Lumbar disc disease          Dr. Ajay Bajaj MCh Neurosurgery, PGI, Chandigarh     Consultant Neurosurgeon  DR BALWANTSINGH...
Very Important Talk!! -- LBP• A major public health problem• The leading cause of disability for people < 45• 2nd leading ...
Frequency• United States• Lifetime incidence of LBP is reported to  be 60-90% with annual incidence of 5%.  Each year, 14....
Types of LBP1. Non-specific “idiopathic”: 85%2. Degenerative disc disease: discogenic pain, disk   herniation, degenerativ...
Disc• Nucleus pulposus-  water rich,  gelatinous,axial load,  pivotal point,binds  vertebrae together• Annulus fibrosus-  ...
SAGGITAL VIEW
DISC PHYSIOLOGY
DISC NUTRITION
DIURNAL CHANGE• During day time- disc shrinks by 20%• Body height reduced by 15 – 25 mm• In night- body height is increased.
MRI appearance• T-2 weighted image• Black disc –  dessication
Natural disc ageing• Loss of the proteoglycan molecule from  the nucleus of the disc.• Progressive dehydration.• Progressi...
FACTORS CONTRIBUTING   TO DISC AGEING
IDIOPATHIC BLOOD VESSEL/NUTRIENT LOSS AND  DEHYDRATION/DECREASED PROTEOGLYCANS               PRODUCTION
Other factors•   Vertebral end plate calcification•   Arterial stenosis•   Smoking•   DM•   Exposure to vibration.
NON ENZYMATIC GLYCATION-GLUCOSE AND DISCCOLLAGEN-ADVANCED GLYCATION END PRODUCT-                  AGE
Disc degeneration
Steps of disc herniation
DISC HERNIATION OR            PROLAPSE• Protrusion ( contained or subligamentous  herniation )• Extrusion ( non-contained ...
Internal disc disruption/grade -3       radial annual tear
Disc protrusion/PLL is still intact
Disc extrusion/ PLL is ruptured
MRI disc extrusion
Disc sequestration/final end stage         of disc disease
NERVE ANATOMYINTRAOPERATIVE VIEW
MRI• The gold standard for imaging of the  herniated lumbar disc is magnetic  resonance imaging
WHAT TO LOOK IN MRI
T-1 AXIAL VIEW
T-2 AXIAL
PROTON DENSITY IMAGE
ZONES OF ANTERIOR EPIDURAL SPACE / HERNIATION ZONES• Central region• Paracentral region or  lateral recess• Intraforaminal...
Posture and intradiscal pressure
• The most common sites for a herniated  lumbar disc are L4-5 and L5-S1, resulting  in back pain and pain radiating down t...
PATHOPHYSIOLOGIC MECHANISM  OF NERVE ROOT INVOLVEMENT• Mechanical deformation of the nerve root• Biochemical activity if t...
Sciatic nerve
TREATMENT OPTIONS• Surgery Vs conservative treatment.( Weber,peul  et al,)• Same results with respect to over-all-long ter...
• Due to our findings, we recommend  conservative treatment for up to 2 months.  If there is no improvement in symptoms  a...
Case
MRI
Operative photograph of disc
Sciatica caused by referred pain from   a disc without neural compression53 year old patient. Left sided buttock pain radi...
F=53L34 Analgesic Discogram. LocalAnesthetic and Omnipaque dyeinjected into the disc space.All her back and left thigh pai...
L34 Posterior Lumbar Interbody Fusion- complete relief of pain         Reports complete         relief of pain 4         w...
Messages• Inflamed discs can cause referred leg pain  without neural compression by irritating the  sinu-vertebral nerve• ...
Take Home Messages• Know the natural history of the disease• Know your patient• Correlate clinical findings, MRI and  disc...
