Disc herniation

Basic disc herniation and anatomy

1. DISC HERNIATION PRESENTED BY DR ANSHUL SETHI

2. INTRODUCTION Spinal disc herniation (commonly called slipped disc ) is a medical condition in which there is outpouching of nucleus pulposus along with few annular fibers and end plate cartilage through tears in annulus fibrosus into extradural space.

3. William Kirkaldy – willis described the spectrum of disc – degeneration & pathologic progression of lumbar disc degeneration and herniation. Genes related to disc degeneration : Aggrecan gene Metalloproteinase-3 gene Collagen type 1 & 3

4. INTERVERTEBRAL DISC IT IS A FIBROCARTILAGENOUS STUCTURE WHICH CONTRIBUTES TO 25% OF THE HEIGHT OF THE SPINAL COLOUMN. ITS MAIN FUNCTION IS TO ACT AS A SHOCK ABSORBER , TRANSMITTING COMPRESSIVE LOADS BETWEEN VERTEBRAL BODIES. INTERVERTEBRAL DISC COMPOSED OF CENTRAL NUCLEUS PULPOSES (NP) AND THE PERIPHERAL ANNULUS FIBROSUS (AF) AND THE END PLATE (EP) WHICH ACT AS GROWTH PLATE OF VERTEBRAL BODY

5. Causes of disc herniation Age related degeneration of the spine Trauma to spine Strain to spine

6. Natural history of disc disease Recurrent strains produce small circumfrential tears in annuus fibrosus which later on enlarge and combone to form radial tears These tears further increases in size until disc is completely disrupted internally As a result disc height reduces due to loss of proteoglycan and water from nucleus , anulus become lax and bulges out which will later on represent as thin slit between vertebral body filed with fibrous tissue.

7. SPECTURUM OF CHANGES IN DISC HERNIATION INTERNAL DISC DISRUPTION DISC HERNIATION WITH DECREASE IN INTERVERTEBRAL DISC SPACE OVERLOADING OF FACET JOINT , LIGAMENTS INSTABILITY DEGENRATIVE SPONDYLOLISTHESIS LIGAMENT HYPERTROPHY SPINAL DEFORMOTY

8. THEORY OF DISC DEGENRATION Stage 1 – stage of dysfunction Seen in 15 year to 45 year old individual Showing circumferential and radial tears of the disc annulus and localized synovitis of facet joints.

9. Stage 2- stage of INSTABILITY/EXTRUSION Seen in 35 to 70 year old Showing features of internal disruption of the disc Progressive disc resorption Degeneration of facet joint with capsular laxity Subluxation and joint erosion

10. STAGE 3 - stage of STABILIZATION/FIBROSIS Seen in older than 60 year Progressive development of hypertrophic bone around the disc and facet joint leading to segmental stiffening or frank ankylosis

11. STAGES OF DISC HERNIATION DISC DEGENRATION WEAKING OF DISC BUT NO HERNIATION WITH DISC SHOWING DEHYDRATION , DESSICATION AND EARLY DEGENRATION OF DISC MATERIAL.

12. 2. PROTUSION NUCLEAR MATERIAL CAUSES BULGING OF OUTERMOST ANNULAR FIBERS. REFERRED AS PIVD .

13. 3. EXTRUSION NUCLEAR MATERIALS BREAK THROUGH ALL ANNULAR FIBERS BUT STILL REMAIN CONNECTED TO NUCLEAR MATERIAL WITHIN DISC

14. 4. SEQUESTRATION NUCLEUS PULPOSUS BREAKS THROUGH ANNULUS FIBROSUS AND LIES OUTSIDE THE DISC IN SPINAL CANAL

15. CLASSIFICATION OF DISC HERNIATION ON THE BASIS OF LOCATION POSTEROLATERAL/ PARACENTRAL PROLAPSE : this is commonest type of disc herniation Post. Longitudnal ligament is weakest in this area Herniated disc impinges on the traversing nerve roots CENTRAL PROLAPSE : Present as back pain only Or as cauda equina in severe cases

16. 3. FORAMINAL/ FARLATERL HERNIATION : LESS COMMON TYPE OF HERNIATION HERNIATED DISC IMPINGES ON THE EXITING NERVE ROOTS

