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CHAPTER 43/NONOPERATIVE TREATMENT / 433
All spinal movements were markedly restricted. Forward
flexion was arrested by pain with fingertips reaching
above the knees. Extension was limited to less than 50%.
Sensation was impaired over the L5 distribution into the
region of the posterolateral leg. In supine lying, there
was marked restriction of SLR (45°) bilaterally, with
crossover sign from the right causing left buttock pain.
Reflexes were diminished at the knees and could not be
elicited at either ankle. Low er limb perfusion w as normal.
Plain films demonstrated long-standing degenerative
changes at L4-5 with some anterior osteophytes and loss
of disc height. A large posterior central disc protrusion at
L4-5 was demonstrated on initial CT. The bony canal
dimensions were good and adjacent disc levels were satisfactory. At 4 weeks post-onset, lumbar MRI sequences
confir med the extent of the central disc herniation with
migration of disc material inferior to the L5 superior end
plate, causing compression of the ventral aspect of the
thecal sac (Figs. 43-5, 43-6). At this time the patient had
epidural steroid injection under radiologic guidance at the
left L4-5 level which resulted in marked improvement in
local and referred pain.
On review at 8 weeks post-onset, SLR was still
reduced to 45° on the left and 60° on the right. Standing
posture was normal and only a mild limp was noticeable.
Although surgery was discussed with the patient she
refused this option preferring to continue with conservative physical therapy, including hydrotherapy and antiinflammatory medications as required. Due to persisting
radicular symptoms and sleep disturbance, a second L45 epidural was given at 9 weeks achieving further good
effect. At this time forward flexion was still limited by
pain to fingertips reaching the knees. While spinal extension was reduced to approximately 75% of the expected
range for her age, SLR had increased to 60° on the left.
A repeat MRI examination at 6 months demonstrated
more than 70% reduction in the size of the central disc
prolapse (Figs. 43-5, 43-6). On review at 12 months following the injury near normal lumbar extension was
achieved and on forward flexion, fingertips reached to
mid-shins. SLR was now approximately 75° bilaterally
with negative nerve root tension signs. Subtle reduction
in sensation persisted over the lateral aspect of the left
leg.
Repeated MRI at 4.5 years demonstrated further reduction in the extent of the L4-5 disc prolapse since the 6month assessment (Figs. 43-5, 43-6). Mild reduced sensation persisted along the L5 distribution. Spinal mobility
was slightly limited although movements were pain-free.
Symptoms had reduced to a significant extent, apart from
FIG. 43-6. Axial T1- (A) and T2- (B) weighted magnetic resonance (MR) images depicting the extent of
the large paracentral disc protrusion at L4-5 resulting in marked displacement of the thecal sac. Comparison with the initial MR images clearly shows the substantial reduction in size of the disc extrusion,
particularly in the anteroposterior dimension. Note the serial changes in muscle cross-sectional area
with marked increase in the relative fatty infiltration and coincident bilateral muscle atrophy.
434 /SECTION V/SPECIFIC CLINICAL ENTITIES
occasional activity related low back pain, in parallel with
restoration of normal activity levels.
It is interesting to note that profound muscle atrophy
persists almost 5 years after this acute disc herniation at
L4-5 (Figs. 43-5, 43-6). This may in part result from
modification of the patient’s occupation and functional
activities to accommodate the requirement for more conservative spinal loading during the postinjury period.
SUMMARY
Epidemiologic and clinical studies show the potential
for the majority of IVD prolapses to regress naturally
over time with conservative management alone. In carefully selected patients with sciatica due to lumbar HNP
that fail to resolve with conservative care, there is good
evidence that surgical discectomy achieves effective clinical relief of symptoms; although the scientific evidence
on the optimal timing for surgery is limited. Even less
clear is the balance of risks associated with delayed intervention, of relative complication rates over the intermediate years following disc injury, and of the longer term
clinical outcomes due to the natural history of nonoperated disc herniation.
The immediate challenge is to improve the planning
and execution of controlled trials of nonoperative management, with particular attention to areas such as
blinded assessment, randomization, follow-up period, and
the use of discriminating clinical outcome measures. Perhaps the single major need is to support longer-term
reviews into the lifetime natural history of disc disease,
including HNP, which can then be referenced to specific
diagnostic groups. In this regard, the work of Boos et al.
