Back PainHerniated Disc

Acute Intervertebral Disc Herniation



  • Axial or radicular pain occurs following an acute injury to the intervertebral disc.
  • May be due to trauma, lifting injuries, or idiopathic.
  • Cervical, thoracic uncommon
Legs of a person lying on the road after a motorcycle and car accident



National incidence of herniated nucleolus pulposus is 1.7%.

  • Majority occur in lumbar region (95% L4–L5 or L5–S1).
  • Second most common occur in cervical region (C5–C6, C6–C7 most common).
  • Thoracic region accounts for only 0.15% to 4.0 % of cases.
Lumbar vertebrae L4



  • 4.8% males older than 35 experience sciatica during their lifetime.
  • 2.5% females older than 35 experience sciatica during their lifetime.
  • Of all individuals, 60% to 80% experience back pain during their lifetime.
    • In 14%, pain lasts more than 2 weeks.
    • Generally, males have a slightly higher incidence than females.

Risk Factors


  • Familial link to discogenic low back pain, no HLA correlation
  • May be congenital link to herniation
  • May be genetic link to disc degeneration in twins’ studies


  • By late 20s and early 30s, nucleus pulposus loses vascular supply and dehydration/degeneration begins.
  • Acute radiculopathy is caused by prolapse of a sequestered fragment of disc through a tear in the annulus fibrosis.
  • Herniations, often posterolateral, incite intense irritation of nerve roots and increases in local inflammatory mediators such as proteinases, nitric acid, phospholipase A2, prostaglandin E2, and IL-6.
  • Lateral (foraminal) herniations result primarily in nerve root compression and radicular symptoms.
  • Dorsolateral herniations may compress the exiting nerve root and create a combination of radicular pain and motor weakness.
  • Midline herniations produce primarily myelopathy.
back pain alone man


  • Minor trauma, such as lifting, bending, twisting, and vigorous athletic maneuvers, are implicated.
  • Major trauma, such as motor vehicle accidents, falls, and industrial accidents, may result in herniation, especially with vertebral fractures.
  • Injury may result after no identifiable traumatic event.
  • Often occurs in the early hours of the day, after extended periods in recumbent position while sleeping.


Signs and Symptoms


  • The history and differential diagnosis for a complaint of back pain and/or leg pain is complex.
  • Generally, acute herniation is more common in younger populations.
  • Patients may have a history of either back or neck pain with periodic exacerbations, or may have no history at all.
  • A precipitating event or trauma often occurs, and the patient may develop symptoms immediately or gradually over several days.
  • Some patients will report a “pop.”
  • Complaints range from isolated back, thoracic, or neck pain, to very specific radicular pain in a single nerve root distribution. Pain often is described as sharp, shooting, or stinging. Knowledge of radiation patterns is critical to accurate assessment.
  • Patients may complain of paresthesia and weakness. Symptoms often exacerbated by maneuvers that increase intraspinal or intradiscal pressure such as Valsalva, coughing, sneezing, and defecation.
  • Pain often improves while supine or when activity decreases. Complaints of associated muscle spasm are common.
  • Suspect cauda equina syndrome with complaint of progressive weakness, difficulty with urination, increased frequency, overflow incontinence, perianal numbness, saddle dysesthesia, and loss of rectal tone; these cases require immediate surgical referral.

Physical Exam

  • Comprehensive musculoskeletal and neurologic exam is mandatory.
  • In lumbar injuries, inspection and gait analysis may demonstrate affected leg in flexed position, with patient listing away from the side of the irritated nerve root.
  • Antalgic gait, with quick transfer of weight away from affected side, is seen.
  • Evidence of motor weakness can be seen.
  • Marked reduction in range of motion is common in cervical and lumbar regions, with loss of lumbar lordosis due to spasm.
  • Tenderness to palpation, hyperesthesia, tenseness is present.
  • Muscular atrophy may be present.
  • Positive straight leg raise for lumbar, radicular pain on cervical foraminal compression (Spurling sign) maneuvers seen.
  • Neurologic examination demonstrates weakness or loss of sensation to cold and sharp stimulus in corresponding nerve root distributions.


Note: Nerve root involvement usually is seen below the level of herniation. Example: L4–L5 herniation affects L5 nerve root.

a sagittal cut of magnetic resonance image showing lumbar disc herniation at L5/S1 level causing low back pain and sciatica

Interventional Diagnosis

Selective nerve root injection with local anesthetic may help establish diagnosis of radiculopathy in cases where history, imaging, and electrodiagnostic testing is unclear.



  • MRI with and without gadolinium contrast
  • CT myelogram in patients with MRI contraindication
  • Axial CT scan
Cervical disc herniation
Cervical disc herniation

Diagnostic Procedures/Surgery

EMG/nerve conduction studies for radiculopathy, minimum of 14 days after symptoms begin.

Differential Diagnosis

  • Mechanical pain
  • Discogenic pain
  • Myofacial pain
  • Spondylosis/spondylolisthesis
  • Spinal stenosis
  • Abscess
  • Hematoma
  • Discitis/osteomyelitis
  • Mass lesion/malignancy Myocardial infarction
  • Aortic dissection

Medication (Drugs)

First Line

  • Nonsteroidal anti-inflammatories (NSAIDs)
  • Acetaminophen
  • Tramadol
  • Mild opioids for short-term use only Muscle relaxants
Tylenol Side Effects

Second Line

  • Oral corticosteroid taper
  • Gabapentin
  • Tricyclic antidepressants



Mental Health/Behavioral

  • Identification and treatment of cormorbid mood disorders
  • Adjustment and adaptation to injury state, to reduce further injury and optimize activity status
  • Education regarding appropriate pacing of activities and avoidance of prolonged rest


Special Therapy

Complementary and Alternative Medicine



  • Generally good
  • Worse prognosis if symptoms persist after conservative measures are employed
  • Risk of permanent nerve injury if progressive weakness is not addressed surgically

Issues for Referral

Referral to pain physician or surgeon if conservative measures fail.


  • Permanent nerve injury
  • Cauda equina syndrome
  • Paralysis
  • Chronic pain


Related Articles

Leave a Reply

Your email address will not be published. Required fields are marked *

Back to top button