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Lumbar disc prolapse


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  • 2. HISTORY  Aurelianus(5th century) clearly described the symptoms of SCIATICA.  Andreas Vesalius (1543) first described the intervertebral disc.  Forst(1811) described the Lasegue sign. He attributed it to Lasegue, his teacher.  Virchow (1857), Kocher (1896) described acute traumatic rupture of the intervertebral disc that resulted in death.  Contugino(18th century) attributed the leg pain to the sciatic nerve.  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.  Stookey(1928) described cartilaginous compression thought as chondromas responsible for clinical prersentation.  Schmorl (1928) described Schmorl nodes.  Dandy (1929) reported removal of a disc tumour or chondroma from patients with sciatica.  Arnell&Lidstorm (1931) first used water soluble contrast medium.  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. ANATOMY OF LUMBAR SPINE There are five lumbar vertebrae making up the lumbar spine. Each vertebra has three functionalcomponents: the vertebral bodies, designed to bear weight; the neural arches, designed to protect theneural elements; and the bony processes (spinous and transverse), designed as out-triggers to increasethe efficiency of muscle action. The vertebral bodies are connected together by the intervertebral discs, and the neural arches arejoined by the facet (zygapophyseal) joints. The discal surface of an adult vertebral body demonstrateson its periphery a ring of cortical bone. This ring, the epiphysial ring, acts as a growth zone in theyoung and in the adult as an anchoring ring for the attachment of the fibers of the annulus. The hyaline cartilage plate lies within the confines of this ring. The size of the vertebral bodyincreases from L1 to L5, which is indicative of the increasing loads that each lower lumbar vertebrallevel has to absorb. The neural arch is composed of two pedicles and two laminae. The pedicles are anchored to thecephalad half of the vertebral body and form a protective cover for the caudaequina contents of thelumbar spinal canal. The ligamentum flavum (yellow ligament) fills in the interlaminar space at eachlevel. The outriggers for muscle attachment are the transverse processes and spinous process. 2
  • 3. THE INTERVERTEBRAL DISC The intervertebral disc consists of outer fibrous annulus, containing inner gelatinous nucleus pulposus. ANNULUS FIBROSUS The fibers of the annulus can be divided into three main groups: the outermost fibers attaching between the vertebral bodies and the undersurface of the epiphyseal ring; the middle fibers passing from the epiphyseal ring on one vertebral body to the epiphyseal ring of the vertebral body below; and the innermost fibers passing from one cartilage end-plate to the other.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 middlefibers of the annulus are most numerous anteriorly and laterally but are deficient posteriorly, wheremost of the fibers are attached to the cartilage plate. The fibers of the annulus are firmly attached to the vertebral bodies and arranged in lamellae, with the fibers of one layer running at an angle to those of the deeper layer. This anatomic arrangement permits the annulus to limit vertebral movements. This important function is reinforced by the investing vertebral ligaments. NUCLEUS PULPOSUS The nucleus pulposus is gelatinous, the load of axial compression is distributed not only vertically but also radially throughout the nucleus. This radial distribution of the vertical load (tangential loading of the disc) is absorbed by the fibers of the annulus. Weight is transmitted to the nucleus through the hyaline cartilage plate. The hyaline cartilage is ideally suitedto this function because it is avascular. If weight were transmitted through a vascularized structure, such asbone, the local pressure would shut off blood supply, and progressive areas of bone would die. Thisphenomenon is seen when the cartilage plate presents congenital defects and the nucleus is in direct contact 3
  • 4. with the spongiosa of bone. The pressure occludes the blood supply, a small zone of bone dies, and the nucleusprogressively intrudes into the vertebral body this is known as SCHMORL’S NODE.COMPOSITION The nucleus consists of approximately 85% water, 10 to 20% of collagen and abundant amount ofproteoglycans. The annulus fibrosus contains 78% of water, 60 to 70% of collagen. The collagen prevent theproteoglycans imbibing water and swell up. Thus collagen gives tensile property to the tissue and proteoglycangives compressive stiffness.FUNCTIONSThe nucleus pulposus acts like a ball bearing, and in flexion and extension the vertebral bodies roll over thisincompressible gel while the posterior joints guide and steady the movements. The annulus acts like a coiledspring, pulling the vertebral bodies together against the elastic resistance of the nucleus pulposus.NUTRITION TO THE DISC The intervertebral discs of a person up to the age of 8 years have a blood supply, but thereafter they aredependent for their nutrition on diffusion of tissue fluids. This fluid transfer is through two routes: (a) thebidirectional flow from vertebral body to disc and from disc to vertebral body and (b) the diffusion through theannulus from blood vessels on its surface. This ability to transfer fluid from the disc to the adjacent vertebralbodies minimizes the rise in intradiscal pressure on sudden compression loading. This fluid transfer acts like asafety valve and protects the disc.THE FACET JOINTSThe facet (zygapophyseal) joints are synovial joints that permit simple gliding movements. These arelike miniature KNEE JOINT. The lax capsule of the zygapophyseal joints is reinforced to some extentby the ligamentum flavum anteriorly and the supraspinous ligament posteriorly, the major structuresrestraining movement in these joints are the outermost fibers of the annulus. When these annular fibersexhibit degenerative changes, excessive joint play is permitted due to this degenerative changes withinthe discs render the related posterior joints vulnerable to strain.THE LIGAMENTS The strongest ligaments in the spine are the anterior longitudinal ligament and the facet joint capsules.The interspinous-supraspinous ligament complex is of intermediate strength, and weakest of all is the posteriorlongitudinal ligament. Anterior longitudinal ligament (ALL) runs the length of the anterior aspect of the spine. It is intimately attached to the anterior annular fibers of each disc and is a fairly strong ligament useful in fracture reduction. Posterior longitudinal ligament (PLL). is the posterior mate to the anterior longitudinal ligament. It is a significant ligament in all areas of the spine except the lower lumbar region 4
