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CHAPTER 42/DISC HERNIATION: IMAGING / 423
enhanced synovial
membrane of the apo-
space occupying mass
with high signal intensity
A
FIG. 42-33. A: Well delineated space occupying lesion with high signal intensity (saggital image, STIR
2000/150/20). B: After intravenous (i.v.) application of gadolinium (Gd) contrast medium, there is a
strong enhancement of the hypertrophic synovial membrane of the apophyseal joint.The synovial cyst
compresses the thecal sac (transverse image, GRE 500/7 out of phase after i.v. administration of Gd
contrast medium).
physeal joint
thecal sac
synovial cyst
B
CLINICAL RELEVANCE
As shown, there are different imaging techniques to
elucidate the pathomorphologic origin of low back pain
and sciatica. The evaluation of methods regarding accuracy and predictive value highly depends on the technical
performance (106) and the expertise of the persons interpreting the data.
A plain radiograph may show a narrowing of the disc
space, osteophytes, and calcification. Therefore, it is not
the method of choice when there are strong clinical hints
for discal herniation, and no suspicion of consuming diseases is given.
Myelography demonstrates filling defects of the thecal
sac and dural recess that may be caused by any stenosing
process (discal, spondylotic, osteoarthritic, or tumorous).
Therefore, this imaging procedure is only indicated today
when patients have metal implants.
Discography describes the internal derangement of the
discs, and rupture and herniation of the outer annulus.
Major disadvantages of discography are: invasiveness,
selectivity of examination, and no dif ferentiation betw een
subligamentous and transligamentous extrusion. It can
be combined with the pain reproduction test to locate the
painful segment. The reliability is controversial (19,21,
101,107–114). When discography is followed by CT
examination, it is possible to precisely locate the herniation and determine the form and volume of herniated
material (62,112). Because of invasiveness and inherent
risks, discography and CT discography are image procedures that are secondary to CT and MRI.
Computed tomography delineates the outer contour of
the disc as well as gas and calcification. It does not supply any information about the disc matrix. Sagittal and
coronal views are only available by reconstruction. This
demands thin contiguous axial section. Exposure to radiographs should not be neglected. Apart from MRI, this
technique is the imaging modality of choice to demon-
strate discus herniation and osseous stenosing processes,
even when subligamentous and transligamentous extensions cannot be evaluated.
Magnetic resonance images correlate well with macroscopic anatomic sections (112). However, in 13% of the
cases, discs that appear normal on MRI may show tears
on discography (71). The high-intensity zone (HIZ) (115)
does not seem to be a relevant feature for an aching disc
(116). Annulus and nucleus can be distinguished. The
location of herniation inside and outside the canal as well
as its correlation with the neurovascular structures can be
exactly identified. Subligamentous and transligamentous
extrusions are hardly ever indistinguishable. Views of the
whole lumbar spine can be taken from all angles without
any risk for the patient. To sum up, it can be said that MRI
has some advantages in comparison with CT regarding
the diagnosis of disc herniation.
One has to review the w ays that image information can
explain patients’ symptoms and therefore for m the basis
for treatment.
There is a high incidence of disc abnormalities, as
described by CT and MR examinations in asymptomatic
individuals (21,117–122).
Studies have shown that spontaneous regression of the
hernia can occur with regression of radicular pain (76,77,
90,123–129). It seems that sequestered disc material has
a greater potential for regression than extruded and protruded disc material (50). The contact of herniated material with the vascular system in the epidural space is
probably responsible for this natural course of herniation
(130–133). Therefore, conservative treatment should be
considered for at least 2 months after onset of radicular
pain (125,134–137).
The morphometric measurements and their ratios (volume or size of the herniation, diameters of the dural sac
and spinal canal), and different types of herniation are
considered for their predictive value for the outcome of
conservative or surgical treatment (137–145).
424 /SECTION V/SPECIFIC CLINICAL ENTITIES
A connection can be assumed of nerve root compression and swelling of the root and ganglia with location
and severity of leg pain (78,117,120,146–148).
For the welfare of the patient, the collaboration
between radiologists and clinicians is a sine qua non. For
this purpose, the following demands have to be accomplished:
1. The technical performance has to be optimal.
2. Disc herniation has to be exactly characterized for
morphology, location, and its relation to the neurovascular system.
