The anatomic basis of vertebrogenic pain and the autonomic syndrome associated with lumbar disk extrusion

Extruded lumbar intervertebral disks traditionally have been classified as posterior or central in location. A retrospective review of 250 MR imaging examinations of the lumbar spine that used mid- and high-field images revealed 145 positive studies, which included a significant number of extrusions extending anteriorly. With the lateral margin of the neural foramen/pedicle as the boundary, 29.2% of peripheral disk extrusions were anterior and 56.4% were posterior. In addition, a prevalence of 14.4% was found for central disk extrusions, in which there was a rupture of disk material into or through the vertebral body itself. The clinical state of neurogenic spinal radiculopathy accompanying posterior disk extrusion has been well defined; however, uncomplicated anterior and central disk extrusions also may be associated with a definite clinical syndrome. The vertebrogenic symptom complex includes (1) local and referred pain and (2) autonomic reflex dysfunction within the lumbosacral zones of Head. Generalized alterations in viscerosomatic tone potentially may also be observed. The anatomic basis for the mediation of clinical signs and symptoms generated within the disk and paradiskal structures rests with afferent sensory fibers from two primary sources: (1) posterolateral neural branches emanating from the ventral ramus of the somatic spinal root and (2) neural rami projecting directly to the paravertebral autonomic neural plexus. Thus, conscious perception and unconscious effects originating in the vertebral column, although complex, have definite pathways represented in this dual peripheral innervation associated with intimately related and/or parallel central ramifications. It is further proposed that the specific clinical manifestations of the autonomic syndrome are mediated predominantly, if not entirely, within the sympathetic nervous system. The directional differentiation of lumbar disk extrusions by MR, together with a clarification and appreciation of the accompanying clinical somatic and autonomic syndromes, should contribute both to understanding the specific causes as well as to establishing the appropriate treatment of acute and chronic signs and symptoms engendered by many nonspecific disease processes involving the spinal column.