A herniated or prolapsed disc occurs when a tear in the outer ring of an intervertebral disc allows the soft inner material to bulge out. This most commonly affects the lumbar region. Symptoms include back pain and pain radiating into the legs. Diagnosis involves physical exam, x-rays, CT scans and MRI. Treatment options range from non-surgical approaches like medication, physical therapy and injections to surgical procedures like discectomy, laminectomy or spinal fusion. The goal of treatment is to relieve pressure on nerves and reduce pain.

1. INTERVERTEBRAL
DISC PROLAPSE
RATHEESH R L

2. DEFINITION
• Spinal disc herniation, also known as
a slipped disc, is a medical condition
affecting the spine in which a tear in the
outer, fibrous ring of an intervertebral
disc allows the soft, central portion
to bulge out beyond the damaged outer
rings.

4. • Is relatively avascular structure and
the Essential minerals and fluids
required for regeneration enter the
disks passively during the night.

5. FUNCTIONS OF IVD
1-It supports the axial load on the column that is
delivered by the body mass.
2- Assist a limited range of motion at the spine.
3- Shock absorbing system.
4- Serve ligamental functions between vertebral
bodies.
5- Assist to keep the normal shape & curvature of
each spinal region (cervical, thoracic, ..etc)

6. Location
 The majority of spinal disc herniation cases
occur in lumbar region (95% in L4-L5 or
L5-S1).
 The second most common site is
the cervical region (C5-C6, C6-C7).
 The thoracic region accounts for only
0.15% to 4.0% of cases.

7. Cervical
 Cervical disc herniations occur in the neck,
most often between the fifth & sixth
(C5/6) and the sixth and seventh (C6/7)
cervical vertebral bodies.
 Symptoms can affect the back of the skull,
the neck, shoulder girdle,
scapula, shoulder, arm, and hand.
 The nerves of the cervical
plexus and brachial plexus can be affected.

8. Thoracic
 Thoracic discs are very stable and
herniations in this region are quite
rare.
 Herniation of the uppermost thoracic
discs can mimic cervical disc
herniations, while herniation of the
other discs can mimic lumbar
herniations.

9. Lumbar
 Lumbar disc herniations occur in the lower
back, most often between the fourth and
fifth lumbar vertebral bodies or between
the fifth and the sacrum.
 Symptoms can affect the lower
back,buttocks, thigh, anal/genital
region (via the Perineal nerve), and may
radiate into the foot and/or toe.

11.  Repetitive mechanical activities –
Frequent bending, twisting, lifting, and
other similar activities without breaks and
proper stretching can leave the discs
damaged.
CAUSES

12.  Traumatic injury to lumbar discs-
commonly occurs when lifting
while bent at the waist, rather
than lifting with the legs while
the back is straight.

13. • Living a sedentary lifestyle –
Individuals who rarely if ever
engage in physical activity are more
prone to herniated discs because the
muscles that support the back and
neck weaken, which increases strain
on the spine.

14.  Obesity – Spinal degeneration can be
quickened as a result of the burden of
supporting excess body fat.
 Practicing poor posture – Improper spinal
alignment while sitting, standing, or lying
down strains the back and neck.
CAUSES

15.  Tobacco abuse – The chemicals
commonly found in cigarettes can
interfere with the disc’s ability to
absorb nutrients, which results in the
weakening of the disc.

16. • Mutation-
in genes coding for proteins
involved in the regulation of the
extracellular matrix, such
as MMP2 and THBS2, has been
demonstrated to contribute to lumbar
disc herniation.

17.  There is now recognition of the importance of
“chemical radiculitis” in the generation of back
pain.
 A primary focus of surgery is to remove
“pressure” or reduce mechanical compression on
a neural element: either the spinal cord, or
a nerve root.
Pathophysiology

18. • But it is increasingly recognized that
back pain, rather than being solely
due to compression, may also be due
to chemical inflammation.

19.  There is evidence that points to a specific
inflammatory mediator of this pain.
 This inflammatory molecule, called tumor
necrosis factor-alpha (TNF), is released not
only by the herniated disc, but also in
cases of disc tear (annular tear), by facet
joints, and in spinal stenosis.

20. • In addition to causing pain and
inflammation, TNF may also contribute
to disc degeneration.

