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THE PROLAPSED INTERVERTEBRAL DISCBy; A. D. LEIGH, M,R.C.P..

Registrar, The Maudsley Hospital, One-time First Assistant, Department of Neurology andPsychiatry, The London Hospital

Neurology lays many claims to being one ofthe more precise and scientific branches ofmedicine but, nevertheless, there have beenseveral neurological conditions almost medi-aeval in their conceptions. One of these is agroup included under the general heading ofthe neuritides-namely, sciatic and brachialneuritis and neuralgia. There is now a largebody of evidence to show that the humoral,atmospheric, rheumatic, infective and othervarious etiologies have resolved' themselves, onanalysis, into problems of anatomy andphysics.

Pain in the. lower limb roughly correspond-ing to the course of the sciatic nerve hadattracted the attention of clinicians since thework of Contugno in the mid-eighteenthcentury. Names such as passio ischiadica,sciatic neuralgia, sciatic neuritis, or simply,sciatica, reflect the diversity of etiologicaltheories. As late as I940 Kinnier Wilsondefined sciatica as ' pain confined to the fieldof the sciatic nerve.' In fact, the pain insciatica is not related to the field of the sciaticnerve. It is a root pain, with a rootdistribution.

Out.of the fog of conjecture, it was Dejerinewho first suggested that the ' sciatic syndromemight be produced by lesions of varyingpathology, limited to one or more of the spinalroots emerging from the inter-vertebral fora-men.' This suggestion was, unfortunately,almost immediately misinterpreted. Therebecame two types of sciatica-high .and low,depending on whether roots or nerve 'wereaffected. Terms like .radiculitis, funiculitis,trunkitis and plexitis crept into the jargon.

In 1925, however, Schmorl of Dresden, onretirement from active life, had taken up thestudy of the vertebral column, and was carry-ing out his painstaking autopsies on the spine.He published his results in I929, and drew

attention to the common occurrence of aprolapse of the nucleus pulposus of the inter-vertebral disc either into the body of a vertebra,or posteriorly into the spinal canal. In 3,000vertebral columns which he examined a pro-lapse was found in 38 per cent.; in I5 percent. backwards into the canal; in 23 per cent.into the vertebral body. Fig. i.

Contemporarily, Elsberg in the Statesoccasionally encountered ' chrondromata ' at-tached to the intervertebral disc, whichsimulated a spinal tumour. He listed I4 inhis monograph on' ioo Spinal Cord Tumours,'but he did not link up his findings with thoseof Schmorl-although remarking that histo-logically'the chondroma corresponded to thenucleus pulposus.

It was not until 1934 that Mixter and Barr,at the Massachusets General Hospital, des-cribed I9 cases of compression of the spinalcord or cauda equina by herniation of thenucleus pulposus through a rupture in theannulus fibrosus. Commenting on this paperGeoffrey Jefferson wrote that 'this newpathological entity deserved widespreadrecognition, many cases must miss diagnosiswhilst being treated symptomatically as casesof low backache or sciatica.' These wereprophetic words. An intensive surgical attackon the problem of sciatic pain now began, andit is largely to the neurosurgeons that we owethe present rational conception of sciatica.

Pain in the shoulder or arm, commonlyknown as brachial neuritis or neuralgia, hasalso not escaped the attention ot the neuro-surgeons. Glen Spurling in I943 recorded I2verified cases of ruptured cervical disc pro-ducing pain in shoulder and arm, and moreevidence is accruing as to the important role ofprolapse or a cervical disc in the productionof arm and shoulder pain.

