Lumbar disc prolapse

vighneshwarn's presentation

2. J.J.M MEDICAL COLLEGE
DAVANGERE
SEMINAR ON

3. HISTORY
 Aurelianus (5
th
century) clearly described the
symptoms of SCIATICA.
 Andreas Vesalius (1543) first described the
intervertebral disc.
 Middleton & Teacher (1911) described a case of
paraplegia following attempting to lift heavy weight from
floor on postmortem they found fibrocartilage in extradural
space.
 Elseberg (1928) described Chondromas derived from
disc of cervical region.

4. Stookey (1928) described cartilaginous
compression thought as chondromas
responsible for clinical prersentation.
Dandy (1929) reported removal of a disc
tumour or chondroma from patients with
sciatica.
Mixter and Barr (1934) described disc
herniation as the cause of Sciatica.

5. Peet& Echols (1934) referred to as Chondroma or
Ecchondrosis was really protrusion of intervertebral
disc.
Lindblom(1948) first described DISCOGRAPHY.
Lyman Smith (1963) described CHEMONUCLEOLYSIS.
Kambin & Gellman (1983) reported percutaneous
approach for lumbar discectomy.

6. LUMBAR SPINE

7. ANATOMY OF LUMBAR SPINE

9. INTERVERTEBRAL DISC

11. NUTRITION TO DISC

12. FUNCTION OF DISC

13. FACET JOINTS

15. LIGAMENTS OF LUMBAR SPINE

16. MOTION SEGMENT
ANTERIOR
ELEMENT
POSTERIOR
ELEMENT

17. DISC & NERVE ROOT RELATION
L5 is
TRAVERSING
NERVE ROOT
L5 is EXITING
NERVE ROOT

18. EFFECT OF AXIAL LOADING

19. THREE JOINT COMPLEX

20. RELATION OF INTRADISCAL
PRESSURE AND POSTURE

21. IN RELATION TO POSTURE

22. CORRECT SLEEPING POSTURE

23. IN RELATION TO MANUAL MATERIALS
HANDLING

24. LUMBAR DISC PROLAPSE
DEFINITION
It is condition in which there is
outpouching of the disc Nucleus pulposus
along with few annular fibres and end plate
cartilage through the tears in annulus fibrosus
into the extradural space.

25. EPIDEMIOLOGY
•AGE: 30 – 40 years
•SEX: Male affected more than female
•MOST COMMON LEVEL: L4-L5 (next common
level is L5-S1)
•MOST COMMON TYPE: Posterolateral type

26. WHY DISC PROLAPSE IS MOST
COMMON POSTEROLATERALLY?

27. ETIOLOGY

29. EFFECT OF SMOKING
Blood vessel get
constricted
Transport of nutrients
& disposal of waste
products decreased
Disc cells get deficient
nutrition or die
Disc degenerates &
results in DISC
INSTABILITY

30. DISC DEGENERATION

31. STAGES OF DISC DEGENERATION
Stage of dysfunction
Stage of instability
Stage of stabilization

32. STAGE OF DYSFUNCTION
Episode of rotational
or compressive trauma
Posterior facet joint
& annular strain
Small capsular &
annular tear occurs
Small subluxation
of posterior joint
Posterior joint
SYNOVITIS
Posterior segment muscle
protect joint by sustained
hypertonic contraction

33. STAGE OF INSTABILITY
FACET
JOINT
Degeneration
of cartilage
Laxity of
capsule
DISC
Coalescence
of tears
Loss of nucleus
internal
disruption
Bulging of
annulus
INCREASED
ABNORMAL
MOVEMENT

34. STAGE OF STABILIZATION
FACET JOINT
DISC
Destruction
of cartilage
Fibrosis in
joint
Loss of
nucleus
Fibrosis in disc
& osteophytes
INCREASED
STIFFNESS
STABILIZATION

35. DISC DEGENERATION

36. PATHOPHYSIOLOGY OF LUMBAR
INTERVERTEBRAL DISC PROLAPSE
With aging, vascular channels start to fail and vascular diffusion
of nutrients decrease thus number of viable chondrocytes in the
nucleus pulposus diminishes
Synthesis rate & concentration of
proteoglycans decreases & proportion of
collagen increase in nucleus pulposus
Water binding capacity of the nucleus
decreases
Nucleus becomes more fibrous & stiffer
Nucleus is less able to bear & disburse load,
transferring load to the posterior annulus

