Materiały źródłowe

• #1 Disc Herniation – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK441822/

  A herniated disc is a condition affecting the spine in which the annulus fibrosus is damaged enabling the nucleus pulposus (which is normally located within the center of the disc) to herniate. This can compress the nerves or spinal cord causing pain and spinal cord dysfunction. […] The pathophysiology of herniated discs is believed to be a combination of the mechanical compression of the nerve by the bulging nucleus pulposus and the local increase in inflammatory chemokines. A herniation is more likely to occur posterolaterally, where the annulus fibrosus is thinner and lacks structural support from the anterior or posterior longitudinal ligaments. Due to its proximity, a posterolateral herniation is more likely to compress the nerve root. On the other hand, spinal cord compression and clinical myelopathy can occur if there is a herniation of a large midline disc. The localized back pain is a combination of the herniated disc pressure on the longitudinal ligament and chemical irritation due to local inflammation.

• #2 Herniated disk – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/herniated-disk/symptoms-causes/syc-20354095

  A herniated disk refers to a problem with one of the rubbery cushions, called disks, that sit between the bones that stack to make the spine. These bones are called vertebrae. […] A spinal disk has a soft, jellylike center called a nucleus. The nucleus is encased in a tougher, rubbery exterior, known as the annulus. A herniated disk occurs when some of the nucleus pushes out through a tear in the annulus. A herniated disk is sometimes called a slipped disk or a ruptured disk. […] Disk herniation is most often the result of a gradual, aging-related wear and tear called disk degeneration. As people age, the disks become less flexible and more prone to tearing or rupturing with even a minor strain or twist. […] Most people can’t pinpoint the cause of their herniated disk. Sometimes, using the back muscles instead of the leg and thigh muscles to lift heavy objects can lead to a herniated disk. Twisting and turning while lifting also can cause a herniated disk. Rarely, a traumatic event such as a fall or a blow to the back is the cause.

• #2 Herniated disk – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/herniated-disk/symptoms-causes/syc-20354095

  Factors that can increase the risk of a herniated disk include: Excess body weight causes extra stress on the disks in the lower back. People with physically demanding jobs have a greater risk of back problems. Repetitive lifting, pulling, pushing, bending sideways and twisting also can increase the risk of a herniated disk. Some people inherit a predisposition to developing a herniated disk. It’s thought that smoking lessens the oxygen supply to disks, causing them to break down more quickly. […] Rarely, disk herniation can compress the entire spinal canal, including all the nerves of the cauda equina. In rare instances, emergency surgery might be needed to avoid permanent weakness or paralysis.

• #3 Lumbar Herniated Disc Video

  https://www.spine-health.com/video/lumbar-herniated-disc-video

  A spinal disc consists of two main parts: the jelly-like nucleus pulposus in the disc’s center and the outer-most layers, collectively called the annulus fibrosus. These two components facilitate the spine’s movement and provide support for the vertebrae. […] Disc degeneration or trauma can cause the nucleus to herniate through the weakened layers of the outer disc and leak out of the annulus fibrosus into the spinal canal. […] In the case of a lumbar herniated disc, the weak spot in the annulus fibrosus is directly underneath the spinal nerve root, so a herniation in this area can put direct pressure on the nerve. […] The nerve root extends down the leg, and any type of pinching or pressure on the nerve in the lower spine can cause pain, numbness, tingling, or weakness to radiate along the path of the nerve down the leg. However, many people have shown a herniated disc on MRI scans yet have no associated pain, so not all herniated discs will cause symptoms.

• #4 Non-Surgical Spinal Decompression for Bulging Discs, Herniated Discs and Ruptured Discs – Irvine Spine & Sport |Yelp 5-Star Irvine Chiropractors

  https://irvinespineandsport.com/treat-the-cause-with-spinal-decompression/

  The healthy spinal disc is 86% water and needs water, oxygen and nutrients to continue to survive. […] A unique feature of the spinal disc is that it is avascular (without blood) which is a fancy word that means it does not have a direct blood supply. The only way the disc gets the water, oxygen and nutrients the circulation that it needs to survive is by a very specific mechanism called the pump mechanism of disc nutrition. This mechanism works as we move and works like a pump. If you injure the disc the pump mechanism does not work properly and over time will cause bulging discs, herniated discs and degenerative disc disease and, possibly, spinal stenosis. […] So the main problem causing your pain and symptoms is the failure of the pump mechanism. […] The treatment that we provide in our office will fix your pump mechanism that is not working in your injured spinal discs.

