PainSci commentary on Pople 1994: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.
This old study from the 90s followed 100 patients with back and/or leg pain plus a disk herniation (radiologically proven). They were all scheduled for microdiscectomy. An independent doctor assessed them from scratch before surgery, and their assessment was then compared with the surgical findings. Almost half of them had a disc protrusion, and the remainder had an extruded fragment — quite different spinal situations. Interestingly, pain levels in the two groups were equal.
They found one very strong correlation between symptoms and disc status: almost all the patients (96%) who mainly had leg pain also had a disc extrusion. Only two of the extrusion patients had more back than leg pain. Apparently disc extrusions mostly cause leg pain… not back pain. It was a striking finding, but it does make senses:
Pain fibers are present in the outer layers of the annulus and posterior longitudinal ligament and produce severe central low back pain, when stimulated directly or stretched by injection of saline. Patients with a disc protrusion will therefore experience more back pain as a result of greater stretching of the posterior longitudinal ligament, than patients who have an extruded fragment and in whom the tension in the posterior longitudinal ligament has been reduced by the exit of disc material through a tear. This may also explain why patients with an extruded fragment often experience a decrease or complete resolution of back pain when root symptoms commence.
This is very consistent with later studies (eg Reihani-Kermani 2005).
~ Paul Ingraham
original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.
To determine whether the presence of an extruded lumbar disc prolapse could be predicted from clinical symptoms, the authors compared the relative proportions of back and leg pain, with operative findings in a prospective observational study of 100 lumbar discectomy patients. All cases were assessed by an independent observer, blind to the knowledge of the operative findings. Of the 58 men and 42 women (mean age 42, range 19-75), 47 patients had a subligamentous disc protrusion and 53 had an extruded disc fragment. Of 27 patients who presented with leg pain only 26 (96%) were found subsequently to have an extruded fragment. Patients with an extruded fragment had a significantly higher proportion of leg:back pain (median 99:1) than those with a subligamentous disc protrusion (median 75:25, P < 0.001). Patients with leg pain only and those with a marked predominance of leg pain over back pain have a high probability of harboring an extruded disc fragment.
- “Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis,” Zhong et al, Pain Physician, 2017.
- “Resolution of Lumbar Disk Herniation without Surgery,” Jennifer Hong and Perry A Ball, NEJM.org.
- “Progression of lumbar disc herniations over an eight-year period in a group of adult Danes from the general population: a longitudinal MRI study using quantitative measures,” Kjaer et al, BMC Musculoskeletal Disorders, 2016.
- “Magnetic resonance imaging in follow-up assessment of sciatica,” Barzouhi et al, New England Journal of Medicine, 2013.
- “Two-year outcome after lumbar microdiscectomy versus microscopic sequestrectomy: part 2: radiographic evaluation and correlation with clinical outcome,” Barth et al, Spine (Phila Pa 1976), 2008.
- “Magnetic resonance imaging findings 10 years after treatment for lumbar disc herniation,” Fraser et al, Spine (Phila Pa 1976), 1995.
- “Lumbar disc herniation: a controlled, prospective study with 10 years of observation,” Weber, Spine, 1983.
- “MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities, and osteoarthritis of the facet joints in asymptomatic volunteers,” Weishaupt et al, Radiology, 1998.
- “1995 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations,” Boos et al, Spine (Phila Pa 1976), 1995.
- “Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study,” Gugliotta et al, BMJ Open, 2016.
- “Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK),” Suri et al, BMC Musculoskeletal Disorders, 2014.
- “Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study,” Konstantinou et al, BMC Musculoskeletal Disorders, 2015.
- “Symptomatic and asymptomatic abnormalities in patients with lumbosacral radicular syndrome: Clinical examination compared with MRI,” van Rijn et al, Clin Neurol Neurosurg, 2006.
This page is part of the PainScience BIBLIOGRAPHY, which contains plain language summaries of thousands of scientific papers & others sources. It’s like a highly specialized blog. A few highlights:
- Inciting events associated with lumbar disc herniation. Suri 2010 Spine J.
- Prediction of an extruded fragment in lumbar disc patients from clinical presentations. Pople 1994 Spine (Phila Pa 1976).
- Characteristics of patients with low back and leg pain seeking treatment in primary care: baseline results from the ATLAS cohort study. Konstantinou 2015 BMC Musculoskelet Disord.
- Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial. Kuyken 2022 Evid Based Ment Health.
- Is there a relationship between throbbing pain and arterial pulsations? Mirza 2012 J Neurosci.