Plid

Orthopaedics

1. Prolapsed Lumbar Intervertebral Disc (PLID) PROF. (DR.) MD. SHAH ALAM MBBS, MS, FCPS, FRCS Fellowship Training in Spine Surgery (USA) Imperial Spine Course (UK) Professor Department of Ortho & Spine Surgery National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR) Dhaka, Bangladesh

2. FUNCTIONS

3. FUNCTIONS

4. Secondary curves Secondary curves develops in response to weight bearing. Purpose of these curves are to keep the spine balanced in sagittal plane. The lordotic cervical & lumbar curves are the secondary curves.

5. LUMBAR SPINE

6. ANATOMY OF LUMBAR SPINE

7. INTERVERTEBRAL DISC

8. Intervertebral foramen

9. Intervertebral Disc Is a hydrostatic, load bearing structure between the vertebral bodies from C2-3 to L5-S1. 1/6 th of vertebral column Nucleus pulposus + annulus fibrosus . Is relatively avascular . L4-5, largest avascular structure in the body.

10. Vital Functions of the IVD Restricted intervertebral joint motion Contribution to stability Resistence to axial, rotational, and bending load Preservation of anatomic relationship.

11. Biochemical Composition Water : 65 ~ 90% wet wt. Collagen : 15 ~ 65% dry wt. Proteoglycan : 10 ~ 60% dry wt. Other matrix protein : 15 ~ 45% dry wt.

12. Annulus Fibrosus Outer boundary of the disc. Helicoid pattern, more than 60 distinct concentric layer of overlapping lamellae of type I collagen. Resist tensile, torsional and radial stress Attached to the cartilaginous and bony end-plate at the periphery of the vertebra.

13. Nucleus Pulposus Type II collagen strand + hydrophilic proteoglycan . Water content 70 ~ 90% Confined fluid within the annulus. Convert load into tensile strain on the annular fibers and vertebral end-plate.

14. Intervertebral Disc

15. Disc Nutrition Nutrition depends on diffusion from adjacent vertebral body through porous central concavity of vertebral column

16. Diurnal Change During day time- disc shrinks by 20% Body height reduced by 15 – 25 mm In night- body height is increased.

17. Natural disc ageing: Degeneration starts as early as at 16 years of age Loss of the proteoglycan molecule from the nucleus of the disc. Progressive dehydration. Progressive thickening. Brown pigmentation formation. Increased brittleness of the tissue of the disc.

18. Factors Contributing To Disc Ageing Idiopathic Blood Vessel/Nutrient Loss And Dehydration/Decreased Proteoglycans Production Vertebral end plate calcification Arterial stenosis Smoking DM Exposure to vibration

19. Disc pressure Normal intra- discal pressure: 10-15 kg/cm 2 (Sitting) In lying: Pressure decreases by 50% than sitting In standing : < 30% Of sitting.

20. Is a medical condition affecting lumbar spine, in which a tear in the outer fibrous ring (annulus fibrosus ) of an intervertebral disc that allows the soft, central portion (nucleus pulposus ) to bulge out beyond the damaged outer rings Prolapsed Lumbar Intervertebral Disc (PLID)

21. This tear may result in the release of inflammatory chemical mediators which cause severe pain, even in the absence of nerve root compression. Disc herniations are a condition in which the outermost layers of the annulus fibrosus are still intact, but can bulge when the disc is under pressure.

22. NORMAL DISC HERNIATED DISC

23. Types of herniation Posterolateral disc herniation Central (posterior) herniation Lateral disc herniation

24. Disc prolapse ( lumbagosciatica )

25. Epidemiology Disc herniation can occur in any disc Two most common forms are lumbar and cervical disc herniation . The former is the most common, causing lower back pain (lumbago) and often leg pain as well (sciatica).

26. Epidemiology Lumbar disc herniation occurs 15 times more often than cervical disc herniation . Most disc herniations occur in thirties or forties when the nucleus pulposus is still a gelatin-like substance. With age the nucleus pulposus changes ("dries out") and the risk of herniation is greatly reduced Mostly at L4/5 level.

