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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ahmad Muneeb, MBBS[2] Synonyms and keywords: Intervertebral Disc Displacements; Disc Displacements, Intervertebral; Disc Displacement, Intervertebral; Intervertebral Disk Displacements; Disk Displacements, Intervertebral; Disk Displacement, Intervertebral; Intervertebral Disk Displacement; Disks, Prolapsed; Slipped Disk; Disk Prolapse; Discs, Slipped; Herniated Disks; Slipped Discs; Herniated Disc; Disks, Slipped; Disk, Prolapsed; Prolapsed Disk; Disc, Slipped; Prolapses, Disk; Slipped Disc; Discs, Prolapsed; Discs, Herniated; Prolapsed Discs; Disks, Herniated; Disk, Herniated; Herniated Disk; Prolapse, Disk; Disk Prolapses; Prolapsed Disc; Disc, Herniated; Disc, Prolapsed; Slipped Disks; Disk, Slipped; Herniated Discs; Prolapsed Disks

Overview

Intervertebral disk slip consists of 2 main parts, nucleus pulposus the central part, and annulus fibrosus the peripheral part. Intervertebral disc slip occurs when nucleus pulposus protrudes through annulus fibrosus. Most commonly disc slip is caused by degenerative changes and traumatic insults to the spine. Although, disc herniation can occur in any part of the vertebral column but lumbar disc slips are far more common than disc herniations in other parts of the spine. Males, obese, smokers and heavy weight lifters are at increased risk of developing disk slip. Clinical features of the disk slip vary depending upon the location and presence or absence of nerve impingement. Common clinical features include back pain, pain radiating to upper or lower extremity, motor weakness, numbness or tingling, absent deep tendon reflexes. MRI and CT scan have excellent sensitivity in diagnosing intervertebral disc slip. Conservative management starts with lifestyle modifications and medical therapy. Most of the patients get pain relief with conservative management. For severe or persistent cases surgical management can be used.

Historical Perspective

Classification

  • Bulging: Disc margins extend beyond vertebral endplate margins.
  • Protrusion: Nucleus pulposus impinges on annulus fibrosus, posterior longitudinal ligament stays intact.
  • Extrusion: Nucleus pulposus extrudes through the annulus fibrosus, posterior longitudinal ligament stays intact.
  • Sequestration: Posterior longitudinal ligament is compromised. Nucleus pulposus extrudes through the annulus fibrosus and posterior longitudinal ligament into epidural space.

Pathophysiology

Causes

Disc slip may be caused by age-related degenerative changes, systemic inflammatory processes, vertebral trauma, sudden vertebral strain, twisted movement of the spine, connective tissue disorders. [9] [10]

Differentiating intervertebral disc slip from other Diseases

Epidemiology and Demographics

  • The incidence of intervertebral disc slip is estimated to be [5-20] cases per 1000 individuals annually. In case of lumbar disc slips, 95% of the herniations in patients aged between 25 to 55 occur at L4-L5 or L5-S1 level. In case of cervical spine, C6-C7 disc is most commonly herniated.[12] [13]

Age

Gender

Race

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Criteria

There are no specific diagnostic criteria for intervertebral disc slip.

History and Symptoms

  • Symptoms of Intervertebral disc slip depend upon the site and extent of the slipped disc and are present in the are supplied by the compressed nerve. They may include the following[10][17]:

Lumbar disc slip

Cervical or thoracic disc slip

Physical Examination

  • Physical examination findings depend upon the nerve root compressed and maybe remarkable for[11]:

Laboratory Findings

Electrocardiogram

There are no ECG findings associated with intervertebral disc slip.

X-ray

There are no x-ray findings associated with intervertebral disc slip. However, an x-ray may be helpful in detecting other etiologies causing similar symptoms like fractures, abscesses, tumors, bony spurs etc.

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with intervertebral disc slip.

CT scan

CT scan may be helpful in the diagnosis of intervertebral disc slip. Like MRI, CT scan also provides a detailed view of the spinal canal and its contents, thus it can detect disc slip along with its extent and location.Findings on CT scan suggestive of intervertebral disc slip include bulging of intervertebral disc, nerve root compression, and spinal cord compression. [10] [18]

MRI

MRI may be helpful in the diagnosis of intervertebral disc slip, as it is considered the gold standard for the diagnosis of this disorder. MRI has an excellent capacity to visualize all the soft tissues including the spinal cord, and nerve roots thus it can easily detect bulging intervertebral disc and also if there is any compression of nerve root or spinal cord. MRI is also very helpful in ruling out other differentials.[18][10]

