Lumber disc bulge/ Herniation/ Prolapse

What is structure of lumber disc? What is disc bulge/prolapse/herniation? What is difference between disc bulge, disc prolapse, disc herniation or disc extrusion? What is criteria to diagnose lumber disc prolapse? How lumber disc herniation is treated medically or surgically? How lumber disc herniation is treated by conservative method? How lumber disc herniation is treated through physical therapy? What is physiotherapy after various disc surgeries? What is radiological method to diagnose disc prolapse?

1. Presented by: Dr. Zunaira Ahmad LUMBER DISC BULGE / herniation

2. Learn anatomy of lumber disc bulge Types Find out causes of it. Elaborate differential diagnosis (DDs) for its signs and symptoms Clinical tests Radiological findings or tests Treatment options OBJECTIVES

3. What is Lumber region? What is disc? What is disc bulge and disc herniation? ANATOMY

4. Lumber region

5. It is a hydrostatic, load bearing structure between the vertebral bodies. The intervertebral disc incorporates of: Annulus fibrosus Nucleus pulposus Endplate A thick outer ring composed of fibrous cartilage called the annulus fibrosus , which surrounds a central gelatinous material known as the nucleus pulposus . Weight is transmitted to the nucleus through the hyaline cartilage plate. The hyaline cartilage is ideally suited to this function because it is avascular The fibers of the annulus can be divided into three main groups: outermost fibers the middle fibers innermost fibers The anterior fibers are strengthened by the powerful anterior longitudinal ligament. The posterior longitudinal ligament affords only weak reinforcement, especially at L4-5 and L5-S1, where it is a midline, narrow, unimportant structure attached to the annulus. The anterior and middle fibers of the annulus are most numerous anteriorly and laterally but are deficient posteriorly, where most of the fibers are attached to the cartilage plate. INTERVARTEBRAL DISC

6. Disc Bulge Extension of the disc margin beyond the margins of the adjacent vertebral endplates. Bulge in the disc but not a complete rupture Protrusion / Bulging Nucleus forced into outermost layer of annulus fibrosus- not a complete rupture Extrusion/ Disc herniation The nuclear material emerges through the annular fibers but the posterior longitudinal ligament remains intact. A small hole in annulus fibrosus and fluid moves into epidural space Sequestration or free fragment The nuclear material emerges through the annular fibers and the posterior longitudinal ligament is disrupted. A portion of the nucleus pulposus has protruded into the epidural space. DISC HERNIATION TYPES

7. A bulging disc is that the nucleus does not push out of the annulus in a bulging disc. The disc simply bulges out of the space it normally occupies in the spine. Considered a normal part of aging, a bulging disc may not even cause any symptoms . If it bulges enough to press on spinal nerves or narrow the spinal canal, then it can lead to symptoms including pain, numbness, tingling, or weakness. A bulging disc can sometimes be a precursor to a herniated disc. Disc BULGing

8. AGE: 30 – 40 years MOST COMMON LEVEL : L4-L5 (next common level is L5-S1) MOST COMMON TYPE: Postero -lateral type WHY DISC PROLAPSE IS MOST COMMON POSTEROLATERALLY?  Incomplete annular lamellae in this quadrant ( i.e ) each lamellae end with fusion to an adjacent lamellae not completely circular.  Fibers of annulus were deficient posteriorly.  Posterior fibers are only weakly reinforced by posterior longitudinal ligament especially L4-5 and L5-S1

9.  Repetitive mechanical activities – Frequent bending, twisting, lifting, and other similar activities without breaks and proper stretching can leave the discs damaged.  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.  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. Sports/ Automobile injury  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. Sitting and bending forwards, lifting heavy weight bending back.  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. CAUSES