  • 5. where it is flimsy and inconsequential thus lumbar disc problems are most common in this region. Interspinous/supraspinous ligament complex helps in flexion of lumbar spine. Ligamentum flavum (the yellow ligament). This ligament is so named because of the yellowish color that is given to it by the high content of the elastin fibers. The ligamentum flavum bridges the interlaminar interval, attaching to the interspinous ligament medially and the facet capsule laterally. It has a broad attachment to the undersurface of the superior lamina and inserts onto the leading edge of the inferior lamina at each segment. Normally, the ligamentum maintains a taut configuration, stretching for flexion and contracting its elastin fibers in neutral or extension. In this way, it always covers but never infringes on the epidural space. With aging, the ligamentum flavum loses its elastin fibers and the collagen hypertrophies, which results in buckling of the ligamentum flavum and encroachment on the thecal sac, potentially contributing to spinal stenosis.MOTION SEGMENT Basic functional unit of spine is MOTION SEGMENT. It includes two adjacent vertebral bodies and intervening soft tissues. It is controlled actively by muscles and passively by ligaments. Disc is protected from both torsional and compressive loads when motion segment in extension. MOTION SEGMENT ANTERIOR ELEMENTS POSTERIOR ELEMENTS It includes vertebral body, It includes pedicles, facet disc, anterior & posterior joints, posterior ligamentous longitudinal ligaments. & muscular attachment. Provides stability & Shock Control the spinal absorption movementsHOW TO KNOW WHICH NERVE ROOT INVOLVED IN CASE OF DISC PROLAPSE? For example the fifth lumbar nerve root passes beneath the fifth lumbar pedicle and is also described as the exiting nerve root at the L5-S1 segment. Proximal to this, the L5 root passes across the L4-5 disc L5 is TRAVERSING space. The L5 nerve root is the traversing root at the NERVE ROOT L4-5 disc space, where it can be encroached on by an L4-5 disc herniation in the common posterolateral position. Distal to the L5 pedicle, the fifth lumbar nerve L5 is EXITING root lies just lateral to the L5-S1 disc space, and a NERVE ROOT lateral disc herniation at L5-S1 can encroach on the fifth lumbar nerve root at this level. 5
  • 6. BIOMECHANICS OF LUMBAR SPINELOAD BEARING In axial compression load, there will be increase in intradiscal pressure which will be counteracted byannular fibre tension and disc bulge.In axial rotation of lumbar spine, Torsion of disc Annular fibres in one direction are stretched significantly and opposite sideshortened stress concentration at region of postero-lateral annulus Fissures in postero-lateralannulus Torsion of vertebral body segment cause only peripheral circumferential tear in annular fibres after damageto the posterior joints. But only lateral bending and flexion will cause acute rupture of lumbar intervertebraldisc.THREE JOINT COMPLEX It includes intervertebral disc & Facet joints. It has load bearing function. Facet joints and disc normallyresist 80% of torsion. 25% of axial compression load transmitted through the facet joints when the person isstanding and the facet joints share 0% axial load on the spine in sitting. The primary function of the facet jointsis to protect the disc from shear and rotational forces.BIOMECHANICS OF LIGAMENTS The ligaments of the lumbar spine act like rubber bands. They have an elastic physical property that allowsthe ligament to stretch and resist tensile forces. Under compression, the ligaments buckle and serve littlefunction. In resisting tensile forces, ligaments allow just enough movement without injury to vital structures.Passively, they maintain tension in a segment so that muscles do not have to work as hard.ROLE OF ABDOMINAL CAVITY Abdominal cavity and its surrounding muscles stabilize the spine for activities such as lifting.INTRADISCAL PRESSURE The final determining factor in biomechanical injury to spine is the INTRADISCAL PRESSURE.IN RELATION TO POSTUREDisc pressure is higher in sitting without support than standingWith use of backrest with inclination of about 1200, arm rest and lumbar support of about 5cm reducesdeformation of lumbar spine and decreases disc pressure. 6
  • 7. In recumbent position on firm bedding surface with flexion at hip and knee, Decrease stress on spine due to relaxation of spinal musculature Decrease the stress on facet joints by decreasing lumbar lordosis.IN RELATION TO MANUAL MATERIALS HANDLINGLifting heavy weight with back stooped and legs straight more stressful than back straight lifting with legsbecause Shear forces are greater when lifting with back flexed Articular facet capsules and posterior ligament are overstrained in flexed posture.Heavy load held close to the body is much less hazardous to back than one lifted further away from the body.DO & DONTS 7
  • 8. LUMBAR DISC PROLAPSESYNONYMS: Herniated disc, Prolapsed disc, Sequestrated disc, Soft disc, Slipped disc, Protruding disc, Bulgingdisc, Ruptured disc, Extruded disc, Disc.DEFINITION It is condition in which there is outpouching of the disc. Nucleus pulposus along with few annular fibresand end plate cartilage through the tears in annulus fibrosus into the extradural space.EPIDEMIOLOGYAGE: 30 – 40 yearsSEX: Male affected more than femaleMOST COMMON LEVEL: L4-L5 (next common level is L5-S1)MOST COMMON TYPE: Postero-lateral typeWHY 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.  Fibres of annulus were deficient posteriorly.  Posterior fibres are only weakly reinforced by posterior longitudinal ligament especially L4-5 and L5-S1 where it is midline, narrow, unimportant structure attached to annulus.ETIOLOGY Congenital/ Developmental – Biochemical and structural abnormality in one or more disc Repetitive microtrauma Accumulated macrotrauma – Sports / Automobile injury Poor nutrition Poor Health habits – Lack of exercise, smoking Biomechanical factors – Rotational torsional stress, flexion and compression injury Poor posture habits – sitting and bending forwards, lifting heavy weight bending back Autoimmune inflammatory reaction Biochemical changes – In inner annulus and nucleus initiate/ potentiate the degradation of DISC MATERIAL and predispose to herniation because of thinning or weakening of annulus. PhospholipaseA2 and arachidonic acid are suspected 8