(38) in differentiating the characteristics of symptomatic
HNP appears helpful.
Nonoperative management of disc herniation can
result in successful resolution of symptoms in a large proportion of individuals although the time course to initial
recovery may be variable and longer than that achieved
with early surgery. While the late results appear similar,
the operated cohort may be more disposed to subsequent
mechanical back pain (43). The initial evaluation for serious pathology and monitoring for the onset of significant
complications, such as neurologic defects, progressive
cauda equina syndrome, or refractory pain, are critical in
the optimal management of disc herniation. The recommendation for a conservative strategy should persist
because a large number of operations performed currently are unnecessary when the late outcomes and morbidity following surgical intervention are considered
(43,50).
In the absence of clear indications for surgery, conservative management, at least for the first 2 months, is recommended to determine the initial progression of the
problem.
In this regard, careful education of each patient is
mandatory as is the patient’s involvement in the decisionmaking process (84–86). Further, clinical education models employing decision leaders can positively influence
surgical intervention patterns (87).Throughout the often
prolonged rehabilitation following HNP, biopsychosocial
issues need to be considered. Acknowledgment that
perseverance is necessary is important when counseling
patients to consider a conservative rather than an operative strategy.
ACKNOWLEDGMENTS
We gratefully acknowledge the input of Dr. Swithin
Song, MD, head of the MRI Unit, Department of Radiology and Mr. Peter Woodland, FRACS, spinal surgeon, Sir
George Bedbrook Spinal Unit and the Department of
Orthopaedics at Royal Perth Hospital.
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CHAPTER 44
Operative Treatment of Disc Herniation: Natural History and Indications for Surgery
Charles G. Greenough
In 1985, Frymoy er and Donagh y (1) reported the 50-year
follow-up of a case of surgical treatment of lumbar disc
herniation. This was a 25-y ear -old man with a 2-year history of left leg pain, commencing after a skiing accident.
On examination the straight leg raise was 25 de grees and
the ankle jerk was absent. A myelogram (Lipiodol) was
negative, the cerebrospinal fluid protein was 108 mg
with a pressure of 145 mm HG and there was a slow rise
with jugular compression. Operation was undertaken
with osteotomy of the spinous processes and left hemilaminectomies from L2-S1. The dural sac was opened
and no abnormalities were seen. Beneath the sheath of
the L5 root, a 1-cm nodule was found arising from disc
L5-1, which was excised. The patient required transfusion. He was discharged in a brace 19 days following
surgery. Fourteen years later he presented with recurrent
leg pain that responded to conservative treatment. A further episode of leg pain occurred 19 years later; at 50
years he was symptom free. The excised specimen was
originally reported as a chondroma, but the pathologist
then remarked on the lack of cellular material and was
able to make the correct diagnosis after comparison with
sections of normal disc material.
“K.N. is of particular interest as he is the first patient
in whom a ruptured intervertebral disc was recognized as
such and as a cause of sciatica. Therefore, he is the man
who started all the damn trouble” (2).
Excision of lumbar disc herniation is the most common spinal operation undertaken and, with precisely
defined indications, one of the most successful.
Prolapsed intervertebral disc is rare in adolescents and
most common in the third, fourth, and fifth decade. Usually occurring at L5-S1 or L4-5, the prolapse most often
consists of nuclear material and is frequently unilateral
within the central canal. Commonly the root exiting
immediately below the affected level is involved, the
direct pressure leading to root dysfunction (loss of sensation or motor power), and the inflammation leading to
radicular pain. Urgent referral is indicated for bowel or
bladder disturbance
ASYMPTOMATIC DISC PROLAPSE
The correlation of radiologic findings to clinical symptoms and examination findings is vital. The incidence of
asymptomatic disc prolapse in the lumbar spine is significant and without careful clinical correlation, the surgeon
may make the mistake of operating on purely archeological findings.
