disc herniation, and the displacement of the nerve root and dural sac. It can also show the laminar and yellow ligament hypertrophy, small joint hypertrophy, and spinal canal. And lateral crypt stenosis, etc., have greater diagnostic value for this disease, has been generally used.

(3) Magnetic resonance (MRI) examination has no radiation damage and is of great significance in the diagnosis of lumbar disc herniation. MRI can comprehensively observe whether the lumbar intervertebral disc is diseased, and clearly show the shape of the disc herniation and its relationship with the surrounding tissues such as the dural sac and nerve roots through sagittal images of different levels and cross-section images of the involved discs. In addition, it can identify the presence of other occupying lesions in the spinal canal. However, it is not as good as CT to show whether the protruded disc is calcified.

(4) Other electrophysiological examinations (electromyogram, nerve conduction velocity and evoked potential) can help determine the scope and extent of nerve damage and observe the effect of treatment. Laboratory tests are mainly used to exclude some diseases and play a role in differential diagnosis.

Disc herniation diagnosis

The diagnosis of typical cases, combined with medical history, physical examination and imaging examination, is generally without difficulty, especially CT and magnetic resonance technology have been widely used.

Intervertebral disc herniation

Cervical disc herniation

This disease is mainly non-surgical therapy. If symptoms of spinal cord compression occur, surgery should be performed as soon as possible.

(1) Non-surgical therapy Non-surgical therapy is the basic therapy of the disease, which is not only suitable for light cases, but also the guarantee of preoperative preparation and postoperative recovery of surgical therapy. The main contents are as follows: Cervical traction Take a sitting or lying position and use a four-head strap (Glisson's strap) for traction. If there is an adverse or discomfort during traction, traction should be suspended. Traction therapy is mainly applicable to lateral cervical disc herniation. Central cervical disc herniation can also be selected, but during the traction process, if the pyramidal tract symptoms worsen, early surgery should be performed. In addition, during traction, do not make the head and neck excessively forward flexion. This position may increase the pressure of the posterior nucleus pulposus on the anterior central spinal cord and worsen the condition. During the whole process of traction, you should closely observe the changes in the condition, and adjust the force line and weight at any time. Neck protection The general simple neck protection can limit the excessive movement of the neck and increase the support of the neck and reduce the pressure in the intervertebral space. Severe patients who need to get up can choose a neck brace with traction. Physical therapy and massage Among the commonly used physical therapy methods, wax therapy and vinegar ion penetration method have better curative effect, and can be used for light cases. Drug treatment Anti-inflammatory and analgesic drugs, such as diclofenac (futalin), diclofenac sodium / misoprostol (Osmog), can be appropriately applied, which have a certain effect on the relief of the disease. Try using chondroprotective agents such as glucosamine sulfate and chondroitin sulfate for supportive care.

(2) Surgical treatment For recurrent episodes, ineffective non-surgical treatment, or symptoms of spinal cord compression, early surgical treatment should be performed. Surgical methods include traditional anterior decompression and fixation fusion, or anterior nucleus pulposus removal, artificial cervical disc replacement, and new techniques such as minimally invasive percutaneous endoscopic nucleus removal. At present, anterior cervical decompression, removal of prominent intervertebral discs and intervertebral bone graft fusion are still the main methods. For patients with spinal canal stenosis, posterior cervical spinal canal decompression is performed.

2. Thoracic disc herniation

(1) Non-surgical therapy It is mainly used for light cases. The main measures include the following: Rest. Depending on the severity of the disease, absolute bed rest, general rest or limited activity can be selected. The former is mainly used in patients with acute stage, or those whose condition suddenly worsens. Chest brake The thoracic spine itself has little mobility, but for safety reasons, it can be supplemented with a chest-back brace to fix active cases, which has a positive significance for reversing the disease or preventing deterioration. Symptomatic treatment Including oral sedatives, topical analgesic anti-inflammatory ointment, chondroprotective agents such as glucosamine sulfate and chondroitin sulfate, physiotherapy, blood stasis drugs and other effective treatments, etc., can be selected as appropriate.

