Diagnostic Considerations

The diagnosis of an internal disk derangement is controversial. The classic patient presents with back pain without imaging abnormalities except for varying degrees of the black disk, which is the converse of the asymptomatic patient with an intervertebral disk herniation.

Patients without a disk herniation have a favorable course and long-term outcome with conservative treatment or surgery. However, some patients with prolonged limitations and limited job skills benefit from surgical intervention for segmental instability or clinical instability. A positive diskogram, if properly done and carefully interpreted in context, may raise the expectation of success for surgical treatment in this patient population.

The greatest controversy is over the effectiveness of fusion surgery. Unfortunately, there is no clear objective criterion; clinical judgment is mandatory and is not perfect; clearly, good patients do well, and patient selection is paramount.

Differential Diagnoses

Workup

Gooch CL, Pracht E, Borenstein AR. The burden of neurological disease in the United States: A summary report and call to action. Ann Neurol. 2017 Apr. 81 (4):479-484. [QxMD MEDLINE Link].
Shamji MF, Jing L, Chen J, Hwang P, Ghodsizadeh O, Friedman AH, et al. Treatment of neuroinflammation by soluble tumor necrosis factor receptor Type II fused to a thermally responsive carrier. J Neurosurg Spine. 2008 Aug. 9 (2):221-8. [QxMD MEDLINE Link].
Battié MC, Videman T, Parent E. Lumbar disc degeneration: epidemiology and genetic influences. Spine (Phila Pa 1976). 2004 Dec 1. 29 (23):2679-90. [QxMD MEDLINE Link].
Zhang Y, Sun Z, Liu J, Guo X. Advances in susceptibility genetics of intervertebral degenerative disc disease. Int J Biol Sci. 2008 Sep 2. 4 (5):283-90. [QxMD MEDLINE Link].
Mixter WJ, Barr J. Rupture of the intervertebral disc with involvement of the spinal cord. N Engl J Med. 1934. 211:210-4.
White AA III, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1990.
Boos N, Weissbach S, Rohrbach H, Weiler C, Spratt KF, Nerlich AG. Classification of age-related changes in lumbar intervertebral discs: 2002 Volvo Award in basic science. Spine (Phila Pa 1976). 2002 Dec 1. 27 (23):2631-44. [QxMD MEDLINE Link].
Roberts S, Evans H, Trivedi J, Menage J. Histology and pathology of the human intervertebral disc. J Bone Joint Surg Am. 2006 Apr. 88 (suppl 2):10-4. [QxMD MEDLINE Link].
SMITH JW, WALMSLEY R. Experimental incision of the intervertebral disc. J Bone Joint Surg Br. 1951 Nov. 33-B (4):612-25. [QxMD MEDLINE Link]. [Full Text].
Kirkaldy-Willis WH, Bernard TN Jr, eds. Managing Low Back Pain. 4th ed. New York: Churchill Livingstone; 1999.
FRIEDENBERG ZB. The results of nonoperative treatment of ruptured lumbar disks. Surg Clin North Am. 1953 Dec. 33 (6):1545-9. [QxMD MEDLINE Link].
Weber H. Lumbar disc herniation. A prospective study of prognostic factors including a controlled trial. Part I. J Oslo City Hosp. 1978 Mar-Apr. 28 (3-4):33-61. [QxMD MEDLINE Link].
Weinstein JN, Lurie JD, Tosteson TD, Skinner JS, Hanscom B, Tosteson AN, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006 Nov 22. 296 (20):2451-9. [QxMD MEDLINE Link].
Strange DG, Fisher ST, Boughton PC, Kishen TJ, Diwan AD. Restoration of compressive loading properties of lumbar discs with a nucleus implant-a finite element analysis study. Spine J. 2010 Jul. 10 (7):602-9. [QxMD MEDLINE Link].
Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2008 Dec 1. 33 (25):2789-800. [QxMD MEDLINE Link].
Meredith DS, Huang RC, Nguyen J, Lyman S. Obesity increases the risk of recurrent herniated nucleus pulposus after lumbar microdiscectomy. Spine J. 2010 Jul. 10 (7):575-80. [QxMD MEDLINE Link].
Bartlett A, Wales L, Houfburg R, Durfee WK, Griffith SL, Bentley I. Optimizing the effectiveness of a mechanical suture-based anulus fibrosus repair construct in an acute failure laboratory simulation. J Spinal Disord Tech. 2013 Oct. 26 (7):393-9. [QxMD MEDLINE Link].
Maity A, Mondal BC, Saha D, Roy DS. A prospective randomized, double-blind, controlled clinical trial comparing epidural butorphanol plus corticosteroid with corticosteroid alone for sciatica due to herniated nucleus pulposus. Perspect Clin Res. 2012 Jan. 3 (1):16-21. [QxMD MEDLINE Link].
Barton JE, Haight RO, Marsland DW, Temple TE Jr. Low back pain in the primary care setting. J Fam Pract. 1976 Aug. 3 (4):363-6. [QxMD MEDLINE Link].
Tomasino A, Gebhard H, Parikh K, Wess C, Härtl R. Bioabsorbable instrumentation for single-level cervical degenerative disc disease: a radiological and clinical outcome study. J Neurosurg Spine. 2009 Nov. 11 (5):529-37. [QxMD MEDLINE Link].
Buchowski JM, Anderson PA, Sekhon L, Riew KD. Cervical disc arthroplasty compared with arthrodesis for the treatment of myelopathy. Surgical technique. J Bone Joint Surg Am. 2009 Oct 1. 91 Suppl 2:223-32. [QxMD MEDLINE Link].
Carragee EJ, Don AS, Hurwitz EL, Cuellar JM, Carrino JA, Herzog R. 2009 ISSLS Prize Winner: Does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine (Phila Pa 1976). 2009 Oct 1. 34 (21):2338-45. [QxMD MEDLINE Link].