• #5 Lumbar Disc Herniation – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK560878/

  Lumbar disc herniation results from several changes in the intervertebral disc including reduced water retention in nucleus pulposus, increased type 1 collagen ratio in the nucleus pulposus and inner annulus fibrosus, destruction of collagen and extracellular material, and an upregulated activity of degrading systems such as matrix metalloproteinase expression, apoptosis, and inflammatory pathways. Ultimately, resulting in a local increase in inflammatory chemokines and mechanical compression applied by the protruding nucleus pulposus on the exiting nerve. […] The pressure exerted by the herniated disc on the longitudinal ligament and the irritation caused by the local inflammation results in localized back pain. The lumbar radicular pain arises when disc material exerts pressure or contacts the thecal sac or lumbar nerve roots, resulting in nerve root ischemia and inflammation.

• #5 Lumbar Disc Herniation – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK560878/

  In LDH, the narrowing of the space available for the thecal sac is attributable to several factors such as protrusion of the disc through an intact annulus fibrosus, extrusion of the nucleus pulposus through the annulus fibrosus while maintaining continuity of the disc space, or obliteration of the disc space continuity and sequestration of free fragments.

• #6 Herniated Nucleus Pulposus: Practice Essentials, Anatomy, Pathophysiology

  https://emedicine.medscape.com/article/1263961-overview

  Disk deterioration and loss of disk height may shift the balance of weightbearing to the facet joint; this mechanism has been hypothesized as a cause of LBP through the facet-joint capsule, as well as through other tissues attached to and between the posterior bony elements. […] Dehydration results from shortening of the hyaluronic chains, deterioration of the state of aggregation, and decreases in the ratio of chondroitin sulfate to keratan sulfate, leading to disk bulging and loss of disk height. […] The consistency of the nuclear material undergoes a change from a homogeneous material to clumps, which leads to the altered distribution of pressures within the disk and resistance to the flow of nuclear material; the nuclear material thereby becomes mechanically unstable. […] These clumps may be lateral to the posterior longitudinal ligament and therefore may have the least resistance to herniating through the corner of the intervertebral disk and into the spinal canal or foramen. […] Using the pituitary rongeur technique to perform a microdiskectomy on a herniated fragment requires a preexisting state of deterioration; the weakened areas in the anulus provide a path of least resistance for egress of the nuclear material.

• #7 Lumbar Disc Herniation: A Comprehensive Overview

  https://kamranaghayev.com/lumbar-disc-herniation/

  Lumbar disc herniation is a condition when degenerated nucleus pulpous of intervertebral disc slips into the spinal canal, causing compression of the nerve roots. […] Disc degeneration is a condition characterized by progressive damage to the nucleus pulposus, leading to desiccation, shrinkage, fragmentation, and eventually complete wear-off. It is the principal disease leading to a herniated disc or spinal canal stenosis. […] Loss of proteoglycans and collagen is the main molecular mechanism of disc degeneration. […] With the loss of aggrecan and other essential proteoglycans, the osmotic pressure in the disc diminishes, leading to disc desiccation. As a result, the mechanical, hydrostatic pressure in the disc diminishes, compromising the load-bearing capacity of the disc joint. […] A key feature of disc degeneration is irreversibility. Like many other age-related changes in the human body, the process cannot reverse itself.

• #8

  https://www.orthobullets.com/spine/2035/lumbar-disc-herniation

  Lumbar Disc Herniation is a very common cause of low back pain and unilateral leg pain, known as radiculopathy. In rare cases a large disc herniation can lead to Cauda Equina Syndrome which requires emergent diagnosis and treatment. […] Diagnosis is made clinically and confirmed with an MRI studies of the lumbar spine. […] Treatment for radicular leg pain is initially nonoperative with oral medications and physical therapy. Surgical microdiscectomy is only indicated for severe pain and/or motor deficit that have failed to respond to nonoperative management. Treatment for Cauda Equina Syndrome in contrast is emergent microdiscectomy within 48 hours. […] Pathoanatomy: recurrent torsional strain leads to tears of the outer annulus which leads to herniation of nucleus pulposis. […] Cellular senescence of fibrochondrocytes leads to loss of proteoglycan production leading to disc height loss.

• #8

  https://www.orthobullets.com/spine/2035/lumbar-disc-herniation

  Increased strain leads to fissures of the annulus fibrils. […] Annular tears compromise hoop stresses that act against the deforming forces of the nucleus pulposus. […] Nucleus pulposus herniates through tear. […] Sciatica symptoms result from combined mechanical compression and associated inflammation. […] TNF-, MMP, NO, PE2, and IL-6 are implicated in nerve irritation leading to radiculopathy. […] Size of herniation decreases over time (reabsorbed). […] Macrophage phagocytosis and enzymatic degradation is the mechanism of reabsorption. […] Surgical treatment is equivalent to nonsurgical treatment in the long term; surgery provides faster pain relief.