27. Epidemiology After age 50 or 60, osteoarthritic degeneration ( spondylosis ) or spinal stenosis are more likely causes of low back pain or leg pain. Of all individuals, 60% to 80% experience back pain during their lifetime. Generally, males have a slightly higher incidence than females.

28. Causes of PLID Unaccustomed work Bad posture Over weight Heavy weight lifting Prolong standing /sitting Pregnancy Strenuous activity ( sneezing , coughing, chronic Constipation)

29. ETIOLOGY

30. 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

31. History Age : 20-45 yrs Pain starts while lifting/forward bending. Radiation :towards buttock ,lower limbs. It is worsen by coughing or straining. Later paraesthesia /numbness in legs/feet . Cauda equina : urinary retention & perineal numbness. Muscle Weakness

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

33. Clinical Features Vary depending on the location of the herniation and the types of soft tissue that become involved. Often herniated discs are not diagnosed immediately, as the patients come with undefined pains in the thighs, knees, or feet.

34. Clinical Features Unlike a pulsating pain by muscle spasm, pain from a herniated disc is usually continuous or at least is continuous in a specific position of the body. If the disc protrudes to one side, it may irritate the dural covering of the adjacent nerve root causing pain in the buttock, posterior thigh and calf (sciatica).

35. Clinical Features Neurological changes such as numbness, tingling, muscular weakness, paralysis, paresthesia , and affection of reflexes. A large central rupture may cause compression of the cauda equina . Sometimes a local inflammatory response with oedema aggravates the symptoms

36. Clinical Features A posterolateral rupture presses on the nerve root proximal to its point of exit through the intervertebral foramen; thus a herniation at L4/5 will compress the fifth lumbar nerve root, and a herniation at L5/S1, the first sacral root.

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

38. Features Of Cauda Equina Syndrome Bladder and bowel incontinence. Perineal numbness. Bilateral sciatica . Lower limb weakness. Crossed straight-leg raising sign .

39. Physical Examinations Straight Leg Raise Test The straight leg raise test is positive if pain in the sciatic distribution is reproduced between 30° and 70° passive flexion of the straight leg. Dorsiflexion of the foot exacerbates the pain

40. Physical Examinations Root Tension Signs Straight-leg raising : L5, S1 root. Contralateral SLR : sequestrated or extruded disc. Femoral stretching, reverse SLR : L3, L4 root.

41. Physical Examinations Fever – possible infection. Vertebral tenderness - not specific and not reproducible between examiners. Limited spinal mobility – not specific. If sciatica or pseudoclaudication present – do straight leg raise.

42. Physical Examinations Positive test reproduces the symptoms of sciatica. Ipsilateral test sensitive – not specific: crossed leg is insensitive but highly specific.

43. Diagnosis Examination in a patient with suspected lumbar ( intervertebral ) disk disease may feature the following: Abnormal gait Abnormal postures Decreased lumbar range of motion Positive straight leg raising test: Indicative of nerve root involvement

44. Diagnosis Usually negative nerve root stretch test results Perform the usual motor, sensory, and reflex examinations (including perianal sensation and anal sphincter tone when appropriate). It is also mandatory to perform a careful abdominal and vascular examination .

45. Differential diagnosis Of PLID Mechanical Pain Discogenic Pain Myofascial Pain Spondylosis / spondylolisthesis Spinal stenosis Abscess Hematoma Discitis / osteomyelitis Mass lesion/malignancy Myocardial infarction Aortic dissection

46. Investigations Laboratory tests are generally not helpful in the diagnosis of lumbar disk disease. Indications for screening laboratory tests such as the following include pain of a non mechanical nature, atypical pain pattern, persistent symptoms, and age older than 50 years .

