general overview of PIVD/DEGENERATIVE DISC DISEASE

1. INTERVERTEBRAL
DISC
HERNIATION
D Dr.Praveen K
Tripathi

3. LUMBAR SPINE MOTION SEGMENT
 Three joint complex
 Intervertebral disc + 2 facet
joint
 Ligamentous structure,
vertebral body

4. INTERVERTEBRAL DISC
 Hydrostatic, load bearing structure between the
vertebral bodies from C2-3 to L5-S1 .
 Twenty-three discs span the vertebral column
between C2 and S1.(6 cervical, 12 thoracic and 5
lumbar )
 Nucleus pulposus + annulus fibrosus
 No blood supply
 L4-5, largest avascular structure in the body

5. INTERVERTEBRAL DISC
•Type II collagen strand + hydrophilic
proteoglycan
•Water content 70 ~ 90%
•Confine fluid within the annulus
•Convert load into tensile strain on the annular
fibers and vertebral end-plate
Nucleus Pulposus

6. ANNULUS FIBROSUS
 Outer boundary of the disc
 More than 60 distinct, concentric layer of
overlapping lamellae of type I collagen
 Fibers are oriented 30-degree angle to the disc
space
 Helicoid pattern
 Resist tensile, torsional, and radial stress
 Attached to the cartilaginous and bony end-plate at
the periphery of the vertebra

7.  Anterior annulus is almost straight whereas
posterior margins have a physiological bulge
which increases with extension and
straightens with flexion
 Peripheral fibres of annulus insert above and
below the apophyseal bony rings(vertebral
end plates) in to the periosteum of the
vertebra
ANNULUS FIBROSUS

8. •Cartilaginous and osseous component
•Nutritional support for the nucleus
•Passive diffusion
VERTEBRAL END-PLATE

9. INNERVATION
 Outer 1/3 of anulus
and PLL innervated
by sinuvertebral
nerves
 Anterior disc has
some sensory input
through sympathetic
trunk
 Posterior spinal
elements carry
nociception through
medial branch
nerves
The lumbar disc is supplied by a network of pain
fibers from the sympathetic chain arising from the
sinuvertebral nerve, which innervates the outer six

10. SPINAL LIGAMENTS

11. PHYSIOLOGY OF DISC
 Disc able to support weight because it contains
proteoglycans
 Substantial osmotic gradient between disc and
plasma
 Resulting force favouring flow of water into
disc opposed by compressive force of upright
posture
 Two opposing forces reach a balance point
based on position
 Water flows into the disc in supine posture and

13. INTERVERTEBRAL DISC HERNIATION
 Is a medical condition affecting the spine in
which a tear in the outer, fibrous ring
(annulus fibrosus) of an intervertebral disc
allows the soft, central portion (nucleus
pulposus) to bulge out beyond the
damaged outer rings.

14. BURDEN OF THE PROBLEM
 60-90% life time incidence of
backache
 The incidence 5 to 20 cases per
1000 adults annually
 1-3 percent of patients symptomatic
.
 95 % chance of herniated discs
occurring either at L4-L5 or L5-S1
 Peak in 40’s (third to the fifth decade
)
 Male to female ratio of 2:1

15. ETIOLOGY
There is a higher rate of disc
herniation in the lumbar and
cervical spine due to the
biomechanical forces in the
flexible part of the spine.
Other causes
• Connective tissue disorders
• congenital disorders such as
short pedicles.
Trauma - second
most common
cause . The most common cause -
degenerative process in
which, as humans age, the
nucleus pulposus becomes
less hydrated and weakens.
This process will lead to a
progressive disc herniation
that can cause symptoms.

16. RISK FACTORS
 Repetitive mechanical activities
 Living a sedentary lifestyle
 Traumatic injury to lumbar discs commonly
occurs when lifting while bent at the waist
 Obesity – degeneration quickens
 Practicing poor posture
 Tobacco abuse – The chemicals commonly
found in cigarettes can interfere with the
disc’s ability to absorb nutrients

17. PATHOPHYSIOLOGY

18. PATHOPHYSIOLOGY

23. PATHOPHYSIOLOGY - DISCOGENIC PAIN

24. DISCOGENIC PAIN
Sciatica has been known since antiquity, but the
relationship between sciatica and disc herniation
was not discovered until the beginning of the
20th century.
In 1934,Mixter and Barr were the first to describe
this correlation
Discogenic pain is classically associated with sitting
intolerance and flexion of the spine
Symptoms vary depending on the location of the herniation
and the types of soft tissue that become involved.

25. 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.
 Symptoms vary depending on the location of
the herniation and the types of soft tissue
that become involved.

26. SYMPTOMS
 Axial Back Pain
 Radicular Pain - The cardinal symptoms of lumbar disc
herniation are radicular leg pain with or without a
sensory loss (dermatomal)and motor deficit
 Difficulties stooping and picking up things
 Restriction in running and jumping
 Diminished stride
 Cauda equina syndrome (massive herniation) which
is characterized by:
 Incapacitating back and leg pain
 Numbness and weakness of the lower extremities (saddle
anaesthesia)
 Bladder bowel incontinence
 Paralysis of affected nerve distribution(below the
dermatome in thoracic)

27. CAUDA EQUINA SYNDROME
(SPINAL CANAL COMPRESSION)

28. SYMPTOMS
Axial Back Pain from Intervertebral Disc
Disease (without Deformity)
 The most classic disc-related mechanical pain
syndromes present
 as pain that worsens with activity and lessens
with rest.
 Anterior thigh pain can also be associated with low
back pain, as the symptoms may follow a
somatotopic pattern.

