The document discusses lumbar disc disease and degenerative disc disease. It begins by describing the anatomy of the lumbar spine including vertebrae, discs, and ligaments. It then discusses the intervertebral disc structure and how degeneration occurs due to loss of water content. Disc degeneration can lead to herniations which are classified as protrusions, extrusions, or sequestrations depending on the shape. Common signs and symptoms include low back pain and sciatica. Evaluation involves patient history, physical exam, and MRI to diagnose the specific herniation type. Treatment options may include conservative care or surgery depending on the severity of symptoms.
5. INTERVERTEBRAL DISC
Nucleus pulposis
- Gelatenous substance
- Proteoglycan
- 80% water content
Annulus fibrosus
-Fibrocartilage
-Closely attach to the end plate
-Contain laminated Layers
6. OBJECTIVES
1. Identify the etiology of lumbar disc herniations.
2. Review the proper steps in the evaluation of lumbar disc
herniations.
3. Outline the management options available for lumbar disc
herniations.
4. Summarize interprofessional team strategies for improving
care coordination and communication to improve outcomes
of lumbar disc herniations
7. LOW BACK PAIN
• strain of the muscles
• ligaments and tendons
• Herniation of lumbar disc
• sciatica
• Various other conditions
10. • In the normal, healthy disc, the
nucleus distributes the load equally
throughout the anulus
• As the disc undergoes
degeneration, the nucleus loses
some of its cushioning ability and
transmits the load unequally to the
anulus
• In the severely degenerated disc,
the nucleus has lost all of its ability
to cushion the load, which can lead
to disc herniation
Etiology of Disc Degeneration
12. COMPLETE HISTORY
• Did you have an injury?
• Where is the pain?
• Do you have any numbness? Where?
• Do you have any weakness? Where?
• Have you had this problem or something like it before?
• Have you had any weight loss, fevers, or illnesses recently?
13. CAUDA EQUINA SYNDROME
• Most serious complication
• Ruptured disc material may press on
the nerves that control the bowels and
bladder
• It can cause permanent damage lead
to lose the ability to control bowels
and bladder
• Surgery immediately is recommend
14. PHYSICAL EXAMINATION
1. Motion of Spine
2. Weakness
3. Pain
4. Sensory Changes
5. Reflex changes
6. Motor skills
7. Special signs
18. Degenerative changes of the disc
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8
Pathological changes
Water and proteoglycan content decreases
Collagen fibers of AF become distorted
Tears may occur in the lamellae
Results in:
Decreased disc height and volume
Impaired mobility
Pain
Inflammation
Neurological signs and symptoms
20. A) DISC BULGE
2
0
•Generalized or circumferential disc
displacement
• (involving 50% to 100% of the disc
circumference) is known as “bulging”
•and is not considered a form of herniation.
TYPES
•Bulging can be symmetrical (displacement
of disc material is equal in all directions)
•asymmetrical (frequently associated with
scoliosis)
22. ). ANNULAR TEAR
2
2
Disruption of concentric collagenous fibers
comprising
the anulus fibrosus
TYPES:
1. Concentric tears
2. Radial tears
3. Transverse tears
MR Findings
• T1WI: Contrast-enhancing nidus in disc margin
• T2WI: High signal zone at edge of disc which has low
intrinsic signal
23. A. Concentric tears
•are circumferential lesions which are found in
the outer layers of the annular wall.
•They represent splitting between adjacent
lamellae of the annulus, like onion rings.
•Concentric tears are most commonly
encountered in the outer annulus fibrosus,
are believed to be of traumatic origin
especially from torsion overload injuries.
2
3
TYPES
24. B. RADIAL TEARS
2
4
• are characterized by an annular tear
• permeates from the deep central part of the disc (nucleus
pulposus)
• extends outward toward the annulus
• either a transverse or cranial-caudal plane.
25. C. TRANSVERSE TEARS
2
5
• also known as “peripheral tears” or “rim lesions”
• are horizontal ruptures of fibers, near the insertion in the bony
ring apophyses.
• Their clinical significance remains unclear.
• Transverse tears are believed to be traumatically induced and
are often associated with small osteophytes
27. C). DISC HERNIATION
Herniation is defined as a localized displacement
of disc material (nucleus, cartilage, fragmented
apophyseal bone, fragmented annular tissue)
beyond the limits of the intervertebral disc space.
Intravertebral
Herniations
Protruded Disc
Extruded Disc
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7
28. •Are protrusions of
the nucleus pulposus of
the intervertebral
disc through
the vertebral
body endplate and into
the adjacent vertebra.
•(also known as
Schmorl’s nodes).
•They are often
surrounded by reactive
bone marrow changes.
INTRAVERTEBRAL HERNIATIONS
15
30. “PROTRUDED DISC
• The terminology “protruded disc” is used
when the base of the disc is broader than
any other diameter of the displaced
material.
•Based on a two-dimensional assessment
of the disc contour in the transverse plane,
a protruded disc can be:
•focal (involving <25% of the disc
circumference)
•broad-based (involving 25%–50% of the
17
disc circumference).
31. • The terminology “extruded disc” is used for a focal disc
extension of which the base against the parent disc is narrower than
diameter of the extruded disc material, measured in the same plane.
EXTRUDED DISC HERNIATIONS
Extrusion: the base of the herniation is
narrower than the apex (toothpaste
sign) 18
32. •Extrusion is also used when
there is no continuity between
the herniated disc material
beyond the disc space and that
within the disc space
•If the displaced disc material
has no connection with the
parent disc, it is called a
“sequestrated fragment”.
•This is synonymous with a “free
fragment”.
3
2
34. MIGRATION – SEQUESTRATION
Migration
indicates displacement of disc material away from the site
extrusion, regardless of whether sequestrated or not.
Sequestration
indicate that the displaced disc material has lost
any continuity with the parent disc
3
4
35. A. Small subligamentous herniation (protrusion) without significant
disk material migration.
B.Subligamentous herniation with downward migration of disk
material under the PLLC.
C.Sub-ligamentous herniation with downward migration of disk
material and sequestered fragment (arrow). 22
36. • X-ray: show spinal degenerative changes but
not a herniated disc; rule out obvious
underlying problems
• CT: relatively less used
• MRI: The best
DIAGNOSIS
3
6
Low back pain is a prevalent symptom, as approximately 80 % of the population sustains an episode once in their lifetime. Within the many differentials of low back pain, the most common cause is the intervertebral degeneration which leads to lumbar disc herniation and degenerative disc disease. This activity reviews the evaluation and management of lumbar disc herniation and discusses the role of the healthcare team in evaluating and improving care for patients with this condition.
Objectives:
Identify the etiology of lumbar disc herniations.
Review the proper steps in the evaluation of lumbar disc herniations.
Outline the management options available for lumbar disc herniations.
Summarize interprofessional team strategies for improving care coordination and communication to improve outcomes of lumbar disc herniations
In the normal, healthy disc, the nucleus distributes the load equally throughout the anulus
As the disc undergoes degeneration, the nucleus loses some of its cushioning ability and transmits the load unequally to the anulus
In the severely degenerated disc, the nucleus has lost all of its ability to cushion the load, which can lead to disc herniation
A herniated disc occurs when the intervertebral disc's outer fibers (the annulus) are damaged and the soft inner material of the nucleus pulposus, under extreme pressure, bulges out through the annulus fibrosus ring. If the annulus tears near the spinal canal, the nucleus pulposus material can push into the spinal canal.