  • 9. NATURAL HISTORY OF DISC DEGENERATION The three stages of disc degeneration are:  Stage of dysfunction  Stage of instability  Stage of stabilization STAGE OF DYSFUNCTIONEpisode of rotational or compressive Posterior facet joint Small capsular &trauma (uncoordinated muscle & annular strain annular tear occurscontraction) Small subluxation of posterior joint Muscle splint the Posterior segment Posterior joint Muscle become ischaemic posterior joint muscle protect joint by synovium injured & & metabolites get subluxation sustained hypertonic result in SYNOVITIS accumulated cause pain maintained contraction STAGE OF INSTABILITY FACET Degeneration Attenuation Laxity of capsule JOINT of cartilage of capsuleIncreased INCREASEDdysfunction ABNORMAL MOVEMENT Coalescence Loss of nucleus Bulging of DISC internal disruption annulus of tears STAGE OF STABILIZATION Destruction Fibrosis Enlargement Locking facets FibrosisFACET JOINT of cartilage in joint of facets around joint INCREASED Loss of Approximation Destruction Fibrosis in disc STIFFNESS DISC nucleus of bodies of plates & osteophytes STABILIZATION 9
  • 10. 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 ANNULUS ANNULUS INTACT FAILS Facet joints share even Fissures develop across annular more of the axial load lamellae may extend upto disc periphery Facet joints undergo Internal disc disruption cause degenerative changes & AXIAL PAIN develop osteophytes Expression of this degradedFACET JOINT SYNDROME nuclear material through these radial fissures DISC 10 HERNIATION
  • 11. FATE OF DISC HERNIATION Nucleus pulposus is anExtrude disc & degraded immunogenic which induce an Produces radicular painnuclear material impinge inflammatory response mediated syndrome &on the nerve roots by TNF alpha, IL, Phospholipase RADICULOPATHY A2, Ntric oxide. Extruded disc, Large herniations, Sequestrations have a greater tendency to resolution than small herniations & disc bulges. WHAT IS RADICULOPATHY? Radiculopathy means the presence of objective signs of NEURAL DYSFUNCTION including motor weakness, sensory loss/ paresthesias or diminished deep tendon reflexes. It is typically accompanied by radiating limb pain which is intermittent, lanciating, electric or burning. TYPES OF DISC PROLAPSE Based on the intactness of annulus fibrosus CONTAINED (intact NON CONTAINED annular fibres) (disruption of annular fibres) PROTRUSION SUBANNULAR TRANSANNULAR SEQUESTERED EXTRUSION EXTRUSION AREA OF THE DISC SHAPE OF THE DISC AXIAL LOCATION SAGITTAL LOCATION Extrusion Central Discal <25% Focal Protrusion R/L Central Pedicular 25-50% Broad based protrusion R/L Subarticular Infrapedicular R/L Foraminal Suprapedicular R/L Extraforaminal 11
  • 12. AXIAL LOCATION SAGITTAL LOCATIONCLINICAL FEATURES STAGE OF DEGENERATIVE STAGE OF DYSFUNCTION STAGE OF INSTABILITY STAGE OF DISEASE OF DISC STABILIZATION - Low back pain often - Catch in back on movement. - Low back pain localized or referred to - Pain on coming to standing decrease in severity groin/ greater trochanter/ position after flexion. posterior thigh SYMPTOMS - Aggravated on movement - Relieved on rest - Local tenderness on one -Abnormal movement of spine - Muscle tenderness side & at one level - Observation of catch - Stiffness -Hypomobility sway or shift when coming erect - Reduced - Muscle activity abnormality after flexion movements SIGNS - Extension painful -Reversal spinal rhythm - Scoliosis - Neurological examination normal -Abnormal movement AP VIEW - Enlarged facets - Spinous process not rotate -Lateral shift - Loss of disc height to the side of bend - Rotation - Osteophytes - On lateral bending disc - Abnormal tilt - Small foramina height on concave side not - Malaligned spinous process - Reduced movementRADIOLOGICAL reduced OBLIQUE VIEW - Scoliosis - Irregularity of posterior -Opening of facets CHANGES facets LATERAL VIEW - Small osteophyte on -Spondylolisthesis on flexion anterior surface vertebral -Retrospondylolisthesis on body extension - Slightly decreased disc -Narrowing of foramen on height extension -Abnormal opening of disc -Abrupt change in pedicle height 12
  • 13. CLINICAL FEATURES OF LUMBAR DISC PROLAPSENERVE ROOT L1 L2 L3 L4 L5 S1COMPRESSEDLEVEL OF DISC T12 – L1 L1 – L2 L2 - L3 L3 – L4 L4 – L5 L5 – S1PROLAPSEPAIN Thoraco lumbar Thoraco Upper lumbar Lower back, Sacroiliac joint, Sacroiliac joint, junction, groin, lumbar spine, anterior hip, postero hip, lateral hip, postero proximal part of junction, groin, aspect of lateral thigh, thigh & laterallateral thigh & thigh proximal part proximal thigh anterior leg leg postero lateral of thigh leg to heelPARESTHESIA Oblique band Oblique band Oblique band Medial to shin Lateral leg, Posterior aspect proximal 3 of mid 3rd of thigh rd lower part of of tibia, dorsum of foot, of thigh, back of thigh anteriorly anteriorly thigh anteriorly medial aspect 1st web space calf, lateral side just below just above the of the foot and sole of foot inguinal knee ligamentMUSCLE Iliopsoas (Hip Iliopsoas (Hip Iliopsoas (Hip TIBIALIS EXTENSOR PERONEUSAFFECTED flexion) flexion), flexion), ANTERIOR HALLUCIS LONGUS &MAINLY Quadriceps Quadriceps (Foot LONGUS BREVIS (Foot (Knee (Knee inversion), (Dorsiflexion of eversion), extension), extension), Quadriceps great toe), Flexor hallucis adductor adductor (Knee Extensor longus (Plantar brevis, longus, brevis, longus, extension), digitorum flexion of great magnus (Hip magnus (Hip adductor longus & brevis toe), Flexor adduction) adduction) brevis, longus, (Dorsiflexion of digitorum magnus (Hip foot), Gluteus longus & brevis 13
  • 14. adduction) medius (Hip (Plantar flexion abduction) of foot), Gastronemius, Soleus (Difficulty in walking on toes), Gluteus maximus (Hip extension)WEAKNESS Hip flexion Hip flexion, Hip flexion, Foot Dorsiflexion of Foot eversion, Knee Knee inversion, great toe & Plantar flexion extension, Hip extension, Hip Knee foot, Difficulty of great toe & adduction adduction extension, Hip in walking on foot, Difficulty adduction, heels, Hip in walking on Difficulty in abduction toes, Hip walking on extension heelsATROPHY - Quadriceps Quadriceps Quadriceps Minor Gastrocnemius, Soleus,REFLEXES - Knee jerk Knee jerk Knee jerk Changes Ankle jerk slightly slightly diminished or uncommon ( absent or diminished diminished absent Posterior tibial diminished reflex diminished or absent 14