10. Patient presents with LOW BACK PAIN with or without buttock involvement . AGGRAVATING FACTORS Pain will aggravate on bending, stooping, lifting heavy weight. RELIEVING FACTORS: Pain relieved on lying or rest. No position of comfort in case of high lumbar root lesions. MORNING STIFFNES Patient presenting COMPLAINT Patient presents with lower leg pain more dominated than low back pain . follows a dermatomal pattern Weakness And Paresthesia (pins and needles feeling) Numbness Difficulty / painful walking in case of herniated disc causing stenosis Difficulty/ painful stepping down stairs in case of herniated disc causing stenosis AGGRAVATING FACTORS Pain will aggravate on bending, stooping, lifting heavy weight, coughing, sneezing, deep breathing or laughing. But in case of stenosis aggravate on extension. RELIEVING FACTORS Pain relieved on extension but pain relieved on flexion posture if stenosis. MORNING STIFFNES BULGING HERNIATION

11. AROM Flexion- Painful and restricted Lateral bending to same side- Painful and restricted If stenosis, extension painful and restricted PROM (carefully) Tenderness + ve on involved vertebra or Over The Spinous Process Paraspinal muscle spasm- Central Furrow sign Gait- Antalgic/ limping gait Loss of lumber lordosis Scoliosis in Lumbar spine/ Sciatic scoliosis Loss of Normal Lumbar Lordosis Perform clinical tests Dermatome and myotome examination EXAMINATION

12. SLR Test/ LASEGUE’S TEST BRAGGARD’S SIGN BOWSTRING SIGN Contralateral SLR Positive/ Crossed Straight Leg Raise Test (Crossed Lasègue test)/ CONTRALATERAL STRAIGHT LEG RAISING TEST (FRAJERSZTAGN TEST) NAFFZIGER’S TEST Tripod Test/Flip Sign Valsalva maneuver Slump test FEMORAL NERVE Traction TEST (REVERSE SLR TEST) Prone knee bend (PKBI) Clinical tests

13. SLR (passive test)

14. Perform SLR, move out of painful range and add dorsiflexion Stretching of the sciatic nerve will cause intense pain BRAGGARD’S SIGN

15. BOWSTRING SIGN

16. Crossed SLR Test | Crossed Over Lasègue Contralateral SLR/ F ajersztajn test/ crossover sign Indicates a large central disc herniation or sequestration Contralateral side pain reproduction on 40 to 60 degree hip flexion in knee extended position

17. Here pressure applied on the jugular vein for 10 seconds, the patient face flush. Now patient asked to cough which produce pain in back indicate test is positive. Indication of thecal sac / spinal theca compression NAFFZIGER’S TEST

18. Shooting pain in entire leg in case of nerve root involvement but muscular tension in case of hamstring contracture. Flip sign or tripod test

19. Pt. seated, asked to take a breath, hold breath, and bear doen as if evacuating stool. Pain reproduce. Indicate thecal sac compression Valsalva maneuver

20. Hands behind back, slump back of pt. ,flex head, exert over pressure to head in flexion, extend involved knee with added pressure in dorsiflexion Neurological signs or shooting pain reproduction Slump test

21. Patient side lying, extent hip 15 degree flex knee Test for L2 to L4 nerve root compression test Pain in groin or hip that radiate down anterior medial thigh indicate L3 nerve lesion Pain extending to midtibia indicates L4 nerve root problem FEMORAL NERVE traction TEST (REVERSE SLR TEST)

22. Pt. prone, flex knee to 90 degree pain, maintain position for 45 to 60 seconds. Pain provoke. When taking heel to buttock indicate SI or lumber pain. Could indicate tight rectus femoris. Maintaining position with careful history and its modification lead to find femoral nerve compression Prone knee bend (PKBI)

23. Neurological examination

24. To check dermatomes have sensory examination at respective levels as above Examine for any muscular atrophy

25. MYOTOMES L2: Hip Flexion L3: Knee extension L4: Ankle Dorsiflexion L5: Great toe extension S1: Ankle plantar flexion, eversion, hip extension S2: Knee flexion pt. in supine, perform respective resisted movements. Can adopt alternative positions in standing, For S1 pt. can have single leg heel raise.

26. The diagnosis of disc rupture is dependent on demonstration of root impairment as reflected by signs of motor weakness, changes in sensory appreciation or reflex activity.

