Spinal disc herniation (EDL)

What is it?

A herniated disc is a degenerative disease of the intervertebral discs in the spinal column. It mainly affects the lumbar or cervical spine, and less commonly the thoracic/dorsal spine. The cause is a weakening of the structure of the intervertebral disc, called the fibrous ring, which tends to dehydrate and crack due to mechanical stress. Thus, a hernia represents the outlet of the nucleus pulposus (the inner part of the intervertebral disc) through the fissures of the ring. Hernia can be posterior median (the most common form) or paramedian (right-sided or left-sided), intraforaminal, extraforaminal (if located outside the intervertebral foramen from which the nerve root comes out).

The pathogenesis of a herniated disc is usually acquired, in which case it can be of traumatic or degenerative (more often) origin.

Which are the symptoms?

Symptoms are the result of a hernia compressing a nerve root or spinal cord. Compression of the nerve root causes pain (often with an acute attack) radiating to the arm or leg, or neurological deficits (sensory and/or movement) with radicular syndrome spreading to the limb.  Symptoms of spinal cord compression are characterized by paralysis of the four limbs if the cervical spine is affected, or the lower limbs if the thoracic or lumbar spine is affected, difficulty walking, loss of sensation in the perineal area, impaired sphincter function.

  • pain
  • cervicobrachialgia
  • lumbocruralgia
  • lumboischialgia
  • dysesthesia
  • paraesthesia
  • sensory deficit
  • movement deficit
  • paresis/paralysis
  • walking difficulties
  • spinal cord disorders
  • sphincter dysfunction/sexual impairment.

How is it diagnosed?

To diagnose a herniated disc, a thorough physical and neurological examination of the patient is performed to detect the presence of a neurological disorder or deficit. To make the diagnosis, the patient is required to undergo the following radiological examinations:

Standard radiographic examinations (radiography of the lumbosacral spine in 2 projections in orthostasis, if necessary, radiography of the lumbosacral spine in dynamic projections with maximum extension and flexion, if indicated, teleradiography of the entire spine in orthostasis).

MRI: assessment of the presence and position of hernia, radicular conflicts and concomitant conditions: canal stenosis, discopathy, compression and/or damage to the spinal cord.    Computed tomography: useful to investigate the presence of calcifications behind the discs or posterior longitudinal ligament (cervical/dorsal hernia).

Instrumental examinations should reveal the presence of disease correlating with the clinical picture. In some cases, nerve conduction studies of the peripheral (electromyography/ electroneurography) or central (evoked potentials) nervous system may be indicated.

Suggested exams

How is it treated?

Non-surgical treatment is the first-line treatment that should be used in the initial phase of the onset of symptoms, and consists of drug therapy with anti-inflammatory drugs, pain therapy, corticosteroid therapy and, if indicated, injection therapy. Subsequently, after the acute phase, physiotherapy can be useful if indicated. It is very important, if possible and if indicated, to change physical activity that can put stress on the spinal axis. Except for taper-caudal hernias causing cauda equina syndrome (paraparesis, loss of perianal sensation and sphincter dysfunction) or acute post-traumatic hernias, which cause symptoms in the spinal cord and require urgent surgical treatment, patients with intervertebral disc herniation have an indication for surgical treatment when there are disabling pain symptoms, resistant to medication and physical therapy, present for at least 6-7 weeks, or neurologic deficits.

It is very important to assess the clinical picture and analyze the radiological picture, which will help to establish the severity of the pathology and, therefore, choose a program of action.

The main goal of surgical intervention is to remove the hernia, reduce pain, and decompress the nerve structures to ensure the best possible recovery in the case of neurological deficits. In cervical hernia, when complete disc removal is performed with anterior approach surgery, interbody spondylodesis with a cage and possibly an anterior plate is envisioned.

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