3. A generally accepted nomenclature is necessary.
4. In the absence of disc abnormalities the imaging
should be able to detect other reasons to explain the
pain of the patient.
5. The results of imaging have to correlate with the
patient’s symptoms.
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CHAPTER 43
Disc Herniation: Nonoperative Treatment
Kevin P. Singer and Peter J. Fazey
“... surgical treatment of spinal disorders produces the best
results when clinical symptoms and signs are congruous and
confir med by carefully selected imaging studies, and when
they have resulted in an unequivocal diagnosis amenable to
surgical management. An additional and important caveat is
that the surgical result ought to be better than the ‘natural
history’ of the disease being treated.”
—J.W. Frymoyer, 1997
Herniations of the intervertebral disc (IVD) have probably afflicted man since earliest times, with the associated
backache entrenched within folklore. The depiction by
Luschka in 1885 of a central nuclear herniation of a lumbar IVD (1) (Fig. 43-1) is perhaps the f irst illustration of
a specific spinal pathology that continues to command
the attention of modern societies. The fact that, for tens
of thousands of years, humans have been reliant upon
nature underscores the challenge from John Frymoy er (2)
to not disadvantage the individual if the natural history of
spinal disease may be better in the long term than surgical interventions. The early clinical reports by Lindblom
and Hultquist (3), and Hakelius (4), which identified progressive recovery following sciatica, have been quantified by others using cross-sectional computed tomography (CT) and magnetic resonance imaging (MRI) (5,6).
These observations of the spontaneous regression of disc
herniations have since prompted investigation into the
physiology of this process.
The natural history of disc herniation describes a
process of resolution both of symptoms and often a
diminution of the herniation itself; which may be aided
pharmacologically through epidural steroids and nerve
root sleeve blocks or through rest and other conservative
interventions. The purpose of this chapter is to revie w the
natural history of lumbar disc herniation and principles of
nonoperative management of this clinical problem. A
case study report of the sequence to spontaneous regression of a large central disc herniation at L4-5 in a 32year-old woman is provided to illustrate the natural
course of this condition.
In the case of established herniated nucleus pulposus
(HNP) there is an abundance of literature that confers
advantage to conservative management (7). The efficacy
of nonoperative management, observed through spontaneous regression of disc herniation, has been reported not
only for the lumbar (8–10), but also thoracic (11–13) and
cervical disc herniations (14,15). Further reinforcement
for the principle of management by “watching and waiting” stems from the numerous reports of disc herniation
and related disease in a large proportion of asymptomatic
individuals.
In the 10-year controlled follow-up study reported by
Weber (16), similar patterns of neurologic recovery in
groups treated surgically and conservativ el y w ere demonstrated. In contrast, the 5-year follow-up study by Atlas et
al. (17) determined that patients with moderate or severe
sciatica, who had lower functional status at baseline,
reported better outcomes following surgery compared
with nonoperated patients. Irrespective of the extent of
the initial neurologic deficit, a trend favoring nonoperative treatment was reported by Saal and Saal (18) who
confirmed the capacity of HNP to resolve clinically without surgery or chemonucleolysis. The trend for larger herniations and sequestrated fragments to show an enhanced
capacity for regression was supported by subsequent
reports (9,19–21). Importantly, a 10-year review by
Fraser et al. (22) clearly indicated that long-term
improvement of a patient’s symptoms of HNP could
occur with or without regression of the herniation.
EVALUATION OF DISC HERNIATION
Early postmortem studies of the thoracic and lumbar
spine by Andrae (23) and Schmorl (24) indicated that
HNP was a frequent occurrence (Fig. 43-2). Since the
advent of plain radiography, a high prevalence of spinal
disease has been identified within asymptomatic individuals (25). Similarly, CT and MRI have highlighted the
extent to which advanced pathology of the IVD, includ-
427
428 /SECTION V/SPECIFIC CLINICAL ENTITIES
FIG. 43-1. Depiction of posterior disc her niation, as represented by Luschka (1) showing a nuclear fissure (reflected)
passing through the posterior anulus (A) and protruding into
the vertebral canal (B).
ing disc herniations, are present in asymptomatic study
cohorts (26–30). These observations make more difficult
the interpretation of results from diagnostic procedures
used to investigate individual patients presenting with
low back pain. According to Beauvais et al. (31), CT
imaging did not predict the outcome of lumbar IVD herniation. Although a lar ger herniation or free fragment was
found in the group with the best clinical outcome, the differences at 3 months were not significant in conferring
any prognostic value. In contrast, a review by Henmi et
al. (32), which followed the conservative management of
10 individuals with HNP, found signal intensity ratios
derived from T2-weighted MRI sequences in the acute
and late follow-up phases that predicted the pattern of
HNP reduction. These authors reported that those HNPs
with lower signals did not show size reductions.
