Lumbar Disc Herniation: A review article

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IP International Journal of Orthopaedic Rheumatology 2020;6(1):1–11
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IP International Journal of Orthopaedic Rheumatology
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Review Article
Lumbar Disc Herniation: A review article
Nikhil Jain1, Mudit Mathur2,*, Saksham Sharma2, Saurabh Rawall1,
Shiv Bhagwan Sharma2
1Institute of Spine Jaypee Hospital, Noida, Uttar Pradesh, India
2Dept. of Orthopaedics, SRG Hospital and Jhalawar Medical College, Jhalawar, Rajasthan, India
ARTICLE INFO
Article history:
Received 03-04-2020
Accepted 10-05-2020
Available online 17-07-2020
Keywords:
Disc herniation
Low back pain
ABSTRACT
Nearly 80% of the population sustains an episode of low back pain (LBP) once during their lifetime.
Within the vast differential of LBP, the most common source is intervertebral disc degeneration leading
to degenerative disc disease (DDD) and lumbar disc herniation (LDH). Thus, an effective understanding
of LDH, its origins, and how to appropriately treat it is of substantial importance. Through this article we
try to dispel some uncertainties about disc herniation and study in detail its aetiology, treatments available,
their indications and their clinical outcomes.
© 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license
(https://creativecommons.org/licenses/by-nc/4.0/)
1. Introduction
Lumbar intervertebral disc prolapse and sciatic pain has
been in a focus since many years. Though Mixter and
Barr in 1932 published it as only one cause of sciatic
pain and gave surgical disc excision as treatment, sciatica
still continues to perplex many physicians who proclaim a
bulging disc as the cause of radicular symptoms, but find
no obvious herniated fragment on surgical exploration. It
occurs because physicians overlook other findings on a MRI
scan which can also present clinically similar to sciatica.
(Figure 1)
Spine surgery has advanced many folds in the past few
decades but the complexity to arrive at the right diagnosis
has not become simpler. Even in the presence of advanced
radiological techniques like MRI (with or without contrast)
and CT (with and without myelogram) the incidence of
failed back surgeries is increasing. Through this article
we try to dispel some uncertainties about disc herniation
and study in detail its aetiology, treatments available, their
indications and their clinical outcomes.
Etiology of disc herniation
* Corresponding author.
E-mail address: muditmathur2690@gmail.com (M. Mathur).
Fig. 1: 64 years male presenting with facet cyst at L4-L5 level
along with L4-L5 disc bulge. Patient had right leg radiculopathy.
Performing only discectomy in this case will lead to no relief in
patient’s symptoms.
1. Men (especially in their 3rd to 4th decades of life1,2
2. Obesity (especially BMI >302
3. Diabetes mellitus and hyperlipidaemia (affect micro-
circulation of the disc3
4. Smokers (affect microcirculation of the disc and
frequent coughing increase strain on the annulus4
5. Driving for long hours, physically demanding work,
manual labour and prolonged sitting (increased
https://doi.org/10.18231/j.ijor.2020.001
2581-8112/© 2020 Innovative Publication, All rights reserved. 1

2Jain et al. / IP International Journal of Orthopaedic Rheumatology 2020;6(1):1–11
twisting, bending and vibration from machinery)5
6. Genetic predisposition (positive family h/o disc
herniation6
7. Acute trauma7
8. Mobility (lumbar spine is the most common site of
disc herniation while thoracic spine is least involved)8
1.1. Anatomy & biochemical structure of an
intervertebral disc
Intervertebral disc (IVD) is the largest avascular, anural and
alymphatic organ of our body. 9A single intervertebral disc
is composed of 3 components:
1. Two cartilaginous end plates on either side, adjoining
the adjacent vertebrae
2. Nucleus pulposus: a gelatinous pulpy core
3. Annulus fibrosus: a tough fibrous layer which holds
the gelatinous pulp in its place10
These structure act synergistically to convert shock loads on
the vertebral bodies to a smooth movement.
