Lumbar-Disc Intradural Sequestration

Lumbar-disc intradural sequestration happens when a fragment from the soft centre of a lumbar inter-vertebral disc (the ­nucleus pulposus) ruptures through the outer ring (annulus fibrosus), pierces the posterior longitudinal ligament and the tough dura mater, and finally comes to rest inside the spinal canal, bathed in cerebrospinal fluid. Because the fragment has completely separated from its parent disc, the event is called “sequestration,” and because it lies within the dura, it is termed “intradural.” The condition is exceptionally uncommon—roughly 0.04 – 0.33 % of all herniations take this path—and its rarity often delays diagnosis.MDPI MRI can even look deceptively normal when the annulus and ligament seem intact, so surgeons frequently discover the errant fragment only after opening the dura.PubMed Central

An intradural sequestered lumbar disc happens when a fragment of a worn-out spinal disc breaks completely free, slips through a tiny rent in the tough dura covering the nerves, and settles inside the fluid-filled sac that holds the cauda equina. It is rare—less than 0.3 % of all lumbar herniations—but dangerous because the fragment now presses directly on nerve roots or the cord itself. Adhesions between the back of the vertebral body, the posterior longitudinal ligament, and the dura seem to create a weak spot through which the fragment bursts PubMed CentralResearchGate.

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Anatomy

Structure & location.

Each lumbar disc sits between two vertebral bodies from L1 down to L5–S1. A gelatinous nucleus pulposus sits centrally, surrounded by a multilayered fibro-cartilaginous annulus fibrosus. Superior and inferior surfaces are capped by thin cartilaginous end-plates that anchor the disc to the adjacent vertebrae and help nutrients diffuse inward.

Muscle origins & attachments.

Several deep spinal muscles take purchase on or near the discs. Multifidus fibres arise from the posterior-lateral aspect of each sacral and lumbar vertebra and insert two to four levels above, stabilising each motion segment. The erector spinae group—iliocostalis lumborum, longissimus thoracis, and spinalis—originates partly from the sacrum, iliac crest, and lumbar spinous processes, running upward to ribs and thoracic vertebrae. Psoas major originates from the lateral surfaces of T12–L5 vertebral bodies and discs before inserting on the lesser trochanter, acting as a dynamic anterior stabiliser.

Blood supply.

Lumbar segmental (lumbar) arteries—branches of the abdominal aorta—feed the vertebral bodies and outer one-third of the annulus via tiny periosteal and equatorial vessels. The nucleus has no direct vessels; it relies on diffusion through the end-plates. Venous drainage mirrors arterial inflow, joining the lumbar veins then the azygos or caval system.

Nerve supply.

The sinu-vertebral (recurrent meningeal) nerves loop back from each spinal nerve and share sympathetic fibres from the grey rami communicantes. They perforate the posterior longitudinal ligament and supply the outer annulus, anterior dura, and periosteum, explaining discogenic pain when the annulus tears.

Functions of a healthy lumbar disc.

1. Load sharing: Spreads compressive forces evenly between adjacent vertebrae.

2. Shock absorption: Gel-like nucleus deforms under impact, protecting facet joints and neural elements.

3. Motion control: Contributes to flexion, extension, lateral-bend, and axial-rotation ranges without dislocation.

4. Spinal height & foraminal patency: Maintains the distance between pedicles so nerve roots exit freely.

5. Hydrostatic stabiliser: The nucleus functions like a pressurised ball, stiffening the segment under load.

6. Proprioceptive feedback: Annular nerve endings inform the central nervous system about segment position, enabling coordinated posture.

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Sub-types of intradural sequestration

• Intradural extra-arachnoid: The fragment lies between dura and arachnoid without breaching the delicate arachnoid layer.

• Intradural intra-arachnoid (sub-arachnoid): Even rarer—disc material floats inside the cerebrospinal-fluid space among cauda-equina rootlets.

• Intraradicular: The sequestrated fragment tunnels along the dural sleeve of a specific nerve root.