37. ANNULUS
IN TACT
Facet joints share
even more of the
axial load
Facet joints undergo
degenerative
changes & develop
osteophytes
FACET JOINT
SYNDROME

39. ANNULUS FAILS

40. Extruded disc &
degraded nuclear
material impinge on
the nerve roots
Nucleus pulposus is an
immunogenic which
induce an inflammatory
response
Produces radicular
pain syndrome &
RADICULOPATHY

41. STAGES OF DISC PROLAPSE

43. AXIAL LOCATION

44. SAGITTAL SECTION

45. ATTITUDE

46. LIST (SCIATIC SCOLIOSIS)

49. L4

50. L5

51. S1

52. L3

53. L2

54. L1

55. STRAIGHT LEG RAISING TEST

56. LASEGUE SIGN

57. LASEGUE TEST

58. CONTRALATERAL LEG RAISING
TEST (FRAJERSZTAGN TEST)

59. WHY PAIN OCCURS ON AFFECTED
SIDE ON RAISING NORMAL LEG?
AFFECTED SIDE NORMAL SIDE

60. BOWSTRING TEST

61. FEMORAL NERVE STRETCH TEST

62. FLIP TEST
NEGATIVE POSITIVE

63. NAFFZIGER TEST

64. VALSALVA MANEUVRE

66. CAUDA EQUINA SYNDROME
•Marked reduction in SLRT
•Saddle anaesthesia
•Bilateral ankle jerk depression
•Involuntary overflow
incontinence
•Decreased tone in external
sphincter

67. DIFFERENTIAL DIAGNOSIS
INTRASPINAL CAUSES
Proximal to disc: Conus and Cauda equine lesions (eg.
Neurofibroma, ependymoma)
Disc level
•Herniated nucleus pulposus
•Stenosis (Canal or recess)
•Infection: Osteomyelitis or discitis ( with nerve root pressure)
•Inflammation: Arachnoiditis
•Neoplasm: Benign or malignant with nerve root pressure

68. EXTRASPINAL CAUSES
Pelvis
•Cardiovascular conditions (eg. Peripheral vascular disease)
•Gynaecological conditions
•Orthopaedic conditions ( osteoarthritis of hip, Muscle related disease,
Facet joint arthropathy)
•Sacroiliac joint disease
•Neoplasm
Peripheral nerve lesions
•Neuropathy (Diabetic, tumour, alcohol)
•Local sciatic nerve conditions (Trauma, tumour)
•
Inflammation (herpes zoster)

69. KEY DIAGNOSTIC POINTS
LUMBAR DISC PROLAPSE
Leg pain greater than back pain
Neurological deficit present
ANNULAR TEARS
Back pain greater than leg pain
Bilateral SLRT positive
FACET JOINT ARTHROPATHY
Localized tenderness present unilaterally over joint
Pain occurs immediately on spinal extension
Pain exacerbated with ipsilateral side bending

70. SPINAL STENOSIS
Back and/or leg pain develops after walks a limited distance.
Flexion relieves symptoms
No neurological deficit
Pain not reproduced on SLRT
MYOGENIC OR MUSCLE RELATED
Pain localised to affected muscle
Pain increases on prolonged muscle use
Pain reproduced with sustained muscle contraction against
resistance
Contralateral pain with side bending

71. INVESTIGATION

THE CORNERSTONE OF DIAGNOSIS OF
LUMBAR DISC DISEASE IS THE HISTORY AND
PHYSICAL EXAMINATION NOT THE
INVESTIGTION.

72. PLAIN RADIOGRAPH
OSTEOPHYTE
DECREASED DISC
SPACE

73. NORMAL RETROSPONDYLOLISTHESIS

74. MARKED
RETROSPONDYL
OLISTHESIS

75. REDUCTION IN THE
HEIGHT OF THE
PEDICLE

76. FORWARD
DISPLACEMEN
T OF L3 OVER
L4

77. MYELOGRAPHY

78. DISADVANTAGE OF MYELOGRAPHY
•Myelographyis capable of showing the level
at which the pathology lies but fails to show
the nature of the lesion or its precise location
in the anatomic segment .