17. RED FLAG SIGN IN CASE OF BAK PAIN AGE MORE THAN 50 YEAR SIGNIFICANT TRAUMA NEUROMUSCULAR DEFICIT UNEXPLAINED WEIGHT LOSS SUSPICION OF ANKYLOSING SPONDYLITIS DRUG OR ALCHOL ABUSE HISTORY OF CANCER USE OF CORTICOSTEROIDS FOR LONG TERM

18. INVESTIGATIONS : SKIGRAM skigram of the specific level of spine in both AP and LATERAL view in order to rule out other associated causes and to see the degenerative changes 2. Melography : It is done in suspicion of intra-spinal lesion of the spine 3. Computed Tomography (CT 4. MAGNETIC RESONANCE IMAGING (MRI) on of the definitive investigation to diagnose disc herniation

19. SIGN AND SYMPTOMS OF DISC HERNIATION Back pain radiating to sacroiliac region and buttock Weakness Paraesthesia Loss of bladder , bowel movements Marked paraspinal muscle spasm Loss of lumbar lordosis Point tenderness at the level of involved spinous process

20. Diffrential diagnosis Ankylosing spondylitis Multiple myeloma Arthritis of hip Osteoprosis with stress fracture Extradural tumors Synovial cyst Vascular insufficiency

21. TREATMENT BROADLY DIVIDED INTO TWO PARTS NON OPERATIVE OPERATIVE

22. NON OPERATIVE BED REST FOR 3 -4 DAYS (IN SEMIFLOWER POSITION WITH PILLOW IN BETWEEN LEGS ) ICE PACK APPLICATION TO RELIEVE SPASM OF PARASPINAL MUSCLE IN ACUTE BACK PAIN NSAID’S FOLLOWED BY ISOMETRIC ABDOMINAL , LOWER EXTERMITY AND SPINAL EXTENSION EXERCISES TO STRENGTHEN THE MUSCLES.

23. OPERATIVE DISC SURGERY PROVIDE SYMPTOMATIC RELIEF , IT DOES NOT STOP THE PATHOLOGIC PROCESS OF THE DISEASE INDICATIONS FOR SURGERY UNILATERAL LEG PAIN EXTENDING BELOW KNEE FOR MORE THAN 6 WEEKS REOCCURENCE OF PAIN AFTER CONSERVATIVE MANAGEMENT (EPIDURAL, PHYSIOTHERAPHY ) AFTER A GAP OF 2 MONTHS EVIDENCE OF LOCALIZING NEUROLOGIC IMPAIRMENT CT , MRI OR MYELOGRAPHY CONFIRMING THE LEVEL OF INVOLVEMENT

24. SURGICAL OPTIONS : DISSECTOMY : surgical removal of the whole or part of an intervertebral disc. MICRO- DISSECTOMY : also known as MICRODECOMPRESSION in hich portions of herniated disc will be removed to relieve pressure on spinal nerve coloumn . LAMINOTOMY : remove part of the lamina of a vertebral arch to relieve pressure in vertebral canal LAMINECTOMY : removal of whole lamina to ease the pressure from spinal cord

25. 5. HEMI LAMINECTOMY : in this only a part of lamina or part of facet joint is removed to allow more space of nerve root 6. INTER LAMINAR FENESTRATION

26. STEPS : PATIENT MADE TO LIE IN THE PRONE POSTION AFTER GIVING G.A WITH ENDOTRACHEAL INTUBATION WITH THE HELP OF BOLISTERS PLACED LONGITUDNALLY UNDER THE PATIENTS SIDES ALONG WITH PADDING DONE FOR PRESSURE POINTS AND KNEE OR PATIENT MADE TO LIE IN PRONE POSITION IN A SPECIAL SPINAL FRAME WHICH ALLOWS THE ABDOMEN TO HANG FREE RESULTING IN DECREASING INTRAVENOUS PRESSURE AS A RESULT THERE WILL BE COLLAPSE OF EPIDURAL VENOUS PLEXSUS

