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HNP

ClinicalPracticeGuideline
for
HERNIATEDNUCLEUSPULPOSUS
Developedforthe

AerospaceMedicalAssociation
bytheirconstituentorganization

AmericanSocietyofAerospaceMedicineSpecialists

Overview:Theintervertebraldisciscomprisedofthreeparts.Thenucleuspulposis(NP)isamucoproteingel
locatedintheposterocentralportionofthedisc.SurroundingtheNPistheannulusfibrosis(AF),concentric
laminatedbandsoffibroustissue.Andfinally,cartilaginousendplatesseparatethediscfromthevertebralbody.
HNPoccurswhentheNPherniatesthroughtheAF,usuallyinaposteriororposterolateralfashion.Thiscanonly
occurwhentheAFisdisruptedeitherbyviolenttraumaorrecurrentmicrotrauma.Ahistoryoftraumahasbeen
elicitedinover50%ofthosewithlumbarHNP.

Approximately80%ofHNPsoccurinthelumbarregion.TheageincidencecurveforlumbarHNPpeaksinthe
secondthroughfourthdecadesoflifeandtheincidenceishigherinmalesthanfemales.Otherpathologiclesions
(i.e.spondylosisandspinalstenosis)havebeennotedin50%ofthecaseswithlumbarHNP.Approximately20%
ofHNPsoccurinthecervicalregionand2033%ofthesehaveconcurrentlumbardiscinvolvement.Theage
incidencecurveforcervicalHNPpeaksinthefifththroughsixthdecadesoflifeandtheincidenceishigherinmales
thanfemales.Lessthan1%oftheHNPsoccurinthethoracicregion.TheageincidencecurveforthoracicHNP
peaksinthefifththroughsixthdecadesoflifeandtheincidenceisequalforbothsexes.

SymptomsfromHNPvaryfromasymptomatictoparaplegia.Herniateddiscmattermaycompressnerveroots,
vascularstructures,andeventhespinalcord(aboveL2).Symptomssuchaspain,numbness,paresthesias,
weaknessandmusclewastingareusuallythepresentingfindings.However,progressionofdiseasemayleadto
quadriparesis,paraplegia,andemergentconditionssuchascaudaequinasyndromeandconussyndrome.

AeromedicalConcerns:Inabilitytoperformflyingdutiesmaybearesultofbaselinesymptoms(pain,weakness).
Suddenincapacitationandpermanentdisabilityaresignificantconcerns,particularlyinahighGenvironmentor
duringejection.Andfinally,theforcesappliedtotheintervertebraldiscunderhighGstressmayleadtoaccelerated
progressionofdisease.FollowingsurgicaltreatmentofHNP,concernsareraisedregardingvertebraljointstability
andsubsequentcatastrophicfailureofthevertebralcolumn,dependingonthetypeandnatureoftheprocedure.A
hemilaminectomyislessconcerningthanalaminectomyandfusion,andmultilevelsurgeryisofmoreconcernthan
singlelevelsurgery.

Recurrencesandfrequentremovalfromaviationdutiesmayhaveadverseeffectsonaviationmissions,particularly
inthemilitary.Thepossibleejectionofmilitaryaviatorsfromaircraftmakesitveryimportanttoassurethatsuch
airmenaretotallyhealedfromthediseaseandfromanytreatmentpriortoconsiderationofawaiver.

MedicalWorkup:DiagnosisofHNPisbasedoncharacteristicsymptomatology,confirmedbyradiologicstudies.
ThepredominantstudiesusedtodocumentHNParemyelography,CTandMRimaging.HNPisconfirmedbythe
demonstrationofherniationofdiscmaterial(sizeanddirection)anddistortion/displacementofthethecalsac,
epiduralfat,and/ornerveroot.However,repeatedstudieshavefailedtodelineateadirectrelationshipbetweenthe
degreeofherniationandtheamountofsymptoms.Infact,35%ofindividualovertheageof40yearshavebeen
notedtohavevariousanomaliesofintervertebraldiscswhileremainingasymptomatic.

StandardtreatmentforHNPconsistsofconservativetherapy,surgery,andchemonucleolysis.Conservative
therapy(i.e.,bedrest,painmedication,andphysicaltherapy)hasresultedinsymptomaticimprovementin3095%of
HNPs.Severalstudieshavedocumentedregressionandevencompleteresolutioninupto50%ofHNPswithin6
months.SurgicalresectionofHNPiseffectivein90%ofcarefullyselectedHNPsbutupto30%ofthosewho
undergosurgeryhaveunsatisfactoryresults(extraduralfibrosis/scarring,recurrentHNP,andspinalstenosis
secondarytoboneovergrowth).Surgeryshouldbelimitedto:1)severeintractablepainnotrespondingto
conservativetherapy,2)significantneurologicdeficit(mostnotablyweakness)thatisatriskforbecoming
permanent,and3)frequentlyrecurringepisodesofradiculopathythatcausessignificantfunctionalimpairment.In
addition,operativecomplicationssuchasnerverootorcordinjuryandpostoperativejointinstabilitymayoccur.
ChymopapaininjectedintotheHNPresultsinenzymatichydrolysisofthechondromucoproteinportionoftheHNP.
Althoughthisprocedurehasbeeninusefortwentyyears,longtermeffectsfromchemonucleolysisareunknown
thistreatmentmodalityhasfallenintodisfavorinthepastfewyears.Severalstudieshavedocumenteda2030%
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HNP

