HISTORY Aurelianus (5th century) clearly described thesymptoms of SCIATICA. Andreas Vesalius (1543) first described theintervertebral disc. Middleton & Teacher (1911) described a case ofparaplegia following attempting to lift heavy weight fromfloor on postmortem they found fibrocartilage in extraduralspace. Elseberg (1928) described Chondromas derived fromdisc of cervical region.
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.
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.
LUMBAR DISC PROLAPSEDEFINITION 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.
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
WHY DISC PROLAPSE IS MOSTCOMMON POSTEROLATERALLY?
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
PATHOPHYSIOLOGY OF LUMBARINTERVERTEBRAL 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
Facet joints undergoANNULUS Facet joints share degenerative IN TACT even more of the changes & develop axial load osteophytes FACET JOINT SYNDROME
KEY DIAGNOSTIC POINTSLUMBAR DISC PROLAPSE Leg pain greater than back pain Neurological deficit presentANNULAR TEARS Back pain greater than leg pain Bilateral SLRT positiveFACET JOINT ARTHROPATHY Localized tenderness present unilaterally over joint Pain occurs immediately on spinal extension Pain exacerbated with ipsilateral side bending
SPINAL STENOSIS Back and/or leg pain develops after walks a limited distance. Flexion relieves symptoms No neurological deficit Pain not reproduced on SLRTMYOGENIC 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
INVESTIGATION THE CORNERSTONE OF DIAGNOSIS OFLUMBAR DISC DISEASE IS THE HISTORY AND PHYSICAL EXAMINATION NOT THE INVESTIGTION.
PLAIN RADIOGRAPH OSTEOPHYTE DECREASED DISC SPACE
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
CT DISCOGRAPHYUSES• 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.
COMPUTED TOMOGRAPHYADVANTAGES• 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.
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.
MAGNETIC RESONANCE IMAGING• It allows direct visualization of herniated disc material and its relationship to neural tissue including intrathecal contents.
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.
OTHER DIAGNOSTIC TESTS• ELECTROMYOGRAPHY – to rule out peripheral neuropathy.• SOMATOSENSORY EVOKED POTENTIALS (SSEP) – to identify the level of root involvement• POSITRON EMISSION TOMOGRAPHY
EXERCISESGENERAL 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.
CHEMONUCLEOLYSIS Chymopapain Degrades the Water holdinginjected into the proteoglycans in the capacity of the disc disc nucleus is decreased Shrinkage of the disc
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
SURGERYGOAL To relive neural compression and henceradiculopathy while minimizing complications.
INDICATIONSABSOLUTE• Bladder and bowel involvement: The cauda equine syndrome• Increasing neurological deficitRELATIVE• Failure of conservative treatment• Recurrent sciatica• Significant neurological deficit with significant SLR reduction• Disc rupture into a stenotic canal• Recurrent neurological deficit
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
COMPLICATIONS OFLAMINECTOMY 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
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
COMMON CAUSES – Neuritis, Referred pain from nonspinous siteUNCOMMON CAUSES• Discitis / Osteomyelitis/ Epidural abscess• Arachnoiditis• Conus tumour• Thoracic, High lumbar Herniated Nucleus Pulposus• Epidural haematoma
The recurrence of pain after disc surgeryshould be treated with all availableconservative treatment modalities initially. The surgery should be tailored to theanatomic problem only.
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.
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.
REFERENCES• MACNAB’S BACKACHE by DavidA.Wong 4th edition• THE LUMBAR SPINE by Sam W Wiesel 2nd edition• MANAGING LOW BACK PAIN by W.H.Kirkildy – Willis 3rd edition• ORTHOPAEDIC PHYSICAL ASSESSMENT by David Magee 5th edition• ORTHOPAEDIC PRINCIPLE AND THEIR APPLICATION by TUREK 4TH Edition• CAMPBELL’S OPERATIVE ORTHOPAEDICS 11TH EDITION• INTERNET
“LEARN TO BE GOOD TO YOUR BACK AND YOURBACK WILL BE GOOD TO YOU….”