  • 16. AGGRAVATING FACTORS Pain will aggravate on bending, stooping, lifting heavy weight, coughing, sneezing and straining at stool.RELIEVING FACTORS Pain relieved on lying in hip-knee flexed position, pillow under the knees or on the asymptomatic side infetal position. No position of comfort in case of high lumbar root lesions.PHYSICAL EXAMINATIONATTITUDE The lumbar spine is flattened and slightly flexed, hip and knee slightly flexed on the affected side and hip rotates forward to relax Piriformis GAIT – Slow and deliberate walk holding their loins with the hands. In gross nerve root tension, TIP-TOE WALK due to not able to put the heel to the floor.INSPECTION Deviation of spine to one side to take the nerve away from the prolapsed disc is called SCIATIC SCOLIOSIS which become more obvious on bending forwards. Deviation of spine depends on the type of disc prolapsed medial or lateral to nerve root, Trunk deviated to opposite side – SHOULDER TYPE (lateral) Trunk deviated to same side – AXILLARY TYPE (medial)The SCIATIC SCOLIOSIS disappears on recumbency. The loss of lateral curvature of the lumbar spine onrecumbency helps differentiates the sciatic scoliosis from fixed structural scoliosis in which there will be nochange in curvature of lumbar spine on recumbency.Loss of lumbar lordosis and paravertebral muscle spasm are seen in acute phase of the disease.PALPATIONOn applying lateral thrust to the spinous process may produce pain in the back at the affected level. 16
  • 17. Tenderness on the adjacent paraspinal region due to muscle spasm and tenderness at the point between theischial tuberosity and the greater trochanter, at the centre point of the posterior aspect of the thigh, just lateralto middle of the popliteal space, the middle of the calf and just behind the medial malleolus. Tender points inthe myotome corresponding to the probable segmental level of nerve root involvement.MOVEMENTSForward flexion and extension are restricted. But lateral flexion can be free and full to one side depends on theposition of the protrusion in relation to the nerve root .If the patient feel leg pain on extension it is indicative ofSEQUESTRATED OR EXTRUDED DISC.The cardinal signs of lumbar root compromise are ROOT TENSION, ROOT IRRITATION & ROOT COMPRESSIONTEST FOR ROOT TENSION AND ROOT IRRITATION These are the test which tighten the sciatic nerve and compress the inflamed nerve root against a herniatedlumbar disc.STRAIGHT LEG RAISING TEST PROCEDURE: Patient in supine position, there should be no compensatory lumbar lordosis. One of the examiner hand is placed over the knee firm pressure exerted to maintain knee in full extension and other hand of the examiner under the heel, the examiner slowly raises the leg until leg pain is produced. FINDING: If reproduction of pain before reaching 60 to 70 degree, aggravated by dorsiflexion of ankle (LASEGUE’S SIGN)and relieved by flexion of the knee IMPRESSION: Tension on the fifth lumbar or first sacral root. In patient in whom paresthesia in foot is predominant on repetitive SLR intensifies the sensation of numbness.BRAGGARD’S SIGN: After a SLRT is done the limb is slightly lowered and the foot is dorsiflexed. Stretching of thesciatic nerve will cause intense painSICCARD’S TEST: It involves SLR along with extension of the big toe.TURYN’S TEST: It involves only the extension of great toe.CONTRALATERAL STRAIGHT LEG RAISING TEST (FRAJERSZTAGN TEST)PROCEDURE: It is performed same manner as SLRT except that THE NON PAINFUL LEG is raised. 17
  • 18. FINDING: If patient develops reproduction of pain in opposite extremity then the test is positive.IMPRESSION: Positive test is very suggestive of HERNIATED DISC & also an indication of the location of extrusionusually disc lies medial to the nerve root in the axilla.Why reproduction of pain in affected limb occurs on elevation of the normal limb? On lifting the normal Nerve root on the Along with this right Produce limb (e.g) Left limb left will move side root brought pain over against herniated disc right buttockBOWSTRING SIGN It is most important indication of root tension or irritation. PROCEDURE: SLR is carried out until pain is reproduced at this level knee is slightly flexed until pain abates. Then examiner rests the limb on his or her shoulder and places the thumb in the poipliteal fossa over the sciatic nerve and sudden pressure applied on the nerve. FINDING: If patient developed pain in the back or down the leg test is positive IMPRESSION: Significant root tension and irritation of nerve root by ruptured discFEMORAL NERVE STRETCH TEST (REVERSE SLR TEST) PROCEDURE: Patient is placed in prone position and the knee is flexed and the hip is extended. FINDING: If the patient develops pain over unilateral thigh and which gets aggravated on further knee flexion indicates test is positive IMPRESSION: Tension on the 2nd, 3rd or 4th lumbar roots. LIMITATION: Difficult to assess in the presence of hip or knee pathologyLASEGUE’S TEST: Here the patient in supine position, the hip and knee are gently flexed to 90degree, then theleg is gradually extended which reproduces the symptoms of sciatica.CROSS OVER TESTIt is an important determinant of compression of lumbosacral roots in the midline.PROCEDURE: The examiner gently raise the affected legFINDING: If patient develop symptoms in asymptomatic contralateral extremity 18