THANK YOU
Lumbar disc presentation dr ajay bajaj neurosurgeon
Lumbar disc presentation dr ajay bajaj neurosurgeon
Lumbar disc presentation dr ajay bajaj neurosurgeon
Lumbar disc presentation dr ajay bajaj neurosurgeon
Lumbar disc presentation dr ajay bajaj neurosurgeon
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Lumbar disc presentation dr ajay bajaj neurosurgeon

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  • Four concentric layers of the intervertebral disc: (1) an outer anulus fibrosus, (2) a fibrocartilaginous inner anulus fibrosus, (3) a transition zone and (4) the central nucleus pulposus
  • Distribution of load in the intervertebral disc. (A) In the normal, healthy disc, the nucleus distributes the load equally throughout the anulus. (B) As the disc undergoes degeneration, the nucleus loses some of its cushioning ability and transmits the load unequally to the anulus. (C) In the severely degenerated disc, the nucleus has lost all of its ability to cushion the load, which can lead to disc herniation.
  • demonstrates the &apos;pre-cursor&apos; to a disc herniation. This type of disc lesion - that bulges into the anterior epidural space without any area of focal-ness or out-pouching - would be called a &apos; Disc Bulge &apos; on MRI (only because the MRI can NOT show the condition within the disc), although in reality it is a &apos;Grade 3 Radial Anular Tear&apos; (you would need CT discography to identify the tear) that has disrupted the posterior annulus and allowed irritating nucleus pulposus material to enter into the outer fibers of the disc. Again, this in of itself (IDD) may cause severe and disabling pain in some unfortunate people; however, the subject of Internal Disc Disruption is not the focus of this page. Also note that the PLL, although bulged, continues to be intact and has not ruptured. As well shall see later, the PLL is the &apos;key&apos; to differentiating between a disc protrusion and a disc extrusion. Finally, note that the Sinuvertebral nerves are irritated (red) and are sending pain signals on to the brain through the sympathetic nervous system (gray ramus communicans). Also note that this IDD may cause some referred lower leg pain as well (spinal nerve has some orange in it to indicate referred pain.)   demonstrates the &apos;pre-cursor&apos; to a disc herniation. This type of disc lesion - that bulges into the anterior epidural space without any area of focal-ness or out-pouching - would be called a &apos; Disc Bulge &apos; on MRI (only because the MRI can NOT show the condition within the disc), although in reality it is a &apos;Grade 3 Radial Anular Tear&apos; (you would need CT discography to identify the tear) that has disrupted the posterior annulus and allowed irritating nucleus pulposus material to enter into the outer fibers of the disc. Again, this in of itself (IDD) may cause severe and disabling pain in some unfortunate people; however, the subject of Internal Disc Disruption is not the focus of this page. Also note that the PLL, although bulged, continues to be intact and has not ruptured. As well shall see later, the PLL is the &apos;key&apos; to differentiating between a disc protrusion and a disc extrusion. Finally, note that the Sinuvertebral nerves are irritated (red) and are sending pain signals on to the brain through the sympathetic nervous system (gray ramus communicans). Also note that this IDD may cause some referred lower leg pain as well (spinal nerve has some orange in it to indicate referred pain.)  
  • demonstrates a 4 millimeter disc protrusion and represents a worsening of our disc bulge. The posterior of the disc is &apos;focally&apos; or &apos;eccentrically&apos; pushing backwards into the anterior epidural space and has contacted, and even somewhat compressed, the traversing nerve root (white star) and right front corner of the thecal sac. Note that the PLL (blue) still has NOT be disrupted and is still &quot;containing&quot; the near-herniated nuclear material.