McGirt MJ, Eustacchio S, Varga P, Vilendecic M, Trummer M, Gorensek M, et al. A prospective cohort study of close interval computed tomography and magnetic resonance imaging after primary lumbar discectomy: factors associated with recurrent disc herniation and disc height loss. Spine (Phila Pa 1976). 2009 Sep 1. 34 (19):2044-51. [QxMD MEDLINE Link].
Fish DE, Kobayashi HW, Chang TL, Pham Q. MRI prediction of therapeutic response to epidural steroid injection in patients with cervical radiculopathy. Am J Phys Med Rehabil. 2009 Mar. 88 (3):239-46. [QxMD MEDLINE Link].
Hirsch JA, Singh V, Falco FJ, Benyamin RM, Manchikanti L. Automated percutaneous lumbar discectomy for the contained herniated lumbar disc: a systematic assessment of evidence. Pain Physician. 2009 May-Jun. 12 (3):601-20. [QxMD MEDLINE Link].
Dasenbrock HH, Juraschek SP, Schultz LR, Witham TF, Sciubba DM, Wolinsky JP, et al. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. J Neurosurg Spine. 2012 May. 16 (5):452-62. [QxMD MEDLINE Link].
Yamaya S, Okada Y, Higashino K, Sakai T, Tezuka F, Yamashita K, et al. Early outcomes of transforaminal percutaneous endoscopic lumbar discectomy for high school athletes with herniated nucleus pulposus of the lumbar spine. J Pediatr Orthop B. 2020 Nov. 29 (6):599-606. [QxMD MEDLINE Link].
Harada GK, Siyaji ZK, Mallow GM, Hornung AL, Hassan F, Basques BA, et al. Artificial intelligence predicts disk re-herniation following lumbar microdiscectomy: development of the "RAD" risk profile. Eur Spine J. 2021 Jun 7. [QxMD MEDLINE Link].
Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity?. Spine (Phila Pa 1976). 1994 May 15. 19 (10):1132-7. [QxMD MEDLINE Link].
Varlotta CG, Ge DH, Stekas N, Frangella NJ, Manning JH, Steinmetz L, et al. MRI Radiological Predictors of Requiring Microscopic Lumbar Discectomy After Lumbar Disc Herniation. Global Spine J. 2020 Feb. 10 (1):63-68. [QxMD MEDLINE Link]. [Full Text].
Dillane JB, Fry J, Kalton G. Acute low back syndrome - a study from general practice. BMJ. 1966. ii:82-4.
Sinclair SM, Shamji MF, Chen J, Jing L, Richardson WJ, Brown CR, et al. Attenuation of inflammatory events in human intervertebral disc cells with a tumor necrosis factor antagonist. Spine (Phila Pa 1976). 2011 Jul 1. 36 (15):1190-6. [QxMD MEDLINE Link].
Hurwitz EL, Morgenstern H, Kominski GF, Yu F, Chiang LM. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study. Spine (Phila Pa 1976). 2006 Mar 15. 31 (6):611-21; discussion 622. [QxMD MEDLINE Link].
Conn A, Buenaventura RM, Datta S, Abdi S, Diwan S. Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician. 2009 Jan-Feb. 12 (1):109-35. [QxMD MEDLINE Link].
Parr AT, Diwan S, Abdi S. Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician. 2009 Jan-Feb. 12 (1):163-88. [QxMD MEDLINE Link].
Oxland TR, Crisco JJ 3rd, Panjabi MM, Yamamoto I. The effect of injury on rotational coupling at the lumbosacral joint. A biomechanical investigation. Spine (Phila Pa 1976). 1992 Jan. 17 (1):74-80. [QxMD MEDLINE Link].
Garringer SM, Sasso RC. Safety of anterior cervical discectomy and fusion performed as outpatient surgery. J Spinal Disord Tech. 2010 Oct. 23 (7):439-43. [QxMD MEDLINE Link].
Patel DV, Yoo JS, Karmarkar SS, Lamoutte EH, Singh K. Minimally invasive lumbar decompression in an ambulatory surgery center. J Spine Surg. 2019 Sep. 5 (Suppl 2):S166-S173. [QxMD MEDLINE Link]. [Full Text].
Benoist M, Bonneville JF, Lassale B, Runge M, Gillard C, Vazquez-Suarez J, et al. A randomized, double-blind study to compare low-dose with standard-dose chymopapain in the treatment of herniated lumbar intervertebral discs. Spine (Phila Pa 1976). 1993 Jan. 18 (1):28-34. [QxMD MEDLINE Link].
Sairyo K, Sakai T, Higashino K, Inoue M, Yasui N, Dezawa A. Complications of endoscopic lumbar decompression surgery. Minim Invasive Neurosurg. 2010 Aug. 53 (4):175-8. [QxMD MEDLINE Link].
Kepler CK, Brodt ED, Dettori JR, Albert TJ. Cervical artificial disc replacement versus fusion in the cervical spine: a systematic review comparing multilevel versus single-level surgery. Evid Based Spine Care J. 2012 Feb. 3 (S1):19-30. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Hyaluronan long chains form backbone for attracting electronegative or hydrophilic branches, which hydrate nucleus pulposus and cause swelling pressure within anulus to allow it to stabilize vertebrae and act as shock absorber. Deterioration within intervertebral disk results in loss of these water-retaining branches and eventually in shortening of chains.
Nuclear material is normally contained within anulus, but it may cause bulging of anulus or may herniate through anulus into spinal canal. This commonly occurs in posterolateral location of intervertebral disk, as depicted.
Spinal nerves exit spinal canal through foramina at each level. Decreased disk height causes decreased foramen height to same degree, and superior articular facet of caudal vertebral body may become hypertrophic and develop spur, which then projects toward nerve root situated just under pedicle. In this picture, L4-5 has loss of disk height and some facet hypertrophy, thereby encroaching on room available for exiting nerve root (L4). Herniated nucleus pulposus within canal would embarrass traversing root (L5).
Appearance of lumbar disk herniation on MRI.

