disc herniations

Goal of the article?

The goal of this study, 1 is to examine why there is an increasing incidence of disc herniation in young people. 

 

Why are they doing this review?

Disc herniation is often the result of natural degeneration changes accompanied by age as the vertebral discs lose water and become less resilient and less responsive to dynamic shock. However, increasingly, disc herniations are appearing in younger people. The cause of this early degeneration is most likely from inactivity sustained by static compressive loads, as well as other factors such as smoking, obesity, familial predisposition and other factors like prolonged sitting. As this can have long-term implications, understanding causes and potential treatments of early degeneration is critical to minimizing the negative outcomes for individuals and society at large.

 

What was done?

This is a prospective study with a total of 33 young patients, all with extruded lumbar disc herniations managed by conservative or surgical approaches between 2017 and 2018. On average, patients were 25 years old. In addition to age, the researchers asked each patient about smoking, familial predisposition, sporting activity, and occupation. They measured pain using a visual analog scale (VAS) and measured patients’ BMI. All patients had lumbar MRI imaging.

 

Helping patients understand compressive loads with a Dynamic Disc Model

 

What did they find?

The researchers found that 18 patients (8 females and 10 males) had a disc extrusion at the L5-S1 level, 12 patients (8 females and 4 males) had a disc extrusion at the L4 and L5 level, and 3 patients had a disc extrusion at both the L4-L5 and L5-S1 levels. Motor deficits were detected in 4 patients who then required surgical treatment. For these patients, three procedures involved the L4-L5; one had right L5 radiculopathy and motor deficit, while the others were on the left side. 

The remaining 29 patients were treated conservatively with physical therapy and pain medication. They were given information on ergonomics and help with stopping smoking. In follow-up, the VAS scores were reduced, and all patients had lost weight. However, only three patients had quit smoking.

When the researchers looked at occupations, they found that all patients sat during the day and lacked movement. They also found that 61% of the patients were smokers and the mean BMI was 32.5 kg/m2.  Additionally, in line with existing research, this study found that familial predisposition with lumbar disc herniation played a role. 

 

Why do these findings matter?

Understanding factors contributing to early disc degeneration can help patients make lifestyle changes that can postpone pain and mobility issues. 

lordosis. degenrative joint disease

Flat Back (Lack of Lumbar Lordosis) and Disc Herniation

Lordosis, or the lack of it, has been thought to be a biomechanical precursor to disc herniation in the lumbar spine. To investigate this possible correlation, a group of researchers from Gothenburg University looked at sixteen young active young patients with a median age of 18yrs old who experienced a disc herniation and underwent discectomy surgery. 1

Lordosis is the curve in the lower back—which they measured before and after the surgery.

Lordosis

Researchers used the Roussouly 4-type classification system to measure the degree of lordosis in the lumbar spine.

The researchers found less lordosis in the subjects that had surgery for their disc herniation. In other words, disc herniation was twice as likely to be present in the group with a flatter back. All the disc herniations were found to be in the lowest two levels of the lumbar spine (L4-5 and L5-S1), consistent with other epidemiological studies. 2

Dynamic Disc Designs Models

At Dynamic Disc Designs Corp. we have worked to represent the anatomy accurately. Our Professional LxH  Dynamic Disc Model is created with 12mm of disc height anteriorly and 10mm posteriorly providing a slight lordotic curve. Further, the model has been created with a higher percentage of nucleus pulposus which is often found in younger lumbar spines. To demonstrate that disc herniation occurs more likely with less lordosis all one has to do is dynamically move the single-level model into a less lordosis position and manually create compression. With more lordosis, the nucleus has a more difficult time penetrating through the outer annulus fissure. This can be an important posture teaching point in the prevention of disc herniation.

If you want to take your patient education to a dynamic level, explore what Dynamic Disc Designs models can do for you, your practice and ultimately, your patients.

A review 1 in the European Spine Journal went over the treatments available for Lumbar Disc Herniation (LDH) in children and adolescents. The review shared which treatment showed the best results.

Why Conduct Such a Review?

Research has shared that LDH or lumbar disc herniation, while affecting adults, also impacted children as well as adolescents (pediatric LDH). It is important to note that pediatric LDH has a number of distinctive features due to the physiological natures of children and adolescents being unique.

Due to adult Lumbar Disc Herniation getting a lot of focus, there’s still a lot that needs to be understood about pediatric LDH. One of the areas involves the treatment available for such LDH and the possible effects of such treatments.

The current review study was conducted to help present an in-depth look at treatments for pediatric LDH and what they entail.

What Was the Methodology?