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MPROLAPSED INTERVERTEBRAL DISC

The Anatomy and Physiology of theIntervertebral Disc

The intervertebral discs are tough, fibro-cartilaginous structrlres comprising one quarterof the whole vertebral column. Each is com-posed at its circumference, of laminae offibrous tissue and fibrocartilage, strongeranteriorly and laterally than posteriorly-theannulus fibrosus.' In the centre is a soft,pulpy, highly elastic substance of yellowcolour, which projects above the surface of thecut disc. This pulpy substance, the nucleuspulposus, is particularly well developed in thelumbar region, and contains the remnant ofthe notochord. The nucleus pulposus re-ceives no nervous supply, but Roofe has shownthat there are many nerve endings in theposterior part of the annulus fibrosus and inthe posterior longitudinal ligament. Thesenerve endings he considers to be of the typemediating pain impulses.The annulus fibrosus behaves as a slightly

elastic membrane binding together the verte-bral bodies. The nucleus pulposus functionsas a shock absorber-physically, it behaves asa fluid and transmits pressure equally over'thewhole intervertebral surface. When injury tothe annulus has allowed the escape of nuclearmaterial, the pressure equalizing system is re-moved, and the annulus is subjected to stresseswith which it is unable to cope. The inter-vertebral disc may then be ground betweenthe vertebral bodies, and further damageoccurs.The third structure of importance is the

ligamentum flavum, which connects thelaminae of adjacent vertebrae, and again isparticularly thick in the lumbar region. Itforms the posterior wall of the intervertebralforamen, and so is intimately related to theemergent nerve root.

Prolapse of the Intervertebral DiscTrue herniation of the nucleus pulposus

occurs when the enclosing annulus is ruptured,and a 'sufficient amount of fibrocartilageescapes through the opening beneath theposterior longitudinal ligament to produce anintraspinal tumour. The rupture may arisesuddenly or gradually; it is most com-monly situated postero-laterally, the weakest

part of the annulus. This rather constantlocalization of the herniation lies directlybeneath the emerging nerve root, and leads toearly compression of a single nerve root (Fig.2). In most persons the spinal canal is cou-siderably flattened or narrowed at the lumbo-sacral junction, which leads to earlier com-pression here of the nerve root against theoverlying ligamentum flavum and lamina.Some, however, have a much larger spinalcanal than others, and may have many episodesof low backX trouble without definite rootsymptoms, as mere displacement of an un-restricted, overlaying ioot is not likely to causemuch pain.The commonest site of herniation is at the

lumbo-sacral junction and here both fifthlumbar and first sacral roots are related to theintervertebral disc (Fig. 3). The first sacralroot, which is involved in over 50 per cent. ofcases, is rather long in its extra-dural coursewithin the spinal canal, being 4 cms. in length.It leaves the main dural canal above the fifthlumbar disc and courses well lateral in theflattened spinal canal of the first sacral region.The sensory ganglion of the root lies beneaththe first sacral lamina, below the disc, andhence herniation compresses the nerve rootproximal to the sensory ganglion, and distal tothe motor neurones in the spinal cord. Thisfact is significant-motor regeneration may beexpected after a compressive lesion, but sen-sory regeneration may not occur, as theinterruption is a proximal to the ganglion.Another anatomical peculiarity is the absenceof trophic changes the roots owing to the factthat there is no overflow of preganglionicsympathetic fibres below L.2.The first symptom of nerve compression is

pain in the hip, which has been called by manynames-the superior gluteal nerve syndrome(in spite of the fact that this is a purely motornerve), gluteal myofasciitis, fibrositis, sacroiliac strain, and sciatic neuritis. The factualexplanation is shown in Fig. 2. The posteriorprimary division of the root involved comes upagainst the unyielding ligamentum flavum,producing pain in the distribution of theposterior primary division-which is -thegluteal region. Greater compression of theroot now involves the central portion, made upof sensory fibres for the anterior primai-y

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POST-GRADUATE MEDICAL JOURNAL

division to the leg, hence the onset now of rootpains in the leg. The last portion of the rootto be affected is the anterior portion, which ispurely motor and produces paresis or paralysis.The great sciatic nerve is formed from fiveroots (L 4, 5, S 1, 2, 3) and this is the crux ofthe problem, that the pain in sciatica is a rootpain, in the distribution of a root, and not in anerve distribution.The great sciatic nerve supplies sensation to

a large area below the knee and the pain insciatica does not correspond to this area (Fig.4). It is extremely unlikely that a neuritiswould select only a portion of the nerve,causing perhaps pain In the buttock, or painin the back of the thigh or leg. The distribu-tion of the pain, in the classical case, is in thefirst sacral root area, and this raises somepoints concerning the anatomy of the fiveroots involved.Each of the five roots of the great sciatic

