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Lumbar Disc Disease CHAPTER Lower Back Pain and Disorders 39 of Intervertebral Discs Keith D. Williams N Ashley L. Park Epidemiology, ••• Psychological testing, ••• Nonoperative treatment, ••• General disc and spine anatomy, ••• Cervical disc disease, ••• Epidural steroids, ••• Neural elements, ••• Signs and symptoms, ••• Operative treatment, ••• Anatomical proportions, ••• Differential diagnosis, ••• General principles for open disc Natural history of disc disease, ••• Confirmatory testing, ••• surgery, ••• Nonspecific lumbar pain, ••• Myelography, ••• Ruptured lumbar disc excision, ••• Diagnostic studies, ••• Nonoperative treatment, ••• Microlumbar disc excision, ••• Roentgenography, ••• Operative treatment, ••• Endoscopic techniques, ••• Myelography, ••• Removal of posterolateral herniations Additional exposure techniques, ••• Computed tomography, ••• by posterior approach (posterior Lumbar root anomalies, ••• Magnetic resonance imaging, ••• cervical foraminotomy), ••• Results of open (micro or standard) Positron emission tomography, ••• Anterior approach to cervical disc, ••• surgery for disc herniation, ••• Other diagnostic tests, ••• Thoracic disc disease, ••• Complications of open disc Injection studies, ••• Signs and symptoms, ••• excision, ••• Epidural cortisone injections, ••• Confirmatory testing, ••• Dural repair augmented with fibrin Cervical epidural injection, ••• Treatment results, ••• glue, ••• Thoracic epidural injection, ••• Operative treatment, ••• Free fat grafting, ••• Lumbar epidural injection, ••• Costotransversectomy, ••• Chemonucleolysis, ••• Zygapophyseal (facet) joint injections, ••• Anterior approach for thoracic disc Spinal instability from degenerative disc Cervical facet joint, ••• excision, ••• disease, ••• Lumbar facet joint, ••• Thoracic endoscopic disc excision, ••• Disc excision and fusion, ••• Sacroiliac joint, ••• Lumbar disc disease, ••• Lumbar vertebral interbody fusion, ••• Discography, ••• Signs and symptoms, ••• Anterior lumbar interbody fusion, ••• Lumbar discography, ••• Physical findings, ••• Posterior lumbar interbody fusion, ••• Thoracic discography, ••• Differential diagnosis, ••• Failed spine surgery, ••• Cervical discography, ••• Confirmatory imaging, ••• Repeat lumbar disc surgery, ••• Humans have been plagued by back and leg pain since the Several physical maneuvers were devised to isolate the true beginning of recorded history. Primitive cultures attributed problem in each patient. The most notable of these is the such pain to the work of demons. The early Greeks recognized Lase`gue sign, or straight leg raising test, described by Forst in the symptoms as a disease and prescribed rest and massage for 1881 but attributed to Lase`gue, his teacher. This test was the ailment. The Edwin Smith papyrus, the oldest surgical text devised to distinguish hip disease from sciatica. Although dating to 1500 BC, includes a case of back strain. Unfortunately, sciatica was widespread as an ailment, little was known about the text does not include the treatment rendered by the ancient it because only rarely did it result in death, allowing Egyptians. In the fifth century AD, Aurelianus clearly described examination at autopsy. Virchow (1857), Kocher (1896), and the symptoms of sciatica. He noted that sciatica arose from Middleton and Teacher (1911) described acute traumatic either hidden causes or observable causes, such as a fall, a ruptures of the intervertebral disc that resulted in death. The violent blow, pulling, or straining. In the eighteenth century correlation between the disc rupture and sciatica was not Cotugnio (Cotunnius) attributed the pain to the sciatic nerve. appreciated by these examiners. Goldthwait in 1911 attributed Gradually, as medicine advanced as a science, the number of back pain to posterior displacement of the disc. Oppenheim and specific diagnoses capable of causing back and leg pain Krause in 1909 performed the first successful surgical excision increased dramatically. of a herniated intervertebral disc. Unfortunately, they did not Copyright 2003. Elsevier Science (USA). All Rights Reserved. 