Boden et al. (3) noted the presence of asymptomatic
lumbar disc prolapse on magnetic resonance imaging
(MRI) in 20% of subjects under 60 and in 36% of subjects over 60. These findings were conf irmed by Jensen
et al. (4), who noted protrusion in 27% of 98 volunteers
and one patient with extruded disc. Boos et al. (5) examined a cohort of subjects matched by age, sex, and work
intensity to a group of patients who presented with symptomatic disc prolapse. These asymptomatic matched subjects were found to have abnormalities in 76% of the 46
volunteers, 27 volunteers had a protrusion and three an
extrusion. Therefore, it is clear that radiologic disc prolapse is common, particularly in subjects whose work
environment is associated with an increased incidence of
prolapsed intervertebral disc.
Follow-up of patients with asymptomatic disc prolapse
has been undertaken. Boos et al. (6) followed 41 of their
original 46 matched volunteers for a period of 5 years. At
follow-up the subjects underwent MRI scanning and
completed a questionnaire. There was almost no change
in the radiologic classification of the disc prolapse (Tab le
44-1). Magnetic resonance images also were assessed for
severity and at follow-up 31 out of 41 subjects were rated
437
438 /SECTION V/SPECIFIC CLINICAL ENTITIES
TABLE 44-1. Asymptomatic disc prolapse, progression
over 5 years
Baseline Follow-up
No prolapse 11 11
Protrusion 27 26
Extrusion 3 4
Neural compromise 29 29
Source: Adapted from Boos N, Semmer N, Elfering A, et
al. Natural history of individuals with asymptomatic disc
abnormalities in magnetic resonance imaging: predictors of
low back pain-related medical consultation and work incapacity. Spine 2002;21:1484–1492, with per mission.
the same and 10 rated radiologically worse. However,
multiple regression analysis of these subjects indicated
that presence or absence of asymptomatic disc prolapse
or its type and extent had no predictive value for duration
of low back episodes during the follow-up period, for
consultations with health care professionals for low back
pain or time off work. These findings were corroborated
by Borenstein (7), who performed a 7-year follow-up of
50 subjects with a symptomatic disc prolapse. During the
follow-up period, 20 reported low back pain; in seven
patients this was a duration of more than 7 weeks. However, no correlation was found with the MRI appearances.
Thus, it appears that asymptomatic disc prolapse is not
only relatively common, but when present does not
appear to progress significantly over time in the majority
of subjects. Therefore, it is not clear why some disc prolapses are symptomatic and others are not. Recently an
intriguing hypothesis has been suggested by a research
group in Birmingham, England. Stirling et al. (8) made
use of an enzyme-linked immunosorbent assay (ELISA)
incorporated with lipid S antigen, an antigen that is present in the cell wall or membrane of gram-positive cocci.
This assay has already been established in gram-positive
bacterial endocarditis and other deep-seated staphylococcal infections. The assay was being investigated for suitability in diagnosing and monitoring spinal infection.
However, an unexpectedly high incidence of positive
results was found in a group of disc prolapse patients who
had been used as controls. In a formal trial, 108 patients
undergoing surgery for prolapsed intervertebral disc were
studied. Forty-sev en positive cultures were obtained from
excised disc material taken under the strictest of aseptic
precautions. Nineteen patients were found to have a positive immunolo gic assay (Table 44-2). There was a significant association between positive culture and positive
assay (p < 0.01). The bacteriologic species cultured are
given in Table 44-3. Although these f indings need to be
replicated in other centers, it remains possible that at least
some cases of symptomatic disc prolapse are related to
subclinical bacteriologic infection.
Turning to the natural history of symptomatic disc prolapse some information is available. In 1992, Gogan and
TABLE 44-2. Immunological assay
Culture→ Positive Negative Total
Serology
↓
Positive 13 6 19
Negative 34 55 89
TOTAL 47 61 108
Source: Adapted from Stirling A, Worthington T, Mathur K,
et al. Association between sciatica and skin commensals.
Presented at the Annual Meeting of the Society of Back Pain
Research, Manchester, UK, 2001, with permission.
Fraser (9) perform a randomized control of Chymopapain
against placebo (saline injection) for prolapsed intervertebral disc. Thirty subjects were injected with saline.
Twenty-six of these subjects were reviewed at 10 years;
approximately half subsequently underwent surgery (10).
Of the remaining 12, six were symptom free at review,
four were significantly improved, and two were not
improved.