nerve represents a segmental motor andsensory pattern which is arranged in serialorder, as with the dermatomes of the trunk.The difference is that the extension and rota-tion of the limb buds, and the fusion of thenerves in the sciatic plexus obscures the orderof distribution. We have all been reared onthe dermatome charts of Foerster and Head,but recently. Foerstei's dictum that division ofa single root produces no loss of sensibility hasbeen questioned. Keegan, by careful quantita-tive testing has been able to map out areas ofhypalgesia due to single nerve root compression'by a prolapsed disc, proved at operatiori.Details may be obtained on reference to hispaper, suffice it to say that radicular areas ofsensory change are commonly observed incases of sciatica, particularly in the distributionof the first sacral root.

Sciatica in the Light of these AnatomicalFindings

Sciatica may now be defined as painoccurring in the lower limb in a root distribu-tion, resulting from affections of one or more ofthe five roots which comprise the great sciaticnerve (L 4, 5, S I, 2, 3). The commonestcause is prolapse of the nucleus pulposus of anintervertebral disc, usually either the fourth orfifth lumbar disc, affecting the fifth lumbar orfirst sacral roots, either separately or combined.

There are two components of a typicalattack of sciatica, pain in the back and pain inthe lower limb of radicular origin.

i. The pain in the back is usually sudden inonset, situated in the lower lumbar region, andassociated with stiffness of the lumbar spine.It is well recognized by the laity as ' lumbago.'Trauma or strain determine its origin inapproximately 50 per cent. of cases-liftingheavy weights with the back flexed, crankingan obstinate engine, pregnancy or parturitionmay all precipitate an attack. In the Army thehighest incidence was amongst the artillery,particularly the ammunition numbers, and incivil life labourers are frequently affected.However, acute prolapse may be quite un-related to trauma, and since three-quarters ofthe cases are past the fourth decade, it seemslikely that'degenerative processes in the dischave occurred in such patients.The back pain is severe, unilateral or bi-

lateral, and the patient feels as if gripped in avice. He may be fixed in an attitude of flexion,and have to be' carried to bed, where hotbottles applied to the lumbar region producetime honoured relief. The pain usually per-sists for ten days or longer, and may, or maynot, be accompanied by pain in buttock, thigh.or leg.The presence of nerve endings in the annulas

fibrosus has already been referred to-theback pain may result from ' irritation ' of thesenerve endings when the annulus fibrosus isinjured.

2. Root pain in buttock, thigh, leg or foot isthe second component, and occurs in which-ever dermatome area is concerned. A gooddeal of the confusion of thought concerningsciatica has resulted from the unfortunatecoincidence that the course of the sciatic rnerveroughly corresponds to the first sacral derma-tome.The pain may be confined to the buttock, or

radiate to the posterior aspect of the thigh.With the common lumbo-sacral disc herniationaffecting the first sacral root, the pain starts inthe buttock, spreads down the posterior aspectof the thigh, to the antero-lateral aspect of theleg, and along the outer border of the fo6t,involving the outer three toes and the outerside of the sole. In character the pain isvariously described as 'stabbing,' 'burning,'

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March,. i947 PROLAPSED INTERVERrIEBRAL DISC [45

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'gnawing,' or 'shooting,' and is increased bycoughing or sneezing, or by any circumstancewhich increases the intraspinal pressure. Thisis the basis of Naffziger's test, on bilateraljugular compression there is an increase in theleg pain. 'Tingling and numbness along theouter border of the foot commonly occur.

Certain postures aggravate the pain, and ascoliosis is developed to 'protect' the rootfrom pressure.

'Physical SignsThe signs of most diagnostic import are:i. A stiff and rigid lumbar spine.2. A positive Lasegue's sign.3. Dermatome changes.4. Motor and reflex change.i. Loss of the normal lumbar curve, with

limitation'of forward flexion of the lumbarspine is constantly present. The normal rippleof vertebral' movement is lost, and the wholelumbar spine becomes stiff and rigid. This iswell demonstrated when the patient attemptsto touch his toes, with the knees extended.