In patients with acute chest and back pain and MRI that does not clearly show thoracic disc herniation, most do not require surgery, and when symptoms ease, they can resume strenuous exercise.

(2) Surgical treatment The main surgical methods used for thoracic discectomy and fusion are the following three types: Anterior approach : The thoracic spine or thoracoabdominal incision is used to reach the front of the thoracic vertebral vertebra and the protruding nucleus pulposus is removed and given simultaneously Internal fixation (fusion). posterior approach This traditional procedure has been used for many years. Most physicians are familiar with this surgical approach and it is easier to operate. However, it is difficult to remove the nucleus pulposus in front of the thoracic spinal canal, especially in central cases. Lateral and posterior surgery Thoracolumbar spinal canal subcircular decompression, the surgical approach is easier to remove the pressure in front of the spinal canal and the damage is small, which basically does not affect the stability of the vertebral section.

3. Lumbar disc herniation

(1) Non-surgical treatment Most patients with lumbar disc herniation can be relieved or cured by non-surgical treatment. The treatment principle is not to restore the degenerated disc tissue to its original position, but to change the relative position or partial resorption of the disc tissue and the compressed nerve root, reduce the pressure on the nerve root, loosen the adhesion of the nerve root, and eliminate the nerve root. Inflammation, thereby relieving symptoms. Absolute bed rest In the first episode, bed rest should be strictly carried out, emphasizing that neither urine nor urination should get out of bed or sit up in order to have a better effect. After bed rest for 3 weeks, you can get up under the protection of waist circumference, and do not bend over and hold objects for 3 months. Traction The use of pelvic traction can increase the width of the intervertebral disc, reduce the internal pressure of the intervertebral disc, and receive the protrusion of the intervertebral disc to reduce the stimulation and compression of the nerve root, which needs to be performed under the guidance of a professional doctor. Physical therapy, massage and massage can alleviate muscle spasm and reduce the pressure in the disc. But pay attention to the violent massage can lead to aggravating the condition, you should be careful. Corticosteroid and epidural injection Corticosteroid is a long-acting anti-inflammatory agent that can reduce inflammation and adhesion around nerve roots. Long-acting corticosteroids + 2% lidocaine are usually used for epidural injection. In addition, try using chondroprotective agents such as glucosamine sulfate and chondroitin sulfate. Chemical dissolution of nucleus pulposus Using collagenase or papain to inject into the intervertebral disc or between the dura mater and the prominent nucleus pulposus, to selectively dissolve the nucleus pulposus and the fibrous ring without damaging the nerve root, in order to reduce the pressure in the intervertebral disc or make The prominent nucleus pulposus becomes smaller to relieve symptoms. However, this method has the risk of producing an allergic reaction.

(2) Percutaneous nucleus pulposcopy / nucleus pulposus laser vaporization enters the intervertebral space through X-ray monitoring through special equipment, sucks out part of the nucleus pulposus or laser vaporizes, thereby reducing the pressure in the intervertebral disc to relieve symptoms , Suitable for patients with bulging or slightly protruding, not suitable for patients with side crypt narrowing or already prominent prominent and those who have prolapsed into the spinal canal.

(3) Surgical treatment Surgical indications Patients with a history of more than three months, strict conservative treatment is ineffective or conservative treatment is effective, but often relapses and the pain is severe; the first episode, but the pain is severe, especially the symptoms of the lower limbs are obvious, the patient is difficult to move and Those who fall asleep and are in a forced posture; those with combined cauda equina compression; those with single nerve root paralysis accompanied by muscle atrophy and decreased muscle strength; those with spinal stenosis. Surgery method: A posterior lumbar and back incision, partial laminectomy and articular process resection, or discectomy through the laminar space. Central disc herniation, after laminectomy, the epidural or intradural discectomy. Patients with lumbar spinal instability and lumbar spinal stenosis need to undergo spinal fusion at the same time.

In recent years, minimally invasive surgical techniques, such as microendoscopic discectomy, microendoscopic discectomy, and percutaneous discectomy, have reduced surgical damage and achieved good results.