  • demonstrates a more serious progression of our pathologically degenerated disc: An 8 millimeter Disc Extrusion (aka: non-contained herniation, transligamentous herniation) is now present. The PLL (blue) has finally been defeated and has completely ruptured, hence allowing for further migration of the the nucleus pulposus into the anterior epidural space. Note the marked displacement of the traversing nerve root (white star) AND the exiting nerve root (green star) (which has now turned completely red with inflammation and venous congestion - the precursors for Radiculopathy). This Disc Extrusion is NOT typically seen in the asymptomatic person and is often an indication for surgical decompression; the sooner the better IF you&apos;re NOT improving with conservative care. Another interesting phenomenon about extrusions are the fact that these larger disc lesions have a greater ability to be &apos;reabsorbed&apos; by the body! This &apos; shrinkage phenomenon &apos; has been demonstrated time and time again in the literature; in fact, you can expect that in 80% of large disc extrusions, there will be at least a 50% &apos;shrinkage&apos; of size (5,6). Unfortunately, this doesn&apos;t always mean that the pain associated with the extrusion will fade! Some patients recover from disc extrusion yet demonstrate NO change in the size of their extrusion at all, where others fail to recover yet their extrusion has markedly decreased in size! That just goes to prove that we still have a lot to learn about the relationship between disc herniation and pain
  • represents the end-of-the-line for the cycle of disc herniation. Now we can see that a big &apos;chunk&apos; or &apos;fragment&apos; of nuclear material has detached itself from the main body of the extrusion is and loose in the epidural space. Note the resulting severe compression of the traversing nerve root (white star), the exiting nerve root (green star) and the lateral aspect of the Thecal Sac (blue star). Sequestration (aka: sequester, free-fragment) may be excruciatingly painful (back and leg pain - sciatica) and, if centrally located, may occasionally cause the patient to lose control of their bowl and bladder function, i.e., Cauda Equina Syndrome , which is considered a &apos; Medical Emergency &apos;! As with the disc extrusion, the sequestration may also undergo a reduction in size from a combination of an immune attack {macrophage attack} and dehydration, although frequently the patient will need immediate decompressive surgery to beat this monster!
  • demonstrates a large 9mm disc extrusion (red star) as visualized on both the Axial (over-head) and Sagittal (side) views. Note that this extrusion has completely blotted out (can&apos;t see) the right traversing S1 nerve roots (left side of image) and has pinched it against the lamina (tiny green arrow). Note the thecal sac is moderately to severely compressed by this large herniation, as noted on both the axial and sagittal images (between blue arrow and red star). This young man (24 years) has avoid surgery and is doing fairly well, although his days of heavy work are probably over for good.  
  • Relative increases and decreases in intradiscal pressure in relation to different body positions. Note that seated and bending postures apply more pressure to the disc than do standing and recumbent positions. This explains the exacerbation of symptoms of herniated disc when patients are in the former positions.
  • Lumbar disc presentation dr ajay bajaj neurosurgeon

    1. 1. Lumbar disc disease Dr. Ajay Bajaj MCh Neurosurgery, PGI, Chandigarh Consultant Neurosurgeon DR BALWANTSINGH HOSPITAL GEORGETOWN
    2. 2. Very Important Talk!! -- LBP• A major public health problem• The leading cause of disability for people < 45• 2nd leading cause for physician visits• 3rd most common cause for surgical procedures• 5th most common reason for hospitalizations• Lifetime prevalence: 49%–80% Pai et al. 2004, Orthop Clin N Am
    3. 3. Frequency• United States• Lifetime incidence of LBP is reported to be 60-90% with annual incidence of 5%. Each year, 14.3% of new patient visits to primary care physicians are for LBP, and nearly 13 million physician visits are related to complaints of chronic LBP, according to the National Center for Health Statistics.
    4. 4. Types of LBP1. Non-specific “idiopathic”: 85%2. Degenerative disc disease: discogenic pain, disk herniation, degenerative scoliosis3. Developmental: spondylolisthesis, idiopathic scoliosis4. Congenital: scoliosis5. Traumatic6. Infectious7. Inflammatory8. Neoplastic9. Metabolic10. Referred
    5. 5. Disc• Nucleus pulposus- water rich, gelatinous,axial load, pivotal point,binds vertebrae together• Annulus fibrosus- fibrous and tougher, less water content,contained the nucleus pulposus
    6. 6. SAGGITAL VIEW
    7. 7. DISC PHYSIOLOGY
    8. 8. DISC NUTRITION
    9. 9. DIURNAL CHANGE• During day time- disc shrinks by 20%• Body height reduced by 15 – 25 mm• In night- body height is increased.
    10. 10. MRI appearance• T-2 weighted image• Black disc – dessication
    11. 11. Natural disc ageing• 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.
    12. 12. FACTORS CONTRIBUTING TO DISC AGEING
    13. 13. IDIOPATHIC BLOOD VESSEL/NUTRIENT LOSS AND DEHYDRATION/DECREASED PROTEOGLYCANS PRODUCTION
    14. 14. Other factors• Vertebral end plate calcification• Arterial stenosis• Smoking• DM• Exposure to vibration.
