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disc_herniation

Disc herniation

Spine disease

The German Hubert von Luschka (1820-1875) described for the first time a herniated disc in a pathologic specimen.

Herniation of nuclear or disc material along with inflammatory chemokines such as prostaglandin E2, interleukin-6, matrix metalloproteinase and nitric oxide has definite correlations, possibly they are over produced 1).

Types

Soft disc herniation that involves herniation of the nucleus pulposus through a tear at the annulus fibrosus

Hard disc herniation.

Acute disc herniation

Disc herniation of a relatively recent occurrence. Note: Paradiscal inflammatory reaction and relatively bright signal of the disc material on T2-weighted images suggest relative acuteness. Such changes may persist for months, however. Thus, absent clinical correlation and/or serial studies, it is not possible to date precisely by imaging when a herniation occurred. An acutely herniated disc material may have brighter signal on T2-weighted MRI sequences than the disc from which the disc material originates.

Note that a relatively acute herniation can be superimposed on a previously existing herniation. An acute disc herniation may regress spontaneously without specific treatment. See chronic disc herniation.Aging disc: Disc demonstrating any of the various effects of aging on the disc. Loss of water content from the nucleus occurs before MRI changes, followed by the progression of MRI-manifested changes consistent with the progressive loss of water content and increase in collagen and aggregating proteoglycans. See Pfirrmann classification.

Observer variability is a major hurdle to radiologists in the assessment of discs due to the lack of consensus regarding the nomenclature of disc herniation 2)

Cervical disc herniation

Thoracic disc herniation

Lumbar disc herniation.

see recurrent disc herniation

Etiology

The cause of disc herniation is not well understood yet. It is assumed that heavy lifting and extreme postures can cause small injuries starting either in the inner anulus or from the outside close to the endplate. Such injuries are accumulated over years until its structure is weakened and finally a single loading event leads to a sudden failure of the last few intact lamellae.

Recent work showed an increased risk of cervical and lumbar intervertebral disc (IVD) herniations in astronauts.

Based on literature review the most likely cause for lumbar IVD herniations was concluded to be swelling of the IVD in the unloaded condition during spaceflight. For the cervical IVDs, the knowledge base is too limited to postulate a likely mechanism or recommend approaches for prevention. Basic research on the impact of (un)loading on the cervical IVD and translational research is needed. The highest priority prevention approach for the lumbar spine was post-flight care avoiding activities involving spinal flexion, followed by passive spinal loading in spaceflight and exercises to reduce IVD hyper-hydration post-flight 3).

Treatment

Therapeutic armamentarium for symptomatic intervertebral disc herniation includes conservative therapy, epidural infiltrations (interlaminar or trans-foraminal), percutaneous therapeutic techniques and surgical options. Percutaneous, therapeutic techniques are imaging-guided, minimally invasive treatments for intervertebral disc herniation which can be performed as outpatient procedures. They can be classified in 4 main categories: mechanical, thermal, chemical decompression and biomaterials implantation. Strict sterility measures are a prerequisite and should include extensive local sterility and antibiotic prophylaxis. Indications include the presence of a symptomatic, small to medium sized contained intervertebral disc herniation non-responding to a 4-6 weeks course of conservative therapy. Contraindications include sequestration, infection, segmental instability (spondylolisthesis), uncorrected coagulopathy or a patient unwilling to provide informed consent. Decompression techniques are feasible and reproducible, efficient (75-94% success rate) and safe (>0.5% mean complications rate) therapies for the treatment of symptomatic intervertebral disc herniation. Percutaneous, imaging guided, intervertebral disc therapeutic techniques can be proposed either as an initial treatment or as an attractive alternative prior to surgery for the therapy of symptomatic herniation in both cervical and lumbar spine 4).

1)
Kalichman L, Hunter DJ. The genetics of intervertebral disc degeneration. Associated genes. Joint Bone Spine. 2008;75:388–96.
2)
van Rijn JC, Klemetso N, Reitsma JB, Bossuyt PM, Hulsmans FJ, Peul WC, et al. Observer variation in the evaluation of lumbar herniated discs and root compression: spiral CT compared with MRI. Br J Radiol. 2006;79:372–377.
3)
Belavy DL, Adams M, Brisby H, Cagnie B, Danneels L, Fairbank J, Hargens AR, Judex S, Scheuring RA, Sovelius R, Urban J, van Dieën JH, Wilke HJ. Disc herniations in astronauts: What causes them, and what does it tell us about herniation on earth? Eur Spine J. 2016 Jan;25(1):144-54. doi: 10.1007/s00586-015-3917-y. Epub 2015 Apr 18. PubMed PMID: 25893331.
4)
Kelekis A, Filippiadis DK. Percutaneous treatment of cervical and lumbar herniated disc. Eur J Radiol. 2015 May;84(5):771-6. doi: 10.1016/j.ejrad.2014.02.023. Epub 2014 Mar 3. PubMed PMID: 24673977.
disc_herniation.txt · Last modified: 2018/01/25 09:57 by administrador