• Level-based description: Most pieces settle at L4–5 or L3–4 because these segments bear peak shear forces.Lippincott Journals

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Causes

(Each cause is followed by a plain-English explanation.)

1. Age-related disc dehydration. Water and proteoglycans leave the nucleus with age, making it brittle and prone to fissures.

2. Chronic mechanical overload. Years of heavy lifting or vibration accelerate annular micro-tears that invite nucleus escape.

3. Single traumatic flexion-rotation injury. A sudden twist under load can rip the annulus and posterior ligament in one event.

4. Congenital narrow canal. Reduced dural “buffer space” means even a small extrusion may pierce the dura.

5. Prior lumbar surgery. Scarred posterior elements change biomechanics, raising stress on adjacent discs.

6. High-energy spinal fracture. Vertebral body burst fragments can drag disc material intradurally during retropulsion.

7. Facet-joint osteoarthritis. Hypertrophic facets limit normal glide, forcing extra stress onto the disc.

8. Metabolic bone disease (osteoporosis). Micro-end-plate cracks let nucleus creep toward the canal.

9. Diabetes mellitus. Glycation stiffens collagen and weakens annular fibres.

10. Smoking. Nicotine diminishes disc nutrition by constricting end-plate vessels.

11. Obesity. Constant axial load accelerates degeneration and increases peak shear during bending.

12. Genetic collagen defects (COL9A2, COL11A1 variants). Poor-quality annular collagen tears easily.

13. Ankylosing spondylitis. Enthesitis alters disc-ligament complex tension, predisposing to rupture.

14. Repeated epidural steroid injections. Needle trauma and steroid-induced tissue thinning weaken dura and ligament.

15. Spinal infection (discitis). Inflammatory enzymes erode annulus, clearing a path for nucleus escape.

16. Auto-immune spondyloarthropathy. Cytokines stimulate matrix-metalloproteinases that digest annular collagen.

17. Hyperflexion sports (wrestling, gymnastics). Extreme ranges repeatedly strain outer annular layers.

18. Vitamin-D deficiency. Weak bone–disc interface transmits abnormal loads to the annulus.

19. Occupational vibration (truck driving). Low-frequency vibration accelerates nuclear pressurisation cycles.

20. Steroid-induced connective-tissue fragility. Long-term systemic steroids thin the PLL and dura, easing penetration.

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Common symptoms

1. Deep central low-back pain that worsens on sitting because seated flexion increases intradiscal pressure.

2. Sharp sciatica along a single leg, reflecting chemical and mechanical root irritation.

3. Cross-leg pain when the sequestrated fragment drifts medially and touches the opposite root.

4. Saddle numbness as cauda-equina fibres within the dura become compressed.

5. Bladder urgency or retention—early cauda-equina involvement impairs autonomic control.

6. Bowel dysfunction with difficulty starting or stopping defecation in more advanced cases.

7. Foot-drop when L4–L5 motor axons fail to activate the anterior – tibialis.

8. Big-toe numbness signalling L5 dorsal-root compromise.

9. Ankle-jerk loss from S1 motor-root pressure.

10. Postural list—patients lean away from the herniation to decompress the dural sac.

11. Night-time burning pain driven by inflammatory cytokines that peak overnight.

12. Electric shocks on coughing or sneezing due to transient rises in cerebrospinal-fluid pressure.

13. Tight hamstrings—protective muscle guarding around the irritated nerve.

14. Waddling gait if both L5 roots are partially affected.

15. Weak hip abductors causing a Trendelenburg sign during single-leg stance.

16. Para-spinal muscle spasm palpable as hard cords beside the spinous processes.

17. Reduced lumbar flexion because pain inhibits forward bending.

18. Positive straight-leg raise below 45 ° reproducing typical radicular pain.

19. Anxiety and sleep loss—persistent neuropathic pain disturbs quality of life.

20. Depression in chronic cases where functional limitation lasts months.

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Diagnostic tests

Physical-examination tests

1. Inspection & posture check – looks for antalgic list or flattened lumbar lordosis indicating protective guarding.

2. Palpation for spasm – tense paraspinals suggest acute nociceptive drive from the disc.

3. Active range-of-motion assessment – flexion or extension that abruptly stops at pain points to discogenic origin.

4. Straight-leg-raise (Lasègue) test – stretches the L5/S1 root; reproduction of leg pain below 70 ° supports radicular irritation.