1.2. Biomechanics of loading forces on an
intervertebral disc
Forces acting on a disc produced by loading can mainly be
divided into three groups
1. Vertical compression
2. Torsion
3. Bending
Annulus is a highly resilient structure. It takes very high
forces for nucleus to rupture an intact young annulus and
herniate out of its periphery.11 But since many patients
give history of only a trivial trauma like lifting weight or
an unbalanced fall, high energy trauma cannot be the sole
factor for disc herniation.
Disc failure has been studied to occur through follow
ways
1. Annulus integrity breaks from inside progressing to
its outer border. This happens when the extracellular
matrix becomes altered and weak in a degenerating
disc.
2. Forces acting on annulus exceed its tensile strength
and break its outer borders. The crack subsequently
progresses inwards towards the nucleus with further
movements and injuries.
Repetitive loads along with the degenerative cascade,
over years lead to gradual breakdown of annular fibres.
Posterolateral region is inheritably the weakest area in the
annulus and henceforth becomes the most common site
of nucleus herniation. It is important to note that for a
nucleus should by well hydrated to herniate through the
cracked annulus. Therefore disc herniation is more common
in individuals in their 3rd and 4th decades of life.
2. Investigations
Of all the radiological investigations MRI plays the most
important role as it helps delineate the soft tissue structures
exceptionally well. (Figure 2)
High quality 3 Tesla MRI helps to:
1. Confirm the diagnosis of disc herniation and rule out
other pathologies
2. Shows the size of the herniated disc
3. Shows the morphology of herniation: symmetric disc
bulge, asymmetric disc bulge (not considered as disc
herniation but can cause radicular symptoms), focal
protrusion, broad based protrusion, extrusion, and
sequestration.11
4. Shows the location of herniation: central, paracentral/
subarticular, foraminal, extraforaminal
5. Shows if the disc herniation is contained or non-
contained
6. Shows migration of fragments: superior, inferior,
axillary, intradural12,13
7. Assess the extent of nerve root compromise14
8. Assess the health status of other discs
9. Assess the size of intervertebral neural foramina
10. Decide if the patient can be managed conservatively or
will need decompression
11. Decide the surgical approach to the procedure
2.1. Electrophysiological tests
In cases where MRI does not correspond to clinical findings,
electrophysiological testing (EMG & NCV) is a useful tool
to investigate metabolic, central neurological and peripheral
neurological causes for radiculopathy besides nerve root
compression at disc level.
2.2. Blocks
In cases where MRI shows multiple level disc herniation,
it can be difficult to identify the right pathological level.
In such cases epidural, selective nerve root injections and
intraarticular injections in the facets and SI joints can be
used as diagnostic tools to locate the pathology.
2.3. Treatment
2.3.1. Non operative treatment
When the patient presents with sciatica for the first time in
the outpatient department, in the absence of the following
indications the patient can always be started on a non-
operative trial
1. H/o significant trauma
2. C/o loss of bowel or bladder control
3. C/o saddle anaesthesia
4. C/o bilateral lower limb weakness
5. C/o rapidly progressing neurological deficit

Jain et al. / IP International Journal of Orthopaedic Rheumatology 2020;6(1):1–11 3
Fig. 2: A 67 year old female presented with left L5 radiculopathy.
MRI showed left L5-S1 foraminal disc herniation showing
obliterated peri-neural fat & narrowing of the IV foramina with
compressed exiting nerve root (L5)
The patient should be managed non-operatively with:
1. Reassurance
2. 2. Short period of bed rest (2-3 days) especially
in a semi-fowler position It helps by unloading the
spine11 (Figure 3)
3. Nonsteroidal anti-inflammatory drugs (NSAIDS
It helps by decreasing inflammation at the disc and
nerve root interface
4. Muscle relaxants if required
Help relieve the loading from lumbar spasm
5. Heat massage/ ice therapy
Potentiate the actions of muscle relaxants and NSAIDS
6. Analgesics (acetaminophen preferred Avoid nephro-
toxic drugs
7. Anticonvulsants
• Gabapentin and pregabalin have been found to have a
beneficial role in neuropathic pain15
Fig. 3: Semi- Fowler positon: Patient lies relaxed with hips and
knees flexed. This position can also be achieved in lateral decubitus
by maintaining flexion at hips and knees.