  • 19. IMPRESSION: A large central disc protrusionFLIP TEST PROCEDURE: Patient is made to sit with knees dangling over the side of the bed, the hip and knee are both flexed at 90degrees. Now extend the knee joint fully. FINDING: If patient develops sudden, severe pain, and patient will throw his or her trunk backwards to avoid tension the nerve indicates that the test is positive. IMPRESSION: Root compromiseNAFFZIGER’S TEST: Here pressure applied on the jugular vein until the patient face flush. Now patient asked tocough which produce pain in back indicate test is positive.VALSALVA MANEUVER: Ask the patient to bear down as if he were trying to pass stools. If bearing down causespain in the back or radiating down to the leg it indicates test is positive. 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. CAUDA EQUINA SYNDROME The syndrome is a true spine surgical emergency that is often missed due to its rare occurance. Thecondition is usually caused by a massive midline disc sequestration into the spinal canal, usually at L4-L5 but also at L5-S1 and L3-L4. Higher disc ruptures are a rare cause of this syndrome. The presentation is fairly classic. The patient usually has a prodromal stage of back pain and some legsymptoms.Without much in the way of intervening trauma, there is a dramatic increase in back pain and theoccurrence of bilateral leg pain and perineal numbness. The numbness usually extends to the penis in men. Thepatient then notices an inability to void because of the paralysis of the S2, 3, and 4 roots in the cauda equina. On examination, marked reduction in SLR; numbness to pinprick in the perineal region (S2, 3, 4 dermatomes)SADDLE ANAESTHESISA; and weakness corresponding to the level of the disc rupture. Reflexes will usually bedepressed (e.g., bilateral ankle reflex depression with either an L4-L5 or L5-S1 sequestered disc). The bladderwill be full to palpation/percussion, and any passage of urine will be due to involuntary overflowincontinence.On rectal examination, decreased tone in the external sphincter will be noted.If there is anysuspicion at all that bladder and bowel function are impaired, in a back pain patient, an immediate diagnosticstudy like EMERGENCY MRI is indicated. It should operated as early as possible because delay in surgeryincreases the risk of permanent impairment of bowel and bladder function. 19
  • 20. CRITERIA FOR THE DIAGNOSIS OF THE ACUTE RADICULAR SYNDROME ( SCIATICA DUE TO A HERNIATED NUCLEUS PULPOSUS) DIFFERENTIAL DIAGNOSIS OF SCIATICAINTRASPINAL CAUSESProximal 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 pressureEXTRASPINAL CAUSESPelvis Cardiovascular conditions (eg. Peripheral vascular disease) Gynaecological conditions Orthopaedic conditions ( osteoarthritis of hip, Muscle related disease, Facet joint arthropathy) Sacroiliac joint disease Neoplasm 20
  • 21. Peripheral nerve lesions Neuropathy (Diabetic, tumour, alcohol) Local sciatic nerve conditions (Trauma, tumour) Inflammation (herpes zoster) KEY DIAGNOSTIC TIPS FOR DISTINGUISHING AMONG FIVE IMPORTANT CAUSES OF SCIATICAHERNIATED NUCLEUS PULPOSUS  H/o specific trauma  Leg pain greater than back pain  Neurologic deficit present; Nerve tension signs present  Pain increases with sitting & leaning forwards, coughing, sneezing, and straining  Pain reproduced with ipsilateral straight leg raising and sciatic stretch tests, contralateral legraising test  Radiologic evidence of nerve root impingementANNULAR TEARS  H/o significant trauma  Back pain usually greater than leg pain; Leg pain bilateral or unilateral  Nerve tension signs are present ( But no radiologic evidence of impingement)  Pain increases with sitting & leaning forwards, coughing, sneezing, and straining  Back pain is exacerbated with bilateral straight leg raising and sciatic stretch tests  Discography is diagnostic ( neither CT nor Myelogram shows abnormality)FACET JOINT ARTHROPATHY  H/o injury  Localized tenderness present unilaterally over joint  Pain occurs immediately on spinal extension  Pain exacerbated with ipsilateral side bending  Pain blocked by intrajoint injection of local anaesthetic or corticosteroidSPINAL STENOSIS  Back and/or leg pain develops after patient walks a limited distance; symptoms worsen with continued walking  Leg weakness or numbness present, with or without sciatica  Flexion relieves symptoms  No neurological deficit present  Pain not reproduced on straight leg raising; pain reproduced with prolonged extension of spine and relieved afterwards when spine flexed  Radiologic evidence: Hypertrophic changes, disc narrowing, interlaminar space narrowing, facet hypertrophy, degenerative spondylolisthesis L4-L5 21
  • 22. MYOGNIC OR MUSCLE - RELATED DISEASE  H/o Injury to muscle, recurrent pain symptoms related to its use  Lumbar paravertebral myositis produce back pain; gluteus maximus myositis causes buttock and thigh pain  Pain is unilateral or bilateral, rather midline; does not extend below knee  Soreness or stiffness present on rising in the morning and after resting; is worse when muscles are chilled or when the weather changes ( arthritis like symptoms)  Pain increases with prolonged muscle use ; is most intense after cessation of muscle use( directly afterward and on following day)  Symptom intensity reflects daily cumulative muscle use  Local tenderness palpable in the belly of the involved muscle  Pain reproduced with sustained muscle contraction against resistance, and passive stretch of the muscle  Contralateral pain present with side-bending  No radiologic evidence INVESTIGATION THE CORNERSTONE OF DIAGNOSIS OF LUMBAR DISC DISEASE IS THE HISTORY AND PHYSICAL EXAMINATION NOT THE INVESTIGTION.CT and MRI are ordered for two reasons: (a) almost always to verify the clinical diagnosis as correctand at the same time to plan a surgical approach to the problem and (b) infrequently to solve adifferential diagnosis problem.PLAIN RADIOGRAPH It is not of much value in the diagnosis of disc herniation It is mainly used to rule out other causes like ankylosing spondylitis, neoplasms. Most commonly the herniation occurs at the end of phase I or in early phase II. Thus features of phase II disc degeneration maybe seen Radiological features are  Narrowing of disc space  Osteophyte formation along the peripheries of the adjacent vertebral bodies  Sclerosis or condensation of subchondral bone of the adjacent vertebral bodies above and below the affected disc  Loss of lumbar lordosis  Translation of vertebral bodies 22
  • 23. MYELOGRAPHYTechnique: water-soluble contrast agent is injected into the epidural space.Abnormalities in myelography indicative of an Herniated nucleus pulposus (HNP) are as follows: Normal Double density Distortion of S1 root sleeve Root sleeve myelogram sac absent shorteningFALSE NEGATIVE MYELOGRAM SEEN IN Foraminal HNP Unscanned area (high lumbar disc not scanned). Insensitive space at L5-S1 Short or narrow dural sac at L5-S1 Conjoint nerve roots distorting the contrast columnDISADVANTAGEMyelography is capable of showing the level at which the pathology lies but fails to show the nature of thelesion or its precise location in the anatomic segment .CT MYELOGRAPHY CT myelography is minimally invasive modality here CT scan taken after myelography is done.INDICATIONS Patient with contraindication for MRI Postoperative spine in which metal artifacts present 23