2z Straight leg raising is limited in everycase-a sign first described by Lasegue inI864. The sign is positive most commonlyon the affecied side, but occasionally on theside contralateral to the pain. It is a usefulobjective indication of the degree of pain, andis helpful in assessing recovery. O'Connell hasshown that flexion of the extended lower limbor the thigh stretches the fixe'd extradural partof the nerve root. Thi3 is the portion of theroot which is commonly related to the discprotrusion hence the limitation of straight legraising, known as Lasegue's sign.

3. Dermatome changes. Careful testing bydrag pin discloses areas of hypalgesia in asmany as 8o per cent. of cases, the commonestsite being the outer aspect of the foot, in-dicating a first sacral root lesion. (Figs. 5and 6.)The more severe the degree of root com-

pression, the more extensive will be the area ofsensory change. Two or more roots- may beaffected depending on the site, size, or multi-plicity of prolapse. A complete cauda equinasyndrome may occur when the prolapse is alarge one.

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146 POSL-GRADUAIE MEDICAL JOURNAI, March, 1947

THE COMMON SIGNS OF Disc PROLAPSE.

RootDisc Involved $ensory Signs Motor Signs Reflexes

4th Lumbar 5th Lumbar Hypalgesia over dorsum Weakness of extensors Ankle jerk normal,of foot extending up of foot and toes, and diminished, or ab-lateral aspect of leg. of peronei. sent.

5th Lumbar Ist Sacral Hypalgesia over outer as- Weakness of peronei. Ankle jerk diminishedand/or pect of foot and sole. or lost.

sth lumbar

5th Cervical 6th Cervical Hypalgesia posterior as- Weakness of biceps. Biceps jerk diminishedpect of thumb. or absent.

6th Cervical 7th Cervical Hypalgesia of index and Weakness of triceps. Triceps jerk dimin-middle fingers. _ ished or absent.

4. Motor and Reflex Change. In the acutestage it may be difficult to assess motor poweron account of the pain. A little weakness ofthe peroneii, and the dorsiflexors of the footand toes, is most commonly found. 'I he anklejerk is diminished or absent in half the cases,and indicates a first sacral root lesion. it iswell to test the ankle jerk in several positions,and to use reinforcement, but it is importantto realize that a patient may have severesciatica with no change in his ankle jerk. Adiminished or absent knee jerk occurs with aprolapse of the third lumbar disc, where thefourth lumbar root is affected.

C.S.F.

Lumbar puncture should not be made aroutine procedure, but is of great value whena neoplasm is suspect. The C.S.F. proteinmay be increased with a prolapsed inter-vertebral disc, but not to the same degree aswith a neurofibroma of a nerve root, the com-monest differential problem. A protein ofover ioo mgms. per cent. is very suggestive ofneoplasm.

Radiology

A roentgram serves mainly to distinguishthose causes of radicular pain which producebony changes. The variation in the size of thedisc spaces is so extreme that narrowing of thelumboscral disc is to be interpreted with ex-treme caution. Contrast radiography, using

'Miodil,' is a matter for special clinics, andis largely related to neurosurgical problems.

Differential DiagnosisProlapse of either the fourth or fifth lumbar

disc is the commonest cause of sciatica, butevery case of low backache and ' sciatic' painmust not be regarded as due to this one cause.Almost identical symptoms may result fromany process producing compression of fourthliumbar-third sacral nerve roots. In largeseries of cases in America a neurofibroma of aroot, or roots,, of the cauda equina, has provedto be the likeliest source of diagnostic error.Dandy missed nine such tumours in i,IOOoperations for presumed disc prolapse, and ofI5 cases of tumour of the spinal canal operatedon by Love, in 8 the symptoms were consideredto be the result of a prolapsed intervertebraldisc. The differential diagnosis may thus beextremely difficult. However, with a rootneoplasm the course is more likely to be pro-gressive, the neurological signs more wide-spread, and rigidity of the lumbar spine absent.Examination of the spinal fluid is perhaps themost valuable diagnostic aid, a C.S.F. proteinof more than ioo mgms. per cent. usuallyindicates the presence of a neoplasm.