5. Crossed straight-leg-raise – pain in the opposite leg is highly specific for large, medial herniations.

6. Slump test – sitting neural tension manoeuvre that amplifies radicular pain when the dura is tugged.

Manual or provocation tests

7. Femoral-nerve stretch – prone knee flexion reproduces anterior-thigh pain in L2–L4 root compression.

8. Valsalva manoeuvre – bearing down raises intrathecal pressure; symptom provocation hints at space-occupying disc material.

9. Kemp (lumbar-extension-rotation) test – closes the inter-vertebral foramen; pain suggests posterolateral herniation.

10. Hoover sign – differentiates genuine weakness from functional overlay by feeling contralateral heel pressure.

11. Manual muscle-testing (myotomes) – grades strength to map the injured root (e.g., L5 controls toe extensors).

12. Light-touch and pin-prick mapping – locates dermatomal sensory loss.

Laboratory & pathology investigations

13. Complete blood count – rules out infection or anaemia that could mimic neuropathy.

14. Erythrocyte sedimentation rate (ESR) & C-reactive protein (CRP) – elevated levels hint at discitis or systemic inflammatory disease.

15. HLA-B27 typing – screens for spondyloarthropathy if back pain began very young.

16. Serum calcium, phosphate, parathyroid hormone – detects metabolic bone contributors like osteomalacia.

17. Vitamin D level – low vitamin D correlates with accelerated disc degeneration.

18. Histopathology of excised fragment – confirms nucleus pulposus tissue and excludes tumour when surgery is performed.

Electro-diagnostic studies

19. Needle electromyography (EMG) – picks up fibrillation potentials in muscles supplied by compressed roots.

20. Nerve-conduction studies (NCS) – slowed sensory conduction across the foramen supports demyelination from chronic compression.

21. F-wave latency – prolonged return-waves point to proximal (root) pathology.

22. H-reflex testing – absent or delayed reflex implicates S1 root.

23. Somatosensory evoked potentials (SSEPs) – monitor dorsal-column pathway integrity in severe canal compromise.

24. Motor evoked potentials (MEPs) – assess corticospinal tract conduction when cord level symptoms are suspected.

Imaging tests

25. Lumbar MRI (T1 & T2) – first-line visualisation; an intradural fragment can appear as a ring-enhancing mass displacing nerve roots.

26. Gadolinium-enhanced MRI – contrast outlines the sequestrated piece because granulation tissue develops around it, aiding differentiation from tumour.

27. Multi-slice CT scan – superb for bony anatomy, revealing vertebral end-plate damage that facilitated disc escape.

28. CT-myelography – water-soluble contrast outlines filling defects inside thecal sac when MRI is contraindicated.

29. Dynamic flexion–extension radiographs – detect segmental instability that may coexist with the herniation.

30. High-resolution ultrasound of paraspinals – shows real-time muscle wasting or oedema secondary to chronic denervation.

Non-Pharmacological Treatments

Below you will find 15 physiotherapy/electro-modalities, 5 exercise approaches, 5 mind-body options, and 5 education-based self-management tools. Each entry states purpose and how it works in straightforward language.

Physiotherapy & Electrotherapy

1. Manual traction – gently stretches the spine to enlarge the intradural space, reducing pressure on the sequestered fragment for temporary pain relief.

2. Mechanical lumbar traction table – computerized pull-and-release cycles improve disc hydration and open the neural canal.

