About Hernia nucleus pulposus

1. LUMBAR DISC HERNIATION
TEAM: SPINE
NO/YA
MODERATOR:VI
SUPERVISOR: dr. Jainal Arifin, MKes, SpOT (K) Spine
Tuesday, 24th September 2019

2. PATIENT IDENTITY
Name : IC
Age : 31 years old
Registration : 672070

3. History Taking
 Chief complaint
Low back pain
 History of illness
Suffered since two years ago before admitted to the hospital. Initially, pain intermitten. But the three
weeks ago the raight, pain felt getting worse and pain radiated to the lower limb. Pain occurred by
activity, and decreased by rest. Cough(-), sneeze(-), straining at stool, History of fever (-).
 History of trauma (+) : patients had a motorcycle accident two years ago and the patient falls in the
sitting position. After that, the patient can walk and move as usual. History of lifting heavy weight (-)
 History of chronic cough(-), history of loose weight (-), history of night sweat (-), history of TB
treatment (-).
 History of same complain in his family (-). Hipertension (-), Diabetic (-).

4. Composmentis/well nourished
VITAL SIGN
BP : 120/80 mmHg
HR: 88x/mnt, regular
RR: 20x/mnt, thoracoabdominal type
T : 36,6˚C
General Status

5. Vertebra Region :
• I : deformity (-), hematome (-),
swelling (-), wound (-)
• P : tenderness as level as vertebra L5 (+),
step off sign (-)
Localized Status

6. Clinical picture

7. 5
5
5
5
5
5
5
0
5
5
5
5
5
5
5
5
5
5
5
5
5
yes
Motoric
Examination

8. 2
2
2
2 2
2
2
2
2
2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
2
2
2
2
2 2
2 2
2 2
2 2
2 2
2 2
2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2
2 2
2 2
2 2
2
2
2
2
2
2
2 2
2 2
2 2
2 2
2
2
2
2 2 2
2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
2 2 2 2
0 → Absent
1 → Impaired
2 → Normal
NT → Not testable
Any anal sensation
Y
2

9. Physiologic reflex
R L
• Biceps (+) (+)
• Triceps (+) (+)
• Achilles (+) (+)
• Patellar (+) (+)
Pathologic Reflex
R L
• Babinski (-) (-)
• Chadock (-) (-)
• Openheim (-) (-)
• Hoffmentromner(-) (-)
Reflex

10. Special test
R L
• Straight leg raise : (+) (-)
• Laseque sign : (+) (-)
• Femoral stretch test : (-) (-)

11. RBC: 5,13 x 10^3/µL
Hb : 15,6 g/dl
WBC : 4,34 x 1o^6/µl
HCT: 44,5%
PLT : 226 x 10^3/µL
HbsAg : Negatif
Laboratory

12. toracolumbal AP
Lumbosacral AP

13. toracolumbal lateral
Lumbosacral lateral

18. A man 31 years old come to the hospital with chief complaint of low back
pain, Suffered since two years ago before admitted to the hospital. Pain
occurred by activity, cough (-), sneeze(-), straining at stool, and decreased
by resing, pain radiated to lower limbs. History of trauma (+) : patients
had a motorcycle accident two years ago and the patient falls in the
sitting position. After that, the patient can walk and move as usual.
History of lifting heavy weight (-)
 From physical examination, there is no deformity at the region of
vertebra. The motoric strength of upper and the lower extremities are
normal. Special test straight leg raise(+), laseque sigh(+), bowstring
sign(+) at right lower extremity.
 The laboratory findings are in normal limit.
Summary

19. Diagnosis
• Low Back Pain due to herniation nucleus pulposus L3-L4, L4-L5

20. •Analgesic
•Plan for discectomy
Treatment

21. Introduction
• 95 % L4-L5 or L5-S1 (most common)
• 4th and 5th decades of life
• 3:1 male:female ratio and 5% symptomatic
• 90 % patient will have improvement of symptoms within 3 monts w/o
surgery
Orthobullets.com

22. Pathoanatomy
• The disc is the anterior border of the spinal canal at the facet joint
level
• Posterolateral (or paracentral) herniations are the most frequent
location
• Cumulative degenerative changes occur from:
 Concentration of torsional
 Axial loading
 Flexion-induced biomechanical strains
Rothman, The Spine

23. Pathoanatomy
Rothman, The Spine

24. Pathophysiology
Disc Degeneration and Herniation
• Anulus fibrosus tear – compression the nucleus – herniation
• Nucleus must be fluid/well-hydrate (younger age) to be herniated through the
anulus
Disc Herniation and Sciatica
• Usually occur with radicular pain following dermatomal distribution
• Sciatic-type pain is produced only if the nerve root is concurrently irritated or
inflamed
Disc Herniation and Back Pain
• Most patients with symptomatic disc herniations present with leg and back pain
• Nociceptive pain transmission from disc degeneration
Rothman, The Spine