The searching strategy involved a literature search using electronic databases such as PUBMED and EMBASE. MeSH terminologies (adolescent, child, intervertebral disc displacement, and treatment outcome) and keywords (LDH, adolescent, and child) were used. There were no limitations applied.

The inclusion criteria involved articles featuring relevant information about LDH in adolescents and children. Related references were included, too. The clinical outcome in the articles was assessed, too. 

Take note; case series that didn’t feature a detailed description of the outcome were excluded. Also, case series involving patients over 21-years-of-age were excluded as well. The age-specific exclusion was because previous research demonstrated the human body had almost reached completion of growth during that time.

In the end, 44 series and a total of 8 case reports (with 1,664 cases) were included in the current review. All of the included articles fell in the 1945 to 2008 timeframe.

What Was Observed?

The review shared that LDH is quite a common disorder among adults. The frequency is believed to be much lower in children and adolescents. In all patients hospitalized for LDH, only 0.5-6.8% of the cases were reported as being pediatric patients.

Pediatric LDH is said to be caused by several potential factors. Self-reported or sport-related injury is considered to be the most common cause. This was because 30-60% of adolescents and children experiencing symptomatic LDH were reported to have a history of trauma before pain occurred. However, adult cases usually didn’t report a traumatic experience before the onset of symptoms.

Some recent studies have suggested trauma being an inciting factor that exacerbated pre-existing lesion in discs.

Another factor is considered to be genetics. It has been reported that 13-57% of adolescents with LDH have a first-degree relative with the same condition.

Looking at it from a clinical perspective, pediatric LDH clinically presents itself similarly to adult LDH. Take note; a distinctive feature is that up to 90% of the patients demonstrated a positive straight-leg raising test. 

This can be explained by the fact the nerve root tension is greater in children and adolescents. Also, adolescents and children had a lower chance of presenting neurological symptoms (including weakness and numbness).

What Were the Treatments?

Coming to the treatment part of the review, there’s Conservative treatment, Intradiscal therapy, and Surgical treatment.

Breaking it down, Conservative treatment for pediatric LDH included physical therapy, bed rest, analgesic and anti-inflammatory agents, and limiting physical activity.

As for Intradiscal therapy, chemonucleolysis was the only type being administered for adolescents and children.

Surgical treatment for pediatric LDH was recommended for pediatric LDH on a case-by-case basis. Percutaneous endoscopic discectomy or PED and Microsurgical discectomy or MD were involved.

What Was Concluded?

The review concluded that the diagnosis for adult and pediatric LDH remained similar. As for the treatment, Conservative methods have been reported to be less effective for pediatric LDH when compared to being used for adults. However, Conservative treatment remained the go-to for pediatric LDH cases.

If the said treatment failed, certain patients could be moved to Chemonucleolysis. Excellent short-term outcomes were reported when pediatric LDH was treated surgically (regardless of the modality). Take note; the outcome decreased during the mid-term follow-up, yet it’s considered effective for the long run.

Except for a few exceptions, Spinal fusion isn’t recommended for pediatric LDH.

The review also reported that pediatric LDH could occur in 10-year-olds and younger, with surgical treatments offering positive results.

From this review, one can realize the need to conduct more research involving pediatric LDH for improving treatments and being ready to address any post-treatment related issues.

Disc Herniation Spondylolisthesis

Spondylolisthesis is the slippage of one vertebra on another—frequently found with disc herniation. However, in this recent paper titled: “Over-reporting of the disc herniation in lumbar spine MRI scans performed for patients with spondylolisthesis” 1 they sought to find if disc herniation is over-reported and in turn, possibly over-treated.

Spondylolisthesis is best diagnosed when the spine is under load. Many MRI scans, because done in the lie-down position, miss these small (or large) slippages. To accurately assess one for a spondylolisthesis, the spine is best visualized by x-ray in the forward bending and backward bending position. Upright MRI is also another great way to assess; however, the access to these expensive machines may not be available.

The authors of the above paper discuss how it is imperative to find an accurate diagnosis for both the conservative and surgical management of back pain.

Disc herniation is often found with spondylolisthesis. However, what they found was disc herniation reporting was often over-reported and believed that the disc herniation was more of a pseudo disc herniation rather than an actual disc herniation.

 

What do the authors mean by pseudo-herniation?

 

The authors point to a nomenclature issue. In Fardon’s 2014 paper 2 he helps clarify the language professionals use when discussing disc herniation, extrusion, protrusion and bulge. However, the authors of this paper explain that Fardon’s article does not address this nomenclature in light of spondylolisthesis.