• #9 Clinical Evaluation and Treatment Options for Herniated Lumbar Disc | AAFP

  https://www.aafp.org/pubs/afp/issues/1999/0201/p575.html

  Degeneration of the intervertebral disc from a combination of factors can result in herniation, particularly at the L4-5 and L5-S1 levels. […] Lumbar disc herniations are believed to result from anular degeneration that leads to a weakening of the anulus fibrosus, leaving the disc susceptible to anular fissuring and tearing. […] Several factors, including genetic factors and changes in hydration and collagen, are believed to play a role in the development of degenerative disc disease. […] Decreased hydration of the disc can reduce the cushioning effect, thus transmitting a greater portion of the applied loads to the anulus in an asymmetric distribution, which could lead to injury. […] Increases in the collagen content of the nucleus and in its crystallinity have been reported to be partially responsible for disc degeneration. […] One study reported a strong familial predisposition to discogenic low back pain and suggested that the etiology of degenerative disc disease includes both genetic and environmental factors.

• #10 Slipped disc

  https://www.nhs.uk/conditions/slipped-disc/

  A slipped disc, also called a prolapsed or herniated disc, is when a soft cushion of tissue between the bones in your spine bulges outwards. […] A slipped disc can happen because of: […] ageing […] exercising too hard […] lifting heavy objects the wrong way […] sitting down or driving for long periods of time […] being inactive or overweight. […] There’s some evidence that manual therapies, like osteopathy, can help ease lower back pain.

• #11 Slipped Disc: Causes, Symptoms, And Treatment Options

  https://regenexx.com/condition/spine/exploring-slipped-disc/

  Repetitive strain occurs when the spine endures continuous stress from activities like heavy lifting, bending, or twisting. Over time, this pressure may weaken the discs, making them more vulnerable to slipping or bulging. […] Sudden impacts or trauma, such as falls, car accidents, or sports injuries, can damage spinal discs, causing them to slip or rupture. […] Genetics may play a role in the likelihood of developing disc problems. […] Excess body weight can contribute to additional strain on the spine, potentially increasing stress on discs. […] A lack of physical activity can weaken the muscles that support the spine, making the spinal discs more prone to injury and degeneration. […] Poor posture, such as slouching, can place uneven pressure on the spine and discs. Over time, this stress may weaken the discs, making them more susceptible to slipping or bulging.

• #12 Disc herniation – Wikipedia

  https://en.wikipedia.org/wiki/Disc_herniation

  There is evidence that points to a specific inflammatory mediator in back pain: an inflammatory molecule, called tumor necrosis factor alpha (TNF), is released not only by a herniated disc, but also in cases of disc tear by facet joints, and in spinal stenosis. […] Some authors favour degeneration of the intervertebral disc as the major cause of spinal disc herniation and cite trauma as a minor cause. […] With degeneration, the disc components the nucleus pulposus and annulus fibrosus become exposed to altered loads. […] If the fissures reach the periphery of the annulus, the nuclear material can pass through as a disc herniation. […] Herniation of the contents of the disc into the spinal canal often occurs when the anterior side (stomach side) of the disc is compressed while sitting or bending forward, and the contents (nucleus pulposus) get pressed against the tightly stretched and thinned membrane (annulus fibrosus) on the posterior side (back side) of the disc.

• #12 Disc herniation – Wikipedia

  https://en.wikipedia.org/wiki/Disc_herniation

  A disc herniation or spinal disc herniation is an injury to the intervertebral disc between two vertebrae, usually caused by excessive strain or trauma to the spine. […] When a tear in the outer, fibrous ring of an intervertebral disc allows the soft, central portion to bulge out beyond the damaged outer rings, the disc is said to be herniated. […] Disc herniation is frequently associated with age-related degeneration of the outer ring, known as the annulus fibrosus, but is normally triggered by trauma or straining by lifting or twisting. […] A tear in the disc ring may result in the release of chemicals causing inflammation, which can result in severe pain even in the absence of nerve root compression. […] It is increasingly recognized that back pain resulting from disc herniation is not always due solely to nerve compression of the spinal cord or nerve roots, but may also be caused by chemical inflammation.

