Diagnosing ACUTE Disc Herniation on MRI

Diagnosing ACUTE Disc Herniation on MRI

When a herniated intervertebral disc (herniated nucleus pulposus or HNP) is diagnosed on MRI, there are ways to use that technology to determine whether that injury is new or it pre-dated a specific traumatic injury. Yussen and Swartz (1993) wrote a research paper published in a peer-reviewed indexed journal describing the acute herniated intervertebral disc, its pain pattern and its clinical presentation. Understanding this is a very important part of diagnosing an acute herniation.

Relating to the age of the patient they stated, “The acute lumbar herniated nucleus pulposus (HNP) usually affects the young to middle-aged patient. In older patients, the nucleus pulposus has typically degenerated and undergone fibrous replacement making acute herniation less likely (although not rare) in this population. The acute HNP may present with a variety of clinical signs and symptoms depending on the size, anatomic level, and direction of the herniated nuclear material” (Yussen & Swartz, 1993, p. 389). In relation to the “type” of pain and its pattern in an acute intervertebral disc herniation, the authors state, “HNP [herniated nucleus pulposus] does not necessarily produce radiculopathy and may cause vague low back pain.” (Yussen & Swartz, 1993, p. 389). This is a common scenario in practice and this paper shows that, in fact, it is not a rare occurrence. The fact that there is no nerve root involvement (radiculopathy) does not mean there is no injury.

“The outer third of the annulus fibrosis is innervated by branches of the dorsal ramus of each exiting nerve root (recurrent nerve of Luschka)" (Yussen & Swartz, 1993, p. 389) . "The posterolateral HNP may cause radiculopathy in the distribution of either of the two adjacent segments ("ventral ramus" pattern)" (Yussen & Swartz, 1993, p. 389) . The distribution of this type of low back pain may actually extend into the buttocks and upper thighs and can mimic radiculopathy" (Yussen & Swartz, 1993, p. 390). It should be noted that the “ventral ramus” pattern can involve multiple nerve roots resulting in a “non-traditional” pain pattern.

“There is general agreement that the acute HNP often is preceded by annular tear, thereby creating a channel for migration of nuclear material. Annular tears may be a degenerative phenomenon or result from acute trauma in an otherwise normal disc” (Yussen & Swartz, 1993, p. 392). “…annular tears can cause either a dorsal ramus pattern of low back pain or radiculopathy/ventral ramus pattern depending on the extent of nuclear herniation" (Yussen & Swartz, 1993, p. 395-396).

Reference:

Yussen, P. S., & Swartz, J. D. (1993). The acute lumbar disc herniation: Imaging diagnosis. Seminars in Ultrasound, CT, and MRI, 14(6), 389-398.

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