47. Investigations Complete blood count with differential Erythrocyte sedimentation rate Alkaline and acid phosphatase levels Serum calcium level Serum protein electrophoresis

48. Imaging studies Plain radiograph MRI: Imaging modality of choice CT scanning Myelography : Dynamic L/S spine X-ray . : to rule out the instability . Bone scanning: To rule out tumors, trauma, or infection

49. Imaging studies X-Ray : lumbo -sacral spine Loss of lumber lordosis Narrowed disc spaces CT scan : lumber spine Shape and size of the spinal canal Its contents and the structures around it

50. Imaging studies Myelogram pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurs MRI : lumbar spine Intervertebral disc protrusion Bulging out disc Compression of nerve root

51. X-ray findings

52. MRI findings Normal central Right Left

53. Treatment options Conservative & Surgery

54. Conservative Non-steroidal anti-inflammatory drugs (NSAIDs) Patient education on proper body mechanics Oral steroids Physical therapy (i.e. traction, electrical stimulation massage

55. Conservative Anti-depressants Lumbosacral back support Tobacco cessation Weight control Intravenous sedation, analgesia-assisted traction therapy (IVSAAT) Epidural cortisone injection.

56. Epidural Steroid Injection (ESI) The ESI is usually reserved for more severe pain due to a herniated disc. It is not usually suggested if surgery is indicated The ESI is probably only successful in reducing the pain in about half the cases that it is used.

57. Indications Of Surgery Cauda equina syndrome Progressive neurologic deficit Profound neurologic deficit and Severe and disabling pain refractory to four to six weeks of conservative treatment .

58. The objectives of surgery Relief of nerve compression. Allowing the nerve to recover. Relief of associated back pain. Restoration of normal function

59. Surgical Options Discectomy / Microdiscectom : This procedure is used to remove part of an intervertebral disc that is compressing the spinal cord or a nerve root.

60. Surgical Options The Tessys method: The Tessys method ( transforaminal endoscopic surgical system) is a minimally invasive surgical procedure to remove herniated discs .

61. Surgical Options Laminectomy : To relieve spinal stenosis or nerve compression

62. Surgical Options Hemilaminectomy : Hemilaminectomy is surgery to help alleviate the symptoms of an impinged or irritated nerve root in the spine

63. Surgical Options Chemonucleolysis : Chemical destruction of nucleus pulposus . Intradiscal injection ofchymopapain , causes hydrolysis of protein of the nucleus pulposus . Indicated in disc herniation not responding to conservative therapy

64. Surgical Options Intradiscal electrothermic therapy (IDET) : The procedure works by cauterizing the nerve endings within the disc wall to help block the pain signals. IDET is a minimally invasive outpatient surgical procedure developed over the last few years

65. Surgical Options Lumbar fusion : 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

66. Surgical Options Disc arthroplasty : Artificial Disc Replacement (ADR) or Total Disc Replacement (TDR) is a type of arthroplasty . Degenerated intervertebral discs in the spinal column are replaced with artificial devices in the lumbar (lower) or cervical

67. Surgical Options Dynamic stabilization: Dynamic stabilization is a surgical technique designed to allow for some movement of the spine while maintaining enough stability to prevent too much movement.

68. Surgical Options Nucleoplasty : The most advanced form of percutaneous discectomy developed to date. Tissue removal from the nucleus acts to “decompress” the disc and relieve the pressure exerted by the disc on the nearby nerve root . As pressure is relieved the pain is reduced

69. Future treatment (stem cell therapy) Substantial progress has been made in the field of stem cell regeneration of the intervertebral disc. Autogenic mesenchymal stem cells in animal models can arrest intervertebral disc degeneration or even partially regenerate it and the effect is suggested to be dependent on the severity of the degeneration.

70. Persistent pain after disc surgery ? Wrong disc surgery Recurrent disc Prolapse Double root in same space Spare of root in a space Segmental instabilty Incomplete removal of disc Injury to root ( Iatrogenic )

71. PLID ….? Is a medical condition affecting lumbar spine due to trauma, lifting injuries, or idiopathic, in which a tear in the outer fibrous ring (annulus fibrosus ) of an intervertebral disc that allows the soft, central portion (nucleus pulposus ) to bulge out beyond the damaged outer rings