79. DISCOGRAHY

80. USES OF DISCOGRAPHY
•To evaluate equivocal abnormality seen on myelography, CT
or MRI
•To isolate a symptomatic disc among multiple level
abnormality
•To diagnose a lateral disc herniation
•To establish contained discogenic pain
•To select fusion levels
•To evaluate the previously operated spine

81. CT DISCOGRAPHY
USES
•To determine whether the disc herniation is
contained, protruded, extruded or
sequestrated.
•To evaluate previously operated lumbar spine
to distinguish between mass effect from scar
tissue or disc material.

82. COMPUTED TOMOGRAPHY
ADVANTAGES
•CT is an extremely useful, highly accurate & noninvasive tool in
the evaluation of spinal disease.
•CT provides superior imaging of cortical and trabecular bone
compared with MRI.
•It provides contrast resolution and identify root compressive
lesions such as disc herniation.
•It also helps to differentiate between bony osteophyte from
soft disc.
•It helps to diagnose foraminal encroachment of disc material
due to its ability to visualize beyond the limits of the dural sac
and root sleeves.

83. LIMITATIONS
•It cannot differentiate between scar tissue
and new disc herniation
•It does not have sufficient soft tissue
resolution to allow differentiation between
annulus and nucleus.

84. MAGNETIC RESONANCE IMAGING
• It allows direct visualization of herniated disc
material and its relationship to neural tissue
including intrathecal contents.

85. INDICATIONS FOR SPINE IMAGING
•Presence ofunderlying systemic disease
•Progressive neurological deficits
•Cauda equine syndrome
•Candidate for therapeutic intervention
•Failed clinically directed conservative therapy

98. CONTRAST ENCHANCED MRI
•Here GADOLINIUM labeled
diethylenetriaminepentaacetate (Gd-DTPA)
administered intravenously and MRI scan
done.
ADVANTAGES
•Display the inflammatory reaction critical to
the pathophysiology of radicular pain or
radiculopathy
•Allows discrimination of scar from recurrent
disc.

99. OTHER DIAGNOSTIC TESTS
•ELECTROMYOGRAPHY – to rule out peripheral
neuropathy.
•SOMATOSENSORY EVOKED POTENTIALS
(SSEP) – to identify the level of root
involvement
•POSITRON EMISSION TOMOGRAPHY

100. TREATMENT
•CONSERVATIVE
•SURGICAL

101. CONSERVATIVE
Majority of disc prolapse respond well to
conservative therapy. Resolution of first disc
prolapse takes place approximately 75% of
patients over a period of 3 months.

102. BED REST

103. PHYSIOTHERAPY

104. EXERCISES
GENERAL RULES FOR EXERCISE
•Do each exercise slowly. Hold the exercise position for a slow
count of five.
•Start with five repetitions and work up to ten. Relax
completely between each repetition.
•Do the exercises for 10 minutes twice a day.
•Care should be taken when doing exercises that are painful. A
little pain when exercising is not necessarily bad. If pain is
more or referred to the legs the patient may have overdone
it.
•Do the exercises every day without fail.

105. FOR ACUTE STAGE
BRIDGING EXERCISE KNEE HUGS

106. FOR RECOVERY OR SUBACUTE
STAGE
EXTENSION CONTROL
HAMSTRING STRETCH
KNEE ROLLS

108. YOGAASANAS
TADASANA
(Mountain pose)
MARICHYASANA III
(Marichi's Pose)
BHARADVAJASANA
(Bharadvaja's Twist)

109. VIRABHADRASANA II
(Warrior II Pose)
ARDHA URDHVA MUKHA
SVANASANA
(Half Upward-Facing Dog Pose)
BALASANA
(Child's Pose)

110. UTTHITA PARSVAKONASANA
(Side Angle Pose)
UTTHITA TRIKONASANA
(Triangle Pose)
SHAVASANNA
(Corpse Pose)

111. DO’S & DON’T’S

112. EPIDURAL STEROID INJECTION

113. CHEMONUCLEOLYSIS
Chymopapain
injected into the
disc
Degrades the
proteoglycans in the
nucleus
Water holding
capacity of the disc
is decreased
Shrinkage of the
disc