    15. 15. NON ENZYMATIC GLYCATION-GLUCOSE AND DISCCOLLAGEN-ADVANCED GLYCATION END PRODUCT- AGE
    16. 16. Disc degeneration
    17. 17. Steps of disc herniation
    18. 18. DISC HERNIATION OR PROLAPSE• Protrusion ( contained or subligamentous herniation )• Extrusion ( non-contained or transligamentous herniation )• Sequestration ( freek fragment )
    19. 19. Internal disc disruption/grade -3 radial annual tear
    20. 20. Disc protrusion/PLL is still intact
    21. 21. Disc extrusion/ PLL is ruptured
    22. 22. MRI disc extrusion
    23. 23. Disc sequestration/final end stage of disc disease
    24. 24. NERVE ANATOMYINTRAOPERATIVE VIEW
    25. 25. MRI• The gold standard for imaging of the herniated lumbar disc is magnetic resonance imaging
    26. 26. WHAT TO LOOK IN MRI
    27. 27. T-1 AXIAL VIEW
    28. 28. T-2 AXIAL
    29. 29. PROTON DENSITY IMAGE
    30. 30. ZONES OF ANTERIOR EPIDURAL SPACE / HERNIATION ZONES• Central region• Paracentral region or lateral recess• Intraforaminal zone or subarticular zone• Extraforaminal zone
    31. 31. Posture and intradiscal pressure
    32. 32. • The most common sites for a herniated lumbar disc are L4-5 and L5-S1, resulting in back pain and pain radiating down the posterior and lateral leg, to below the knee• Back pain caused by a herniated lumbar disc is exacerbated by sitting and bending; conversely, the pain of lumbar muscular strain is aggravated by standing and twisting movements.
    33. 33. PATHOPHYSIOLOGIC MECHANISM OF NERVE ROOT INVOLVEMENT• Mechanical deformation of the nerve root• Biochemical activity if the disc tissue on the nerve root
    34. 34. Sciatic nerve
    35. 35. TREATMENT OPTIONS• Surgery Vs conservative treatment.( Weber,peul et al,)• Same results with respect to over-all-long term improvement.• Advantage of surgery: if indicated:-faster pain relief and back to work.• Exception: severe pain with radiculopathy,progressive neurological deficit, development of cauda equina syndrome.
    36. 36. • Due to our findings, we recommend conservative treatment for up to 2 months. If there is no improvement in symptoms and signs, surgery should then be considered without further conservative treatment options."• if patients are improving slowly, then they should continue conservative care.
    37. 37. Case
    38. 38. MRI
    39. 39. Operative photograph of disc
    40. 40. Sciatica caused by referred pain from a disc without neural compression53 year old patient. Left sided buttock pain radiatingdown left leg up to knee for 2 years.Recurring flare-ups.Pain aggravated on sitting.Not sleeping wellTried Physio for 7 months. On Gabapentin,Amitrptilline, Oxyxontin .Left L34 Nerve Root Block- no benefitMRI- Degenerative changes at L34. No neuralcompression.?? Cause of Pain, and what are the treatmentoptions
    41. 41. F=53L34 Analgesic Discogram. LocalAnesthetic and Omnipaque dyeinjected into the disc space.All her back and left thigh paineased for 4 weeks . Was able tosleep comfortably for first time in2 years
    42. 42. L34 Posterior Lumbar Interbody Fusion- complete relief of pain Reports complete relief of pain 4 weeks after surgery.
    43. 43. Messages• Inflamed discs can cause referred leg pain without neural compression by irritating the sinu-vertebral nerve• Mild disc degeneration can result in quite severe pain- because of inflammatory chemicals in the disc space- not seen on MRI scans• Analgesic Discography- a new technique – offers a simple way to confirm the relevant disc as the pain generator• Interbody fusion can then be used to treat the problem definitively.
    44. 44. Take Home Messages• Know the natural history of the disease• Know your patient• Correlate clinical findings, MRI and discograms if needed• Until definitive evidence available, choose the most cost-effective available treatment option: cognitive therapy, exercise, fusion, arthroplasty, dynamic stabilization
    45. 45. THANK YOU
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