In his seminal paper, Weber (11) found that in patients
with radiologically proved disc prolapse, 70% reported
decreased pain and 60% returned to work within 4 weeks
during initial conservative management. Further, on
long-term (10-year) follow-up, they were able to show
that patients with good long-term results with conservative therapy had demonstrated signif icant improvement
within 3 months of onset. This study remains the only
controlled trial of surgical intervention against conservative therapy. A group of 126 patients with proved disc
prolapse and “uncertain indications” for surgery was
defined. Of these 66 were allocated to conservative treatment and 60 were treated surgically. Of the randomized
subjects at 1 year, those allocated to surgical treatment
were significantly better. At 4 years, improvement was
still noted but less marked and statistically nonsignificant. At 10 y ears, the results w ere identical. This trial may
be criticized on a number of grounds, particularly
because there was no blinding and a crossover of some
26% of the conservative group to surgery in the first year.
However, it did provide evidence that surgery may
improve the outcome in the short term. Subsequently it
TABLE 44-3. Positive cultures (47 cases)
Propionibacterium acnes 29 (62%)
Coagulase negative staphylococcus 8 (17%)
Propionibacterium + CNS 6 (13%)
Mixed CNS 1 (2%)
Coryne Prop. 1 (2%)
Coryne sp./micrococcus 1 (2%)
CNS, central nervous system.
Source: Adapted from Stirling A, Worthington T, Mathur K,
et al. Association between sciatica and skin commensals.
Presented at the Annual Meeting of the Society of Back Pain
Research, Manchester, UK, 2001, with permission.
CHAPTER 44/ NATURAL HISTORY AND INDICATIONS FOR SURGERY / 439
was estimated by Malter et al. (10) that operative treatment for lumbar disc prolapse provided 5 months of
healthy life as compared with conservative treatment.
Hakelius (12) retrospectively examined 583 patients
with sciatica. He noted that surgically treated patients had
a better result initially but this advantage over conservatively treated cases was not demonstrable at 6 months.
However, at 7 years the conservatively treated group had
more back pain, recurrences, and time lost from work.
Radiologic appearances also can change with time, but
not consistently (13,14). Delauche-Cavallier et al. (13)
performed repeat scans at 12 months and found that in 21
patients with disc prolapse, five had completely disappeared, five had undergone major reduction, four minor
reduction, and no significant change was observed in
seven. At 1 year, Matsubara found the size of the herniation decreased by more than 20% in 11 patients (34%), by
10% to 20% in eight (28%), and was unchanged in 12
(38%). Even after treatment, in some cases the radiologic
appearance remains unchanged. Fraser et al. (15) rescanned 39 patients 10 years after therapy. Twelve had
been treated by saline injection alone, 14 by chemonucleolysis alone, and 13 had subsequently required laminectomy for a failed intradiscal injection. The signal of the
treated disc was absent in all cases in each group. Thirtyseven percent of patients were found to have a persistent
herniated disc and the incidence was similar in all three
treatment groups. The presence or absence of radiologic
herniation at 10 years had no significant bearing on a successful outcome.
Not all patients who recover spontaneously go onto
have permanent improvement. Following the f irst attack
of sciatica, some 5% of subjects experience a recurrent
attack. Following the second attack, the incidence of
recurrence rises to 20% or 30%, and following the third
or subsequent attack, recurrence occurs in 70% of
patients (G. Findlay, personal communication).
a satisfactory method of investigation. It is important that
scanning is undertaken from pedicle to pedicle rather
than simply at disc space level to ensure sequestrated
fragments are visualized. There is no place for myelography, radiculography, or discography in the diagnosis of
prolapsed lumbar intervertebral disc.
CLINICAL INDICATIONS FOR SURGERY
Increasing Neurologic Def icit
If neurologic deficit is progressive, then intervention is
indicated.
General indications for surgical intervention in herniated lumbar discs are well understood. Disc excision
surgery is far most successful in relieving leg pain than
back pain. It has been outlined in the preceding that the
natural history in this condition is favorable; 70% report
decreased pain and 60% have returned to work within 4
weeks of the onset of symptoms. This is not dependent on
the size or location of the prolapse radiologically. Longterm success with conservative management is indicated
by substantial improvement within 3 months. Except in
the case of profound motor deficit, there is little indication for operative intervention within 6 w eeks of the onset
of symptoms. Further, little improvement may be
expected in patients with neurologic deficit that is pain
free, because neurologic recovery is unusual.