The patient should be followed weekly and repeat
physical and neurological examination should be performed
at every visit. If there is adequate pain relief and no
further neurologic deficit, the patient can be started
on physiotherapy. This includes back stretching, back
strengthening and back schools. The type of exercise
depends on how long the patient has been disabled and
on the grade of muscle atrophy. The patient should be
advised modification of his/ her activities which includes to
avoid prolonged sitting, forward bending and lifting heavy
weights. Most of the patients recover in 4-6 weeks and are
allowed to get back to their daily routine life with above
mentioned precautions.16
If there is no improvement from the non-operative
management at the end of 4-6 weeks or if there is
a progressive neurological deficit or if there is cauda
equina syndrome, the patient is advised urgent radiological
investigations. Of all the radiological investigations MRI
plays the most important role as it helps delineate the soft
tissue structures exceptionally well.
2.4. Epidural and selective nerve root block (SNRB)
This procedure is a part of the non-operative management
besides being a diagnostic aid. The block is a mixture
of a local anaesthetic (0.25% bupivacaine or 0.5%
lignocaine) and a corticosteroid (triamcinolone acetate
or methylprednisolone) which is delivered at the target
level (herniated disc) under fluoroscopic guidance to help
relieve the acute radicular pain by its anesthetic and anti-
inflammatory action. (Figure 4)
Fig. 4: Fluoroscopic image of epidural root block being given at
L3 level left side.
2.4.1. Indications for the SNRB include
1. Patient with herniated disc with a severe root
compression not willing to undergo surgery
2. Disc morphology not correlating to the clinical
symptoms : it helps confirm if the cause of the radicular
pain is the same herniated disc or something else

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(Figure 5)
3. Predict the outcome: a patient getting relief from
the SNRB will have a favourable outcome if treated
surgically.
4. Atypical extremity pain17
A single shot of epidural or SNRB provides short term relief
of around 3 months. It is proven that a patient can delay his
her surgery for a few years if they respond well to SNRB
or epidural blocks. A patient can have a maximum of 4
injections in a year. Each injection must have a gap of 1-
2 weeks in between.18,19
Fig. 5: 34 years old man presented with bilateral lower limb
radiculopathy. MRI showed disc herniation at both L4-L5 and
L5-S1 levels. The pathological level can be confirmed by giving
selective nerve root block to avoid surgical failure.
2.5. Operative Treatment
2.5.1. Indications
All the patients with acute disc herniation:
1. Who have failed a non-operative and epidural/ SNRB
trial for 3 -4 months, do not have waddle signs
or symptoms and are not involvement in workers
compensation litigation.20
2. Have cauda equina syndrome
3. Have progressive neurological deficit
4. Have severe extremity pain 21,22
5. Have severe extremity pain 21,22
2.6. Chemonucleolysis
Chymopapain is proteinase enzyme extracted from papaya
fruit. It has high activity over nucleus pulposus. It breaks
the proteoglycan chain and decreases the water holding
capacity of the nucleus. Henceforth the nucleus shrinks
and the compression is relieved. But it has poor action in
extruded/ sequestered disc herniation (because they have
lower proteoglycan and higher collagen content), calcified
disc herniation, bony canal/ foramen stenosisand instability.
It can pose some serious complications (hypersensitivity,
anaphylaxis, subarachnoid haemorrhage and transverse
myelitis). Therefore it is not a very popular procedure.
