Disc prolapse and degenerative changes

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  • i have a prolapse of the L3 to S1 only did this 6 mouths ago at work and it is still painful i don't yet know my long term outlook as i am still going to get MRI and just trying to work out how bad it is i have pain down the back of my left leg and over the top of my hips i have found that i can not sit stand or lay down for to long
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  • 2. Intervertebral DiscsIntervertebral Discs  Gel like Tissue betweenGel like Tissue between each vertebraeach vertebra  fibro cartilaginousfibro cartilaginous cushionscushions  serve as the spine's shockserve as the spine's shock absorbing systemabsorbing system  protect the vertebrae, brain,protect the vertebrae, brain, and other structuresand other structures  The discs allow someThe discs allow some vertebral motion extensionvertebral motion extension and flexion.and flexion.
  • 3. Intervertebral DiscsIntervertebral Discs  The disc is made up ofThe disc is made up of 3 structures the3 structures the  (1) Nucleus pulposus,(1) Nucleus pulposus, gelatinous centergelatinous center  (2) Annulus Fibrosus.(2) Annulus Fibrosus. Its job is to contain theIts job is to contain the nucleusnucleus  (3) Vertebral end plates(3) Vertebral end plates that attach the disc tothat attach the disc to the vertebraethe vertebrae
  • 4.  Process of wear and tear of intervertebral discs, vertebral bodies, and facet joints is called spondylosis  Commonest cause of entrapment spinal neuropathy  Usual age group >60 yrs  Usually asymptomatic
  • 5. DISC PROLAPSE  Extrusion of nucleus pulposus through posterior or posteriolateral radial tear in annulus fibrosis
  • 6. TYPES Focal herniation is a herniated disc less than 90° of the disc circumference. Broadbased herniation is a herniated disc in between 90°-180° of the disc circumference. Bulging Disc is the presence of disc tissue 'circumferentially' (180°-360°) beyond the edges of the ring apophyses and is not considered a form of herniation
  • 7.  AXIAL LOCALISATION OF HERNIATED DISCS  Central or medial posterior longitudinal ligament is thickest in this region,disc usually herniates slightly to the left or right of this central zone.  Paramedian or lateral recess PLL is not as thick in this region, this is common region for disc herniations.  Foraminal or subarticular It is rare for a disc to herniate into the intervertebral foramen. 'Dorsal Root Ganglion' lies in this zone resulting in severe pain, sciatica and nerve cell damage.  Extraforaminal or lateral Disc herniations in this region are uncommon.
  • 8. IMAGING for disc prolapse CT SCAN Disc material is denser than CSF in thecal sac…… so clearly seen against epidural fat BUT, very large extrusion may be missed.
  • 9. MRI Extruded fragments brighter on T2 Enhance after contrast Sometimes heavily calcified More reliable in cervical spine where there is less epidural fat
  • 10. X-RAYS Non specific findings Reduction of disc space or vertebral mal alignment or normal
  • 11. Axial T1-weighted image shows protrusion of a left paracentral disc with compression of left S1 root
  • 12. Axial T2-weighted image shows protraction of a left paracentral disc with compression of left S1 root
  • 13. CT axial.L3,4 disc space. Soft tissue mass in R. posterolateral aspect of disc encroaching into intervertebral foramen and extending lateral to it.arrow…L3 N
  • 14. T1W axial. L4,5 disc, disc fragment extends behind upper part of right side of body of sacrum. Displacing 1st sacral nerve root post and erodes sacral body.
  • 15. L5/S1 disc space.low signal mass protruding posteriorly and to the right from the posterior disc margin.This causes only minor compresion on the anterior margin of the theca (the bright, CSF containing sac in the spinal canal). The nerve roots within the theca are visible around its posterolateral margins and are not affected. However the neural foramen on the right is obliterated - compare with the other side where the higher signal fat, and the lower signal S1 nerve root are clearly seen
  • 16. Sagittal T2 weighted MRI images of 49-year male with history of radiculopathy. a. Pre-op image showing disc prolapse at C5/6 level. b,c,d are post-op images
  • 17. MRI of a patient showing disc prolapse between L5 and S1 vertebra
  • 18. DEGENERATIVE CHANGES  osteophytosis & marginal sclerosis  Mostly in lower cervical and lumbar region  reactive changes  Degeneration in ligaments  ossification  calcification
  • 19.  these changes occur in  post. longitudinal ligament  cruciform ligament  ligamenta flava  capsular ligament of facet joints
  • 20.  Also include  Ossification of post. long. Ligament  Retro-odontoid pseudotumor  Ossification of ligamentum flavum  Synovial cysts
  • 21. degenerative changes are seen in  Ochronosis  Charcot spine  Ankylosing spondylitis  Rheumatoid arthritis  Isolated phenomenon
  • 22. X-RAYS most of the features of degeneration can be seen If, sagittal diameter of spinal canal in cervical region <10mm…..spinal cord compressed
  • 23. CT SCAN / MRI Deformation of spinal & intervertebral canals…CT / MRI Better visualization of neural structures… MRI Differentiation from infection….MRI… absent/ non-uniform high signal, irregularity/fragmentation.
  • 24. Sagittal T2W contrast.ossification of post. Longitudnal ligament
  • 25. SPINAL STENOSIS Most common in  Achondroplasia  Acromegaly
  • 26. CT / MRI Spinal canal is very narrow Cross-sectional area less than 110mm² No CSF signal on T2 weighted image Reduntant coiling of intradural roots above stenosis…on MRI… entrapment of cauda equina
  • 27. Sagittal T2W ,with contrast. Stenosis of spinal canal at L4,5. no CSF signal at stenosis
  • 28. POST-OPERATIVE CHANGES  Post-op recurrent myelopathy / radiculopathy  2 types  Discogenic  Reactive
  • 29.  CT / MRI  Discogenic  Typical mass continuous with disc substance  Reactive  Contracting lesion standing around theca / nerve root, continuing into soft tissue.
  • 30.  T2W, disc higher signal than scar  Recent scar enhances faster, old scar less and slowly.