Spinal hernias

Clinical manifestations and lesion syndromes

The clinical picture depends on the location and volume of the herniated protrusion:

• $L_{IV}$ root syndrome: characterized by pain and paresthesias along the anteromedial surface of the thigh (sometimes extending to the lower leg), loss of the knee reflex, decreased sensitivity in the corresponding area, and paresis of the m. quadriceps femoris.
• Compression of cauda equina roots (cauda equina): massive $L_{IV}-L_V$ and $L_V-S_I$ disc herniations provoke sharp pain in the lower extremities, saddle anesthesia of the perineum, and pelvic organ dysfunction (fecal and urinary incontinence).
• Cervical radiculopathy and myelopathy: occur against the background of age-related degenerations or stenosis; they can provoke double crush syndrome (double crush), lowering the damage threshold of peripheral nerves (for example, the median nerve in the carpal tunnel).

Differential diagnosis and spinal stenosis

Disc herniations are often combined with hypertrophy of the ligamentum flavum and spondyloarthrosis, forming lumbar stenosis (narrowing of the anteroposterior diameter of the canal to less than 10.5 mm):

During the examination, it is mandatory to exclude red flags — rare specific causes of pain (bone and spinal cord tumors, infections), which mimic radiculopathy in 1% of cases.

Diagnostic algorithms

Diagnosis is based on a sequential comparison of objective data:

1. Clinical and neurological examination: assessment of gait, posture (lordosis, kyphosis, scoliosis), movements in the spine in all planes, search for asymmetries and zones of palpation tenderness.
2. Radiological methods (CT and MRI): visualize the dimensions of the protrusion, the relationship with the dural sac, and the area of the spinal canal (favorable prognosis with an area >70 mm²).
3. High-resolution protocols: 3D reconstructions (FIESTA, CISS) are necessary to differentiate herniated defects of the dura mater from anterior meningoceles and arachnoid cysts.

Therapeutic tactics and risks

The choice of technique is based on the severity of symptoms and the dynamics of the process:

• Conservative approach: indicated for moderate symptoms and a wide canal. Prolonged bed rest is unacceptable, as excessive restriction of mobility and anxiety lead to chronic pain.
• Surgical treatment: highly effective for radiculopathies (>90% success) and mandatory for pelvic disorders. When stabilizing three or more segments (spondylodesis), there is a danger of accelerated degeneration of adjacent discs — adjacent segment disease (adjacent segment disease).
• Limitations of manual techniques: cervical manipulations are contraindicated in muscle weakness, limb numbness, or bone anomalies due to the risk of exacerbating the hernia or stroke.

Class and exam questions

What else to study on this topic

• Differential diagnosis of extradural and intradural spinal arachnoid cysts
• Radiological criteria and clinical features of true spondylolisthesis
• Imaging features of anterior spinal meningocele on MRI (CISS and FIESTA sequences)
• Pathogenesis of fibromyalgia and identification of tender trigger points
• Psychosocial factors in the chronic course of dorsalgia

Other topics in "Chapter 27. Neck, back, and limb pain. Vertebrogenic neurological disorders"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.