MODEL OF DISC RESORPTION
Although the mechanisms of disc resorption remain
unclear, it has been proposed that, following HNP and its
immediate postinflammatory sequence, intrinsic hydrophilic capacity is impaired which leads to progressive
FIG. 43-2. Axial views of the thoracic (A) and lumbar (B)
cadaveric discs, depicting a midline radial fissure through the
posterior anulus with degeneration and dissication in the
nuclear region of the disc. Apart from a localized osteophyte
to the right side of the vertebral body in B, and the radial anular defect, the anulus appears relatively normal.
desiccation. End stages of the inflammatory cascade are
phagocytosis and eventual resorption (33). Larger isolated disc fragments may regress more readily given their
tendency to migrate and regress due to the inflammatory
mediated response (34,35). Fibroblast growth factor,
inducing neovascularization, appears to be one potent
source for this functional change in morphology of the
fragment (36). In a study by Bozzao et al. (37), reductions
of more than 70% were recorded for large and medium
herniations, averaged across an 11-month follow-up
period. Similar observations have been noted by Ito (7).
In an interesting study by Boos et al. (38), 22 symptomatic and asymptomatic disc herniations, matched
according to age, gender, disc le vel, and the e xtent of disc
herniation, were compared using MRI (T1 and T2 relaxation times). In the symptomatic disc herniations, significantly reduced T1 and T2 relaxation times were recorded
compared with the matched asymptomatic herniations. In
addition, the symptomatic disc herniations were associated with more advanced levels of disc degeneration.
These results suggest that symptomatic and morphologi-
CHAPTER 43/NONOPERATIVE TREATMENT / 429
cally matched asymptomatic disc herniations differ with
regard to the matrix composition of the whole disc.
An early consideration during the acute phase of HNP
is the role of epidural steroid injection, either local to the
site of the HNP, or nerve root sleeve injections (39).
Epidural steroids introduced specifically into the epidural
space adjacent to the HNP can aid the inhibition of
inflammatory mediators, moderate pain, and facilitate the
resorption process (40). Although there has been considerable debate over the years, recent reviews provide support for spinal epidurals and nerve root sleeve blocs,
respectively, as adjuncts to the conservative management
of disc herniation and radiculopathies (40,41).
DISC HERNIATION AND SURGERY
The lifetime prevalence for lumbar radicular syndrome
has been estimated at approximately 5% (42). However,
there are marked regional and international differences in
rates for surgery and conservative management of this
problem that reflect a wide range of issues (2). Candidates for surgery following lumbar disc herniation
account for a relatively small proportion of all spinal
cases. Classic indications include: cauda equina syndrome, functional weakness of the lower extremity, and
severe pain (2). In selecting surgical cases, many factors
have been found to be predictive of outcome including
unequivocal radicular symptoms and associated sensory
changes, motor weakness, and straight-leg raising (SLR)
test reduced to less than 30°, with positive tension signs
from contralateral SLR, all of which must be confirmed
by concordant positive imaging studies (43). An increasingly important consideration of presurgical screening is
the determination of psychosocial factors that can moderate the outcome (44).
While the study by Weber (16) provided evidence that
discectomy produced better clinical outcomes at 1 year,
delaying surgery in cases where indications were uncertain to monitor the natural recovery did not produce long-
term harm. The reviews by Hoffman et al. (45) and
Stevens et al. (46) reiterate the importance of careful
patient selection and confirm clinical empiricism that the
principal benefit of surgery for HNP is the rapid relief of
sciatica in those individuals who have failed to improve
under conservative care. Consideration of the state of the
involved disc as a whole may be important given the
observations by Boos et al. that symptomatic HNP cases
tended to be associated with more advanced disc degeneration (38). It is valuable to determine, during the physical examination, whether peripheral (radicular) symptoms can change to a more central location following
repeated movements (47). If symptoms can be changed
with mechanical maneuvers, such a finding should
encourage a “wait and watch” approach.