Other Imaging Findings

Myelogram may be helpful in the diagnosis of intervertebral disc slip. It is a modified x-ray technique in which the spinal canal is visualized after injection of a contrast material. It can show if a slipped disk is compressing a nerve root or spinal cord

Other Diagnostic Studies

Electromyogram and nerve conduction studies may be helpful in the diagnosis of intervertebral disc slip. These tests assess the response of nerve or muscle to electric stimulation. They can reveal if there is any nerve damage or compression as a consequence of slipped disk.[10][18]

Treatment

Certain non-pharmacologic treatments and lifestyle modifications can be used before any pharmacologic treatment is done. They include maintenance of activity level that is painless, physiotherapy, avoidance of any activity that incites pain, avoidance from lifting heavy weights, weight control, use of spinal support, spinal massage, spinal manipulation, spinal traction, heat or ice application.

Medical Therapy

Surgery

Prevention

References

  1. Truumees E (June 2015). "A history of lumbar disc herniation from Hippocrates to the 1990s". Clin. Orthop. Relat. Res. 473 (6): 1885–95. doi:10.1007/s11999-014-3633-7. PMC 4418987. PMID 24752913.
  2. Alemo S, Sayadipour A (September 2010). "Sources and patterns of pain in lumbar disc disease: revisiting Francis Murphey's theory". Acta Neurochir (Wien). 152 (9): 1555–8. doi:10.1007/s00701-009-0315-4. PMID 19404576.
  3. Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, Singer DE (August 1996). "The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica". Spine. 21 (15): 1777–86. doi:10.1097/00007632-199608010-00011. PMID 8855462.
  4. "Disc Herniation - Physiopedia".
  5. Kadow T, Sowa G, Vo N, Kang JD (June 2015). "Molecular basis of intervertebral disc degeneration and herniations: what are the important translational questions?". Clinical Orthopaedics and Related Research. 473 (6): 1903–12. doi:10.1007/s11999-014-3774-8. PMC 4418989. PMID 25024024.
  6. 6.0 6.1 Mayer JE, Iatridis JC, Chan D, Qureshi SA, Gottesman O, Hecht AC (March 2013). "Genetic polymorphisms associated with intervertebral disc degeneration". The Spine Journal : Official Journal of the North American Spine Society. 13 (3): 299–317. doi:10.1016/j.spinee.2013.01.041. PMC 3655694. PMID 23537453.
  7. Colombier P, Clouet J, Hamel O, Lescaudron L, Guicheux J (March 2014). "The lumbar intervertebral disc: from embryonic development to degeneration". Joint Bone Spine. 81 (2): 125–9. doi:10.1016/j.jbspin.2013.07.012. PMID 23932724.
  8. Martirosyan NL, Patel AA, Carotenuto A, Kalani MY, Belykh E, Walker CT, Preul MC, Theodore N (2016). "Genetic Alterations in Intervertebral Disc Disease". Frontiers in Surgery. 3: 59. doi:10.3389/fsurg.2016.00059. PMC 5116693. PMID 27917384.
  9. 9.0 9.1 "Herniated Disk in the Lower Back - OrthoInfo - AAOS".
  10. 10.0 10.1 10.2 10.3 10.4 10.5 "Herniated Disc – Symptoms, Causes, Prevention and Treatments".
  11. 11.0 11.1 Dydyk AM, Ngnitewe Massa R, Mesfin FB. "Disc Herniation - StatPearls - NCBI Bookshelf".
  12. 12.0 12.1 Fjeld OR, Grøvle L, Helgeland J, Småstuen MC, Solberg TK, Zwart JA, Grotle M (April 2019). "Complications, reoperations, readmissions, and length of hospital stay in 34 639 surgical cases of lumbar disc herniation". The Bone & Joint Journal. 101-B (4): 470–477. doi:10.1302/0301-620X.101B4.BJJ-2018-1184.R1. PMID 30929479.
  13. Jordan J, Konstantinou K, O'Dowd J (March 2009). "Herniated lumbar disc". BMJ Clinical Evidence. 2009. PMC 2907819. PMID 19445754.
  14. 14.0 14.1 "Lumbar Disk Disease (Herniated Disk) | Johns Hopkins Medicine".
  15. "Herniated Lumbar Disk - Clinical Evidence Handbook - American Family Physician".
  16. "Slipped (Herniated) Disc: Symptoms, Causes, and Effects".
  17. "Herniated disk - Symptoms and causes - Mayo Clinic".
  18. 18.0 18.1 18.2 "Herniated Lumbar Disc, low back, ruptured disc, bulging disc | Mayfield Brain & Spine, Cincinnati, Ohio".

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