• #13 The inflammatory response in the regression of lumbar disc herniation | Arthritis Research & Therapy | Full Text

  https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-018-1743-4

  Lumbar disc herniation (LDH) is highly associated with inflammation in the context of low back pain. […] However, inflammation has also been indicated as the main factor responsible for LDH regression. […] This review addresses the molecular and cellular mechanisms involved in LDH regression, including matrix remodeling and neovascularization, in the scope of the clinical decision on conservative versus surgical intervention. […] The phenomenon of spontaneous regression of LDH, extensively reported in the literature, is therefore analyzed here under the perspective of the modulatory role of inflammation. […] The main hypothesis behind the initiation of spontaneous LDH regression has been described as the exposure of herniated disc material to the epidural vascular supply through the ruptured posterior longitudinal ligament (PLL).

• #13 The inflammatory response in the regression of lumbar disc herniation | Arthritis Research & Therapy | Full Text

  https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-018-1743-4

  The third theory, the most extensively studied with preclinical and clinical evidence to support it, is the gradual hernia resorption through enzymatic degradation and phagocytosis induced by an inflammatory reaction and neovascularization. […] This inflammatory reaction is supposed to be triggered when the disc content extrudes into the epidural space and is then recognized as foreign. […] The immune-privileged environment of the NP is the pillar of the theory of the inflammatory reaction behind LDH resorption. […] This theory proposes that the extrusion of the NP tissue into the epidural space evokes an autoimmune reaction that leads to the infiltration of immune cells which will interact with IVD cells and secrete a variety of molecules initiating the hernia resorption process. […] Macrophages are indicated as the most important immune players in the resorption process of herniated discs.

• #13 The inflammatory response in the regression of lumbar disc herniation | Arthritis Research & Therapy | Full Text

  https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-018-1743-4

  These cells have the capability to actively phagocyte the herniated tissue and process it in their lysosomes filled with collagen-degrading enzymes. […] The presence of T and B lymphocytes on isolated human herniated discs was further confirmed by the same group. […] It is clear that the inflammatory response that occurs associated with LDH is crucial to its spontaneous resorption.

• #14 Painful intervertebral disc degeneration and inflammation: from laboratory evidence to clinical interventions | Bone Research

  https://www.nature.com/articles/s41413-020-00125-x

  The high osmotic pressure and acidic environment in the IVD further exacerbate the stress state. […] Discogenic pain refers to pain induced by degenerative changes in the IVD, resulting in the early stages of disc degeneration. […] Pain-related molecules, including tumor necrosis factor (TNF) alpha, interleukin (IL)-1 beta, IL-4, IL-6, IL-8, IL-12, prostaglandin E2 (PGE2), interferon-gamma, and nitric oxide (NO), were found to be upregulated in herniated human IVDs. […] In degenerated and herniated discs, nerves were found to be localized in distorted tissues. […] The identified inducers of nerve ingrowth include TNF-, IL-1, and NGF. […] The discogenic pain signal passes through the IVD and adjacent structures and is transmitted through peripheral afferent nerve fibers. […] Nerve fibers interact with inflammatory mediators in the NP and cause discogenic LBP.

• #14 Painful intervertebral disc degeneration and inflammation: from laboratory evidence to clinical interventions | Bone Research

  https://www.nature.com/articles/s41413-020-00125-x

  Furthermore, inflammatory mediators such as TNF- and IL-1 induce the expression of pain-related factors such as nitric oxide (NO), cyclooxygenase 2 (COX-2), and nerve growth factors (NGF), which promote nerve ingrowth. […] All of these factors together contribute to the occurrence of LBP. […] Treating discogenic LBP requires a good understanding of IDD and the underlying inflammation. […] In this review, we tried to provide an overview of discogenic LBP studies with a focus on advances in inflammation-related pain in IDD. […] We review the role of inflammation in IDD and pain induction, as well as the currently available animal models for the study of painful IDD and the underlying signaling pathways contributing to inflammation and discogenic pain production. […] The etiology of IDD is complicated. Most degeneration begins in adults and progresses with age.

• #14 Painful intervertebral disc degeneration and inflammation: from laboratory evidence to clinical interventions | Bone Research

  https://www.nature.com/articles/s41413-020-00125-x

  Compared with herniated IVDs, painful discs contain more inflammatory mediators. […] However, not all patients with disc degeneration are symptomatic with LBP. […] Studies have shown that the proportion of severely degraded but painless IVDs increases with age. […] The lack of persistent inflammation might be crucial to determine whether a degenerated disc becomes symptomatic. […] Taken together, these reports strongly suggest a correlation between sensory nerve ingrowth, inflammatory mediators, and discogenic LBP. […] Various pathways, such as the nuclear factor kappa-B (NF-B) and mitogen-activated protein kinase (MAPK) pathways, have been found to play essential roles in the production of inflammatory factors and catabolism of ECM in the IVD, and increasing evidence supports the importance of these signaling pathways and Toll-like receptor (TLR) signaling in painful disc diseases.