The astute clinician is able to identify salient indications
for surgery based principally upon symptomology, while
recognizing that patient preference and psychosocial indicators also play a role in determining outcomes (48,49).
PRINCIPLES OF CONSERVATIVE
MANAGEMENT
As a consequence of the burden of back pain on health
care systems, a diverse range of nonoperative management options exist. At present, not all interventions have
an established scientific basis, however this deficiency is
progressivel y changing through the impetus of systematic
reviews of published literature and randomized controlled studies into specific therapies (50). The Cochrane
Back Review Group maintains a comprehensive resource
of contemporary systematic reviews of many of these
therapeutic strategies (51), which is updated and
expanded according to the cyclic review process (46,
52–57) (Table 43-1). In addition, other published nonsystematic reviews are available from this resource (58).
The goals associated with many conservative interventions are: reduction of disability, symptomatic management of pain and gradual restoration of premorbid levels
TABLE 43-1. Selected Cochrane reviews and protocols related to spine surgery and rehabilitation (51,58)
Author (yr) Title of review
Hagen KB et al., 1999 Bed rest for acute low back pain and sciatica
Gibson JNA et al., 2000 Surger y for lumbar disc prolapse
Ostelo RWJG et al., 2000 Rehabilitation after lumbar disc surgery
van Tulder MV et al., 2000 Traction for low back pain with or without radiating symptoms
Hilde G et al., 2001 Advice to stay active as a single treatment for low back pain and sciatica
Karjalainen K et al., 2001 Multidisciplinary biopsychosocial rehabilitation for subacute low back pain among
Rozenberg et al., 1999
Faas et al., 1996
a
Nonsystematic reviews.
From Cochrane Back Review Group. Available at: http://www.cochrane.iwh.on.ca/review.htm. Accessed
October 30, 2003, with permission.
a
a
working age adults
Efficacy of epidural steroids in low back pain and sciatica; a critical appraisal by a
French Task Force of randomized trials
Exercises: Which ones are worth trying, for which patients, and when?
430 /SECTION V/SPECIFIC CLINICAL ENTITIES
of spinal motion, cardiovascular fitness, muscle strength,
motor coordination, and function. Conservative therapeutic options for the management of disc herniation are
many and mirror, in part, the strategies that are employed
for mechanical back pain, namely (a) limited bed rest,
physical therapy including exercise prescription, manual
therapy, and forms of electric stimulation for pain management; (b) local and systemic analgesic and antiinflammatory medications; and (c) holistic groupings of
rehabilitation strategies which include cognitive behavioral approaches (53).
The need to guide patients to an informed decision,
based upon careful monitoring of the severity of the clinical presentation and their tolerance of symptoms over the
first 2 months, is cr ucial to successful conservative outcome (Table 43-2). Understanding the physiologic sequelae of the natural history (7), and imparting this information objectivel y and positiv el y to the patient is essential to
optimize outcomes. The issue of psycholo gical support to
this patient group is particularly important (50,53,56,59).
This process has been likened to that of a coach motivating a patient throughout the rehabilitation program (60).
In addition to describing the expected natural history of
recovery as it relates specifically to the individual, there
is the need to provide accurate information regarding the
various progressions that the rehabilitation program will
involve (60). Such programs need to be modified according to the extent and location of the HNP. If the chosen
approach is one of a conservative rehabilitation strategy,
the patient can be encouraged to progressively avoid prolonged bed rest and to increase activity lev els within pain
limits. The role of pain and antiinflammatory medications should be explained, along with promoting an
expectation that recovery will occur, and that surgery
may not be required. Careful selection of a combination
of interventions such as manual therapy, including mobilization, manipulation and traction of spinal segments in
the involved area; active exercises for range of motion
and trunk stabilization; in addition to education concerning back care and short-term rest during exacerbations
will be necessary, along with ongoing reassurance.
According to some investigations, specific supervised
retraining of trunk stabilizing muscles appears superior to
general exercise programs in restoring spinal function
and preventing recurrence of symptoms (61,62). However, general exercise in the form of super vised gym cir-
cuits may combine elements of many of these interventions and contribute positively in terms of social interactions with others who are well.