3. McKenzie directional-preference therapy – repeated prone extensions re-centralize the nucleus and desensitize pain circuits.

4. Mulligan SNAGs (Sustained Natural Apophyseal Glides) – therapist glides vertebrae while patient moves, restoring painless range.

5. Soft-tissue myofascial release – reduces guarding in lumbar and piriformis muscles, cutting reflex spasm.

6. High-voltage pulsed galvanic stimulation – short bursts drive analgesic currents deep without skin burn, dampening pain signaling.

7. Interferential current (IFC) – two medium-frequency currents cross inside tissue producing a low-frequency beat that blocks nerve pain gates.

8. Low-level laser therapy – photons boost cellular ATP, calm inflammation, and may speed nerve healing.

9. Short-wave diathermy – electromagnetic waves heat tissues 3–5 cm deep, easing stiffness.

10. Ultrasound phonophoresis – drives anti-inflammatory gel through skin into sore paraspinals.

11. Transcutaneous electrical nerve stimulation (TENS) – sticky-pad pulses compete with pain messages at the spinal cord.

12. Neuromuscular electrical stimulation (NMES) – contracts weak multifidus to restore segmental stability.

13. Instrument-assisted soft-tissue mobilization (IASTM) – metal tool scrapes scarred fascia, improving glide.

14. Cryotherapy packs – cold lowers metabolic demand and local swelling after flare-ups.

15. Kinesio-taping – elastic tape supports posture and gives constant gentle sensory input that dampens pain.

Exercise Therapies

1. Core stabilization program – trains deep transverse abdominis and multifidus to form an “internal brace”.

2. Aquatic therapy – buoyancy unloads the spine, allowing pain-free gait drills.

3. Dynamic lumbar stabilization on Swiss ball – challenges proprioception while maintaining neutral spine.

4. Pilates for low back – controlled breathing plus segmental control improve flexibility and endurance.

5. Graded walking plan – step-count goals slowly restore disc nutrition through rhythmic loading.

Mind-Body

1. Mindfulness-based stress reduction (MBSR) – teaches non-judgmental awareness; reduces catastrophizing.

2. Cognitive-behavioral therapy for pain – rewires thought patterns that amplify pain signals.

3. Guided imagery relaxation – lowers sympathetic drive, easing muscle tension.

4. Progressive muscle relaxation – systematic tensing-and-releasing dissolves guarding.

5. Breath-focused yoga nidra – combines slow diaphragmatic breathing with body scan to drop pain perception.

Educational Self-Management

1. Back-school classes – short workshops on safe bending, lifting, and posture.

2. Smart-phone app reminders – cues micro-movement breaks every 30 minutes.

3. Pain neuroscience education videos – explain how nerves sensitize, empowering patients to move.

4. Sleep-hygiene coaching – positions and routines that unload lumbar discs overnight.

5. Weight-management counseling – sheds excess load, slowing further disc collapse.

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First-Line & Adjuvant Drugs

(Always prescribed by a qualified clinician; typical adult doses given for illustration only. “Tid” = three times a day.)