Radiology will distinguish such causes ofroot pain as a primary or secondary vertebralneoplasm, spinal injury, spondylolisthesis orhypertiophic osteoarthritis. Careful physicaland ancillary examinations will excludesyphilis, herpes zoster, and neoplasm of pelvicorgans. A rectal examination must always beperformed.

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PROLAPSED INTERVERTEBRAI. DISC

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FIG. 3.-Drawing made over roentgenogram to show relation of first sacral and fifth lumbar roots to intervertebral discs.

MWarch, I-947 -147

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148 POST-GRADUATE MEDICAL JOURNAL March, 1947

BRACHIAL NEURITISPain occurring at the root of the neck,

spreading to the shoulder, arm and hand, for'which no organic lesion could be discovered,has been, until recently, as obscure a subjectas that of sciatica. ' Rheumatism, chills,wetting, exposure, overstrain and infection'were said to be the more usual antecedents.Happily, however, this 'brachial neuritis' isslowly resolving into several clear cut clinicalpattems. One of these'is the syndrome ofcervical disc prolapse; in particular, prolapseof the sixth cervical disc.

AnatomyThere are eight cervical nerves, but owing

to the articulation between skull and atlas, onlyseven cervical intervertebral discs. Thus thefirst cervical disc is related to the secondcervical root, the sixth disc to the seventh root,and so on. The spinal canal in the cervicalregion is more nearly filled with ne'rvous tissuethan the lumbar canal, and the ligamentadenticulata allows only a limited movement ofthe spinal cord. Hence a prolapse of thenucleus pulposus in the cervical region is morelikely to produce early neurological signs thanprolapse of a lumbar disc. A central prolapseof a cervical disc produces cord compression,and indeed the earliest reports of cervical discprotrusion are of such lesions (Stookey).When the prolapse is more laterally placed, itprojects into the intervertebral foramen pro-ducing early compression of the related root.

The Syndrome of Lateral Prolapse of theSixth Cervical Disc

Onset of pain and stiffness of the neck isfollowed by radiation of the pain to the outeraspect of the shoulder and arm, to the postero-lateral aspect of the foreann, and into thefingers. Burning, stabbing, or gnawing inquality, there are electric shock like exacerba-tions of the pain, especially on movement ofthe neck. Coughing, sneezing or strainingcauses the pain to shoot down the limb.Paresthesiae in the thumb, index' and middlefingers are commonly noted by the patient,and the grip may be weak.

Physical examination discloses evidence ofa seventh cervical root lesion. There is weak-

ness and wasting of triceps, with some weak-ness of extension of the wrist and fingers.The triceps jerk is reduced or absent. Sensorydiminution to pin prick and cotton wool isfound over the index finger; the middlefinger and terminal phalanx of the thumb mayalso be affected. There is limitation of neckmovement, and pressure lateral to the sixthcervical spine may produce the characteristicpain.

RadiologyNarrowing of the disc space is of more

significance in the cervical region than in thelumbo-sacral region, and the X-ray may dis-

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March, ii947 PROLAPSED INTERVERTEBRAL DISC 14k,close narrowing of the sixth cervical disc, withattempts at bridging between C.6 and C.7.

Differential DiagnosisThe commonest source of error, as in the

diagnosis of sciatica, is a neurofibroma of acervical nerve root, and again an increase ofprotein in the C.S.F. is suggestive, althoughlower figures obtain than with cauda equinaneoplasms. A particular variety of neux o-fibroma may present as a swelling in the neck-the so-called dumb-bell tumour-whichgrows out of the spinal canal through theintervertebral foramen.A cervical rib usually produces pain in the

fingers or hand, in a first dorsal root, distribu-tion. Other causes of brachial plexus com-pression such as neoplastic invasion, a Pan-coast tumour, or infiltration by lymphadeno-

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15Q0 POST-GRADUATE MEDICAL JOURNAL March, I947

matous tissue are excluded by generalexamination, as are affections of the head ofthe humerus or shoulder joint-osteoarthritis,injury or infections.Angina pectoris, with radiation of pain to

the upper limb, is characterized by its relationto effort and is unaccompanied by the physicalsigns so typical of disc prolapse. Herpeszoster, syphilitic radiculitis, and syringo-myelia are mentioned only to be dismissed.

