Hernia Nucleus Pulposus: Pathophysiology, Risk Factors, and Clinical Management – A Literature Review
Keywords:
herniated nucleus pulposus, lumbar disc herniation, low back pain, pathophysiology, clinical management
Abstract
Introduction: Lumbar Herniated Nucleus Pulposus (HNP) is a leading cause of low back pain and radicular symptoms that significantly impair functional capacity and quality of life. The condition arises from a complex interaction of biomechanical stress, inflammatory responses, and degenerative biological changes in the intervertebral disc. This article aims to comprehensively review current evidence on the pathophysiology, risk factors, and clinical management of lumbar HNP using a narrative literature review approach. Methods: A literature search was conducted across PubMed, Google Scholar, and accredited national journals using the keywords “hernia nucleus pulposus,” “lumbar disc herniation,” “low back pain,” “pathophysiology,” and “clinical management.” Eligible articles were full-text publications in English or Indonesian published between 2015 and 2025, including original research, literature reviews, systematic reviews, and clinical practice guidelines. Studies related to traumatic or non-lumbar disc herniation and those without full-text availability were excluded. Selected articles were analyzed descriptively and synthesized narratively. Results: The review indicates that lumbar HNP is a progressive degenerative disorder influenced by altered disc biomechanics, inflammatory cascades, and cellular aging. Major risk factors include advancing age, increased body mass index, sedentary lifestyle, and occupational exposure to heavy physical workload. Clinical management follows a stepwise strategy, prioritizing conservative therapy, while surgical intervention is reserved for selected cases. Conclusion: A comprehensive understanding of the pathophysiological mechanisms and associated risk factors of lumbar HNP is essential to support evidence-based and individualized patient management.
References
1. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-2367. doi:10.1016/S0140-6736(18)30480-X
2. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173
3. Dudli S, Fields AJ, Samartzis D, Karppinen J, Lotz JC. Pathobiology of Modic changes. Eur Spine J. 2016;25(11):3723-3734. doi:10.1007/s00586-016-4459-7
4. Zhang Y, Sun Z, Liu J, Guo X. Advances in Susceptibility Genetics of Intervertebral Degenerative Disc Disease. Int J Biol Sci. Published online 2008:283-290. doi:10.7150/ijbs.4.283
5. Hermawati L, Irawati NBU, Zulfa HA, Diana WA. The Role of Balanced Nutrition Knowledge in Influencing Nutritional Status and Health Risks: A Literature Review. Int J Med Public Heal. 2025;2(1):1-14. https://jurnal.untirta.ac.id/index.php/inomed/article/view/31567
6. Darifah S, Trisnasari E, Yuniarti TE, Sugiharto A, Wulansari ER, Hermawati L. Skrining gizi dan edukasi nutrisi untuk pencegahan masalah gizi dan metabolik komunitas e-sport. J Pembelajaran Pemberdaya Masy. 2025;6(3):983-992. doi:10.33474/jp2m.v6i3.24080
7. Darifah S, Hermawati L, Wulansari ER, Eva A, Agustianti E, Asma F. Remaja dan Gaming : Perkembangan Gaya Hidup Sedentari dan Risiko Kesehatan. 2025;1(3):38-50. doi:10.58218/jhp.v1i3.1850
8. Sholicha Dyananti AL, Yekti M, Rohmani A. HUBUNGAN INTENSITAS NYERI DENGAN KUALITAS TIDUR: STUDI PADA PENDERITA HERNIA NUKLEUS PULPOSUS (HNP) LUMBAL. Cerdika J Ilm Indones. 2023;3(09):850-856. doi:10.59141/cerdika.v3i09.670
9. Ameliya Widya Astuti, I Made Lana Prasetya, Tri Asih Budiarti. Penatalaksanaan Pemeriksaan Magnetic Resonance Imaging (MRI) Lumbal Dengan Kasus Hernia Nukleus Pulposus. J Anestesi. 2023;2(1):331-342. doi:10.59680/anestesi.v2i1.806
10. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180-191. doi:10.1016/j.spinee.2013.08.003
11. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
12. Oichi T, Taniguchi Y, Oshima Y, Tanaka S, Saito T. Pathomechanism of intervertebral disc degeneration. JOR SPINE. 2020;3(1). doi:10.1002/jsp2.1076
13. Risbud M V., Shapiro IM. Role of cytokines in intervertebral disc degeneration: pain and disc content. Nat Rev Rheumatol. 2014;10(1):44-56. doi:10.1038/nrrheum.2013.160
14. Molinos M, Almeida CR, Caldeira J, Cunha C, Gonçalves RM, Barbosa MA. Inflammation in intervertebral disc degeneration and regeneration. J R Soc Interface. 2015;12(104):20141191. doi:10.1098/rsif.2014.1191
15. Rider SM, Mizuno S, Kang JD. Molecular Mechanisms of Intervertebral Disc Degeneration. Spine Surg Relat Res. 2019;3(1):1-11. doi:10.22603/ssrr.2017-0095
16. Silwal P, Nguyen-Thai AM, Mohammad HA, et al. Cellular Senescence in Intervertebral Disc Aging and Degeneration: Molecular Mechanisms and Potential Therapeutic Opportunities. Biomolecules. 2023;13(4):686. doi:10.3390/biom13040686
17. Zhou M, Theologis AA, O’Connell GD. Understanding the etiopathogenesis of lumbar intervertebral disc herniation: From clinical evidence to basic scientific research. JOR SPINE. 2024;7(1). doi:10.1002/jsp2.1289
18. Alessa F, Ning X. Changes of lumbar posture and tissue loading during static trunk bending. Hum Mov Sci. 2018;57:59-68. doi:10.1016/j.humov.2017.11.006
19. Hoffeld K, Lenz M, Egenolf P, et al. Patient-related risk factors and lifestyle factors for lumbar degenerative disc disease: a systematic review. Neurochirurgie. 2023;69(5):101482. doi:10.1016/j.neuchi.2023.101482
20. Wahlström J, Liv P, Stjernbrandt A, et al. Occupational risk factors for surgically treated lumbar disc herniation – a 33-year follow-up. Scand J Work Environ Health. 2025;51(6):550-558. doi:10.5271/sjweh.4253
21. Jo M, Chae SW. Stress analysis of intervertebral disc during occupational activities. Comput Methods Programs Biomed. 2021;208:106298. doi:10.1016/j.cmpb.2021.106298
22. Schröder C, Nienhaus A. Intervertebral Disc Disease of the Lumbar Spine in Health Personnel with Occupational Exposure to Patient Handling—A Systematic Literature Review and Meta-Analysis. Int J Environ Res Public Health. 2020;17(13):4832. doi:10.3390/ijerph17134832
23. Alzahrani H, Alshehri MA, Alzhrani M, Alshehri YS, Al Attar WSA. The association between sedentary behavior and low back pain in adults: a systematic review and meta-analysis of longitudinal studies. PeerJ. 2022;10:e13127. doi:10.7717/peerj.13127
24. Fotakopoulos G, Makris D, Kotlia P, Tzerefos C, Fountas K. Recurrence Is Associated With Body Mass Index in Patients Undergoing a Single-Level Lumbar Disc Herniation Surgery. J Clin Med Res. 2018;10(6):486-492. doi:10.14740/jocmr3121w
25. Masuda S, Fukasawa T, Matsuda S, Kawakami K. One-year body mass index change and subsequent risk of lumbar disc herniation: a population-based cohort study. Eur Spine J. Published online October 30, 2025. doi:10.1007/s00586-025-09508-2
26. Hincapié CA, Kroismayr D, Hofstetter L, et al. Incidence of and risk factors for lumbar disc herniation with radiculopathy in adults: a systematic review. Eur Spine J. 2025;34(1):263-294. doi:10.1007/s00586-024-08528-8
27. Pojskic M, Bisson E, Oertel J, Takami T, Zygourakis C, Costa F. Lumbar disc herniation: Epidemiology, clinical and radiologic diagnosis WFNS spine committee recommendations. World Neurosurg X. 2024;22:100279. doi:10.1016/j.wnsx.2024.100279
