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1. INTERVERTEBRAL DISC PROLAPSE RATHEESH R L

2. DEFINITION Spinal  disc herniation , also known as a  slipped disc , is a medical condition affecting the spine in which a tear in the outer, fibrous ring of an  intervertebral disc  allows the soft, central portion to  bulge  out beyond the damaged outer rings.

3. Is relatively avascular structure and the Essential minerals and fluids required for regeneration enter the disks passively during the night .

4. FUNCTIONS OF IVD 1-It supports the axial load on the column that is delivered by the body mass. 2- Assist a limited range of motion at the spine. 3- Shock absorbing system. 4- Serve ligamental functions between vertebral bodies. 5- Assist to keep the normal shape & curvature of each spinal region (cervical, thoracic, ..etc)

5. Location The majority of spinal disc herniation cases occur in lumbar region (95% in L4-L5 or L5-S1).  The second most common site is the cervical region (C5-C6, C6-C7). The thoracic region accounts for only 0.15% to 4.0% of cases.

6. Cervical Cervical disc herniations occur in the neck, most often between the fifth & sixth (C5/6) and the sixth and seventh (C6/7) cervical vertebral bodies. Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula, shoulder, arm, and hand. The nerves of the cervical plexus and brachial plexus can be affected.

7. Thoracic Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the uppermost thoracic discs can mimic cervical disc herniations , while herniation of the other discs can mimic lumbar herniations .

8. Lumbar Lumbar disc herniations occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum. Symptoms can affect the lower back,buttocks , thigh, anal/genital region (via the  Perineal nerve), and may radiate into the foot and/or toe.

9. Repetitive mechanical activities – Frequent bending, twisting, lifting, and other similar activities without breaks and proper stretching can leave the discs damaged. CAUSES

10. Traumatic injury to lumbar discs- commonly occurs when lifting while bent at the waist, rather than lifting with the legs while the back is straight.

11. Living a sedentary lifestyle – Individuals who rarely if ever engage in physical activity are more prone to herniated discs because the muscles that support the back and neck weaken, which increases strain on the spine.

12. Obesity – Spinal degeneration can be quickened as a result of the burden of supporting excess body fat. Practicing poor posture – Improper spinal alignment while sitting, standing, or lying down strains the back and neck. CAUSES

13. Tobacco abuse – The chemicals commonly found in cigarettes can interfere with the disc’s ability to absorb nutrients, which results in the weakening of the disc .

14. Mutation- in genes coding for proteins involved in the regulation of the extracellular matrix, such as MMP2 and THBS2, has been demonstrated to contribute to lumbar disc herniation.

15. There is now recognition of the importance of “chemical radiculitis ” in the generation of back pain.  A primary focus of surgery is to remove “pressure” or reduce mechanical compression on a neural element: either the spinal cord, or a nerve root. Pathophysiology

16. But it is increasingly recognized that back pain, rather than being solely due to compression, may also be due to chemical inflammation.

17. There is evidence that points to a specific inflammatory mediator of this pain.  This inflammatory molecule, called  tumor necrosis factor-alpha (TNF), is released not only by the herniated disc, but also in cases of disc tear (annular tear), by facet joints, and in spinal stenosis . 

18. In addition to causing pain and inflammation, TNF may also contribute to disc degeneration.

19. SYMPTOMS The symptoms of a herniated or prolapsed disc may not include back or neck pain in some individuals, although such pain is common. The main symptoms of a prolapsed disc include: In severe cases, loss of control of bladder and/or bowels, numbness in the genital area, and impotence (in men) Numbness, pins and needles, or tingling in one or both arms or legs

20. Pain behind the shoulder blade(s) or in the buttock(s) Pain running down one or both arms or legs The location of these symptoms depends upon which nerve(s) has been affected. In other words, the precise location of the symptoms helps determine your diagnosis. Weakness involving one or both arms or legs

21. TYPES OF HERNIATION posterolateral disc herniation – protrusion is usually posterolateral into vertebral canal, compress the roots of a spinal nerve. protruded disc usually compresses next lower nerve as that nerve crosses level of disc in its path to its foramen. ( eg.protrusion of fifth lumbar disc usually affects S1 instead.

22. central (posterior) herniation : less frequently, a protruded disc above second lumbar vertebra may compress spinal cord itself or or may result in cauda equina syndrome. in the lower lumbar segments, central herniation may result in S1 radiculopathy.

23. lateral disc herniation: may compress the nerve root above the level of the herniation L4 nerve root is most often involved & patient typically have intense radicular pain.

24. Diagnosis is based on the history, symptoms, and physical examination. At some point in the evaluation, tests may be performed to confirm or rule out other causes of symptoms such as  spondylolisthesis,degeneration ,  tumors , metastases and space-occupying lesions. DIAGNOSIS

25. X-Ray : lumbo -sacral spine; Narrowed disc spaces. Loss of lumber lordosis . Compensatory scoliosis. CT scan lumber spine; It can show the shape and size of the spinal canal, its contents, and the structures around it, including soft tissues. Bulging out disc. IMAGING

26. MRI lumber spine; Intervertebral disc protrusion. Compression of nerve root. Myelogram ; pressure on the spinal cord or nerves, such as herniated discs, tumors , or bone spurs.

27. Normal MRI

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30. Bed rest. Non-steroidal anti-inflammatory drugs (NSAIDs). Patient education on proper body mechanics. Physical therapy, to address mechanical factors, and may include modalities to temporarily relieve pain (i.e. traction, electrical stimulation massage). medical treatments .

31. Oral steroids (e.g. prednisone or methylprednisolone). Epidural cortisone injection. Intravenous sedation, analgesia-assisted traction therapy (IVSAAT). Weight control. Tobacco cessation. Lumbosacral back support. anti-depressants.

32. Discectomy / Microdiscectomy  - This procedure is used to remove part of an intervertebral disc that is compressing the spinal cord or a nerve root.

33. The Tessys method The Tessys method ( transforaminal endoscopic surgical system) is a minimally invasive surgical procedure to remove herniated discs .

34. Laminectomy - to relieve spinal stenosis or nerve compression

35. Hemilaminectomy  - Hemilaminectomy is surgery to help alleviate the symptoms of an impinged or irritated nerve root in the spine

36. Lumbar fusion Anterior lumbar fusion is an operation done on the front (the anterior region) of the lower spine. Fusion surgery helps two or more bones grow together into one solid bone.  

37. Fusion cages are new devices, essentially hollow screws filled with bone graft, that help the bones of the spine heal together firmly. Surgeons use this procedure when patients have symptoms from disc degeneration, disc herniation, or spinal instability. lumbar fusion is only indicated for recurrent lumbar disc herniations , not primary herniations

38. Total Disc Replacement Artificial Disc Replacement (ADR) , or  Total Disc Replacement (TDR) , is a type of  arthroplasty . It is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial devices in the lumbar (lower) or cervical (upper) spine.

39. Complications

40. NURSING MANAGEMENT Assess the general condition of the patient Check the vital signs Assess the level and characteristics of pain Provide proper back care and skin care to the patient Advice patient to do proper exercise Provide adequate nutrition

41. Change the position frequently Advice to avoid heavy exercise like heavy weight lifting Put traction for the prescribed period of time. Continue the medications till the doctor adviced