114. CONTRAINDICATION FOR
CHEMONUCLEOLYSIS
•Sequestrated disc
•Significant neurological deficit
•Disc herniation with lateral stenosis
•Cauda equine syndrome
•Previous treatment with chymopapain
• Spinal tumour
•Recurrence of disc herniation
• Spondylolisthesis
•Pregnancy
•Diabetic Neuropathy

115. SURGERY
GOAL
To relive neural compression and
henceradiculopathy while minimizing
complications.

116. INDICATIONS
ABSOLUTE
•Bladder and bowel involvement: The cauda equine syndrome
•Increasing neurological deficit
RELATIVE
•Failure of conservative treatment
•Recurrent sciatica
•Significant neurological deficit with significant SLR reduction
•Disc rupture into a stenotic canal
•Recurrent neurological deficit

117. CONTRAINDICATIONS FOR
SURGERY
•Wrong patient ( poor potency for recovery)
•Wrong diagnosis
•Wrong level
•Painless HNP (do not operate for primary complaint
of weakness or paresthesia, in the absence of pain)
•Inexperienced surgeon applying poor technical skills
•Lack of adequate instruments

118. KNEE CHEST POSITION

119. HEMI OR PARTIAL LAMINECTOMY

120. FENESTRATION

121. TOTAL LAMINECTOMY

122. LAMINOTOMY & DISCECTOMY

123. COMPLICATIONS OF
LAMINECTOMY AND DISCECTOMY
•Infection – Superficial wound infection , Deep disc space
infection
•Thrombophlebitis/ Deep vein thrombosis
•Pulmonary embolism
•Dural tears may result in Pseudomeningocoele, CSF leak,
Meningitis
•Postoperative cauda equine lesions
•Neurological damage or nerve root injury
•Urinary retention and urinary tract infection

124. FAILED BACK SYNDROME
It is a condition characterized by persistent
postoperative backache and sciatica.
VERY COMMON CAUSES
•Recurrent/ Persistent disc material at operated site
•Herniated Nucleus Pulposus at other site
•Epidural scar / Fibrosis
• Facet arthrosis / Spinal stenosis

125. COMMON CAUSES – Neuritis, Referred pain from
nonspinous site
UNCOMMON CAUSES
•Discitis / Osteomyelitis/ Epidural abscess
•Arachnoiditis
•Conus tumour
•Thoracic, High lumbar Herniated Nucleus Pulposus
•Epidural haematoma

126. The recurrence of pain after disc surgery
should be treated with all available
conservative treatment modalities initially.
The surgery should be tailored to the
anatomic problem only.

127. MICRODISCECTOMY

128. PERCUTANEOUS DISCECTOMY

129. PERCUTANEOUS SUCTION
DISCECTOMY

131. MICROENDOSCOPIC DISCECTOMY

132. PERCUTANEOUS LASER
DISCECTOMY

133. LUMBAR ARTIFICIAL DISC
REPLACEMENT

134. Patient not suitable for artificial disc
replacement are
•Osteoporosis
•Spondylolisthesis
•Infection or tumour of spine
•Spine deformities from trauma
•Facet arthrosis

135. TECHNIQUE

138. INTRADISCAL ELECTROTHERMAL
THERAPY
•It is a new minimally invasive technique done
as an outpatient procedure.
•Done in patients with low back pain caused by
tears in the outer wall of the intervertebral
disc.

139. PROGNOSIS
•Extruded disc, Large herniations,
Sequestrations have a greater tendency to
resolution than small herniations& disc
bulges.
•Recurrence of disc prolapse can be prevented
by a proper exercise programme and
avoidance of stress to the lower part of back.

140. REFERENCES
•MACNAB’S BACKACHE by DavidA.Wong 4
th
edition
•THE LUMBAR SPINE by Sam W Wiesel 2
nd
edition
•MANAGING LOW BACK PAIN by W.H.Kirkildy – Willis 3
rd

edition
•ORTHOPAEDIC PHYSICAL ASSESSMENT by David Magee 5
th

edition
•ORTHOPAEDIC PRINCIPLE AND THEIR APPLICATION by TUREK
4
TH
Edition
•CAMPBELL’S OPERATIVE ORTHOPAEDICS 11
TH
EDITION
•INTERNET

141. “LEARN TO BE
GOOD TO
YOUR BACK
AND YOUR
BACK WILL BE
GOOD TO
YOU….”