1. Ibuprofen 400 mg tid – NSAID pain relief; blocks COX enzymes; can irritate stomach.

2. Naproxen 500 mg bid – longer-acting NSAID; similar mechanism; may raise blood pressure.

3. Etoricoxib 90 mg daily – COX-2 selective; gentler on stomach; but watch kidneys.

4. Paracetamol 1 g q6h – central COX inhibition; safe for many; watch total daily (≤ 4 g).

5. Prednisone 50 mg taper – short “burst” to shrink nerve root swelling; can cause insomnia, glucose spike.

6. Methylprednisolone dose-pack – convenient taper pack; same cautions.

7. Gabapentin 300–600 mg tid – calms hyper-excited nerve cells; dizziness common.

8. Pregabalin 75–150 mg bid – similar to gabapentin; faster onset; watch edema.

9. Duloxetine 30–60 mg daily – SNRI that modulates pain pathways; nausea early on.

10. Amitriptyline 10–25 mg at night – tricyclic; improves sleep and neuropathic pain; dry mouth.

11. Tramadol 50–100 mg q6h PRN – weak opioid and SNRI; risk of dependence.

12. Tapentadol 50–100 mg q8h – opioid plus noradrenaline reuptake block; less nausea vs strong opioids.

13. Oxycodone 5 mg q4h PRN – moderate opioid; constipation, respiratory depression risk.

14. Cyclobenzaprine 10 mg at night – muscle relaxant; drowsiness.

15. Tizanidine 4 mg tid – α2-agonist spasmolytic; can drop blood pressure.

16. Lidocaine 5 % patch 12 h on/12 h off – local sodium-channel block; minimal systemic effect.

17. Epidural steroid injection (triamcinolone 40 mg) – local anti-inflammatory; temporary sugar rise.

18. Facet joint medial-branch block (bupivacaine + steroid) – diagnostic and therapeutic.

19. Calcitonin nasal spray 200 IU daily – some analgesic effect on root pain; nausea possible.

20. Vitamin D3 2,000 IU daily – corrects deficiency that worsens muscle pain; hypercalcemia if excessive.

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Emerging or Special-Purpose Drugs & Biologics

(These are usually delivered in trials or specialist centers.)

1. Zoledronic acid 5 mg IV yearly – bisphosphonate dampening Modic Type 1 inflammatory bone changes, improving back pain PubMed.

2. Denosumab 60 mg SC q6 months – RANK-L inhibitor; similar anti-bone-edema effect.

3. Platelet-rich plasma (PRP) intradiscal 2–4 mL – growth factors spark disc cell repair.

4. Low-dose recombinant BMP-7 – anabolic cytokine encouraging matrix regeneration.

5. Hyaluronic-acid epidural gel 10 mg – lubricates nerve root, reduces adhesions PubMed Central.

6. Hyaluronic-acid facet joint 1 mL – viscosupplementation; evidence mixed PubMed.

7. DiscGenics allogeneic disc progenitor cells 1.5 million cells – injected into nucleus; early RCT shows pain and disability drop PR Newswire.

8. BioRestorative BRTX-100 autologous stem cells 1 × 10⁶ – Phase 2 trial for chronic disc disease WSJ.

9. Mesenchymal stem cell (MSC) suspension 2 mL – studied worldwide; secretes anti-inflammatory cytokines PubMed Central.

10. Peptide-based hydrogel carrier with stromal cells – scaffolds support cell survival; trials ongoing PubMed Central.

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Dietary Molecular Supplements

(Discuss with a physician before use; doses for healthy adults unless noted.)

1. Omega-3 fish oil 2 g EPA/DHA daily – shifts eicosanoid balance toward anti-inflammation.

2. Turmeric (curcumin) 500 mg tid with black-pepper extract – blocks NF-κB inflammatory pathway.

3. Boswellia serrata 300 mg bid – inhibits 5-lipoxygenase, reducing pain and stiffness.

4. Glucosamine sulfate 1,500 mg daily – raw material for cartilage glycosaminoglycans.

5. Chondroitin sulfate 1,200 mg daily – adds viscoelasticity to disc matrix; synergy with glucosamine.

6. Type II collagen peptides 40 mg daily – oral tolerance lowers autoimmune attack on joint proteins.

7. Magnesium glycinate 400 mg nightly – relaxes muscles and dampens NMDA-driven pain.

8. Resveratrol 250 mg daily – antioxidant supporting micro-circulation around discs.

9. Vitamin K2 (MK-7) 90 µg daily – directs calcium to bone, not vessels, improving vertebral strength.

10. Methylcobalamin (B12) 1 mg sublingual daily – fuels myelin repair in compressed nerve roots.

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Surgical Procedures

1. Microsurgical intradural fragment removal – gold standard; tiny midline laminectomy, dura opened, fragment plucked; immediate decompression.