 

They point out in this retrospective study of 258 patients that disc herniation was over-reported because the disc herniation was read with the superior vertebra in mind rather than referencing the lower vertebra. In other words, if the radiological reporting used the lower vertebra as a reference point, the reporting of a disc herniation would be much less because the outer disc border remained anterior to the posterior vertebral ring apophysis. Therefore, it is essential to deferentially diagnose whether symptoms are related to a real disc herniation or due to the mechanics of a spondylolisthesis. A spondylolisthesis can throw off the reporting in this case.

 

 

Dynamic Disc Designs creates 3d models to help reveal the dynamics of disc herniation, including the up-roofing of the disc material. This mechanism is shown in our Professional LxH Model, with the added features of spondylolisthesis.

 

LBP and Disability

A cross-section study 1, in Spine, was conducted to investigate the link low back pain (LBP) and disability had with the structural features of the thoracolumbar fascia. The results shared that a relationship existed between these factors.

The Context

While the Global Burden of Disease Study has researched LBP to be the leading cause of disability in humans, a lot of work needs to be done to fully understand the etiology associated with LBP. More research needs to be done to address all of the factors linked to LBP. Such understanding is crucial because it will help with creating targeted prevention strategies to help millions around the globe.

Previous research has analyzed LBP and disability to be associated with structural abnormalities of the lumbar spine. Furthermore, MRI has shown LBP to be linked to disc protrusion, disc degeneration, nerve root displacement or compression, and high-intensity zone. While more research is still needed, the present results do suggest that the issues of LBP and disability can be addressed by targeting structural factors. Take note, there’s evidence that suggests the thoracolumbar fascia may be linked to LBP. However, few MRI studies have examined such a link.

hypermobility-spine

The Study

The current study had an aim to examine the link present between the lumbar fascia’s length and LBP as well as disability. The study used MRI.

A total of 72 participants (49 females and 23 males) were recruited. They weren’t required to have any history of LBP or current LBP to participate. The MRI was performed, in this study, using a 3.0-T magnetic resonance unit (with the participants in supine position). The study administered the Chronic Pain Grade Questionnaire (CPG) at the time of the MRI.

The study used the Logistic regression analyses for examining any likely associations between fascial length and high pain intensity (or disability).

What did the Results Conclude?

The results of the study concluded that there was a significant association between a shorter length of fascia and high-intensity LBP and/or disability. Such association was after adjusting gender, age, and the body mass index. The association was strengthened after adjustment for the cross-section area (in the paraspinal compartment).

While more studies are required, the current results do suggest that fascia’s structural features likely play a role in disability and LBP.

Do Concepts of Stability and Instability Matter for Back Pain

A clinical commentary 1 in the Journal of Orthopaedic & Sports Physical Therapy was conducted to see if the concepts of stability and instability had any value when talking about Back Pain. The commentary’s argument was that the view of stability needed to be broadened and should also integrate interdisciplinary knowledge. Such a change was deemed necessary due to the complex nature of back pain.

What did it set out to do?

The current clinical commentary had the objective of providing a broad definition of stability. It showed how a unifying framework could be used to integrate different interpretations of spine stability. Furthermore, basic and clinical studies were examined to determine the link of spine stability to back pain. Recent scientific, as well as technological advancements, were also considered. The commentary also speculated on how to evolve the concept of stability (in a manner that also addresses non-mechanical issues lined to experiencing pain).

The main goal of the commentary was to display critical knowledge gathered from studying the concepts of stability and to share the potential present in understanding the etiology concerned with back pain.

Disc Herniation

 

Did it reach the intended goal?

While lumbar spine stability was the focus of this commentary, it was determined that similar concepts could still be used when covering different forms of back pain.

It shared that stability is linked to the central nervous system and how neural and mechanical coupling can help reduce the risk of instability connected to a healthy spine.

The commentary talked about how the messaging surrounding the human spine and its susceptibility should be made better for the general public’s understanding. A better understanding can also help reduce the likelihood of maladaptive strategies. A systems-based framework can also prove beneficial for interdisciplinary integration of knowledge; something this commentary stated needed improvement in the spine community.

The basic conclusion was that we still have a lot to learn about back pain. However, using a framework and using the potential that still exists, we can make the spine community efficient to help others.

lumbar disc herniation

A study investigating kinematic changes in subjects with lumbar disc herniation (LDH) performing five activities of active daily living (ADL) found that LDH patients were more apt than healthy subjects to restrict the lower lumbar (LLx) and upper lumbar (ULx) spinal motions when performing ADLs. The LDH patients used pelvic rotation to compensate for their reduced lumbar flexibility and increased pelvic tilt and lower extremity flexion during problematic ADLs. 