25. Morphology
• Degeneration: Decreased or absent T2-weighted signal is noted from the intervertebral disc. It is not
possible to distinguish symptomatic from asymptomatic degeneration based on MRI
• Disc bulge: Disc material is noted to extend beyond the disc space with a diffuse, circumferential,
nonfocal contour. Disc bulges are caused by early disc degeneration and infrequently cause symptoms in the
absence of spinal stenosis
• Protrusion: Displaced disc material extends focally and asymmetrically beyond the disc space. The
displaced disc material is in continuity with the disc of origin. The diameter of the base of the displaced
portion, where it is continuous with the disc material within the disc space of origin, has a greater diameter
than the largest diameter of the disc tissue extending beyond the disc space
• Extrusion: Displaced disc material extends focally and asymmetrically beyond the disc space. The
displaced disc material has a greater diameter than the disc material maintaining continuity (if any) with the
disc of origin
• Sequestration: Refers to a disc fragment that has no continuity with the disc of origin. By
definition all sequestered discs are extruded. However, not all extruded discs are sequestered
Spine Secret Plus

26. Morphology
Spine Secret Plus
Rothman, The Spine

27. Morphology
Spine Secret Plus
The location of a disc herniation within the spinal
canal is described in terms of a three-floor
anatomic house:
• story 1: disc space level
• story 2: foraminal level
• story 3: pedicle level
The spinal canal is also divided in terms of zones:
• The central zone is located between the pedicles.
• The foraminal zone is located between the medial
and lateral pedicle borders
• The extraforaminal zone is located beyond the
lateral pedicle border

28. Symptoms
Cauda equina syndrome (present in 1-10%)
• Bilateral leg pain
• LE weakness
• Saddle anesthesia
• Bowel/bladder symptoms
Radicular pain (buttock and leg pain)
• Often worse with sitting, improves with standing
• Symptoms worsened by coughing, valsalva, sneezing
Axial back pain (low back pain)
• This may be discogenic or mechanical in nature
Orthobullets.com

29. Physical Examination
• Lower Extremity sensorics and motoric examination
• Gait analysis
• Provocative test:
 Straight leg test
 Contralateral SLR
 Lesegue sign
 Bowstring sign
 Kernig test
 Naffziger test
 Milgram test
Orthobullets.com

30. Imaging
Radiographs:
• loss of lordosis (spasm)
• loss of disc height
• lumbar spondylosis (degenerative changes)
Orthobullets.com

31. Imaging
• MRI without gadolinium modality of choice for diagnosis of lumbar
disc herniations
• highly sensitive and specific
• helpful for preoperative planning
• useful to differentiate from synovial facet cysts
However high rate of abnormal findings on MRI in normal people
Indications:
• pain lasting > one month and not responding to nonoperative management
or
• red flags are present
• infection (IV drug user, h/o of fever and chills)
• tumor (h/o or cancer)
• trauma (h/o car accident or fall)
• cauda equina syndrome (bowel/bladder changes)
Orthobullets.com

32. Imaging
MRI with gadolinium
• Useful for revision surgery
• Allows to distinguish between post-surgical fibrosus (enhances with
gadolinium) vs. recurrent herniated disc (does not enhance with
gadolinium)
Orthobullets.com

33. Treatment
Non Operative:
• Initial treatment options include a short period of bedrest (not to exceed 3
days)
• Oral medications ( NSAIDs, aspirin, mild opioids)
• Progressive ambulation, return to activity, and patient reassurance
• Epidural injections can be considered.
• As acute pain subsides, physical therapy and aerobic conditioning are
advised.
If a patient fails to improve with 4 to 6 weeks of nonsurgical care, further
evaluation is indicated.
The optimal time for nonsurgical treatment ranges from a minimum of 4
weeks to a maximum of 6 months Spine Secret Plus

34. Treatment
Operative:
Appropriate criteria for surgical intervention include:
• Functionally incapacitating leg pain extending below the knee within
a nerve root distribution
• Nerve root tension signs with or without neurologic deficit
• Failure to improve with 4 to 8 weeks of nonsurgical treatment
• Confirmatory imaging study (preferably MRI), which correlates with
the patient’s physical findings and pain distribution
Spine Secret Plus

35. Treatment
Operative:
Laminotomy and discectomy (microdiscectomy)
Indication:
• Persistent disabling pain lasting more than 6 weeks that have failed
nonoperative options (and epidural injections)
• Progressive and significant weakness
• Cauda equina syndrome
Far lateral microdiscectomy
Indication:
• Far-lateral disc herniations
Orthobullets.com