  • 24. ADVANTAGE: Accurate detection of root impingement and central lateral recess and foraminal stenosis DISCOGRAPHY Definition: The discogram is physiologic evaluation of the disc that consists of a manometric, volumetric, radiographic and pain provocative challenge. Technique: Done by injecting saline or water soluble contrast into the disc through extradural or transdural approach under fluoroscopic guidance. PARAMETERS NORMAL DISC ABNORMAL DISC VOLUME 0.5 – 1.5ml >1.5ml END POINT PRESSURE Firm Spongy RADIOGRAPHIC Contrast confined to nucleus Contrast extend beyond the nucleus PAIN RESPONSE None/Pressure Typical/ Atypical/ Painless USES  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 DISCOGRAPHY Post discography CT should be performed within 4hours of discography both axially and sagitally reformatted images are obtained. 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. NORMAL ANNULAR TEAR PROTRUSION EXTRUSION SEQUESTRATIONSCHEMATIC DIAGRAM 24
  • 25. CTDISCOGRAP HY 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. 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. In Lumbar disc prolapse, disc herniation usually focal, asymmetric and dorsolateral in position and is seen to lie directly under the nerve root traversing that disc causing demonstrable nerve root compression or displacement indicating nerve root compression. MRI MRI is a single best diagnostic test for imaging the cervical, thoracic and lumbar disc herniation. It allows direct visualization of herniated disc material and its relationship to neural tissue including intrathecal contents. IMAGE T1 weighted image T2 weighted image SEQUENCE FAT Bright Less bright FLUID Dark Bright USES Study the anatomy of cord and nerve Study the pathologic changes in spine roots and spinal cord Differentiate the nucleus from annulus fibrosus 25
  • 26. T1 weighted image T2 weighted imageINDICATIONS FOR SPINE IMAGING  Presence of underlying systemic disease  Progressive neurological deficits  Cauda equina syndrome  Candidate for therapeutic intervention  Failed clinically directed conservative therapyIn Lumbar disc herniation, MRI shows disc herniation and their effect on the thecal sac and nerve roots,particularly on T2 weighted images.Disc extrusions and sequestrated disc fragments on T2 weighted images shows greater signal intensity than theparent disc due to reflection of inflammation and matched T1 images reveals the lesion hypointense against thebright intra-foraminal fat.CONTRAST ENHANCED MRI Here GADOLINIUM labeled diethylenetriaminepentaacetate (Gd-DTPA) administered intravenously and MRIscan 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 These tests are done to rule out diseases other than primary disc herniation. ELECTROMYOGRAPHY – to rule out peripheral neuropathy. SOMATOSENSORY EVOKED POTENTIALS (SSEP) – to identify the level of root involvement POSITRON EMISSION TOMOGRAPHY 26
  • 27. TREATMENTCONSERVATIVE TREATMENT Majority of disc prolapse respond well to conservative therapy. Resolution of first disc prolapsetakes place approximately 75% of patients over a period of 3 months.BED RESTIn very acute condition patient must be hospitalized and kept on bed rest. Adequate analgesic relive thepain and this helps the muscle spasm to subside. Patient should not be kept in bed rest for not more than 3to 4 days. The amount of straight leg raising obtained without pain is a useful indication of recovery. Duringbed rest, pelvic or skin traction can applied.DRUG THERAPY Bed rest can be supplemented with Non steroidal anti-inflammatory drugs, analgesics, muscle relaxantsand night sedation.PHYSIOTHERAPHY In acute condition, traction should not be applied, only short wave diathermy and ultrasonic massage,infrared therapy can be used. In chronic disc prolapsed, skin traction or pelvic traction with 5 to 10 poundscan be applied.EXERCISESFor the patients with loss of lumbar lordosis, extension exercise are important. For the patient with weakabdominal muscle, flexion exercise must be adviced.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. 27
  • 28. FOR ACUTE STAGE BRIDGING EXERCISE Here lie on the floor, knees bent, feet flat on the floor, palms down and raise lower back and buttocks. KNEE HUGS Lie flat on the floor, pull left knee towards chest firmly and at the same time straighten right leg. It helps to passively stretch erector spinae and the contracted fascia and ligaments over the posterior aspect of the lumbosacral junction. Thus unload posterior disc PELVIC TILT Lie on the floor, knees bent, feet flat on floor, palms down. Push lower back flat against the floor. This decrease the lumbar lordosis and increase the anterior aspect of pelvis.FOR SUBACUTE OR RECOVERY STAGE HAMSTRING STRETCH Lie on your back, bring your knee towards your chest so your hip is at 90º. Place your hands around your thigh; straighten your leg towards the ceiling until you feel a comfortable stretch in the back of the thigh. Hold up to 30 seconds, repeat x3 – 5 times on both legs 28
  • 29. KNEE ROLLS Lie on your back with your knees bent, place your arms out to the side, level with your shoulders and palms turned upwards. Slowly roll your knees to the right, trying to keep your knees and ankles together. Repeat x6 times each side, hold the stretch for as long as is comfortable for you. EXTENSION CONTROL Position yourself on all fours. Lift your opposite arm and leg into a horizontal position. Hold for 5 -10 seconds. Try to keep your body still. Repeat on the other side. PARTIAL CURL (MODIFIED SIT UPS) Lie on your back raise your upper back off the floor as you reach with both hands for your knees. Touch the top of your knees with your fingers. Lower your upper back slowly on the floor. Relax your arms and take a deep breath before repeating the exercise. EXTENSION EXERCISE (PRESS UP) Lying face down, leaning on your elbow/forearms. Arch the small of your back. Keep your knees and shoulders relaxed. Repeat x6 –10 hold for 4 -6 seconds. This helps to increase the extension flexibility and relaxes the muscles of back and abdomen.YOGAASANAS FOR LUMBAR DISC PROLAPSE These should performed only after the pain had relieved and should not be performed in acute state.Recommend poses for Lumbar Disc Prolapse: Tadasana (Mountain Pose) Utthita Trikonasana (Triangle Pose) Marichyasana III (Marichis Pose) Ardha Urdhva Mukha Svanasana (Half Bharadvajasana (Bharadvajas Twist) Upward-Facing Dog Pose) Virabhadrasana II (Warrior II Pose) Balasana (Childs Pose) Utthita Parsvakonasana (Side Angle Pose) Shavasana (Corpse Pose) 29
