South African Medical Journal
Suid,Afrikaanse Tydskrif vir Geneeskunde
Vo!. 23, No. 21 Cape Town, 21 May 1949
HERNIATION OF THE NUCLEUS PULPOSUS IN THE LUMBAR REGION*
J. G. Du TOIT, M.B., CH.M., F.R.C.S.E.
Department of Orthopaedics, University of Pretoria, Pretoria
In the past low back pain with or without sciatic
radiation has been ascribed to a multiplicity of causes.
One author has listed about 200 possible causes
ranging from psychosomatic causes to practically any
affection of any organ from the manubrium sterni to
the tip of the coccyx. Many of these possibilities would
appear to exist more concretely in the minds of the
authors than in actual fact. Our newer knowledge
indicates that herniation of the nucleus pulposus in
the lower lumbar region is the cause of most cases of
severe sciatica and of many cases of d~sabling low
back pain.
The diagnosis of lumbar intervertebral disc protru-
sions has accordingly become very fashionable of late.
While many patients with low back pain with or with-
out sciatica are undoubtedly cured by removal of
nuclear protrusions, it would appear to be a mistake
to advocate a laminectomy in every case complaining of
sciatica and/or low backache pain. Excessive enthusi-
asm here, as in every other surgical treatment, must
inevitably lead to disillusionment.
THE CLINICAL PICTURE
On the average, a history of possible causative ante-
cedent trauma is obtained in only about 45% of cases.
In one of our cases the first symptoms came on very
suddenly while the patient was having a shower. If
a causal trauma does initiate symptoms, one usually
obtains a history of a severe back strain while the
patient was attempting to lift a heavy weight. In these
cases the patient usually develops a severe low back
pain while in the act of lifting. Sometimes the patient
is aware of a ' snap' or a tearing sensation in the lower
back. A typical story after this is that of recurring
attacks of low back pain, later radiating to the buttock
and in later attacks down the leg in the distribution
of the compressed nerve root. Occasionally the leg
* This paper was read at the South African Medical Congress
at Pretoria, July 1948.
391
Weekly 2s
radiation appeared simultaneously with the low back
pain, but in these cases closer questioning often reveals
a history of recurrent attacks of mild backache prior
to the severe attack. In the majority of cases no
definite causal trauma can be elicited.
The patient may not recover from the initial attllck,
which persists until the offending nuclear protrusion
is removed, but this is by no means the rule. Usually
there are recurring attacks with intervals of complete
or comparative freedom in between. Not infrequently
a single attack may pass off and not recur for several
years, if at all.
An important point to stress is that there need not
necessarily be any sciatic radiation. At operation one
has found on occasion that the nerve roots are so
arranged in relation to the protruded material that no
pressure or only very slight pressure is exerted on the
nerve root. In such a case a vague diagnosis of
lumbago usually accompanies the patient in his futile
journey from one doctor to another.
A constant feature in the history is aggravation of
the pain by increased intradural pressure, .such as
coughing or sneezing, and on examination this fact can
occasionally be confirmed by obtaining a positive pain
response to Queckenstedt's test. The pain is also
aggravated by movement and these patients often have
great difficulty in turning over in bed.
Some loss of normal lumbar lordosis with flattening
of the lumbar curve is an almost constant feature.
All movements of the lumbar spine, but especially
forward f1exion and hyperextension, are limited and
the patient can frequently not get his finger tips below
the level of his knees.
Scoliosis in the lower lumbar area of a homo-
lateral type is seen in practically every case and
can easily be discovered by palpating the spinous pro-
cesses and is exaggerated by hyperextension of the
spine.
. Flexion of the cervical spine may aggravate the pain
in the back and legs. Tenderness is usually present in
2
392 S.A. MEDICAL JOURNAL
the midline over the offending disc and frequently firm
pressure here will produce radiation of pain to the
buttock or down the leg.
Unilateral limitation of straight leg raising test is
present in practically all cases. Frequently some
limitation is present on both sides but is more marked
on one side.
The ankle jerk is frequently diminished or absent in
cases of lumbo-sacral disc protrusion.
In cases with leg pain, cutaneous hypoaesthesia to
scratch and pin prick test is usually present in the
dermatome of the compressed root. In this connection
the dermatome chart worked out by Keegan has been
found to be of most value and, incidentally, easy 10
memorise.
The protein content of the cerebrospinal fluid is
normal in the great majority of cases, but may be
elevated to 100 mg. per 100 c.c. or even higher.
RADIOLOGY
Some narrowing of the involved disc may be present
but if this is absent it does not rule out a herniation.
It can readily be understood that it requires a fairly
marked reduction in volume of disc substance to pro-
duce a radiological narrowing. It is as well to remember
that narrowing of the lumbo-sacral disc is a compara-
tively common finding in apparently normal individuals.
A so-called reverse spondylolisthesis is occasionally
found and is regarded as due to degenerative changes
in the disc associated with nuclear protrusion.