of 4

Author

Deepak Gautam, MBBS, MS(Orth) Wellcome Trust DBT/India Alliance Fellow, Assistant Professor, Department of Orthopedics, All India Institute of Medical Sciences, India

Deepak Gautam, MBBS, MS(Orth) is a member of the following medical societies: Indian Orthopedic Association, International Society of Orthopaedic Surgery and Traumatology, Spine Society Delhi Chapter

Disclosure: Received research grant from: Wellcome Trust/DBT India Alliance.

Coauthor(s)

Nishank Mehta, MBBS Resident Physician, Department of Orthopaedics, All India Institute of Medical Sciences, India

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William O Shaffer, MD Former Orthopedic Spine Surgeon, Northwest Iowa Bone, Joint, and Sports Surgeons

William O Shaffer, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, International Society for the Study of the Lumbar Spine, Kentucky Medical Association, Kentucky Orthopaedic Society, North American Spine Society, Southern Medical Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey A Goldstein, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Director of Spine Service, Director of Spine Fellowship, Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center

Jeffrey A Goldstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, AOSpine, Cervical Spine Research Society, International Society for the Advancement of Spine Surgery, International Society for the Study of the Lumbar Spine, Lumbar Spine Research Society, North American Spine Society, Scoliosis Research Society, Society of Lateral Access Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Nuvasive, NLT Spine, RTI, Magellan Health<br/>Received consulting fee from Medtronic for consulting; Received consulting fee from NuVasive for consulting; Received royalty from Nuvasive for consulting; Received consulting fee from K2M for consulting; Received ownership interest from NuVasive for none.

Additional Contributors

Mark R Foster, MD, PhD, FACS President and Orthopedic Surgeon, Orthopedic Spine Specialists of Western Pennsylvania, PC

Mark R Foster, MD, PhD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Physical Society, Christian Medical and Dental Associations, Eastern Orthopaedic Association, North American Spine Society, Orthopaedic Research Society, Pennsylvania Orthopaedic Society

Disclosure: Nothing to disclose.

Acknowledgements

Illustrations by Jonathan Eric Foster

Herniated Nucleus Pulposus Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

Contributor Information and Disclosures

What would you like to print?