What’s at Stake?

Lower back pain affects up to 85 percent of the worldwide population—especially those over 40—and can contribute to musculoskeletal problems when the lower spine and its surrounding structure is overloaded. Because LBP patients often restrict musculoskeletal motions during ADLs to avoid pain, understanding the kinematic idiosyncrasies of LBP patients during their ADLs is essential when treating spinal issues through physical therapy that involves gait and functional training. 

Past research has indicated LBP patients had less transverse plane movement than healthy subjects during level walking exercises. One study found that LBP subjects were more likely to exhibit spinal or pelvic rotation, while another study came to the opposite conclusion but found that LBP patients had less range of motion (ROM) in the lumbar spine than the control group. Conflicting studies have concluded that LBP patients had significant reductions in the range of hip flexion and spinal movement across all three planes during trunk flexion or better ROM in the lumbar spine, with more restriction in the pelvic or thorax ROM. The divergent conclusions are likely due to the trunk and whole lumbar being considered a single, rigid segment, rather than interconnected segments that operate independently. The prior studies may also have neglected to consider the kinematic differences among LBP patient subgroups. Analyzing the variability of joints and segments is vital when studying LBP patients and their unique kinematics. 

This study focused on how lumbar disc herniation (LDH) specifically contributes to LBP, including the lower trunk, thorax, hip, and pelvis. The goal of the study was to use a computing model to study LBP patients with LDH and understand their pain-related modulation of their lower extremities and multi-segmental trunk kinematics during level walking, stair climbing, trunk flexion, ipsilateral pickup, and contralateral pickup. 

The Study

Twenty-six healthy males with a mean age of approximately 24 years and seven LHD diagnosed male patients who were, on average, approximately 28 years old participated in the study. The disc herniations occurred at L4/5 in three of the LDH patients, L5/S1 in three cases, and at both locations in one patient. 

The motion of thorax, ULx, LLx, pelvis, hip, and knee were tracked via 3D active markers placed in various locations on the subjects’ spines, pelvises, thighs, and shanks. All the markers were placed by a single surgeon, who had previously demonstrated the five ADLs the subjects were to perform. After practicing the motions a few times, the subjects repeated them while data was collected through the active markers. 

The kinematics of the thoracic segment, ULx, LLx, pelvis, hip, and knee were calculated using a modified Gait-full-body computing model that would analyze the motion of each lumbar vertebra using at least three markers. The kinematic spine and hip angles were analyzed with the computing model using a Euler rotation sequence of spinal segments or thigh/pelvis movement, and the thoracic segment as it related to the L1 vertebra. The ROM for all segmental or joint angles during flexion-extension or gait cycles across all three planes in three planes was calculated, and data analysis was performed using a custom program. 

Results

The LDH subjects had much more pelvic rotation and LLx rotation than the healthy subjects during level walking. The LDH group had much less ROM for thoracic flexion, pelvic tilt, and hip abduction during stair climbing, but they showed more ROM for LLx rotation. No clinically significant variance was noted between the two groups for thoracic flexion, trunk flexion or ipsilateral and contralateral pickups. Lumbar flexion ROM was significantly decreased in the LDH group—especially for ULx with nearly no sagittal angular displacement.  

The findings suggest that people with LDH modulate their movement patterns and motor regulation in response to, or avoidance of pain. There were evident kinematic differences between the healthy subjects and LDH patients in this study. LDH patients had more pelvic rotation and increased LLx rotation during level walking, contradicting earlier studies where patients had less than or similar pelvic rotation when compared with healthy subjects. The use of different marker sets, study methods, computer models, and speed of motion might account for the varying test results, but it appears that pelvis and LLx motions in the transverse plane may have a more pronounced effect than that of the other two planes during LDH abnormal motion level walking analysis. 

Conclusion

In regard to the direction or range of motion, there were contrasting kinematic characteristics and different adaptations to LDH between the ULx and LLx in this study. The thoracic motion did not appear to be affected by the LDH when subjects were performing the ADLs, with the exception of stair climbing. During all five ADLs the LDH patients maintained limited lumbar flexion, and their pelvises, knees, and hips compensated for the lost lumbar motion capacity in the sagittal plane during contralateral pickups. In four of the five ADLs (the exception being stair climbing), the LDH patients increased their pelvic rotation significantly. They also had higher rates of antiphase movement between thorax and pelvis in the two pickups and in level walking and stair climbing in the transverse plane between ULx and LLx.

The findings of this study should help provide a more comprehensive understanding of how LDH influences kinematics and lead to more specific treatments and better therapeutic outcomes for LDH patients.