As disc herniation is a relative contraindication to
manipulation, such forms of manual treatment are not
usually recommended, particularly at the affected intervertebral level or in the presence of protective muscle
spasm (63). However, in carefully selected individuals
screened for contraindications to manipulation, symptomatic relief can be achieved and sustained over the
medium term from such therapy (64). For example, manual traction or specific mobilization may be effective in
relieving symptoms by decreasing mechanical stress on
sensitized structures and encouraging local physiologic
responses to assist in reduction of edema and inflammatory reaction (65). Some forms of lateral flexion mobilization of the lumbar spine, popularized by McKenzie
(66), may be helpful in correcting a scoliotic list, producing improvement which may be short-lived but beneficial. Of interest are the reports that f ind certain types of
spinal manipulation can achieve marked symptomatic
relief in patients with HNP (64,67,68). Even short-term
reduction in symptoms may reassure patients that their
pain is able to be managed and , importantly, increase their
expectation of a favorable prognosis. Symptom control
will also expedite return to functional activity.
Although focusing on back pain of mechanical origin,
The Back Book (69) conveys essential conservative back
care information (48,70), which can benefit individuals
with disc herniation, particularly if additional cautions
are emphasized during the acute period according to the
severity of symptoms. The principles of such advice for
patients regarding conservative management of herniated
disc are summarized in Table 43-3.
The effect of HNP on the spinal musculature is an
important consideration of rehabilitation following injury . In parallel with pain arising from HNP marked muscle atrophy can occur, particularly in multifidus and
adjoining paraspinal muscles. This atrophy can be unilateral, associated with a specific segmental level (71), and
persist well beyond the time of injury and symptom resolution (72,73) (Fig. 43-2). Although this observation was
confirmed by Kader et al. (74) in a retrospective analysis
of 78 patients with mixed spinal symptoms, the associations between muscle atrophy, radicular symptoms,
root compression, HNP, and degenerated discs were not
TABLE 43-2. Assessment criter ia for conservative versus surgical management for herniated lumbar disc, according to SINS
Severity: Self-repor ted severity of symptoms, using a visual analog scale; confir med by responses during
Irritiability: The ease with which symptoms are aggravated and their duration, which determines physical capacity
Nature: Characteristics of symptoms in relation to local and referred pain, and symptomatic response to
Stage Is the presentation improving, stable, or progressively worsening?
examination of active and passive spinal motion, and ner ve tension testing.
and treatment options. Key indicators: intractable pain, limited range of pain-free motion and functional
activity, poor quality sleep.
compression or traction, or positioning which may caution against activity.
CHAPTER 43/NONOPERATIVE TREATMENT / 431
TABLE 43-3. Principles of patient advice regarding
conservative management of disc herniation
Be aware of the “red flags” and report them if they arise.
These include: bladder and bowel problems, progressive
increase in pain, loss of sensation, progressive peripheral
muscle weakness.
Take it easy initially.When pain is acute, rest is necessar y
but avoid prolonged bed rest.
Believe that you will get better, but be aware that it may
take several months.
Pain management is important: epidural and nerve root
sleeve injections may help.
Maintain general spinal movements, avoiding positions or
directions that increase symptoms. This will assist
recovery and not worsen the problem.
Traction or gentle passive treatment may help during
exacerbations but may offer only short-ter m relief. Active
movement and general exercise are important for the
long term.
Keep mobile without aggravating pain levels. Initial light
activity can be gradually extended to include exercises to
restore spinal muscle strength and endurance, and
cardiovascular fitness. Hydrotherapy may be helpful in
the early stages of recovery.
Minimize prolonged static weight-bearing postures.
Avoid unnecessary lifting.
Surgery may not produce better outcomes than
conservative care in the longer term. Unless “red flags”
are evident, watchful waiting may be better than early
surgery.
After 2 months of conservative management, surgery is
much less likely to be required.
Adapted from Buchbinder R, Jolley D, Wyatt M.Population
based intervention to change back pain beliefs and disability:
three part evaluation. BMJ 2001;322:1516–1520; Nachemson A. Back pain: delimiting the problem in the next millennium. Int J Law Psychiatry 1999;22:473–490; and Weinstein
SM, Herring SA. Lumbar epidural sterioid injections. Spine J
2003;3:37S–44S, with permission.
strong. The morphologic ef fects of spinal muscle damage
and atrophy following surgery and arising from other
forms of back pain have been examined in a series of
investigations (75–77). Similarly, profound effects of
deconditioning on paraspinal muscles have been docu-
mented after disc injury (78). Minimization of muscle
atrophy must be balanced with the need for adequate initial bed rest. Following the acute phase, a graduated
active exercise program, which may include hydrotherapy, should be encouraged and reinforced with education.