Posterior osteophytosis of the affected vertebrae is
sometimes found and is regarded by some as of definite
significance in the diagnosis.
Congenital bony abnormalities such as a spina bifida
of L5 or SI, sacralization of L5 and spondylolysis are
found fairly frequently, but in my opinion these are to
be regarded as coincidental.
When there is a radiological finding of a spondylo-
listhesis, it is now generally accepted that the symptoms
associated with spondylolisthesis are mainly or entirely
due to an associated herniation of the nucleus pulposus
and in every case where an operation is done for a
spondylolisthesis it is felt that, whatever else is done,
a laminectomy should also be done. Failure to do this
in one of our recent cases of spondylolisthesis has
resulted in no improvement of symptoms following a
spinal fusion only.
To summarize, the following radiological points are
of significance:
1. Loss of lumbar lordosis.
2. Lumbar scoliosis of homolateral type.
3. Narrowed disc space between two vertebrae.
4. Posterior osteophyte formation.
5. So-called reversed spondylolisthesis.
6. The presence of a congenital anomaly, especially
spondylolisthesis but also sacralization of the 5th lumbar
vertebra.
Myelography. Everyone of us who has done myelo-
grams has seen cases of arachnoiditis following on the
intrathecal injection of radio-opaque substances. In
my opinion the diagnosis is essentially a clinical one and
routine myelography is not only unnecessary but also
21 May 1949
dangerous and is to be strongly condemned. It should
be confined to doubtful cases to exclude an alternative
pathology.
PATHOLOGY
The work of Ghormley and others has indicated that
from about the age of 20 years gradual degenerative
changes occur in the whole intervertebral disc. Follow-
ing rupture or degenerative attenuation of the annulus
fibrosus the nucleus pulposus may prolapse to appear
under the posterior longitudinal ligament of the spine.
The prolapse usually occurs just lateral to the midline
of the theca and may then compress the outgoing nerve
root. It may lie more medially and away from the
nerve root.
According to Falconer et al., nuclear prolapse may
be divided into four groups.
1. Projections. A localized smooth-domed mass of
nuclear material bulging under an attenuated but intact
annulus fibrosus. This is the commonest form.
2. Extrusions. Fragments of the nucleus pulposus
escape into the extrathecal space through a ruptured
annulus fibrosus and may come to lie at some position
away from the original disc from which it was derived.
One such case was seen by us, the .nucleus lying over
the middle of the body of the vertebra below the
affected disc.
3. Intermittent Prolapse. Here it is believed that
marked degenerative changes are present in the disc
but that it bulges and produces symptoms only inter-
mittently. When palpated with a probe at operation
it is ~ofter than nor:rnal and bulges only slightly.
SometImes a small onfice can be found through which
the probe passes readily into the interior of the disc.
At operation such a disc can often be made to protrude
by hyperextending the lumbar spine. This manoeuvre
does not appreciably affect a normal disc. According
to most surgeons this type comprises about 28 % of
all disc protrusions. The results of surgery here are
as good as in other types.
Clinically there would appear to be no doubt that
the size of the nuclear protrusion fluctuates with conse-
quent alterations in the severity of symptoms. If one
accepts this then the syndrome of intermittent prolapse
is not by any means as unreasonable as it might appear
on the surface.
4. Scarred Discs. This really represents a late stage
in disc prolapse. The projecting or extruded nucleus
becomes desiccated, the disc space becomes markedly
narrowed and the theca and the associated nerve root
may become adherent to the fibrotic disc. Most of
these have probably ceased to produce disabling
symptoms except when the disc is adherent to the nerve
root. Calcification may occur in such a scarred disc.
The compressed nerve root is frequently quite flat-
tened rather than oval. It may be swollen and
oedematous and frequently is somewhat pinker than
normal, due to hyperaemia.
On occasion one has had the impression that the
ligamentum flavum overlying the prolapsed nucleus has
been unduly thick but this may be merely due to indivi-
dual variations and the concept of the hypertrophied
21 Mei 1949 S.A. TYDSKRIF VIR GENEESKUNDE
ligamentum f1avum producing root compression has now
been generally discarded.
Burns and Young as well as most other workers have
found a double herniation in about 20% of cases, the
last lumbar as well as the lumbo-sacral disc being
involved.
DIFFERENTIAL DIAGNOSIS
It is now generally accepted that disc protrusion is the
only common cause of sciatica with or without low back
pain. It would, however, be unwise to forget that other
lesions may produce symptoms and signs which stimu-
late disc protrusion-any pathology which involves one
of the nerve roots entering into the sciatic nerve may
produce sciatica with or without low back pain. The
most important ones to remember are:
1. Tumours of the cauda equina.
2. Inflammatory disease of the intervertebral disc,
especially tuberculosis, which on occasion may present
only as backache with leg pain and radiological
narrowing of the involved disc.
3. Tumours and other diseases affecting the spine and
producing pressure on emerging nerve roots.
4. Spondylolisthesis is mentioned, but, as has been
pointed out, in those cases presenting with symptoms
the symptoms are wholly or to a large degree due to
an associated nucle'ar protrusion.