The criteria of Macnab or “the Rule of Five” (16) have
withstood the test of time and still remain the gold standard for indications for disc excision surgery (Table 44-
4).
Careful examination is required to confirm the presence of neurologic deficit and sciatic tension signs
according to Macnab’s criteria. Muscle spasm and spinal
tilt do not add independent prognostic significance.
TECHNICAL INDICATIONS
DIFFERENTIAL DIAGNOSIS
Differential diagnosis in the spine includes conus and
cauda equina lesions, infection at the vertebral body or
disc, arachnoiditis, and intracanal neoplasia. Extraspinal
differential diagnosis includes peripheral vascular disease, gynecologic conditions, orthopedic conditions (e.g.,
osteoarthritis of the hip or sacroiliac disease), neoplasia
involving the lumbosacral plexus, mononeuropathy, conditions involving the sciatic nerve itself, and shingles.
INVESTIGATION
Magnetic resonance imaging is the tool of choice
today. Computed tomography scanning may be used but
lesions outside the area actually scanned cannot be visualized (e.g., cauda equina lesions). With exact concordance of CT findings with clinical findings, CT remains
Technical factors had been thought to influence the
results of surgical procedure for prolapsed lumbar intervertebral disc, and thus had been relative indications for
surgery. The size of the prolapse and presence of spinal
TABLE 44-4. The “rule of five”
2 Symptoms 1 Leg pain, greater than back pain
2 Specific neurologic symptoms
(paraesthesia)
2 Signs 3 Straight leg raising <50% of
normal or positive crossover test
or positive bowstring test
4 Two of four neurologic signs
(altered reflex, wasting,
weakness, sensory loss)
1 Investigation 5 Positive concordant imaging
Source: Adapted from McCulloch J, Macnab I.Sciatica and
chymopapain. Baltimore: Williams & Wilkins, 1983.
440 /SECTION V/SPECIFIC CLINICAL ENTITIES
TABLE 44-5. Results of surgical discectomy
Facet Joint No Facet Joint
Degeneration Degeneration
Excellent 3 23
Improved 5 15
Poor 5 3
p <0.01.
Source: Adapted from Jensen TT, Overgaard S, Thomsen
NO, et al. Postoperative computer tomography three months
after lumbar disc surgery, a prospective single applicance
study. Spine 1991;16:620–622, with per mission.
stenosis were felt to have an important influence; the
larger the prolapse or the smaller canal, the worse the
results (17,18). More recent studies in large patient
groups, however, have failed to conf irm these f indings.
Van Leeuwen et al. (19) could not find any predictive
value in the size of the herniation or dimensions of the
spinal canal in patients treated by chemonucleolysis. In a
large study of 148 patients, Garreau (20) made a careful
analysis of type and size of herniation and the shape and
size of the spinal canal. The overall dimensions of the
canal were examined together with the shape and size of
the lateral recess. They were unable to demonstrate any
relationship of canal size or hernia size with the results of
chemonucleolysis. Thus, the radiologic size of the prolapse does not appear to constitute an indication for
surgery.
Jensen et al. (21) reported no association of postoperative results with epidural fibrosis or appearance of residual or recurrent disc prolapse. Howe v er, they were ab le to
demonstrate an association of overall result with facet
joint degenerative disease (Table 44-5).
TABLE 44-6. Results of surgical management of discectomy
Compensation Non-compensation
Excellent 3 31
Good 7 68
Fair 20 43
Poor 35 29
p <0.001.
Source: Adapted from Tregonning GD, Transfeldt EE, McCulloch JA, et al. Chymopapain versus conventional surgery for
lumbar disc herniation. 10-year results of treatment. J Bone
Joint Surg (Br) 1991;73-B:481–486, with permission.
percent of the variance was explained of which imaging
studies contributed to 26%. Neurologic signs and sciatic
tension signs were much less predictive at 8% and 5%
respectively. However, the clinical result was overwhelmingly predicted by the personality factors. Total variance
explained all four factors were 40%, of which personality
factors contributed 26%. Imaging studies contributed 10%,
but neurologic signs and sciatic tension signs contributed
only 3% and 1%, respectively.