2.7. Surgery
Currently we have following options if a patient is decided
for a surgical discectomy
1. Open discectomy/ conventional open discectomy
2. Microscopic discectomy
3. Endoscopic discectomy
2.8. Conventional open discectomy
2.8.1. The technique
The patient is given general endotracheal anaesthesia and
placed in a prone position in a Jackson (OSI) table or
Andrews spine frame. The target disc space and inter
spinous space is identified by palpating the landmarks (iliac
crest is at L4-L5 inter spinous space). Same is confirmed on
fluoroscopy. A midline incision about 3-5 cm is placed at the
target level from rostral to the caudal spinous process. The
subcutaneous tissue is dissected and the deep dorsolumbar
fascia is incised. Sub periosteal dissection of the para spinal
muscles is performed using a bovie from the tip spinous
process to its base (the spino-laminar junction). Now using
blunt dissection the muscles are retracted laterally with a
Cobbs retractor without violating the facet joint capsule.
The target inter laminar space is exposed and is confirmed
on fluoroscopy before proceeding further. A Taylor retractor
is placed lateral to the faect joint. Using curettes, Kerrison
rongeurs, nerve and dura retractors the overlying tissue,
ligamentum flavum and lamina bone is removed. Medial
facetectomy without compromising the stability of the facet
joint (not more than 1/3rd of the facet should be resected) is
performed. Dura and the traversing roots are visualised. The
nerve root is retracted medially and the disc is identified.
The annulus is cut and the target fragment is extirpated.
Adequate decompression is confirmed if the angled hooks
can be passed above and below the root in the neural
foramina, nerve root is mobile and there are no visible
fragment inside the canal. Hemostasis is achieved and the
wound is closed in layers.
The extent of removal of bone from lamina of 3 types:
1. Laminectomy
2. Hemilaminectomy
3. Fenestration/ laminotomy
For a large central disc herniation, cauda equine syndrome
and intra-dural migrated disc laminectomy (entire lamina
from medial border of one facet to medial border of opposite
facet) is performed.
For superiorly or inferiorly migrated disc and lateral
recess stenosis hemi laminectomy (from medial border of
one facet to the base of spinous process) is adequate.
For rest all cases minimal bone resection (fenestration/
laminotomy) is enough to expose the root and the lateral
border of dura.23

Jain et al. / IP International Journal of Orthopaedic Rheumatology 2020;6(1):1–11 5
2.9. Micro discectomy
Microsurgery using magnification from microscopes were
innovations that limited these surgical insults with equally
effective decompression.24 (Figure 6) Specialised burr drills
give freedom to remove bone effectively with minimal hand
movement in the limited space. (Figure 7) The surgical
technique is same as the standard open procedure. The
differences are
1. Smaller incision (2-3cm
2. Minimal damage to soft tissue
3. Microscope magnifies the structures in view allowing
a. To undercut the posterior arch without removing it
totally
b. To view the contralateral pedicle and neural structure
by angling the microscope and turning the patient.
c. More accurately identify neural structures and
protect them from unwanted manipulation
d. To record and store the surgical procedure performed
4. Minimises risk of postoperative instability and back
pain as the bone and soft tissue are preserved to
maximum.
5. Minimal blood loss
6. Reduced postoperative hospital stay
7. Faster post-operative recovery
Fig. 6: Surgical microscope
2.10. Endoscopic discectomy
Endoscopic discectomy is a step further to reduce the skin
incision length and minimize soft tissue injury. This method
was first introduced by Kambin and Hijikata.21,25 Currently
there are four techniques to do it
1. Micro endoscopic discectomy using tubular retractors
2. The Destandau technique
3. Full endoscopic inter laminar discectomy
4. Full endoscopic posterior trans´
a foraminal discectomy
Fig. 7: Specialized burrdrill tool
2.11. Micro endoscopic discectomy using tubular
retractors
This technique was given by Foley and Smith in 1997.26
Tubular retractors split the muscles and radially dilate
the muscle fibers. They trick is to not cut through the
muscle fibers. This reduces the muscle injury. Specialized
serial dilating tubes and retractors are used which have
attached light sources. This allows for smaller incisions with
excellent view of the underlying structures. (Figure 8)
Fig. 8: Tubular retractors
2.12. The technique
With patient in prone position, an AP shot is taken on
the C-arm machine and ipsilateral inferior pedicle of the
target level is identified and marked. Lateral view is taken
to confirm the target level. For a left sided L4-L5 disc, left
side L5 pedicle is marked. A 1-2 cm incision is made in
the skin and the underlying dorso-lumbar fascia. Specialized
serial dilators are then progressed with a rotatory motion
that allows separation and serial dilation of muscle fibers.