There are naturally many other possible but less
important conditions to consider, but a comprehensive
list here is out of place and can serve no useful purpose.
TREATMENT
Many cases of nuclear protrusion undoubtedly recover
spontaneously and it would be a mistake to operate in
every case diagnosed as a herniated nucleus pulposus.
Another point of importance is that one should never
operate on a patient unless his symptoms at the time
of operation are severe and disabling. No matter how
classical the patient's history, operation should oniy be
undertaken during an attack.
Operative treatment th~n s~ould be confined to sub-
jects liable to repeated dIsabling attacks and to those
with one or two severe attacks in whom conservative
treatment consisting of bed rest and extending over four
weeks has produced no improvement.
Technique. The operation is done with the patient lying on
the side opposite to that affected by the sciatica. The whole
vertebral column is flexed as much as possible as for a lumbar
puncture and the patient is fixed in this position with adhesive
strapping. With the patient in this position no pressure is
exerted on the inferior vena cava and bleeding is consequently
minimal. It also has the advantage that, during the actual
removal of the disc, blood does not pool in the spinal canal
as it does with the patient in the prone position, but runs
out. This position al~o gives the .maximal amount of exposure.
When the erector spIn:ae are stnp~d off the l?Jllbar spinous
processes, no attempt IS made to pIck up bleeding points, but
the bleeding is controlled by gauze used in vaginal packing.
At operation a h~lpful pomt may b~ the. increased mobility
of the vertebra.e a.dlacent to the offend4Ig disc. If the spinous
processes are mdiVIdually grasped by means of forceps this
increased mobility may be discovered. '
A total fifth lumbar laminectomy is done and occasionally
the lower half of the fourth lumbar lamina is also nibbled
away. The peep-hole interlaminar approach might be dramatic
but has nothing else to recommend it. It has been con-
393
clusively proved that a total fifth lumbar laminectomy
produces no increased disability and it gives ready access to
the lower two intervertebral discs. We accordingly use it
routinely.
When the dura is retracted, the bulging disc can usually
be readily felt by means of a blunt probe. It can also
readily be seen in most cases as a smooth-domed, glistening,
bluish prominence under the posterior longitudinal ligament.
It is important to realise that the protruding disc is not
always situated in the angle betwee~ the nervI< root and the
theca, as is classically described. Occasionaliy the protrusion
is above and slightly lateral to the outgoing root, and this
would explain the absence of leg pain in some cases. In
cases where the nucleus has become totally extruded it can
be seen as a formless, greyish-white mass which may lie
opposite the site of its origin, but frequently is displaced to
overlie the body of the vertebra above or below. The normal
disc not only does not bulge but is usually actually concave.
The herniated nucleus pulposus is removed extradurally
whenever possible and the dura is not opened if it can be
avoided. Occasionally the theca is so adherent to the patho-
logical disc that a transdural removal has to be done, but
this is fortunatdy not common.
Since 20% of patients have double disc protrusions, both
the lower lumbar discs should be examined in every case.
Adequate removal of the pathological nucleus pulposus is
essential if p'ossible recurrence is to be a voided. It has been
repeatedly shown that the whole of the nucleus cannot be
removed from one side only, apd the disc should accordingly
be opened on both sides of the theca and thoroughly
curetted.
Spinal fusion is never done unless there is an associated
pathology such as spondylolisthesis, which req,uires fusion.
Alter Treatment. The importance of adequate post-operative
exercises cannot be over-stressed. Following operation the
erector spinae muscles atrophy in very mqch' the same way
as does the quadriceps in knee injuries, and the restoration of
tone is equally essential if a good result is to be obtained.
At the end of the first week, hyperextension spinal exercises
are commenced, and later on flexion exercises are also done.
The exercises are aone for ten minutes of every waking hour.
The patient is kept in bed until the tone and power of his
erector spinae has been completely restored (usually 3-3{-
weeks). Erector spinae exercises are continued for some
months after the operation.
Return to work should be gradual and the patient should
not resume heavy work before the end of six months post-
operatively.
CONCLUSION
The unfavourable results in disc surgery reported by
some surgeons is, in the writer's opinion, essentially
due to the following factors: Failure to select patients
carefully, lack of appreciation of the fact that the
patient has a 20% chance of having a double disc
lesion and consequently removing only one protrusion.
Other points are inadequate removal of the pathological
nucleus pulposus with subsequent recurrence and above
all failure to prescribe proper after treatment; for as
long as the erector spinae muscles are weak and atonic
so long will the patient complain of pain, tiredness and
weakness of his back.
Disc surgery has come to stay as an important
advance in the surgical treatment of low back pain
and/or sciatica. A critical assessment of every patient
and assiduous attention to detail in treatment and after-
treatment are essentials if good results are to be hoped
for. Failure to do this will inevitably disappoint both
the haphazard surgeon and the luckless victim. *
* A film was shown illustrating a clinical case and the technique
of the operation.