TreatmentIn the past the treatment of sciatica has been

as mystical as its etiology was mysterious.Radiant heat, counter irritation, painting the-skin over the course of the nerve with fuminghydrochloric acid, infiltration of oxygen aroundthe nerve, epidural injections, and acupuncturewere all employed, and still are employed. Asrecently as 1941 Walsh wrote that ' acupunc-ture of the nerve with a seri'es of speciallydesigned needles is a useful and ancientremedy which acts by puncturing the sheathof the nerve, and allowing the escape ofinflammatory exudation.'On the basis of the anatomical and patho-

logical facts now described, an attempt attreatment along simple, rational lines may bemade. The same principles apply to thetreatment of both sciatica and those cases ofbrachial neuritis resulting from disc prolapse.Absolute rest in bed is necessary for a periodsufficient to allow healing of the torn fibres ofthe annulus fibrosus, and at least the inceptionof cicatrization. For a case of sciatica thefollowing regime is adopted:

i. Three weeks absolute bed rest, with aslow a pillow as is comfortable. The patientis kept prone and is not even allowed to sit upin order to keep the weight of the body off thelumbar discs. Skilled nursing care is essential.

2. At the end of the third week, if there hasbeen subjective improvement, the patient isallowed tup to the toilet for the next seven days.

3. In the fifth week he is allowed up for in-creasing periods each day, until by the end ofthe week he is up for the whole day.

4. In the sixth week spinal exercises aregiven. He is then given a simple explanationof the cause of his sciatica, and advised againstlifting heavy weights, playing golf or any pro-cedure likely to cause a further prolapse of hisweakened disc. A change of occupation maybe essential.Throughout this tedious and boring period

of decubitus, encouragement and reassuranceby the doctor plays an important part, and theco-operation of the patient will often depend onthe attitude of the doctor.With the above regime relief occurs in a

large number of patients. There is a residuum,however, who do not respond to suchmeasures, and depending on such factors asthe constitutional make-up, or on environ-mental circumstances, operation may berecommended. Large series of laminectomieshave been performed, especially in the States.In skilled hands the operation is safe, and thepatient is out of hospital in three weeks.Opinions still vary, however, as to the placeof operation in the treatment of sciatica.

In brachial neuritis resulting from prolapseof a cervical disc, a similar, but less lengthyregime is usually successful. When there isevidence of cord compression, laminectomymust be performed,' but it is only rarelynecessary with, lateral prolapses. Sympto-matic therapeusis for relief of pain and sleep-Lssness is conducted on general principles.

ConclusionThere are many aspects of both conditions

which have not been touched upon in thisbrief account. The main stream of papers atthe moment is devoted to the role of surgery intreatment. For the present, however, thetreatment of sciatica and brachial neuritis isstill the purlieu of the physicians.

REFERENCES

s. DANDY, W. E. (1943), Ann. Surg., 4, 639.2. DEJERINEJ. (I9I4), 'Semiologie des Affections du Systeme

Nerveux,' Paris.3. ELLIOTT, F. A., and KRAMER, M. (I945), Lancet, 4.4. ELSBERG, C. A. (I9I6), 'Diagnosis and Treatment of Sur-

gical Disease of the Spinal Cord and Membranes,'Philadelphia.

5. GRAY, H. (I930), 'Anatomy of Human Body,' London.6. JEFFERSON, G. (I936), 'Medical Annual,' Bristol.

7. KEEGAN, J. (I943), A.N. and P., 50, 67-83.8. KINNIER WILSON, S. A. (1940), 'Neurology' London.9. MIXTER W. J., and BARR, J. S. (I934), New Vng..J. of Med.,

211, 210.I0. ROOFE, P. G. (I940), Arch. N. and P., 44, zoo.ii. SCHMORL, G. (1927), 'Verhande d. deutschen Orthop.

Gesellsch, 21, 3.12. SPURLING, G. R., and BRADFORD, F. K. (I941), 'The

Intervertebral Disc,' Springfield.

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