27. A SPINAL NEEDLE OR OTHER RADIO-OPAQUE MARKER IS PLACED AT THE DESIRED LEVEL BY PALPATING THE SPINOUS PROCESSES AND IS CONFIRMED UNDER C-ARM IN LATERAL VIEW A MIDLINE LONGITUDNAL INCISION GIVEN OVER THE SPINOUS PROCESS OF APPROXIMATELY 5 CM EXTENDING FROM 1 SPINOUS PROCESS ABOVE AND BELOW THE DESIRED LEVEL

28. Confirming intervertebral disc space L5-S1 with spinal needle

29. INCISION WILL BE THEN DEEPENED THROUGH FAT AND FASCIA IN THE LINE OF SKIN INCISION AND SUBPERIOSTEAL DISSECTION IS PERFROMED TO DETACH THE ERECTOR SPINAE MUSCLE FROM THE LAMINA (IT IS IMPORTANT TO BE IN THE SUBPERIOSTEAL PLANE TO LIMIT BLEEDING IF PARASPINAL MUSCLES ARE VIOLATED) DISSECTION CARRIED DOWN TO THE SPINOUS PROCESS REMOVING THE INTERSPINOUS LIGAMENT ALOMG THE LAMINA OF THE FACET JOINT AND LIGAMENTUM FLAVUM REMOVED WITH THE HELP OG PENFIELD AND RETRACTED TO ITS ATTACMENT SUPERIORLY EXPOSING THE DURA COVERING NERVE ROOT

30. THAT EXPOSED NERVE ROOT WAS THEN CAREFULLY SECURED AND RETRACTED AWAY FROM DISSECTION FIELD EXPOSING THE THECAL SAC WHERE BULGING EXTRUSION DISC WAS IDENTIFIED DISC LEVEL AGAIN CONFIRMED WITH THE HELP OF A SPINAL NEEDLE UNDER C-ARM IN LATERAL VIEW BULGING DISC REMOVED WITH THE HELP OF RONGEURS AND DISC FORECEPS TO ATTAIN DECOMPRESSION ENSURE TIGHT FASCIAL CLOSURE AND CLOSE THE SKIN IN SIMILAR FASHION

31. CASE NAME : MOHD MUNEER AGE/SEX – 29 YEAR/ MALE PRESENTED WITH COMPLAIN OF : PAIN IN LOWER BACK RADIATING TO RIGHT LOWER LIMB FROM LAST 4 MONTHS AGGRAVATING FACTIORS : SUDDEN FLEXION , PROLONGED SITTING , SNEEZING , COUGHING RELIVED BY TAKING REST

32. NEUROLOGICAL STATUS PRE-OPERTAIVE RIGHT LEFT STRAIGHT LEG RAISE TEST 2 DEGREE 80 DEGREE EHL 4/5 5/5 ANKLE REFLEX MUTE ++ KNEE REFLEX ++ ++ CLONUS - - SENSORY DIMINSION AT ANTERO-LATERAL OF LEG, DORSUM OF FOOT AND GREAT TOE SUGESSTIVE OF L5 ROOT COMPRESSION

33. RADIOLOGICAL IMAGES SKIAGRAM SHOWING STRAIGHTING OF LUMBAR SPINE WITH NEARLY NORMAL INTERVERTEBRAL DISC SPACE

34. MRI OF THE SAME PATIENT SHOWING ANNULAR TEAR WITH DISC BULGE WITH POSTEROLATERAL DISC EXTRUSION WITH CAUDAL MIGRATION AT L5-S1 LEVEL CAUSING MODERATE THECAL SAC INDENTATION

35. INTRA –OP FINDINDS EXCESSIVELY THICKNED NERVE ROOT EXTRUSION OF DISC CEPHALIC END CAUDAL END RIGHT LEFT DURA COVERING THE NERVE ROOT EXCESSIVELY THICKNED NERVE ROOT

36. ZOOM VIEW OF PREVIOUS PICTURE SHOWING EXCESSIVELY THICKNED NERVE ROOT COVERED WITH DURA

37. PEN FIELD RETRACTING NERVE ROOT AND SHOWING BULGING DISC

38. REMOVED EXTRUSION DISC

39. POST OPERATIVE NEUROLOGICAL STATUS ON POD 1 RIGHT LEFT STRAIGHT LEG RAISING TEST 50 DEGREE 80 DEGREE EHL 4/5 5/5 ANKLE JERK MUTE ++ KNEE JERK ++ ++ CLONUS - -

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