The dilators are docked onto the inferior L4 facet and
confirmed radiologically. After a satisfactory position is
achieved specialized expandable retractors are inserted and
serial dilators are removed. The retractor system is fixed to
a flexible arm rigidly fixed to the operating table. The light
source is attached.

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The rest of the procedure is same as microscopic
discectomy using specialized bayoneted instruments and
burr drill.
2.13. The Destandau technique
This technique was described by Jean Destandau in
1999. He developed a specialized endoscopic spine system
(Endospine) and approached the spine via the posterior inter
laminar approach.26,27
This specialized endospine system consists of two
detachable tubes: outer tube and inner tube along with an
endoscope. The inner tube has 4 built in channels, each
for endoscope, suction, working instruments and nerve root
retraction.(Figure 9)
Fig. 9: Endospine system
2.14. The technique
Under endotracheal anaesthesia the patient is placed in knee
chest position.
The target inter laminar space is marked under
fluoroscopy. A para median 1-1.5 cm long incision, about
1 cm from midline towards the affected side is made. Skin
and underlying dorso- lumbar fascia is incised and the para
spinal muscles are lifted subperiosteally off the spinous
process and lamina. The outer tube is placed and docked at
the target inter laminar space. Then the inner tube is placed.
The endoscope is passed through its channel. The rest of the
decompression is same as microscopic discectomy using its
specialised instruments.
2.15. Full endoscopic inter laminar discectomy
In this technique endoscopes has angled lenses. Angled
endoscopic lenses allow for greater field of vision. These
endoscopes have built in channels for working instruments
and light source. These endoscopes are passed through a
working cannula and docked at the target inter laminar.
2.16. The technique
With patient in endotracheal anaesthesia and in prone
position, the target inter laminar space is marked on AP
and lateral fluoroscopy view. An 8-10 mm incision is
made close to the midline. Skin and dorso-lumbar fascia
is incised. Blunt tipped dilators are inserted and docket
over the target inter laminar space. After confirmation a
bevelled working cannula is introduced and the dilator is
removed. The position is again confirmed on fluoroscopy.
After confirming the level, the endoscope is introduced.
Using the specialised long instruments through the channels
in endoscopes, the decompression is performed similar to as
in microscopic discectomy.
2.17. Full endoscopic trans foraminal discectomy
Also called percutaneous trans foraminal endoscopic
discectomy (PTED). The procedure can be performed in
endotracheal and local anesthesia as per the comfort of the
physician. (Figure 10)
Fig. 10: Percutaneous Trans-foraminal Endoscopic Device
Here the disc is approached posterolaterally through
the intervertebral foramen. This technique was given
by Kambin in1992.28 He described a safe pathway for
endoscope and its instruments called as ‘Kambin’s triangle’.
It is a zone bounded with the following boundaries
(Figure 11)
1. Anterolateral: exiting nerve root
2. Posteromedial: superior facet of caudal vertebra
3. Inferior: superior end plate of caudal vertebra
Accessing the disc through this zone involves minimal
risk to neural structures. The equipment involves angled
endoscope with an irrigation channel and working channel,
long spinal needles, bunt guidewires, dilators, beveled
cannula, specialized long handled discectomy instruments
and a radiofrequency probe.
2.18. The technique
The procedure can be performed in both local and
endotracheal anesthesia as per the comfort of the physician.
