Diagnosis and Nonoperative Management of Lumbar Disk Herniation

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Lumbar disk herniation is a common cause of low back pain in the United States. Diagnosis of lumbar disk herniation in a person complaining of low back pain depends on an understanding of anatomy and pathophysiology as well as the ability to synthesize various elements of the history and physical examination. Imaging studies should then be used to confirm and clarify the diagnosis, but it is important to acknowledge that they cannot replace the clinical picture because the high rate of asymptomatic disk herniations can be misleading. The proper nonsurgical treatment of herniated nucleus pulposus revolves around controlling symptoms to strengthen patients and restore their function, and it may involve any combination of analgesic medications, physical therapy, therapeutic modalities, and corticosteroid injections. This article aims to clarify current aspects in the diagnosis and nonoperative management of lumbar disk herniation.

Section snippets

Pathophysiology of Radiculopathy

Various structures in and around the spine have been found to be responsible for pain. Specifically, pain generators exist in the outer third of the annulus fibrosis, the facet synovium, anterior longitudinal ligament, posterior longitudinal ligament, nerve roots, nerves, and muscles. Disk herniation may cause pain by mechanical irritation of these structures. Additionally, pain may be caused by an inflammatory component that occurs with disk herniation. Disruption of the annulus fibrosis

Diagnosis

As mentioned earlier, a careful history and systematic physical examination are essential components of the diagnosis of lumbar disk herniation. They are critical in the differentiation of patients with symptomatic herniated disks from those with asymptomatic herniated disks. Furthermore, the differential diagnosis of radicular symptoms includes degenerative changes, spinal stenosis, spondylolisthesis, synovial cysts, conjoined nerve roots,10 cancer, epidural abscess,11 and visceral disease

Natural History

The natural history of lumbar disk herniation is generally very favorable. Study of pathophysiology reveals that disk herniation is caused by repetitive injury to the annulus fibrosis with gradual prolapse of the intervertebral disk.27 After disk herniation, the disk size often regresses. Multiple studies have shown that patients with lumbar disk herniation who do not undergo surgical intervention routinely have significant reduction in disk size. In fact, more than half of these patients show

Management

The approach to nonoperative management of lumbar disk herniation is often multifaceted and may include medications, physical therapy, and corticosteroid injections.

Corticosteroids

Because inflammation around the spine contributes to the pathology of lumbar disk herniation, corticosteroids are often used to reverse this inflammatory process and relieve symptoms of pain. Corticosteroids can be administered orally, intramuscularly, and epidurally.

Conclusions

In summary, various elements of the history and physical examination are essential in establishing the diagnosis of a symptomatic lumbar disk herniation. Although imaging studies are useful, it is important to acknowledge that they cannot replace the clinical picture because the high rate of asymptomatic disk herniations can be misleading. The proper nonsurgical treatment of herniated nucleus pulposus revolves around controlling symptoms to strengthen patients and restore their function, and it

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