Another large study by Junge et al. (23) examined a
large number of possible predictive factors. The factors
that in his analysis were of prognostic signif icance, however, did not include specific examination findings or
investigations. Eighty percent of good and poor results in
this study were predicted by ph ysical mobility, pain intensity, other pain locations, compensation, and socioeconomic group. They found no prognostic signif icance in
age or sex, sciatic tension signs or imaging appearances.
In 1991 Tregonning et al. (24) found the presence of a
compensation claim had a significant impact on the overall results (Table 44-6).
PATIENT-RELATED INDICATIONS
Patient-related factors also provide important modifiers
to the indications for surgery, because they appear to have
significant influence on the outcome of surgery. In a wellconducted study, Spengler et al. (22) examined the influence of neurologic signs, sciatica tension signs, personality
factors, and imaging studies on the outcome of surgical
discectomy. Careful ev aluation of the history, examination,
and investigation findings was performed and points were
awarded in each category according to a strictly defined
protocol. Personality factors w ere ev aluated using the Minnesota Multiphasic Personality Inventory. Overall, the preoperative assessment scores were highly predictive of the
surgical outcome. Forty-seven patients with good results
had a mean preoperative score of 86, whereas four patients
with fair results had a preoperative score of 73 and 10
patients with poor results scored only 62. However, more
detailed analysis revealed different contributions of the
four factors to the overall outcome. The best predictor of
the operative findings was the imaging studies. Thirty-nine
ADMISSION AND POST OPERATIVE CARE
The management of patients during the operative treatment has also been studied. A number of reports have
examined the performance of micro-discectomy under
day case conditions (25-28). One case series has also
been reported examining fenestration and discectomy
without a microscope undertaken as a day case (29).
Recently a prospective randomized controlled trial has
further examined the use of day case management in conventional fenestration and discectomy surgery (30).
Patients were randomized to day case surgery or to
overnight admission. All patients were admitted on the
day of surgery. Significant advantages in mobility on the
day of surgery, daytime hours spent in bed on the first
post-operative day and walking distance at two weeks
were demonstrated. Patient’s opinion of the length of stay
was good. No increase in complications was noted. Thus,
there is evidence that conventional fenestration and discectomy surgery for prolapsed lumbar intervertebral disc
may be safely and with benefit undertaken as a day case.
CHAPTER 44/ NATURAL HISTORY AND INDICATIONS FOR SURGERY / 441
Postoperative management of patients undergoing surgical treatment for prolapsed intervertebral disc is also
controversial. Fear of recurrence, re-injury, or instability
has lead to the suggestion of several post operati v e protocols to restrict activity. However, a study by Carragee et
al, (31) has indicated that these may not be necessary. In
this study, patients were allowed to determine their own
levels of activity post operatively and no postoperative
restrictions were imposed. All were urged to return to full
activity as soon as possible. The mean time from surgery
to return to work was 1.7 weeks and 25 percent of
patients returned to work the following day. 97 percent of
those working at the time of surgery returned to full duty
by eight weeks. At two years, no patient had changed
employment because of back or leg pain. Recurrent disc
prolapse occurred in six percent (three patients) of whom
one required surgical intervention. Thus when freed from
restrictions imposed by health care professionals, patients
returned to activities and work much more rapidly and in
apparent safety. Magnusson et al (32) have found no
rational basis for lifting restrictions after lumbar spine
surgery.
In a recent review of rehabilitation after lumbar disc
surgery (33) the authors found strong evidence that intensive exercise programs commencing 4 to 6 weeks following surgery were more effective in improving functional
status and produced a faster return to work as compared
to mild exercise programs (34, 35). However, there was
also strong evidence that this influence was not maintained into the long-term. No evidence was found of the
effectiveness of supervised training as compared with
home exercises. There was also no strong evidence of the
effectiveness of multi-disciplinary rehabilitation over the
usual care. Limited evidence indicated that exercises
were more effective in improving low back function status than physical agents, joint manipulations, or no treatment.
CONCLUSIONS
Surgery for prolapsed intervertebral disc is principally
indicated on clinical grounds. The radiologic appearances
do not appear to add significant independent predictive
value but patient-related factors are important.
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