2. Endoscopic trans-foraminal fragment extraction – keyhole, local anesthesia, camera-guided punch retrieves fragment without opening dura widely.

3. Minimally invasive tubular laminectomy – muscle-splitting tunnel; less blood loss and quicker rehab.

4. Duroplasty with dural-patch graft – closes large dural hole preventing CSF leak.

5. Pedicle screw-rod fusion (single level) – added if instability present post-decompression.

6. Dynamic stabilisation device – flexible ligament tether preserves some motion.

7. Total disc replacement – artificial disc restores height and motion; rarely done if severe degeneration.

8. Hybrid disc arthroplasty + fusion – disc replaced at one level, adjacent fused, balancing movement.

9. Posterior lumbar interbody fusion (PLIF) – cage plus bone graft restores lordosis when fragment caused vertebral collapse.

10. Intrathecal drug pump implant – end-stage pain control when surgery is unsafe; pumps tiny opioid doses directly to cord.

Benefits include instant nerve decompression, prevention of progressive paralysis, pain resolution, and return to normal bowel/bladder control. Risks include leak of spinal fluid, infection, and scar tethering.

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Prevention Tips

1. Keep core muscles strong with regular planks.

2. Use hip-hinge technique instead of bending waist.

3. Maintain healthy body weight.

4. Avoid smoking or quit today.

5. Limit vibration exposure—use air-suspension seats.

6. Stay hydrated; discs need water.

7. Break up sitting every 30 minutes.

8. Treat chronic cough promptly.

9. Control blood sugar if diabetic.

10. Schedule ergonomic assessment of your workspace.

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When should you see a doctor right away?

• Today, not tomorrow if you suddenly cannot pee or you leak stool, feel numb in the groin, or one/both legs go weak.

• Within 24 h for steadily rising leg pain not eased by rest or pills.

• Soon (inside a week) if tingling spreads, sleep is impossible, or pain shoots below the knee for the first time.

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Things to do and avoid

Do

1. Keep walking short distances.

2. Use a lumbar support cushion.

3. Log symptoms in a diary.

4. Apply ice 15 min after flare-ups.

5. Practice belly breathing for pain.

Avoid

1. Bed-rest beyond 48 h.

2. Heavy lifting above 10 kg early on.

3. Twisting while carrying objects.

4. Smoking during recovery.

5. Self-medicating with high-dose steroids.

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Frequently Asked Questions

1. Will an intradural fragment ever dissolve on its own? – Very rarely; because it sits in CSF, enzymes can break it down but most still need surgery.

2. Is the surgery high-risk? – In experienced hands, complication rates are under 5 %.

3. How soon can I walk after operation? – Same day or next morning for minimally invasive removal.

4. Do I need a spinal fusion too? – Only if the surgeon sees instability or severe disc collapse.

5. Can I treat this with chiropractic adjustments? – High-velocity manipulations are discouraged because they can worsen dural tears.

6. Is MRI with contrast safe? – Yes for most people; speak up if you have kidney failure or contrast allergies.

7. What exercises are safe at home? – Gentle pelvic tilts, cat-camel stretches, and short walks on level ground.

8. Could this condition come back? – Recurrence inside the dura is extremely rare after fragment removal, but new herniations at other levels may occur.

9. Are stem-cell injections approved? – Still investigational; only available in regulated trials.

10. How long do steroid shots last? – Relief ranges from days to a few months and does not “cure” the fragment itself.

11. Can women have this during pregnancy? – Yes, but it’s uncommon; MRI without contrast is safe after the first trimester.

12. Will insurance cover surgery? – Usually, because the condition threatens permanent nerve damage.

13. What anesthesia is used? – General anesthesia for open or microscopic removal; local + sedation for endoscopic.

14. Is there a role for acupuncture? – Evidence is limited but some patients report short-term pain relief.

15. How can I sleep comfortably? – Try side-lying with a pillow between knees or on back with knees over a bolster to flatten the lumbar curve.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members

Last Updated: May 19, 2025.

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