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1. Low Backache, Prolapse
Intervertebral Disc And Lumbar
Canal Stenosis
Dr. Pankaj Kumar Singh
M. S. Orthopaedics; D. ortho (Ru.)
Fellowship in Ilizarov and Reconstructive Surgery

2. LUMBAR SPINE

3. ANATOMY OF LUMBAR SPINE

5. INTERVERTEBRAL DISC

7. NUTRITION TO DISC

8. FUNCTION OF DISC

9. FACET JOINTS

11. MOTION SEGMENT
ANTERIOR
ELEMENT
POSTERIOR
ELEMENT

12. DISC & NERVE ROOT RELATION
L5 is
TRAVERSING
NERVE ROOT
L5 is EXITING
NERVE ROOT
L4
L5

13. EFFECT OF AXIAL LOADING

14. THREE JOINT COMPLEX

15. RELATION OF INTRADISCAL
PRESSURE AND POSTURE
highest

16. IN RELATION TO POSTURE

17. CORRECT SLEEPING POSTURE

18. IN RELATION TO MANUAL MATERIALS
HANDLING

19. LUMBAR DISC PROLAPSE
along with few annular fibres and end plate
cartilage through the tears in annulus fibrosus
into the extradural space.
It is condition in which there is
outpouching of the disc Nucleus pulposus

20. EPIDEMIOLOGY
• AGE: 30 – 40 years
• SEX: Male affected more than female
• MOST COMMON LEVEL: L4-L5 (next common
level is L5-S1)
• MOST COMMON TYPE: Posterolateral type

21. ETIOLOGY

22. EFFECT OF SMOKING
Blood vessel get
constricted
Transport of nutrients
& disposal of waste
products decreased
Disc cells get deficient
nutrition or die
Disc degenerates &
results in DISC
INSTABILITY

23. DISC DEGENERATION

24. PATHOPHYSIOLOGY OF LUMBAR
INTERVERTEBRAL DISC PROLAPSE
With aging,
vascular channels start to fail
vascular diffusion of nutrients
decrease thus number of viable chondrocytes
Synthesis rate & concentration of
proteoglycans decreases
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

25. ANNULUS
INTACT
Facet joints share
even more of the
axial load
Facet joints undergo
degenerative
changes & develop
osteophytes
FACET JOINT
SYNDROME

27. ANNULUS FAILS

28. Extruded disc &
degraded nuclear
material impinge on
the nerve roots
Nucleus pulposus is an
immunogenic which
induce an inflammatory
response
Produces radicular
pain syndrome &
RADICULOPATHY

29. STAGES OF DISC PROLAPSE

31. LIST (SCIATIC SCOLIOSIS)

33. STRAIGHT LEG RAISING TEST

34. LASEGUE SIGN

35. CONTRALATERAL LEG RAISING
TEST (FRAJERSZTAGN TEST)

36. WHY PAIN OCCURS ON AFFECTED
SIDE ON RAISING NORMAL LEG?
AFFECTED SIDE NORMAL SIDE

37. BOWSTRING TEST

38. FEMORAL NERVE STRETCH TEST

39. FLIP TEST
NEGATIVE POSITIVE

41. CAUDA EQUINA SYNDROME
• Marked reduction in SLRT
• Saddle anaesthesia
• Bilateral ankle jerk depression
• Involuntary overflow
incontinence
• Decreased tone in external
sphincter

42. DIFFERENTIAL DIAGNOSIS
INTRASPINAL CAUSES
Proximal 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 pressure

43. EXTRASPINAL CAUSES
Pelvis
•
•
•
Cardiovascular conditions (eg. Peripheral vascular disease)
Gynaecological conditions
Orthopaedic conditions ( osteoarthritis of hip, Muscle related disease,
Facet joint arthropathy)
Sacroiliac joint disease
Neoplasm
•
•
Peripheral nerve lesions
•
•
•
Neuropathy (Diabetic, tumour, alcohol)
Local sciatic nerve conditions (Trauma, tumour)
Inflammation (herpes zoster)

44. KEY DIAGNOSTIC POINTS
LUMBAR DISC PROLAPSE
➢ Leg pain greater than back pain
➢ Neurological deficit present
ANNULAR TEARS
➢ Back pain greater than leg pain
➢ Bilateral SLRT positive
FACET JOINT ARTHROPATHY
➢ Localized tenderness present unilaterally over joint
➢ Pain occurs immediately on spinal extension
➢ Pain exacerbated with ipsilateral side bending

45. SPINAL STENOSIS
➢ Back and/or leg pain develops after walks a limited distance.
➢ Flexion relieves symptoms
➢ No neurological deficit
➢ Pain not reproduced on SLRT
MYOGENIC OR MUSCLE RELATED
➢ Pain localised to affected muscle
➢ Pain increases on prolonged muscle use
➢ Pain reproduced with sustained muscle contraction against
resistance
➢ Contralateral pain with side bending

46. INVESTIGATION
THE CORNERSTONE OF DIAGNOSIS OF
LUMBAR DISC DISEASE IS THE HISTORY AND
PHYSICAL EXAMINATION NOT THE
INVESTIGTION.

47. PLAIN RADIOGRAPH
OSTEOPHYTE
DECREASED DISC
SPACE

48. NORMAL RETROSPONDYLOLISTHESIS

49. MARKED
RETROSPONDYL
OLISTHESIS

50. 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.
•
•
•
•

51. 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.

52. MAGNETIC RESONANCE IMAGING
• It allows direct visualization of herniated disc
material and its relationship to neural tissue
including intrathecal contents.

53. INDICATIONS FOR SPINE IMAGING
• Presence ofunderlying systemic disease
• Progressive neurological deficits
• Cauda equine syndrome
• Candidate for therapeutic intervention
• Failed clinically directed conservative therapy

61. CONTRAST ENCHANCED MRI
• Here GADOLINIUM labeled
diethylenetriaminepentaacetate (Gd-DTPA)
administered intravenously and MRI scan
done.
ADVANTAGES
• Display the inflammatory reaction critical to
the pathophysiology of radicular pain or
radiculopathy
• Allows discrimination of scar from recurrent
disc.

62. OTHER DIAGNOSTIC TESTS
• ELECTROMYOGRAPHY – to rule out peripheral
neuropathy.
• SOMATOSENSORY EVOKED POTENTIALS
(SSEP) – to identify the level of root
involvement
• POSITRON EMISSION TOMOGRAPHY

63. TREATMENT
• CONSERVATIVE
• SURGICAL

64. TREATMENT
• CONSERVATIVE -
 Bed rest, NSAID’s and hot fomentation.
 Traction – continuous or intermittent traction.
 Epidural injection or facet block has been
proven effective.
 Chemonucleolysis – percutaneous injection of
proteolytic enzyme (Chymopapin) for
dissolution of neucleus pulposus used to
dissolve fibrous and cartilaginous tissue.

65. Physiotherapy -
• Abdominal & back muscle strengthening
exercises.
• SWD (Short wave diathermia) – increases
local blood flow.
• TENS (transcutaneous electric nerve
stimulation)- works on gate control theory.
• IFT (inter-Ferential Therapy)

66. Surgery -
Indication for operative management-
• Cauda equina compression syndrome –
surgical emergency
• Deteriorating neurological condition during
conservative treatment.
• Persistent pain and sciatic tension after 3 – 6
weeks of conservative treatment

67. Surgical options-
 Posterior Approach –
• Laminectomy & discectomy.
• Fenestration & discectomy.
• Microsurgical laminotomy with disc fragment
excision.
 Anterior approach, discectomy with
interbody fusion.
 Endoscopic discectomy.

68. Thank You