• #14 Painful intervertebral disc degeneration and inflammation: from laboratory evidence to clinical interventions | Bone Research

  https://www.nature.com/articles/s41413-020-00125-x

  NF-B activity is physically inhibited when an inhibitor of kappa B (IB) binds to p65. […] Once stimulated, p65 is rapidly released from the NF-B heterodimer and IB and translocates to the nucleus, where it activates the transcription of target genes. […] Numerous studies have shown that the NF-B signaling pathway plays a major role in inflammatory cytokine production and secretion, which is closely associated with disc degeneration and the genesis of discogenic pain. […] These new studies indicated that the NF-B signaling pathway is not only implicated in inflammatory cytokine secretion but also plays a vital role in discogenic pain production.

• #15 Section 2, Chapter 8: Pathophysiology of Lumbar Radiculopathy : Wheeless’ Textbook of Orthopaedics

  https://www.wheelessonline.com/issls/section-2-chapter-8-pathophysiology-of-lumbar-radiculopathy/

  This correlates with clinical observations. […] It is also recognized that reduced blood flow, with subsequent neuro-ischemia and lack of nutrients, is the most important pathophysiological mechanism through which pressure induces nerve dysfunction. […] The hypothesized importance of one or more biologically active substances, or chemical factors, independent of pressure in the pathophysiology of lumbar radiculopathy has been suggested in several articles from early on but was not investigated further until the early 90s. […] The nucleus pulposus triggers the inflammation in disc herniation, but the underlying mechanism is not well understood. […] Pro-inflammatory cytokines such as TNF act to sensitize the nerve root and contribute to symptoms of both nerve dysfunction and radicular pain in lumbar radiculopathy. […] Components of the NP may induce an inflammatory reaction that is likely responsible for the production of these cytokines, and an autoimmune reaction to components of the NP may contribute to this reaction.

• #16 Characteristics and mechanisms of resorption in lumbar disc herniation | Arthritis Research & Therapy | Full Text

  https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-022-02894-8

  Lumbar disc herniation (LDH) can be spontaneously absorbed without surgical treatment. […] The purpose of this review was to summarize previous reports on LDH reabsorption and to discuss the clinical and imaging features that favor natural absorption. […] We highlighted the biological mechanisms involved in the phenomenon of LDH reabsorption, including macrophage infiltration, inflammatory responses, matrix remodeling, and neovascularization. […] Current evidence suggests that macrophage regulation of inflammatory mediators, matrix metalloproteinases, and specific cytokines in intervertebral disc is essential for the spontaneous reabsorption of LDH. […] The first mechanism is retraction of the protrusion, which may occur without separation of the protrusion from the annulus fibrosus.

• #16 Characteristics and mechanisms of resorption in lumbar disc herniation | Arthritis Research & Therapy | Full Text

  https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-022-02894-8

  A third mechanism, which has received extensive attention, states that fragments of herniated IVD enter the epidural space, triggering an autoimmune response including inflammatory cell infiltration and neovascularization. […] This autoimmune system recognizes LDH protrusions as foreigners in the vertebral epidural vascular space, which in turn triggers a cascade of inflammatory responses including neovascularization, matrix protease activation, increased levels of inflammatory mediators, phagocytosis of inflammatory cells, and enzymatic degradation. […] Macrophage infiltration and activation are critical steps in the process of reabsorption. […] The expression of some cytokines and chemokines in IVD is an important factor in macrophage recruitment. […] The interaction of macrophages with IVD induces the production of inflammatory cytokines.

• #16 Characteristics and mechanisms of resorption in lumbar disc herniation | Arthritis Research & Therapy | Full Text

  https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-022-02894-8

  Macrophages play a key role in LDH-mediated inflammatory responses. […] The different effects produced by macrophage infiltration depend on the type of macrophage in IVD. […] The reabsorption of LDH is a complex physicochemical process. […] The known classical biological mechanisms involve the regulation of various cytokines after macrophage infiltration into the intervertebral disc tissue, including phagocytosis, inflammatory response, matrix degradation, and neovascularization.