failureratewiththisprocedureandcomplicationratessimilartosurgery.

AeromedicalDisposition(military):WaivercanbeconsideredfollowingthesuccessfultreatmentofHNP.As
notedabove,thetreatmentmaybeconservativeand/orsurgical.Initialevaluationshouldincludehistoryand
physicalexaminationtoensurethattheexamineeisasymptomaticandabletoperformdutieswithoutlimitations.If
historyorphysicalelicitsfindings,furtherstudies(suchasnerveconductionstudyandelectromyelogram)maybe
neededforfurtherevaluation.Also,aconsultationfromanorthopedicsurgeonshouldcleartheexamineeforflying
dutiesanddelineateprognosis.Finally,imagingstudies(CTorMRI)shoulddocumentstructuralresolutionofthe
HNP.ThetypeofaircraftflownisveryimportantinanaeromedicaldispositionforHNPpatients.

AeromedicalDisposition(civilian):Inthecivilianenvironmentaeromedicalcertificationismorelikelythanforthe
military.Forconsideration,anindividualmustprovideacompleteorthopedicorneurosurgicalevaluation.Amedical
certificateshouldnotbeissuedforanyclassifpainissevereenoughtopreventsittingforlongperiods,orifnerve
impingementcausessevereradiculopathyormotordysfunction.Obviously,theuseofnarcoticanalgesicsor
musclerelaxantsiscontraindicatedintheaerospaceenvironment.Amedicalcertificatemaybeissuedifsymptoms
haveresolvedwithtreatment(conservativeorsurgical),andappropriatewrittenmedicaldocumentationhasbeen
provided.SelectcasesmaybeforwardedfortoaFAAselectedconsultantforreviewandrecommendations.

WaiverExperience(military):Amilitarywaiverfilelists343memberswiththediagnosisofHNP.Ofthose
evaluated,over95%receivedwaiversforflyingduties,twothirdsofwhomwerecorrectedwithsurgeryor
chemonucleolysis.Occasionally,categoricalwaiversareissuedinordertoprecludeflyinginhighGperformanceor
ejectionseataircraft.Waiversareconsideredusually3to6monthsaftersuccessfultreatment.(Athoroughhistory
andphysicalexamshouldbeperformedtoassurenopersistentneurologicorrangeofmotiondeficits).Recurrent
symptomsaftertreatmentwouldprecludewaiverconsideration.

WaiverExperience(civilian):AsofJanuary2001therewere3,329Firstclass,2,627Secondclass,and5,888
ThirdclassairmenwithissuedmedicalcertificatesintheFAAforallvarietyofHNP,laminectomy,andcervicaldisk
surgery.Itshouldbenotedthat520%ofindividualsundergoingsurgerywillhavesignificantrecurrentpain,and
theseaviatorswillmostlikelyposerisksintheaviationenvironment.MildHNPwillmostlikelynotcreateaviation
problemsafterconservativetherapyhasconcluded.

References:

DeeR.DegenerativeDiseasesandDiscDisordersoftheLumbarSpine.DeeR,MangoE,HurstLC(eds).
PrinciplesofOrthopedicPractice.19892:9971034.

EllenbergMR,RossML,HonetJC,SchwartzM,ChodoroffG,EnochsS.Prospectiveevaluationofthecourseof
discherniationsinpatientswithprovenradiculopathy.ArchPhysMedRehabil199374:38.

GentryLR,TurskiPA,StrotherCM,JavidMJ,SackettJF.Chymopapainchemonucleolysis:CTchangesafter
treatment.AmericanJournalofRadiology1989145:3619.

ManelfeC,ChevrotA,ArrueP,MarkAS.DiscHerniations.ManelfeC(ed).ImagingoftheSpineandSpinalCord.
199226972.

RaymanRB.ClinicalAviationMedicine,Thirdedition,NewYork,CastleConnollyGraduateMedicalPublishing,
LLS,2000,pp.5354.

TeplickJG,HaskinME.Computedtomographyofthepostoperativelumbarspine.AmericanJournalofRadiology
1983141:86584.

WhiteAA,PanjabiMM.ClinicalBiomechanicsoftheSpine.19902:35.

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