  • 31. EPIDURAL STEROID Epidural steropid injections are useful for breaking the cycle of pain in acute lumbar disc herniations. Thisinjection relieves pain by suppressing the inflammatory component of nerve root irritation.INDICATIONS OF EPIDURAL STEROID  Painful SLRT or femoral stress test  Patient with appropriate neurological deficit  Patient with acute on chronic symptoms, with a different level of disc pathologyCONTRAINDICATIONS - Infection -Hemorrhagic & Bleeding diasthesis - Evolving neurological disease - Cauda equina syndrome - Uncontrolled diabetes mellitus - HypertensionTECHNIQUE: Methylprednisolone (80-120mg) mixed with 2% xylocaine and normal saline made into 10mland injected into the epidural space through interlaminar approach and patient in lateral decubitus positionusing a glass syringe.COMPLICATIONS OF EPIDURAL STEROID INJECTIONFailure inject drug into epidural spaceBacterial meningitis, Transient hypotension, Severe paresthesia, Headache, Transient corticoidismSURGICAL TREATMENTGOAL: To relive neural compression and hence radiculopathy while minimizing complications.SURGICAL OPTIONSPOSTERIOR APPROACH Standard laminectomy and discectomy Fenestration operation – Limited laminotomy Microsurgical laminotomy with disc fragment excisionANTERIOR APPROACH with or without interbody fusionPERCUTANEOUS APPROACH – Suction, laser or arthroscopic discectomyINDICATIONS FOR SURGERYABSOLUTE  Bladder and bowel involvement: The cauda equina syndrome 31
  • 32.  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 deficitCONTRAINDICATIONS FOR SURGERY o Wrong patient ( poor potency for recovery) o Wrong diagnosis o Wrong level o Painless Disc Prolapse (do not operate for primary complaint of weakness/paresthesia) o Inexperienced surgeon applying poor technical skills o Lack of adequate instrumentsCHEMONUCLEOLYSIS It is technique in which enzymatic dissolution of the disc done using CHYMOPAPAIN. Other substances usedare collagenase, apoproteinin, chondrotininase and cathepsins.INDICATION – Low back with radicular painCONTRAINDICATION OF CHEMONUCLEOLYSIS - Sequestrated disc - Significant neurological deficit - Disc herniation with lateral stenosis - Cauda equina syndrome - Previous treatment with chymopapain - Spinal tumour - Recurrence of disc herniation -Spondylolisthesis - Pregnancy -Diabetic NeuropathyMOA: Chymopapain injected into the intervertebral disc degrades the proteoglycan of the disc thus decreasethe water holding property of the disc and result in shrinkage of the disc. LAMINECTOMY AND DISCECTOMY Anaesthesia: Usually general Position: Prone in knee chest position (Jack knife position) Incision: Midline vertical incision over affected interspace usually 6 -8cms. Exposure: Subcutaneous and deep tissue deepened – Lumbodorsal fascia divided – Supraspinous ligament incised – 32 Paravertebral muscles reflected – Spinous process of 2 or more
  • 33. LumboDorsal fascia divided – Supraspinous ligament incised – Paravertebral muscles reflected – Spinous processof 2 or more vertebra removed - Lamina and ligamentum flavum exposed – Cord exposed –Dura retracted –Nerve root inspected and retracted to expose the disc – Nick is made for any loose fragments of annulus – restof disc material removed using disc forceps.Closure: In layersPost operatively: Patient allowed to turn in the bed and allowed out of the bed by 1st weekDischarged in 10 to 15 daysAdvice on Discharge: Not to do stretching exercises for 6 monthsHEMI OR PARTIAL LAMINECTOMY: Lamina and ligamentum flavum on one side is removed taking care not todamage facet joint.FENESTRATION: Removal of a part of the lamina by inter-laminar approachTOTAL LAMINECTOMY: Removal of all of the laminaFREE FAT GRAFTING: Before closure fat is excised from the subcutaneous tissue, soaked in dexamethasone andplaced over the exposed dura and the spinal nerves. This helps to prevent muscle from adhering to the exposeddura and in patients who required re-operation later.COMPLICATIONS OF LAMINECTOMY AND DISCECTOMYThe complications associated with standard laminectomy and discectomy are 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 equina lesions Neurological damage or nerve root injury Urinary retention and urinary tract infectionFAILED BACK SYNDROME It is a condition characterized by persistent postoperative backache and sciatica. VERY COMMON CAUSES COMMON CAUSES – Neuritis, Referred pain from nonspinous site -Recurrent/ Persistent disc material at operated site UNCOMMON CAUSES - Disc prolapse at other site - Discitis / Osteomyelitis/ Epidural abscess - Arachnoiditis - Epidural scar / Fibrosis 33 - Conustumour - Facet arthrosis / Spinal stenosis - Thoracic, High lumbar HNP - Epidural haematoma
  • 34. The recurrence of pain after disc surgery should be treated with all available conservative treatment modalitiesinitially. The surgery should be tailored to the anatomic problem only.MICRODISCECTOMYIt is technique in which microscope used in performing the disc excision.TECHNIQUEPt in kneeling position – Level disc herniation palpated – A 2 to 3 cm incision directly over disc herniation about1cm to the side of midline – A power burr used to remove few mm of cephalad lamina & 2 to 3mm of medialaspect of inferior facet – release Ligamentum flavum – With Kerrison rongeur 2 to 3mm of medial aspect ofsuperior facet removed – Decompress the lateral recess stenosis to the level of pedicle – exposure of lateral discspace – Nerve root, ligamentum flavum, epidural fat are retracted towards midline – cauterize the bleedingepidural veins over the herniated disc –Herniated disc removed – Disc space irrigated with a catheter – Thepituitary forceps used to remove the remaining loose fragments – spinal canal palpated for any residual discfragments - Bleeding controlled – Wound closed in layers.ADVANTAGES OF MICRODISCECTOMY  Allows more magnification & illumination  Surgery done through a small incision  Decreased tissue trauma  Less blood loss  Shorter hospital stay  Quick recoveryDISADVANTAGES OF MICRODISCECTOMY Increased incidence of missed pathologic changes ( eg: Lateral recess stenosis, recurrent disc herniations) Increased rate of infection Limited field of vision with a small incisionMICROENDOSCOPIC DISCECTOMY  It blends percutaneous procedures and the best of microdiscectomy  It allows for a minimum of tissue injury while optimizing the visualization.  The 1.5cm incision disrupts minimal muscle.  Direct observation of the nerve root maximizes the success of the procedure.  The surgical outcomes in terms of pain relief similar to Microdiscectomy.  Return to activites and work is accelerated due to less tissue trauma.  Improvement in outcome is found by lessening scar tissue (epidural fibrosis) and by enhanced visualization of the nerve root compression. 34