• #17 Herniated Disc – AANS

  https://www.aans.org/patients/conditions-treatments/herniated-disc/

  A herniated disc (also called bulged, slipped or ruptured) is a fragment of the disc nucleus that is pushed out of the annulus, into the spinal canal through a tear or rupture in the annulus. […] Discs that become herniated usually are in an early stage of degeneration. The spinal canal has limited space, which is inadequate for the spinal nerve and the displaced herniated disc fragment. Due to this displacement, the disc presses on spinal nerves, often producing pain, which may be severe. […] A single excessive strain or injury may cause a herniated disc. However, disc material degenerates naturally as one ages, and the ligaments that hold it in place begin to weaken. As this degeneration progresses, a relatively minor strain or twisting movement can cause a disc to rupture. […] Herniated discs can occur in any part of the spine. Herniated discs are more common in the lower back (lumbar spine), but also occur in the neck (cervical spine). The area in which pain is experienced depends on what part of the spine is affected.

• #18 Intervertebral discs: Anatomy, structure and function | Kenhub

  https://www.kenhub.com/en/library/anatomy/herniated-disc

  Intervertebral discs consist of a thick outer ring of fibrous cartilage called the anulus fibrosus (fibrous ring), which surrounds an inner gel-like center known as the nucleus pulposus (meaning pulpy interior). […] The intervertebral disc forms the fibrocartilaginous joint which allows slight movement of the vertebral column, and acts as a ligament to hold the vertebrae together. […] The discs act as fibrocartilaginous cushions, serving as the spines shock absorbing system. This cushions the effect of shock and stress produced when an individual walks, runs, bends, or twists. […] A spinal disc herniation can happen when the gel-like material of the nucleus pulposus is forced out of the surrounding anulus fibrosus, which can put pressure on the nearby nerve. […] One effect of ageing and disc degeneration is that the nucleus pulposus begins to dehydrate and the concentration of proteoglycans in the matrix decreases, thus limiting the ability of the disc to absorb shock.

• #19 Pathophysiology and Etiology of Intervertebral Disc Herniation | Neupsy Key

  https://neupsykey.com/pathophysiology-and-etiology-of-intervertebral-disc-herniation/

  As the degenerative process takes place, there is alteration of the load pattern as areas of the anulus experience greater compressive loads, whereas a decompressed and heterogeneous nucleus is loaded irregularly. […] Herniated discs have been shown to contain increased matrix metalloproteinases (MMPs), nitric oxide, prostaglandin E2 (PGE-2), and interleukin-6 (IL-6). […] Certainly, although in vitro studies suggest the anulus as the primary site responsible for herniation, it is the combination of nuclear degeneration coupled with these complex forces upon the anulus that account for herniation. […] Brinckmann suggested that degeneration and fragmentation of the NP with its separation from the endplate is a prerequisite for herniation. […] Simunic et al, however, showed that healthy discs that were compressed while fully flexed and fully hydrated were highly susceptible to intraannular prolapse through an existing annular division. […] This study emphasizes the role that both vibration and static loads may play in the etiology of disc herniation and helps to explain the increased incidence of disc herniation in truck drivers and others exposed to vibrational loads.

• #20 Herniated Disc – Symptoms, Diagnosis, TreatmentSecond Opinion IconGroup 9Second Opinion IconSpine Surgery

  https://www.barrowneuro.org/condition/disc-herniation/

  Made up of 24 bones called vertebrae, the adult spine is also home to 23 discs between each vertebra that act as shock absorbers when the spine moves and bends. Inside each disc is a soft, jelly-like center called the nucleus pulposus, while on the outside, a tough layer called the annulus fibrosus protects the spongy center. […] When the soft center of a disc pushes through a tear in the outer layer, a herniated disc occurs. If the protruding disc fragment then puts pressure on the spinal cord (cervical or thoracic herniation), it can cause back pain and spinal cord dysfunction. If it’s in the lumbar spine, it can cause nerve root compression and sciatica. The disc fragment also releases chemical irritants that can lead to inflammation. […] A herniated disc is most common in the lower back or lumbar spine, followed by the neck or cervical spine. Herniated discs are least common in the middle part of your back, known as the thoracic spine.

• #21 Lumbar Disc Disease: Practice Essentials, Epidemiology, Presentation

  https://emedicine.medscape.com/article/249113-overview

  Lumbar disc disease is a rather encompassing term. For example, some physicians include back pain alone as a symptom of disc disease. Others make the diagnosis without evidence of disc disease on MRI. The discussion of this article is limited to well-defined lumbar disc herniation. The pathophysiology, clinical presentation, radiographic diagnosis, treatment, and outcome are discussed. […] A disc herniation (lumbar disc disease) most frequently irritates the displaced nerve root. One of the more difficult concepts for beginning medical students to grasp is the anatomic relationship of the fifth lumbar (L5) nerve root to the L4-5 disc herniation. Equally important to understand is the concept of the far lateral or foraminal disc herniation in which the root above the disc herniation is irritated.

