Clinical Appearance of Contained and Noncontained Lumbar Disc Herniation

In a prospective and consecutive study, we evaluated the incidence of common symptoms and neurologic disturbances in 200 patients operated on because of lumbar disc herniation by using a computer-coded protocol with pre- and perioperative registration. The preoperative occurrence of pain at rest, at night, and on coughing was registered. Use of analgesics and walking ability were registered as category data. At examination, a straight-leg-raising (SLR) test was graded in four categories, and results from neurologic findings were collected. At surgery, disc herniation was classified as extruded/sequestered herniation, prolapse, or focal protrusion. There were no significant differences concerning pain at rest or at night related to type of herniation. Pain on coughing was more common in extruded/sequestered herniations. Use of analgesics as well as severe reduction of walking capacity were significantly more common in patients with extrusion/sequestration. The highly restricted SLR test, as well as the crossed positive SLR test, were also significantly more common in patients with extruded/sequestered herniation, and this was also true for the incidence of relevant reflex/extensor hallucis longus (EHL) and sensory disturbance. In conclusion, the clinical appearance of lumbar disc herniation was most "aggressive" in extruded and sequestered disc herniation. The symptoms and signs in disc protrusion were less severe, whereas patients with prolapse had an "intermediate" appearance concerning symptoms and signs. The differences in incidence of common signs in noncontained versus contained herniation were statistically significant; these differences may be of clinical interest for patient selection and information as well as in pathophysiologic considerations.