21. SYMPTOMS
• The symptoms of a herniated or prolapsed
disc may not include back or neck pain in
some individuals, although such pain is
common. The main symptoms of a prolapsed
disc include:
• In severe cases, loss of control of bladder
and/or bowels, numbness in the genital area,
and impotence (in men)
• Numbness, pins and needles, or tingling in
one or both arms or legs

22. • Pain behind the shoulder blade(s) or in the
buttock(s)
• Pain running down one or both arms or legs
• The location of these symptoms depends
upon which nerve(s) has been affected. In
other words, the precise location of the
symptoms helps determine your diagnosis.
• Weakness involving one or both arms or legs

23. TYPES OF HERNIATION
posterolateral disc herniation –
 protrusion is usually posterolateral into
vertebral canal, compress the roots of a
spinal nerve.
 protruded disc usually compresses next
lower nerve as that nerve crosses level of
disc in its path to its foramen.
(eg.protrusion of fifth lumbar disc usually
affects S1 instead.

24. central (posterior) herniation:
 less frequently, a protruded disc
above second lumbar vertebra may
compress spinal cord itself or or may
result in cauda equina syndrome.
 in the lower lumbar segments,
central herniation may result in S1
radiculopathy.

25. lateral disc herniation:
 may compress the nerve root above the
level of the herniation
 L4 nerve root is most often involved &
patient typically have intense radicular
pain.

26.  Diagnosis is based on the history, symptoms,
and physical examination.
 At some point in the evaluation, tests may be
performed to confirm or rule out other causes of
symptoms such
as spondylolisthesis,degeneration, tumors, metasta
ses and space-occupying lesions.
DIAGNOSIS

27. X-Ray : lumbo-sacral spine;
 Narrowed disc spaces.
 Loss of lumber lordosis.
 Compensatory scoliosis.
CT scan lumber spine;
 It can show the shape and
size of the spinal canal, its
contents, and the structures
around it, including soft tissues.
 Bulging out disc.

28. MRI lumber spine;
 Intervertebral disc protrusion.
 Compression of nerve root.
Myelogram;
 pressure on the spinal cord or
nerves, such as herniated discs,
tumors, or bone spurs.

29. Normal MRI

31. .

32. ..

34.  Bed rest.
 Non-steroidal anti-inflammatory
drugs (NSAIDs).
 Patient education on proper body
mechanics.
 Physical therapy, to address mechanical
factors, and may include modalities to
temporarily relieve pain
(i.e. traction, electrical stimulation
massage).
medical treatments.

35.  Oral steroids
(e.g. prednisone or methylprednisolone).
 Epidural cortisone injection.
 Intravenous sedation, analgesia-assisted
traction therapy (IVSAAT).
 Weight control.
 Tobacco cessation.
 Lumbosacral back support.
 anti-depressants.

36. Discectomy/Microdiscectomy -
• This procedure is
used to remove part
of an intervertebral
disc that is
compressing the
spinal cord or a
nerve root.

37. The Tessys method
• The Tessys method
(transforaminal
endoscopic surgical
system) is a
minimally invasive
surgical procedure
to remove herniated
discs .

38. Laminectomy-
to relieve spinal
stenosis or nerve
compression

39. Hemilaminectomy -
Hemilaminectomy is
surgery to help
alleviate the
symptoms of an
impinged or irritated
nerve root in the
spine

40. Lumbar fusion
• Anterior lumbar fusion is an
operation done on the
front (the anterior region) of
the lower spine.
• Fusion surgery helps two or
more bones grow together
into one solid bone.
•

41. • Fusion cages are new devices, essentially hollow
screws filled with bone graft, that help the
bones of the spine heal together firmly.
• Surgeons use this procedure when patients
have symptoms from disc degeneration, disc
herniation, or spinal instability.
• lumbar fusion is only indicated for recurrent
lumbar disc herniations, not primary
herniations

42. Total Disc Replacement
• Artificial Disc Replacement (ADR), or Total
Disc Replacement (TDR), is a type
of arthroplasty.
• It is a surgical procedure in which
degenerated intervertebral discs in the spinal
column are replaced with artificial devices in
the lumbar (lower) or cervical (upper) spine.

43. Complications
Chronic pain
Peeminant nerve
injury
Paralysis

44. NURSING MANAGEMENT
• Assess the general condition of the patient
• Check the vital signs
• Assess the level and characteristics of pain
• Provide proper back care and skin care to
the patient
• Advice patient to do proper exercise
• Provide adequate nutrition

45. • Change the position frequently
• Advice to avoid heavy exercise like heavy
weight lifting
• Put traction for the prescribed period of
time.
• Continue the medications till the doctor
adviced