• #22 Herniated Disc – Lumbar » Lillian S. Wells Department of Neurosurgery at the University of Florida » College of Medicine » University of Florida

  https://neurosurgery.ufl.edu/patient-care/diseases-conditions/herniated-disc-lumbar/

  Herniated disc, commonly known as slipped or ruptured disc, is a condition in which the central part of the intervertebral disc protrudes into the spinal canal. This typically occurs due to a tear in the tough fibrous annular ring that surrounds the soft inner core of the disc. This results in herniation of the softer material (the nucleus pulposus) into the spinal canal. Aging and trauma can predispose to disc herniations. […] Most commonly disc herniations occur in the lowermost part of the spine, especially between the 4th and 5th lumbar vertebral bodies, and between the 5th lumbar vertebral body and the sacrum. This protrusion usually occurs to one side of the spinal canal, compressing one of the nerve roots. Impingement on the nerve causes pain, numbness, and weakness in the part of the skin and muscle that are supplied by that particular nerve root.

• #23 Herniated disk: Causes, symptoms, diagnosis, and treatment

  https://www.medicalnewstoday.com/articles/191979

  A herniated disk, also called a slipped disk, happens when the soft center of a spinal disk slips out of its casing. […] A herniated or slipped disk occurs when some of the soft internal section of a spinal disk (the nucleus) slips out through a crack in the disks fibrous lining. This most commonly occurs in the lower back but can also happen in the spinal column of the neck and middle back. […] The escape of the disks inner section releases chemicals that can irritate nerves in the surrounding area and cause inflammation and pain. The herniated disk can also put pressure on nerves and cause pain through compression. […] A severely herniated disk in any region of the back can potentially cause problems with bowel or bladder control. […] If the herniated disk is in the lower back, the pain often affects the buttocks, thighs, and calves.

• #23 Herniated disk: Causes, symptoms, diagnosis, and treatment

  https://www.medicalnewstoday.com/articles/191979

  If the problem occurs in the neck, pain is more likely in the shoulders and arms. […] A herniated disk in the middle back is likely to cause pain around the location of the herniation. […] Most of the time, disk herniation will improve with nonsurgical treatment. However, the treating doctor may recommend surgery if a person has symptoms such as muscle weakness, pain that persists over time, mobility issues, or problems with bladder or bowel control. […] Surgical treatments for disk herniation include discectomy, nucleotomy, laminectomy, spinal fusion, and disk replacement. […] A herniated disk occurs when the jelly-like center of a spinal disk protrudes through the disks outer casing. This can result in pain, numbness, and weakness if the slipped disk causes pressure or irritation to nearby nerves. […] In many cases, a doctor can use a physical exam to diagnose a herniated disk. They may order imaging tests such as an X-ray or CT scan if they need more information about the condition of the spine and disks.

• #24 Which Stage of Disc Herniation Are You In? | Premier Spine Institute PLLC

  https://premierspineinstitute.com/which-stage-of-disc-herniation-are-you-in/

  In stages three and four, pain is often accompanied by tingling, numbness, and weakness in the nearby tissues. If you have herniated discs in your lower back, you may feel numbness, tingling, and weakness in your lower back and legs. […] Herniated discs in the neck sometimes cause symptoms that radiate to the shoulders and arms.

• #25 Bulging Disc Bladder Problems – The Nerve & Disc Institute

  https://nervediscinstitute.com/blog/bulging-disc-bladder-problems/

  The primary mechanism behind bladder problems due to a bulging disc involves nerve compression. When a disc herniates, it can press against the nerves in the spinal column, particularly those that control the bladder. This pressure disrupts the normal nerve signals between the bladder and the brain, leading to various urinary issues. […] Nerve compression can cause both sensory and motor dysfunction. Sensory dysfunction affects the signals that indicate bladder fullness, leading to problems like urinary retention or frequent urination. Motor dysfunction impacts the muscles involved in urination, resulting in incontinence or difficulty in starting urination. In severe cases, this condition can lead to a condition known as cauda equina syndrome, where the bundle of nerves at the lower end of the spinal cord is compressed, causing severe bladder and bowel dysfunction. This would be a medical emergency and patients experiencing this should go directly to the hospital.

