Extract
Lumbar disc herniations remain among the most common diagnoses encountered
in clinical spine practice. The incidence of symptomatic lumbar disc
herniations in the American population has been estimated to be 1% to
2%1, for which
approximately 200,000 lumbar discectomies are performed
annually2. Yet
despite the frequency with which lumbar disc herniation occurs, there is
substantial controversy regarding its pathophysiology and treatment. For
example, from the standpoint of basic science, mounting evidence suggests that
biochemical factors—in addition to the mechanical effects of the disc
material on the nerve root—underlie the development of symptomatic
radiculopathy, but those factors remain to be clearly elucidated. On the
clinical end of the spectrum, large (five-to-fifteen-fold)
variations3 in the
rates of lumbar surgery in geographically adjacent areas suggest radical
heterogeneity in the application of surgical criteria to this diagnosis. In
this lecture, we examine the available basic science regarding the anatomy and
pathophysiology of lumbar disc herniations as well as the clinical evidence
supporting nonoperative compared with surgical management of this common, yet
surprisingly poorly understood, orthopaedic disorder.