28. Qin B, Baldoni M, Wu B, Zhou L, Qian Z, Zhu Q. Effect of lumbar muscle atrophy on the mechanical loading change on lumbar intervertebral discs. J Biomech. 2022;139:111120. doi:10.1016/j.jbiomech.2022.111120
29. Lum UI. Physiotherapy Management of Lumbar Herniated Nucleus Pulposus: A Case Report. Maj Ilm Fisioter Indones. 2025;13(3):492-497. doi:10.24843/mifi.000000355
30. MEYER G, DA ROCHA ID, CRISTANTE AF, et al. Percutaneous Endoscopic Lumbar Discectomy Versus Microdiscectomy for the Treatment of Lumbar Disc Herniation: Pain, Disability, and Complication Rate—A Randomized Clinical Trial. Int J Spine Surg. 2020;14(1):72-78. doi:10.14444/7010
31. Tu JF, Shi GX, Yan SY, et al. Acupuncture vs Sham Acupuncture for Chronic Sciatica From Herniated Disk. JAMA Intern Med. 2024;184(12):1417. doi:10.1001/jamainternmed.2024.5463
32. Yaman O, Gushcha A, Vaishya S, Zileli M, Zygourakis C, Oertel J. The role of conservative treatment in lumbar disc herniations: WFNS spine committee recommendations. World Neurosurg X. 2024;22:100277. doi:10.1016/j.wnsx.2024.100277
33. Awadalla AM, Aljulayfi AS, Alrowaili AR, et al. Management of Lumbar Disc Herniation: A Systematic Review. Cureus. Published online October 29, 2023. doi:10.7759/cureus.47908
34. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015;29(2):184-195. doi:10.1177/0269215514540919
35. Zhong M, Liu JT, Jiang H, et al. Incidence of spontaneous resorption of lumbar disc herniation: A meta-analysis. Pain Physician. 2017;20(1):E45-E52. doi:10.36076/ppj.2017.1.e45
36. Deyo RA, Mirza SK. Herniated Lumbar Intervertebral Disk. Solomon CG, ed. N Engl J Med. 2016;374(18):1763-1772. doi:10.1056/NEJMcp1512658
37. Liu C, Ferreira GE, Abdel Shaheed C, et al. Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials. BMJ. 2023;381:e070730. doi:10.1136/bmj-2022-070730
38. Lurie JD, Tosteson TD, Tosteson ANA, et al. Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation. Spine (Phila Pa 1976). 2014;39(1):3-16. doi:10.1097/BRS.0000000000000088
39. Poquet N, Lin CWC. Management strategies for sciatica (PEDro synthesis). Br J Sports Med. 2016;50(4):253-254. doi:10.1136/bjsports-2015-095268
40. Raymaekers V, Roosen G, Put E, et al. Transforaminal epidural steroid injection for radiculopathy and the evolution to surgical treatment: a pragmatic prospective observational multicenter study. Pain Manag. 2024;14(4):173-182. doi:10.2217/pmt-2023-0121
41. Kasemen K, Fathimah I, Ahyani A, Alawiyah F. Pelatihan Pengolahan Kulit Melinjo ( Gnetum genemon L . ) Menjadi Nugget dan Sosis sebagai Upaya Optimalisasi Potensi Lokal di. 2025;5(8):1007-1014.
2. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173
3. Dudli S, Fields AJ, Samartzis D, Karppinen J, Lotz JC. Pathobiology of Modic changes. Eur Spine J. 2016;25(11):3723-3734. doi:10.1007/s00586-016-4459-7
4. Zhang Y, Sun Z, Liu J, Guo X. Advances in Susceptibility Genetics of Intervertebral Degenerative Disc Disease. Int J Biol Sci. Published online 2008:283-290. doi:10.7150/ijbs.4.283
5. Hermawati L, Irawati NBU, Zulfa HA, Diana WA. The Role of Balanced Nutrition Knowledge in Influencing Nutritional Status and Health Risks: A Literature Review. Int J Med Public Heal. 2025;2(1):1-14. https://jurnal.untirta.ac.id/index.php/inomed/article/view/31567
6. Darifah S, Trisnasari E, Yuniarti TE, Sugiharto A, Wulansari ER, Hermawati L. Skrining gizi dan edukasi nutrisi untuk pencegahan masalah gizi dan metabolik komunitas e-sport. J Pembelajaran Pemberdaya Masy. 2025;6(3):983-992. doi:10.33474/jp2m.v6i3.24080