The most crucial step of this procedure is marking the right

Jain et al. / IP International Journal of Orthopaedic Rheumatology 2020;6(1):1–11 7
Fig. 11: Kambin’s triangle
entry point. With the patient in prone position the abdomen
is made free of pressure. Next, under fluoroscopic guidance,
two line are marked on the skin using the AP view of the
target disc space.
1. With pedicle equidistant from spinous processes
midline of lumbar spine joining the spinous processes.
(line A)
2. Midline of target intervertebral disc space with line
parallel to the end plates of adjoining vertebra. (line
B)
Additional lines are drawn on the skin using the lateral
fluoroscopic view of the target disc space
1. Midline of target intervertebral disc space with line
parallel to the end plates of adjoining vertebra (line C)
2. Line joining the posterior borders of the facets of
lumbar spine (line D
3. Iliac crest border is marked using finger palpation (line
E) The entry point lies in the area enclosed between
lines B, C and D
The needle is inserted and directed towards the target
disc space at an angle of 20 degrees to the floor. The
needle is advanced under fluoroscopic guidance. Keeping
the kambin’s triangle boundaries in mind, the needle is
proceeded to the medial border of the pedicle on AP view
and posterior vertebral line in of target disc space on lateral
fluoroscopic view.
Now the annulus is pierced and disc is entered. Now
discography is performed and indigo carmine dye is injected
through the needle into the disc. The dye stains the nucleus
blue. Now the needle is replaced with guidewire and
over it dilator, beveled cannula and finally the endoscope
are progressed. Next step is to access the herniated
fragment. Using specialized shavers, drills, curettes and
other instruments discectomy is performed.
2.19. Electro thermal annuloplasty
Procedure was initially introduced to relieve the patients
of the pain in sciatica. It involves introducing an electro
thermal coil into the outer annulus via posterolateral
approach. The heat cauterizes the nerve endings and
contracts the collagen fibers.
2.20. Coablation Nucleoplasty
Indicated only for contained herniation, using a posterolat-
eral approach a needle is inserted into the target nucleus
pulposus and radiofrequency waves are delivered to dissolve
the soft nucleus and decompress the nerve.
2.21. Percutaneous Laser disc decompression
Using posterolateral approach laser energy is used through
a needle to vaporize the water in the nucleus and shrink the
disc fragment. The results have been limited and many cases
required discectomy at a later stage.28
2.22. Ozone nucleolysis
Indicated for contained disc herniation ozone is delivered to
the target nucleus through the ‘kambin’s triangle’ zone via
the transforaminal route. Ozone reacts with nucleus water
and generates peroxide and hydroxyl ions. These ions break
the nucleus and reduce its size.
2.23. Gelified ethanol, infliximab (anti TNF x) and
collagenase
Ethanol mixed with ethyl-cellulose and radiopaque material
for treating lumbar disc herniation has been presented in
literature.29 Similarly infliximab and collagenase have been
tried but the long term results of these methods have been
equivocal.30,31
2.24. Special situations
2.24.1. Migrated disc herniation
Disc migration has been classified by Lee et al into
1. Zone 1: far up: from inferior margin of superior
pedicle to 3mm below
2. Zone 2: near up : within 3mm of inferior end plate of
rostral vertebral body
3. Zone 3: near down: from superior end plate of caudal
vertebral body to centre of inferior pedicle
4. Zone 4: far down: from centre of inferior pedicle to
inferior border of inferior pedicle.32
Another classification system has been given Ahn et al.
They coined the terms low grade up and down for zone 2
and zone 3 respectively, high grade up and down for zone 1
and zone 4 respectively. They introduced one more grade:

8Jain et al. / IP International Journal of Orthopaedic Rheumatology 2020;6(1):1–11
Very high grade: when the disc fragment migrated
beyond the inferior margin of the pedicle on either rostral
or caudal side.33 (Figures 12 and 13)
Fig. 12: Lee and Ahn classification systems schematic diagram
Fig. 13: 32 year old male presenting with right leg radiculopathy
and inferiorly sequestrated disc very high grade down (beyond
inferior pedicle)
2.25. Open/ microscopic technique
When using open or microscopic techniques, for very high
grade migration it is recommended to approach from the
superior border of the lamina of the pedicle where the
fragment is residing.
