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Intervertebral Disc Prolapse N043
In this section
Current RMA Instruments:
|Reasonable Hypothesis SOP||43 of 2016|
|Balance of Probabilities SOP||44 of 2016|
Changes from previous Instruments:
- ICD-9-CM Codes: 722.0,722.1,722.2,722.7
- ICD-10-AM code M50.0, M50.1, M50.2, M51.0, M51.1 or M51.2
Between each pair of vertebral bodies in the spine there is a cushion-like structure known as an intervertebral disc. These discs (help to) hold the vertebrae together, allow movement between vertebrae and provide shock absorption in the spine. Discs are comprised of an outer fibrous layer (the annulus fibrosis) surrounding an inner gel-like centre (the nucleus pulposus). Injury or degeneration of a disc can lead to tearing of the outer layer and protrusion/herniation of the disc contents into the spinal canal. This can result in local pain and/or nerve compression. Intervertebral disc prolpase can occur in isolation (typically in a younger person), or as part of a wider spinal degenerative process. The intervertebral disc prolapse (IVDP) SOP is appropriate for isolated (single level) disc disease/injury. The spondylosis SOPs should usually be applied (instead, not as well) when more generalised degeneration in the spine is present (see further information, below).
Confirming the diagnosis:
To confirm the diagnosis there needs to be evidence on radiological imaging of disc prolapse (i.e. more than just bulging of an intact disc) together with clinical manifestations in the form of:
- pain or stiffness at the involved level; OR
- clinical evidence of nerve root compression; OR
- clinical evidence of spinal cord compression; AND
the clinical manifestations need to be attributable to the disc prolapse and not some other pathology.
Either symptoms/signs alone or radiological evidence alone is insufficient for diagnosis, both components must be present.
This SOP applies when disc prolapse occurs in isolation (i.e. single level disease without more widespread degenerative changes (osteophytes, facet joint arthritis). More generalised spinal degenerative disease is more appropriately covered by one of the spondylosis SOPs (cervical, thoracic or lumbar).
The relevant medical specialist is an orthopaedic surgeon or neurologist.
Additional diagnoses covered by the SOP
- Herniated intervertebral disc
- Ruptured intervertebral disc
Related conditions that may be covered by the SOP (further information required)
- Slipped disc
Conditions not covered by SOP
- Bulging intervertebral disc (generally within normal range – not a disease)
- Cervical, thoracic or lumbar spondylosis*
- Musculoligamentous strain or sprain of the lumbar spine* - sprain and strain SOP
- Schmorl’s nodes#
- Scheuermann’s disease# - under investigation by RMA as at May 2016
* another SOP applies - the SOP has the same name unless otherwise specified
# non-SOP condition
To establish clinical onset the diagnosis first needs to be confirmed and symptoms need to be located at the right level of the spine and attributable to a disc prolpase. Clinical onset can then be backdated to the time of first onset of relevant symptoms. This may have been at the time of, or shortly after, an acute injury, provided the same symptoms of pain or nerve entrapment have persisted from the time of injury.
The clinical course is variable and symptoms may progress, remain or diminish over time. Initial treatment is generally conservative and focussed on pain relief. Injections into the spine do not have any long term benefits. Surgery (discectomy) is usually a last resort and is more likely to be effective to alleviate neurological symptoms (from nerve root compression) than for local pain. Surgery is unlikely to provide any benefit in the longer term (5 to 10 years). Worsening of prolapse can occur with further injury or continuation of activity that led to the problem. This may be manifest by a persisting increase in symptoms or radiological evidence of more pronounced prolapse. Progression to more widespread degeneration may be better dealt with as an onset of spondylosis rather than a worsening of IVDP.
Further comments on diagnosis
Intervertebral disc prolapse (IVDP) may be an initially acute event, in which there is sudden onset of symptoms at a particular level in the spine. This typically occurs in young adults. It needs to be distinguished from intervertebral disc degeneration as part of a wider process (spondylosis). Generally one or other diagnosis will apply, but in certain circumstances both diagnoses may apply to the same area of the spine.
Note that IVDP is a factor in the spondylosis SOPs but not vice versa.
When degenerative disc disease with prolapse is present:
1. If IVDP predates spondylosis:
IVDP may give rise to disc degeneration at the involved level. When degenerative disc disease is present and there is a history of old IVD prolapse at the involved level (predating the spondylosis), a diagnosis of spondylosis (identifying the region involved) should be made. Causes of IVD prolapse will then still be considered as potential causes for the diagnosed spondylosis at that level, via propagation.
2. If IVDP postdates the onset of spondylosis
Protrusion/rupture/herniation of an intervertebral disc that develops in the setting of wider degenerative change is usually part of the degenerative process and is covered by a diagnosis of spondylosis. A separate diagnosis of IVDP will generally not be warranted.
If degenerative disease is present and there is then a separate event, e.g. a trauma, that leads to the onset of new disc prolapse, then in that setting an additional diagnosis of IVDP may be warranted.