  • 35. PERCUTANEOUS DISCECTOMY To avoid the problem due to open disc excision an new technique was developed,PERCUTANEOUS DISCECTOMY. It can be done manually or by suction or laser or under arthroscopic guidanceCandidate for percutaneous discectomy should meet the following criteria:  Contained disc herniation  Major complaint of unilateral leg pain more than back pain  Positive SLRT  Specific neurological deficit  Failure of conservative measuresCONTRAINDICATIONS OF PERCUTANEOUS DISCECTOMY  Sequestrated disc  Previous lumbar spine surgeryPOSITION: Prone / Lateral decubitusTECHNIQUEMANUAL With image intensification under local anaesthesia, Cannula is introduced into affected disc spacethrough posterolateral approach after adequate visualization of cannular placement within the disc.Through this cannula, elongated rongeurs were introduced and manually disc material were removedthus decompress the affected nerve root. SUCTION DISCECTOMY It is also known as AUTOMATED PERCUTANEOUS DISCECTOMY. Here similar to manual method, instead of elongated rongeurs, a thin 2mm cutting aspiration probe that connected to a negative pressure of 600mmhg. The device morselizes the nucleus and carries it away in saline irrigant.PERCUTANEOUS LASER DISCECTOMY Here ablative laser energy delivered through an optical fiber to the interior of the disc space.The discmaterial removed by vaporization. The volume of disc material removal depends on the wavelength of laserenergy and the amount of energy utilized. A variety of laser are utilized like carbondioxide, Holmium: Yttrium-aluminium-garnet (YAG), neodymium:YAG, argon.PERCUTANEOUS ARTHROSCOPIC DISCECTOMY In this technique, the spinal nerve root and offending disc material can be visualized directly and freefragments of extruded disc material can be removed. Thus subannular and sequestrated disc can be removed. 35
  • 36. COMPLICATIONS OF PERCUTANEOUS DISCECTOMYDiscitis, Psoas hematoma, Vasovagal reaction. Neurological and vascular injury are uncommon.ARTIFICIAL DISC The implant is designed to bear the load through the spine at that level and prevent further collapse of theaffected vertebral segments thus protect the remaining disc.Patient not suitable for artificial disc replacement are Osteoporosis Spondylolisthesis Infection or tumour of spine Spine deformities from trauma Facet arthrosisThe estimated life span of an artificial disc prosthesis is over 80years.INTRADISCAL ELECTROTHERMAL THERAPYIt 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.TECHNIQUE: Patient awake and under a local anaesthesia with mild sedation, a special wire known asElectrothermal catheter is inserted into the disc – Electrical current passed through the wire – Heating of thedisc theoretically modify the collagen fibres of the disc - Destroy the pain receptors in the area of discSPECIAL SITUATION WITH LUMBAR DISC PROLAPSELUMBAR DISC PROLAPSE with SpondylolisthesisPatients with a spondylolisthesis may suffer from a disc rupture, which causes an acute radicularsyndrome. Most of these will occur at the level above the spondylolisthesis. A disc herniation at thesame level of the slip usually occurs into the foramen. For the disc herniation above the slip level,simple disc excision or chemonucleolysis. For the disc herniation at the slip level, discectomy should beaccompanied by a stabilization procedure.LUMBAR DISC PROLAPSE in Spinal StenosisSpinal stenosis can occur in the central canal or lateral zones. It can be an asymptomatic or a mildlysymptomatic condition that can suddenly convert to a significant disability when a disc herniationoccurs. The presenting symptoms will be mainly leg. Simple microscopic removal of the disc herniationalong with a local decompression of the stenotic segment is the proposed method of treatment. If, on 36
  • 37. history, the stenotic component was significantly symptomatic before the occurrence of the HNP, awider decompression is needed to treat both the stenosis and the HNP.LUMBAR DISC PROLAPSE in InstabilityPatients with a long history of back pain and significant DDD revealed on plain radiograph may sufferfrom a disc herniation at the degenerative level. If the disc degeneration and HNP are confined to onelevel, consider fusion. If the disc degeneration is present at multiple levels, either on plain radiograph,discography, or MRI, simple disc excision is the best choice.LUMBAR DISC PROLAPSE in the Adolescent PatientThe younger patient with a disc herniation is a special problem. Because of the high incidence ofprotrusions rather than disc extrusions, it is proposed that in this age group the optimal treatment ischemonucleolysis rather than surgical intervention.Recurrent LUMBAR DISC PROLAPSE (After Discectomy)Reherniation of discal material occurs in approximately 2% to 5% of patients. The recurrence mayoccur at any interval after surgery (days to years) and is most often at the same level/same side. If therecurrence is at the same level/opposite side or another level, it can be considered a virgin HNP. But,most recurrences are same level/same side, and scar tissue from the previous surgery introduces awhole new element to diagnosis and treatment.REFERENCES 1. MACNAB’S BACKACHE by David A.Wong 4th edition 2. THE LUMBAR SPINE by Sam W Wiesel 2nd edition 3. MANAGING LOW BACK PAIN by W.H.Kirkildy – Willis 3rd edition 4. ORTHOPAEDIC PHYSICAL ASSESSMENT by David Magee 5th edition 5. ORTHOPAEDIC PRINCIPLE AND THEIR APPLICATION by TUREK 4TH Edition 6. CAMPBELL’S OPERATIVE ORTHOPAEDICS 11TH EDITION 7. INTERNET “LEARN TO BE GOOD TO YOUR BACK AND YOUR BACK WILL BE GOOD TO YOU….” 37