36. Treatment
Operative complication:
• Vascular injury
• Nerve root injury
• Dural tear
• Infection
• Increased back pain
• Recurrent disc herniation
• Cauda equina syndrome
• Medical complications (e.g.
throm-bophlebitis, urinary tract
infection)
Spine Secret Plus

37. QUESTION AND ANSWER

38. 1. Which of the following would most likely explain the physical
examination finding of decreased achilles tendon reflex and positive
straight-leg-raise:
1. Lumbar arachnoiditis
2. L4/L5 paracentral disc herniation
3. L5/S1 paracentral disc herniation
4. L3/L4 far lateral (foraminal) disc herniation
5. L5/S1 far lateral (foraminal) disc herniation

39. Preferred Response 3. L5/S1 paracentral disc herniation
• The clinical presentation is consistent with a S1 radiculopathy. A L5/S1
paracentral disc herniation would compress the descending nerve root (S1)
and cause this physical finding.
The location of a prolapsed lumbar disc determines its symptoms. Central
disc herniations may give rise to back pain or cauda equina syndrome.
Posterolateral (paracentral) disk herniations are the most common type of
lumbar disk herniation, and affect the descending/lower nerve root (90-
95% of cases). For example, an L5/S1 paracentral disc herniation will cause
S1 symptoms. Far lateral disc herniations (5-10%) affect the exiting nerve
root. For example, an L5/S1 far lateral (foraminal) disc herniation will cause
L5 symptoms.

40. 2. Figure A is an axial MR image of the L4-5 disc space. A patient with
the pathology seen in this image would be expected to have all of
the following signs and symptoms EXCEPT
1. Numbness over dorsum of foot
2. Decreased patellar tendon reflex
3. Weakness to hip abduction
4. Weakness of great toe extension
5. Positive straight leg raise

41. Preferred Response 2. Decreased patellar tendon reflex
Figure A is an axial MR image demonstrating a paracentral disc herniation at L45/5. This would
compress the L5 nerve root leading to symptoms that would likely include 1) numbness over
dorsum of foot 3) weakness to hip abduction 4) weakness of great toe extension 5) positive straight
leg raise. A L5 radiculopathy would not be expected to lead to decreased patellar tendon reflex
In the lumbar spine a paracentral disc herniation typically compresses the descending nerve root (at
L4/5 this is the L5 nerve root which exits under the L5 pedicle). This is in contrast to a far lateral
herniation which compresses the exiting nerve root (at L4/5 this is the L4 nerve root which exits
under the L4 pedicle). In the cervical spine, the nerve roots do not "descend" before they exit the
foramen, and therefore a disc, whether central or lateral, always affects the exiting nerve root (a
C4/5 disc hernation compresses the C5 nerve root which exits above the C5 pedicle).
In the cervical spine the exiting nerve root travels above the corresponding pedicle (C5 exits above
the C5 pedicle) whereas in the lumbar spine the exiting nerve root exits below the corresponding
pedicle (L5 exits below the L5 pedicle). The transition from above the corresponding pedicle to
below occurs because there is a C8 nerve root but no C8 pedicle (no C8 vertebral body).

43. 3. A 56-year-old man presents with 6 weeks of worsening back and left
sided lower extremity pain and weakness. He has severe pain that
radiates from the back to the groin and anteromedial thigh. His axial
MRI image is shown in Figure 1. Which of the following physical
examination findings would be most consistent with his imaging?
1. Decreased sensation on the lateral
aspect of the foot
2. Weakness of quadriceps
3. Weakness of hip adduction
4. Weakness of extensor hallucis longus
5. Normal physical examination at rest,
but leg heaviness after ambulation

44. Preferred Response 3. Weakness of hip adduction
• The patient is presenting with a left-sided far lateral disc herniation at L3-
L4 level. This pathology impinges on the exiting L3 nerve root, and more
specifically the dorsal root ganglion, leading to severe pain in the groin and
anteromedial thigh. L3 nerve root compression would be most associated
with hip adduction weakness.
Examination of the hip can be useful for differentiating hip versus spine
pathology and involvement of different nerve roots. Typically hip flexion is
mediated by the L2 nerve root, hip adduction by L3, hip abduction by L5 and
hip extension by S1. Provocative maneuvers of the hip, including flexion
adduction internal rotation (FADIR) and flexion abduction external rotation
(FABER) testing as well hip internal and external rotation testing should be
performed to evaluate the hip joint as a cause of pain. When the source of
pain is still indeterminate, diagnostic injections should be attempted.

45. THANK YOU