7. Darifah S, Hermawati L, Wulansari ER, Eva A, Agustianti E, Asma F. Remaja dan Gaming : Perkembangan Gaya Hidup Sedentari dan Risiko Kesehatan. 2025;1(3):38-50. doi:10.58218/jhp.v1i3.1850
8. Sholicha Dyananti AL, Yekti M, Rohmani A. HUBUNGAN INTENSITAS NYERI DENGAN KUALITAS TIDUR: STUDI PADA PENDERITA HERNIA NUKLEUS PULPOSUS (HNP) LUMBAL. Cerdika J Ilm Indones. 2023;3(09):850-856. doi:10.59141/cerdika.v3i09.670
9. Ameliya Widya Astuti, I Made Lana Prasetya, Tri Asih Budiarti. Penatalaksanaan Pemeriksaan Magnetic Resonance Imaging (MRI) Lumbal Dengan Kasus Hernia Nukleus Pulposus. J Anestesi. 2023;2(1):331-342. doi:10.59680/anestesi.v2i1.806
10. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180-191. doi:10.1016/j.spinee.2013.08.003
11. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530. doi:10.7326/M16-2367
12. Oichi T, Taniguchi Y, Oshima Y, Tanaka S, Saito T. Pathomechanism of intervertebral disc degeneration. JOR SPINE. 2020;3(1). doi:10.1002/jsp2.1076
13. Risbud M V., Shapiro IM. Role of cytokines in intervertebral disc degeneration: pain and disc content. Nat Rev Rheumatol. 2014;10(1):44-56. doi:10.1038/nrrheum.2013.160
14. Molinos M, Almeida CR, Caldeira J, Cunha C, Gonçalves RM, Barbosa MA. Inflammation in intervertebral disc degeneration and regeneration. J R Soc Interface. 2015;12(104):20141191. doi:10.1098/rsif.2014.1191
15. Rider SM, Mizuno S, Kang JD. Molecular Mechanisms of Intervertebral Disc Degeneration. Spine Surg Relat Res. 2019;3(1):1-11. doi:10.22603/ssrr.2017-0095
16. Silwal P, Nguyen-Thai AM, Mohammad HA, et al. Cellular Senescence in Intervertebral Disc Aging and Degeneration: Molecular Mechanisms and Potential Therapeutic Opportunities. Biomolecules. 2023;13(4):686. doi:10.3390/biom13040686
17. Zhou M, Theologis AA, O’Connell GD. Understanding the etiopathogenesis of lumbar intervertebral disc herniation: From clinical evidence to basic scientific research. JOR SPINE. 2024;7(1). doi:10.1002/jsp2.1289
18. Alessa F, Ning X. Changes of lumbar posture and tissue loading during static trunk bending. Hum Mov Sci. 2018;57:59-68. doi:10.1016/j.humov.2017.11.006
19. Hoffeld K, Lenz M, Egenolf P, et al. Patient-related risk factors and lifestyle factors for lumbar degenerative disc disease: a systematic review. Neurochirurgie. 2023;69(5):101482. doi:10.1016/j.neuchi.2023.101482
20. Wahlström J, Liv P, Stjernbrandt A, et al. Occupational risk factors for surgically treated lumbar disc herniation – a 33-year follow-up. Scand J Work Environ Health. 2025;51(6):550-558. doi:10.5271/sjweh.4253
21. Jo M, Chae SW. Stress analysis of intervertebral disc during occupational activities. Comput Methods Programs Biomed. 2021;208:106298. doi:10.1016/j.cmpb.2021.106298
22. Schröder C, Nienhaus A. Intervertebral Disc Disease of the Lumbar Spine in Health Personnel with Occupational Exposure to Patient Handling—A Systematic Literature Review and Meta-Analysis. Int J Environ Res Public Health. 2020;17(13):4832. doi:10.3390/ijerph17134832
23. Alzahrani H, Alshehri MA, Alzhrani M, Alshehri YS, Al Attar WSA. The association between sedentary behavior and low back pain in adults: a systematic review and meta-analysis of longitudinal studies. PeerJ. 2022;10:e13127. doi:10.7717/peerj.13127
24. Fotakopoulos G, Makris D, Kotlia P, Tzerefos C, Fountas K. Recurrence Is Associated With Body Mass Index in Patients Undergoing a Single-Level Lumbar Disc Herniation Surgery. J Clin Med Res. 2018;10(6):486-492. doi:10.14740/jocmr3121w
25. Masuda S, Fukasawa T, Matsuda S, Kawakami K. One-year body mass index change and subsequent risk of lumbar disc herniation: a population-based cohort study. Eur Spine J. Published online October 30, 2025. doi:10.1007/s00586-025-09508-2