1955 #6427 @sunultra1/raid/CLS books/GRP mosby/JOB canale/DIV ch39mktg 7/26/02 303 Pos: 1/74 Pg: 1955 Team: 1956 PART XII N The Spine recognize the excised tissue as disc material and interpreted it Epidemiology as an enchondroma. Oil-contrast myelography was serendipi- tously introduced when iodized poppy seed oil, injected to treat Back pain, the ancient curse, is now an international health sciatica in 1922, was inadvertently injected intradurally and issue of major significance. Hult estimated that up to 80% of was noted to flow freely. Dandy in 1929 and Alajouanine in the people are affected by this symptom at some time in their lives. same year reported removal of a ‘‘disc tumor,’’ or chondroma, Impairments of the back and spine are ranked as the most from patients with sciatica. The commonly held opinion of that frequent cause of limitation of activity in people younger than time was that the disc hernia was a neoplasm. Mixter and Barr 45 years by the National Center for Health Statistics. in their classic paper published in 1934 attributed sciatica to Physicians who treat patients with spinal disorders and lumbar disc herniation. This report also included a series of spine-related complaints must distinguish the complaint of four patients with thoracic disc herniations, and four patients back pain, which several epidemiological studies reveal to be with cervical disc herniations. They suggested surgical treat- relatively constant, from disability attributed to back pain. In ment. Myelography was not used for confirmation of disc 1984, disability was noted by Waddell to be exponentially disease because of toxicity of the agents used in the years that increasing in the United Kingdom (Fig. 39-1). Conversely, an followed. Myelography was refined with the development of insurance industry study revealed a trend toward decreasing nonionic contrast media, and the test was combined with CT; claim rates for low back pain in the United States from 1987 to however, even this appears to have been supplanted by MRI of 1995. the spine. Although back pain as a presenting complaint may account The standard procedure for disc removal was a total for only 2% of the patients seen by a general practitioner, laminectomy followed by a transdural approach to the disc. In Dillane, Fry, and Kalton reported that in 79% of men and 89% 1939 Semmes presented a new procedure to remove the of women the specific cause was unknown. Svensson and ruptured intervertebral disc that included subtotal laminectomy Andersson noted the lifetime incidence of low back pain to be and retraction of the dural sac to expose and remove the 61% and the prevalence to be 31% in a random sample of 40- ruptured disc with the patient under local anesthesia. Love in to 47-year-old men. They noted that 40% of those reporting the same year also described this same technique indepen- back pain also reported sciatica. In women 38 to 64 years of age dently. This procedure, now the classic approach for the the lifetime incidence of low back pain was 66% with a removal of an intervertebral disc, has been improved with the prevalence of 35%. Svensson and Anderson noted psycholog- use of microscopic and video imaging. Kambin, Onik, and ical variables associated with low back pain to be dissatisfac- Helms and others have popularized minimally invasive tion with the work environment and a higher degree of worry techniques for selected disc hernias. and fatigue at the end of the workday. The cost to society and As more people were treated for herniated lumbar discs, it the patient in the form of lost work time, compensation, and became obvious that surgery was not universally successful. treatment is staggering. Snook reported that Liberty Mutual Over the past several decades, studies of patients with back or Insurance Company paid $247 million for compensable back leg pain have led to improved treatment of those in whom a specific diagnosis was possible. Unfortunately, this group remains the minority of patients who are evaluated for low back 105 or leg pain. Complex psychosocial issues, depression, and 95 secondary gain are but a few of the nonanatomical problems that must be considered when evaluating these patients. In 85 addition, the number of anatomical causes for these symptoms 75 has increased as our understanding and diagnostic capabilities 65 have increased. In an attempt to identify other causes of back 55 pain Mooney and Robertson popularized facet injections, thus ays (per year) 45 resurrecting an idea proposed originally in 1911 by Goldthwait. d 35 Smith et al. in 1963 approached the problem by suggesting a ion ll 25 radical departure in treatment—enzymatic dissolution of the Mi disc by injection of chymopapain. Although this technique is 15 still used in Europe, it rarely is used in the United States 5 because of medicolegal concerns. The anatomical dissections and clinical observations of 55 60 65 70 75 80 85 90 95 Kirkaldy-Willis and associates identified pathological pro- Year cesses associated with or complicating the process of spinal Fig. 39-1 Forty-year trends in chronic low back disability. aging as primary causes of disc disease. Additional information United Kingdom statistics for sickness and invalidity benefits for about this process and its treatment continues to be collected. back incapacities from 1953-1954 to 1993-1994 (based on A thorough and complete history of all aspects of lumbar statistics supplied by the Department of Social
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