• #26 Prevalence, clinical predictors, and mechanisms of resorption in lumbar disc herniation: a systematic review | Published in Orthopedic Reviews

  https://orthopedicreviews.openmedicalpublishing.org/article/121399-prevalence-clinical-predictors-and-mechanisms-of-resorption-in-lumbar-disc-herniation-a-systematic-review

  The mechanism of NP spontaneous resorption is mainly due to macrophage infiltration leading to immune response. […] Despite the extensive literature on disc spontaneous resorption, the exact mechanism remains incompletely elucidated. In general, four pathophysiologic mechanisms are widely recognized, including (1) cascading inflammatory response, (2) neovascularization, (3) macrophage infiltration-mediated immune response, and (4) matrix protease activation for degradation. […] The secretion of inflammatory factors promotes the production of a series of matrix-degrading enzymes, accelerates the breakdown of extracellular matrix, and enhances the recruitment of immune cells to this region, thereby maintaining and promoting inflammation. […] The normal intervertebral disc is an avascular one with a unique structure isolating NP from the host immune system, and therefore it inhibits the infiltration of immune cells and cytokines.

• #26 Prevalence, clinical predictors, and mechanisms of resorption in lumbar disc herniation: a systematic review | Published in Orthopedic Reviews

  https://orthopedicreviews.openmedicalpublishing.org/article/121399-prevalence-clinical-predictors-and-mechanisms-of-resorption-in-lumbar-disc-herniation-a-systematic-review

  In the case of disrupted blood-NP barrier, such as NP exposing to the immune microenvironment, an autoimmune response is triggered, leading to the development of a variety of pathological processes such as neovascularization and immune infiltration. […] Macrophage infiltration and activation are critical steps in the resorption process, and macrophage infiltration in disc herniations has been widely demonstrated. […] Macrophages appear to be key immune cells involved in this process, and many histologic studies have demonstrated the presence of macrophages in tissues with herniated NP. […] Macrophages related inflammatory factors stimulate the production of chemokines that induce activation of MMPs to promote herniation resorption. […] The main mediators that induce formation around the herniation are tumor necrosis factor (TNF)-, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and platelet-derived growth factor (PDGF), where VEGF is an important mediator of angiogenesis.

• #27 A new perspective on intervertebral disc calcification—from bench to bedside | Bone Research

  https://www.nature.com/articles/s41413-023-00307-3

  Disc degeneration primarily contributes to chronic low back and neck pain. […] Amongst these phenotypes, disc calcification is the least studied. […] Clinically, disc calcification is associated with poor surgical outcomes and back pain refractory to conservative treatment. […] It is frequently seen as a consequence of disc aging and progressive degeneration but exhibits unique molecular and morphological characteristics: hypertrophic chondrocyte-like cell differentiation; TNAP, ENPP1, and ANK upregulation; cell death; altered Pi and PPi homeostasis; and local inflammation. […] Recent studies in mouse models have provided a better understanding of the mechanisms underlying this phenotype. […] Moreover, the combination of anatomic location, genetics, and environmental stressors, such as aging or trauma, govern the predisposition to calcification.

• #27 A new perspective on intervertebral disc calcification—from bench to bedside | Bone Research

  https://www.nature.com/articles/s41413-023-00307-3

  The link between genetic background and age-dependent progression of disc degeneration in mice has recently been explored in a study utilizing three different inbred mouse strains, C57BL/6, LG/J, and SM/J, which showed distinct degenerative phenotypes, namely, fibrosis, disc calcification, and apoptosis with cell fate change, respectively. […] While we observed that LG/J mice possessed widespread calcifications in the NP and AF, no calcification of spinal ligaments was noted, as is seen during ankylosing spondylitis. […] Mechanistic, transcriptomic, and protein analyses of these three strains suggested a contribution of cell death to elevated free local calcium and phosphate to AF tissue mineralization. […] Noteworthy, transcriptomic analysis highlighted the consequences of Ank loss in affecting ectopic calcification-linked pathways, such as autophagy, with downregulating genes related to protein homeostasis and heat shock protein suggesting proteostasis.

• #27 A new perspective on intervertebral disc calcification—from bench to bedside | Bone Research

  https://www.nature.com/articles/s41413-023-00307-3

  Importantly, in addition to controlling local PPi and citrate levels ANK may play a central role in disc calcification by modulating BMAL1/CLOCK pathways, cell fate, autophagy, local inflammation, and matrix remodeling which, are known promoters of ectopic calcification. […] Overall, these studies underscore the uniqueness of each disc tissue regarding the mineralization process. […] In summary, anatomic location, genetic predisposition, and environmental stress, such as aging or trauma, strongly influence intervertebral disc calcification phenotype.

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