For low and high grade migrations resecting extra bone
using open or microscopic approaches is required. Care
should be taken to avoid too much bone removal leading
to instability.
2.26. Endoscopic techniques
2.26.1. Transforaminal
Lee et al advise ‘half and half technique’ for low grade
(zone 2 and 3) and ‘epiduroscopic technique’ along with
foraminoplasty for high grade (zone 1 and 4) migrations.
2.27. Interlaminar
Similar to microscopic techniques. Due to freedom of
mobility the endoscopes can be angled and flexible
instruments can be used to retrieve the migrated fragment.
If any difficulty is faced, converting the procedure to
microscopic technique is the prudent answer.
2.28. Foraminal disc herniation
2.28.1. Microscopic technique
This can be approached by surgeon standing on the opposite
side of the disc herniation and angling the view under the
medial border of the facet at the involved side.
2.29. Endoscopic techniques
Transforaminal approach from ipsilateral side is very good
procedure for such herniation.
Interlaminar approach can use flexible instruments from
the contralateral side. Requires very high expertise for the
same.
Extra foraminal/ far lateral disc herniation (Figure 14)
Fig. 14: 68 years old male presented with left leg L4
radiculopathy. MRI showed L4-L5 left extraforaminal disc
herniation compressing the exiting L4 nerve root.
2.30. Open/ microscopic technique
Using a paramedian muscle splitting (Wiltse) approach is
advised.
2.31. Endoscopic techniques
Transforminal approach is best suited for such case
scenarios while interlaminar approach should be avoided.
2.32. Recurrent disc herniation (Figure 15)
A patient presenting with a recurrence of similar signs
and symptoms after a symptom free interval post primary
discectomy surgery should be evaluated with contrast
MRI. Epidural fibrosis, arachnoiditis and postoperative

Jain et al. / IP International Journal of Orthopaedic Rheumatology 2020;6(1):1–11 9
granulation tissue should be excluded. After the recurrent
fragment has been identified on the MRI scan the patient
can be taken up for revision micro discectomy. The fragment
appears as hypo intense on T2WI.
Fig. 15: 70 year old male presented with recurrent disc herniation.
The contrast MRI showed low signal core with hyper-intense
margins due to peripheral neovascularisation of sequestrated disc
fragment. (Contrast MRI is the modality of choice to diagnose
recurrent disc herniation.
The dura is thinned out due to recurrent herniation
and it is easily possible to have a dural tear. These
surgeries are best performed using microscopes and wide
decompression.34
2.33. Cauda equina syndrome (Figure 16)
Emergency surgical decompression within 48 hours of
onset of symptoms is advised.35,36 Surgery requires
wide decompression (laminectomy + discectomy) using
either open or microscopic approach. Endoscopic/ mini
open approaches are contraindicated.37,38 Postoperative
physiotherapy including pelvic floor exercises and multidis-
ciplinary approach plays an important role in the recovery
and rehabilitation of the patient.39
Fig. 16: 48 years old male presented with sudden onset
urinary retention and saddle anaesthesia and bilateral lower limb
radiculopathy. Diagnosis of cauda equina syndrome was made.
MRI revealed extruded L5-S1 disc.