26. Hincapié CA, Kroismayr D, Hofstetter L, et al. Incidence of and risk factors for lumbar disc herniation with radiculopathy in adults: a systematic review. Eur Spine J. 2025;34(1):263-294. doi:10.1007/s00586-024-08528-8
27. Pojskic M, Bisson E, Oertel J, Takami T, Zygourakis C, Costa F. Lumbar disc herniation: Epidemiology, clinical and radiologic diagnosis WFNS spine committee recommendations. World Neurosurg X. 2024;22:100279. doi:10.1016/j.wnsx.2024.100279
28. Qin B, Baldoni M, Wu B, Zhou L, Qian Z, Zhu Q. Effect of lumbar muscle atrophy on the mechanical loading change on lumbar intervertebral discs. J Biomech. 2022;139:111120. doi:10.1016/j.jbiomech.2022.111120
29. Lum UI. Physiotherapy Management of Lumbar Herniated Nucleus Pulposus: A Case Report. Maj Ilm Fisioter Indones. 2025;13(3):492-497. doi:10.24843/mifi.000000355
30. MEYER G, DA ROCHA ID, CRISTANTE AF, et al. Percutaneous Endoscopic Lumbar Discectomy Versus Microdiscectomy for the Treatment of Lumbar Disc Herniation: Pain, Disability, and Complication Rate—A Randomized Clinical Trial. Int J Spine Surg. 2020;14(1):72-78. doi:10.14444/7010
31. Tu JF, Shi GX, Yan SY, et al. Acupuncture vs Sham Acupuncture for Chronic Sciatica From Herniated Disk. JAMA Intern Med. 2024;184(12):1417. doi:10.1001/jamainternmed.2024.5463
32. Yaman O, Gushcha A, Vaishya S, Zileli M, Zygourakis C, Oertel J. The role of conservative treatment in lumbar disc herniations: WFNS spine committee recommendations. World Neurosurg X. 2024;22:100277. doi:10.1016/j.wnsx.2024.100277
33. Awadalla AM, Aljulayfi AS, Alrowaili AR, et al. Management of Lumbar Disc Herniation: A Systematic Review. Cureus. Published online October 29, 2023. doi:10.7759/cureus.47908
34. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015;29(2):184-195. doi:10.1177/0269215514540919
35. Zhong M, Liu JT, Jiang H, et al. Incidence of spontaneous resorption of lumbar disc herniation: A meta-analysis. Pain Physician. 2017;20(1):E45-E52. doi:10.36076/ppj.2017.1.e45
36. Deyo RA, Mirza SK. Herniated Lumbar Intervertebral Disk. Solomon CG, ed. N Engl J Med. 2016;374(18):1763-1772. doi:10.1056/NEJMcp1512658
37. Liu C, Ferreira GE, Abdel Shaheed C, et al. Surgical versus non-surgical treatment for sciatica: systematic review and meta-analysis of randomised controlled trials. BMJ. 2023;381:e070730. doi:10.1136/bmj-2022-070730
38. Lurie JD, Tosteson TD, Tosteson ANA, et al. Surgical Versus Nonoperative Treatment for Lumbar Disc Herniation. Spine (Phila Pa 1976). 2014;39(1):3-16. doi:10.1097/BRS.0000000000000088
39. Poquet N, Lin CWC. Management strategies for sciatica (PEDro synthesis). Br J Sports Med. 2016;50(4):253-254. doi:10.1136/bjsports-2015-095268
40. Raymaekers V, Roosen G, Put E, et al. Transforaminal epidural steroid injection for radiculopathy and the evolution to surgical treatment: a pragmatic prospective observational multicenter study. Pain Manag. 2024;14(4):173-182. doi:10.2217/pmt-2023-0121
41. Kasemen K, Fathimah I, Ahyani A, Alawiyah F. Pelatihan Pengolahan Kulit Melinjo ( Gnetum genemon L . ) Menjadi Nugget dan Sosis sebagai Upaya Optimalisasi Potensi Lokal di. 2025;5(8):1007-1014.
Published
2026-04-30
How to Cite
Hermawati, L., Pratiwisitha, M., Hutabarat, M. H., Putri, G. F. T., & Susanto, R. (2026). Hernia Nucleus Pulposus: Pathophysiology, Risk Factors, and Clinical Management – A Literature Review. International Journal of Cell and Biomedical Science, 5(13), 505-515. https://doi.org/10.59278/cbs.v5i13.101
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