27. X-Ray MRI Investigations

28. Lumbar strain, spasm (70%) Facet joint pain Degenerative processes of disc and facets, usually age-related(10%) Spinal stenosis Osteoporotic compression fracture Spondylolisthesis Traumatic fracture Congenital disease Cauda equina Inflammatory/metabolic causes: Diabetes, Ankylosing spondylitis, Paget’s disease, Arachnoiditis, Sarcoidosis Intraspinal synovial cysts Severe kyphosis, Severe scoliosis, Internal disk disruption Non mechanical- systemic cause Differential Diagnosis to LBP

29. 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 ( 12 weeks) surgery should not be recommended for at least 6 weeks of treatment. BED REST In very acute condition patient must be kept on bed rest. Adequate analgesic relive the pain and this helps the muscle spasm to subside. Patient should not be kept in bed rest for not more than 2 to 3days . Conservative managment

30. Modalities Cold or hot pack TENS Ultrasound therapy Hydrotherapy Lumbar Traction Manual treatment PHYSIOTHERAPHY treatment

31. Pain control Ambulation and resumption of exercise Education maintaining healthy weight restoration of functional deficit Restoration of neurological deficits associated with symptomatic disc herniation. GOALS

32. Acute/ protection phase- 0 to 4 weeks Subacute/ Controlled motion phase- 4 to 12 weeks Chronic/ Return to function phase- >12 weeks (6 months in some cases) Phases of management

33. Educate patient- encourage to engage in activities Pain control – modalities, soft tissue mobilization, traction, mobilization, rest for 2 days if needed to settle nerve root irritation Lumber traction for relieving paresthesia Educate good posture - add braces or lumber support if needed Initiate neuromuscular activation and control of stabilizing muscles - Core strengthening – drawing in maneuver , bridging , Start extension bias protocol (McKenzie protocol) Teach safe performance of ADLs- add adjacent muscle strengthening Acute/ protection phase- 0 to 4 weeks

34. Mc-Kenzie extension bias protocol

35. BIDGING

36. Educate patient – engage in all activities in safe mechanics, home exercise program , ergonomics adaptation of work Progress control of stabilizing muscles- Lifting one leg in crawling position Lifting crossed arms and legs in crawling position Lunges Flexibility exercises ( eg , yoga and stretching) Proprioception/coordination/balance (medicine ball and wobble/tilt board) strengthening exercises Trunk curls SLR aerobic activity ( eg , walking, cycling) Subacute/ Controlled motion phase- 4 to 12 weeks

37. Lifting one leg in crawling position, Lifting crossed arms and legs in crawling position, Lunges

38. Educate patient – engage in all activities in safe mechanics, home exercise program , ergonomics adaptation of work - progression Progress control of stabilizing muscles- Lifting one leg in crawling position Lifting crossed arms and legs in crawling position, Lunges progress Flexibility exercises ( eg , yoga and stretching) Proprioception/coordination/balance ( challange balance progress) strengthening exercises- progression aerobic activity ( eg , walking, cycling) (McKenzie approach progression) motor control exercises MCEs Endurance , agility, strength Lumber Traction Chronic/ Return to function phase- >12 weeks

39. Post Surgical Rehab - In case of surgery, program start regularly 4-6 weeks post-surgery. Patient education about the rehabilitation program they will follow the next few weeks. Rehabilitation programs that start four to six weeks post-surgery with exercises versus no treatment found that exercise programs are more effective. The patients are instructed and accompanied in daily activities such as: coming out of bed, going to the bathroom and clothing Patients have to pay attention on the ergonomics of the back. Home exercise programs.

40. Duration of rehabilitation program : 4 weeks Frequency : every day Duration of one session : approximately 60 minutes Treatment: dynamic lumbar stabilization exercises + home exercises Exercises: Prior to the DLS training session patients are provided with instruction or technique to ensure and protect a neutral spine position. During the first 15 minutes of each session stretching of back extensors, hip flexors, hamstrings and Achilles tendon should be performed. (DLS consists of: Quadratus exercises Abdominal strengthening Bridging with ball Straightening of external abdominal oblique muscle Lifting one leg in crawling position Lifting crossed arms and legs in crawling position Lunges) Home Exercises - should be added to the treatment. These should be performed every day. 5 repetitions during the first week up to 10-15 reps in the following weeks Example of Protocol for Rehabilitation Following a Lumbar Microdiscectomy

41. This Photo by Unknown Author is licensed under CC BY-SA