2.34. Fusion
We advocate fusion only if preoperative or postoperative
instability is suspected. Discectomy alone produces best
results in absence of instability.40,41
2.35. Clinical outcomes
2.35.1. Non operative management vs Surgery
Surgical excision of the disc herniation is as obvious as
removing a thorn stuck in the foot. Long term results of
over 39000 patients were analysed and showed success rate
of 78.9% over an average period of 6 years. This study
gave good/excellent results for open discectomy in 78.3%
patients, for microscopic discectomy in 84.3% patients and
for endoscopic discectomy in 79.5% patients.42 SPORT trial
(RCT study) followed patients for 8 years and compared
the results of operated vs non-operatively managed patients
using SF- 36 and ODI scores. The results showed clinically
significant improvements in the operated patients and there
was no degradation in their symptoms over the next 8
year period.43 Maine lumbar spine study reported greater
improvement at one year in surgically treated patients.44
Spetzger showed 93% success rate following surgery. A
5 year study by Rish L found out of the total patients
who were treated with conservative surgery, 41% patients
required surgery. In carefully selected patients they found
the success rate of surgery was more than 90%.45
2.36. Open vs microscopic discectomy
Well performed decompression in carefully selected
patients with proper indication for surgery had similar
clinical outcomes in terms of pain relief, neurological
recovery, complications: dural tear, root injury, reoperation
rate and patient satisfaction. Micro discectomy had longer
learning curve and longer operative time but was superior in
terms of lesser blood loss, lesser tissue damage, lesser post-
operative back pain, early mobilisation, shorter hospital stay
and early patient recovery. 46–49
2.37. Microscopic vs tubular vs fully endoscopic inter
laminar discectomy
Outcome measure were ODI, VAS back and leg pain,
Modified McNab criterion, and serum CPK levels pre op
and post op. As per modified McNab criterion all three
groups showed good to excellent results in >90% patients.
VAS and ODI improved significantly in all three groups
and their results were similar. But endoscopic and tubular
techniques had lesser post op back pain compared to the
micro discectomy group. Post-operative MRI showed that
dura expansion in all three groups was similar. The blood
loss was least in endoscopic and maximum in microscopic
group. The endoscopic group had shortest hospital stay
period. Endoscopic group had least rise in serum CPK

10 Jain et al. / IP International Journal of Orthopaedic Rheumatology 2020;6(1):1–11
levels post op. The disadvantage was longer operative
time and longer learning curve for tubular and endoscopic
techniques.50 Similar results have been supported in many
other studies.51
Many studies support smaller incision leads to minimal
soft tissue dissection and minimal blood loss leading to
less muscle injury, less iatrogenic denervation and less back
pain.52–58
3. Conclusion
It is important to note that discectomy performed in
patients with non-contained disc herniation (sequestration/
trans ligamentous extrusion) show best relief from surgery
followed by contained but ruptured disc herniation (sub
ligamentous extrusion) and contained non-ruptured disc
herniation (focal protrusion). The poorest results are for
patients who are operated for broad based disc protrusion/
bulge which are not true herniation though they can
compress upon a nearby nerve root in a pre-existing
foraminal/ lateral recess stenosis. In the former case
scenarios at the time of surgery if a window is cut into
the annulus the nucleus will extrude spontaneously and the
pathological fragment will be removed. But same does not
happen for broad based protrusions or disc bulges as the
pathological fragment cannot be located and the exploration
turn out to be negative.59 This is how the term concealed
fragment creeped into the literature.60
The takeaway message is to study the MRI films, both
the axial and sagittal images carefully. Focussing only on
a disc with expanded borders beyond its normal contour
can make the physician miss the real cause and lead to
a futile trip of the patient to the operation theatre. In
carefully identified patients, surgery has excellent results.
The surgical technique should depend on the expertise of
the treating physician as the clinical outcomes in terms of
pain relief and neurological recovery are equally good in all
well performed techniques.
Minimally invasive techniques show faster and better
post-operative recovery but only in hands of well-trained
physicians.
4. Source of Funding
None.
5. Conflict of Interest
None.
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Author biography
Nikhil Jain Consultant
Mudit Mathur Post Graduate Resident
Saksham Sharma Post Graduate Resident
Saurabh Rawall Consultant
Shiv Bhagwan Sharma Senior Professor and Unit Head
Cite this article: Jain N, Mathur M, Sharma S, Rawall S, Sharma SB.
Lumbar Disc Herniation: A review article.IP Int J Orthop
Rheumatol 2020;6(1):1-11.