Restoration of muscle strength and endurance through
specific back exercises appears to be achieved initially
through neuromuscular adaptations rather than overt
changes in muscle morphology (77), which hav e a longer
time course for recovery. Abdominal stabilizing exercises
have been demonstrated to play a key role in recruitment
of muscles that sustain lumbar mechanical function
(61,79,80). Aerobic exercise is a recommended component of the rehabilitation in most cases as an aide to
restoration of trunk, spinal, and lower e xtremity musculature (60).
Effective management of pain is a very important consideration during the acute phase (Fig. 43-3), given its
profound inhibitory effect upon function and muscle
morphology (81,82). The model of structural pathology
imposing pain inhibition on joint movement, and contributing to local muscle atrophy, subsequently creating a
vicious cycle of ongoing mechanical pain and dysfunction is a well-recognized sequence for many musculoskeletal systems (83) (Fig. 43-4). Some gentle forms of
passive movement during the acute stage may also be
helpful but must be guided by the symptomatic response
of the individual with consideration of the key elements
of the severity of the clinical presentation, presented in
Table 43-2. Graduated mobilization and some forms of
manipulation for pain-induced limitation of spinal movement may be indicated in the postacute stage of rehabilitation (64,65).
The natural history of HNP is presented in the following clinical case which highlights the process of symptom
reduction and functional improvement and concomitant
changes in MR images. The rehabilitation approach in
this case included initial rest and analgesia followed by
a graduated exercise program, including hydrotherapy,
which was moderated according to symptom changes.
FIG. 43-3. Schematic representation of the interrelationship
between pain, muscle function, and cardiovascular fitness
following disc herniation. Initial chemical pain and related
inhibition can result in early and profound spinal muscle disuse (atrophy), which may contribute to decreased stability of
the involved segment(s). General deconditioning resulting
from reduced functional activity must be addressed if the
rehabilitation program is to be successful. An early focus on
pain management is important in the acute phase followed
by progressive cardiovascular maintenance exercise and
muscle endurance/strength. Unless specific muscle stabilization and strengthening protocols are implemented (A)
there is the potential for chronically inhibited and atrophic
spinal musculature (B) following herniated nucleus pulposus.
Exercise can also contribute to pain control through improved functional capacity and endurance.
432 /SECTION V/SPECIFIC CLINICAL ENTITIES
FIG. 43-4. A “vicious cycle” of pain-mediated inhibition on
the musculoskeletal system is depicted. Initial chemical pain
from the herniated nucleus pulposus produces profound suppression of motor function that may directly contribute to dramatic muscle atrophy and disturbed mechanics of the motor
segment. This compromise can induce fur ther mechanical
disruption and pain that perpetuates the cycle. (Adapted
from Young A, Stokes M, Iles JF. Effects of joint pathology on
muscle. Clin Orthop 1987;18:21–27.)
Case Study
A 32-year-old w oman presented with severe back pain,
radiating to her left buttock, posterior thigh, and lateral
leg as far as the left ankle. This followed an incident
involving shifting of frozen food products from a low
refrigerated container into storage with a time imperative
to avoid deterioration of the frozen goods. This work
required repetitive lifting in a sustained stooped posture.
Over the next 24 hours, progressive worsening of back
pain and leg symptoms forced her to stop work and seek
urgent medical attention. At no time were bladder or
bowel symptoms reported.
On physical examination, at 3 weeks following the
onset of sciatic symptoms, sitting was not tolerated and
the patient preferred to stand and move around during
interview. She reported that sleep was frequently disturbed. Static standing posture showed a list to the right.
FIG. 43-5. Sagittal T1- (A) and T2- (B) weighted magnetic resonance images depicting the extent of the
central disc protrusion at L4-5 in a 32-year- old woman.The initial imaging was performed 4 weeks after
the incident (left), with subsequent investigations at 6 months (middle)and 4 years (right), respectively .
Degenerative changes of the L5-S1 disc are also noted.