29. Radicular Pain
 Sharp, shooting pain in a given dermatome, but
it may be dull or aching as well
 Patients may report an abrupt onset of
symptoms with acute anular tears, which
typically occur while the person is bent over to
lift, and are described as a “pop” in the spine
followed by severe pain.
 Activities that increase intradiscal pressure
(e.g., coughing, sneezing, and bending forward)
or increase axial loading (e.g., running) can
SYMPTOMS

30. CERVICAL DISC PROLAPSE SYNDROMES

32. CLINICAL EVALUATION
 Goals
 Localisation
 Differentiate between mechanical,
neuropathic and non-neurological pain
• Mode of onset
• Character
• Distribution
• Associated motor, sensory symptoms
• Bladder and bowel control
• Exacerbating and remitting factors
• History of predisposing factors
• ( cancer, osteoporosis)
History

33. HISTORY
 Three major concerns:
 Is there evidence of systemic disease
 Is there evidence of neurological disease
 Is there social or psychological stress which
is contributing?
 Exclude serious underlying pathology, such
as infection, malignancy or cauda equina
syndrome (RED FLAGS)

34. EXAMINATION
 Complete neurological examination
 Motor system
 Sensory system
 Gait
 Bowel bladder examination
 Reflexes

35. POSTURES
 Shouldered disc
 Pain is reduced by bending
away from that side
 Axillary disc
 Pain reduced by bending
towards the same side

36. STRAIGHT LEG RAISING
Fajersztajn SignBragard’s TestLasegue Test

37. SCIATIC STRETCH TESTS
 Fajersztajn Sign : Crossed SLR
Favours central disc herniation
 Neri Sign : Forward bending causes flexion
of knee on affected side
 Bragard’s Test : Dorsiflexion of foot while
SLR augments pain
 Naffziger sign : Pain reproduced by
increasing intra spinal pressure

38. THORACIC DISC HERNIATIONS
 Thoracic disc herniations, the physical findings are
subtle unless the patients present with an obvious
paraparesis or paraplegia.
 Symptomatic thoracic disc herniation presents with signs
of a myelopathy
 Disturbed gait
 Sensory deficits (non-dermatomal)
 Decreased motor weakness of the lower extremities (uni- or
bilateral)
 Increased muscle reflexes
 Clonus
 Decreased abdominal reflexes
 Positive babinski reflex
 Bowel and bladder dysfunction

39. DIFFERENTIAL DIAGNOSIS
 Discal cyst
 Mechanical back pain
 Degenerative spinal stenosis
 Epidural abscess
 Epidural hematoma
 Metastasis
 Diabetic amyotrophy
 Neurinoma
 Osteophytes
 Cauda equina syndrome
 Synovial cyst
 Piriformis syndrome

40. PIRIFORMIS SYNDROME
Pain from piriformis
muscle – irritation of
sciatic nerve passing
deep or through it
Pain on resisted
abduction / external
rotation of leg

41. IMAGING MODALITIES
 Xrays good first line Ix if red flags,
osteoporotic fracture
 CT Scan bone tumours fractures and spinal
stenosis
 MRI spinal cord, nerve roots, discs,
haemorrhage
 Myelography

42. RADIOGRAPHS (X RAYS)
Shows bones only
Helpful in older patients where cause of stenosis is likely
to be a result of degenerative changes or listhesis
If spondylolisthesis is present, need flexion and
extension views to evaluate for segmental instability
Scoliosis evaluation may be beneficial in some cases

43. MRI
Provides the best anatomic
picture and allows focus on
soft tissue
Needs to correlate with
physical examination
Many findings on MRI can
be asymptomatic
High-field better than Open,
need complete study

44. Anatomical classification MRI BASED
Herniation
Protrusion
extrusion
Migration-
displacement of disc
material away from
the site of extrusion,
regardless of
whether
sequestrated or not
Sequestration-
Extrusion may be
further specified as
sequestration, if the
displaced disc
material has lost
completely any
continuity with the
parent disc
Herniation- localized displacement of disc
• >50% (180º) = bulge
• <50% = herniation

45. Protrusion Extrusion
Canal
Disc
Bony
Endplate
Normal Bulge

46. Location Classification
central prolapse
• may present with cauda equina syndrome which
is a surgical emergency
posterolateral (paracentral)
• most common (90-95%)
• PLL is weakest here
foraminal (far lateral, extraforaminal)
• less common (5-10%)
axillary
• can affect both exiting and descending nerve roots

48. MYELOGRAM
 Study of choice
when MRI can not
be done
 Frequently an
uncomfortable
procedure
 Post-myelogram CT
can give additional
information about
canal contents

49. CAVEATS OF MANAGEMENT
 Adequate/complete
initial evaluation
 Follow-up evaluations
 1-3 days for acute pain
 4-6 weeks for chronic
pain
 Activity Activity Activity
 Survey for Red Flags

50. MANAGEMENT OPTIONS
 Non-operative management
 Bed rest
 Physiotherapy –
 In the acute phase: Use of hotpacks, short wave
diathermy, • microwave therapy.
 After the acute phase: graduated regime of back
•exercises is instituted
 Use of lumbar corset whenever the patient is
active
 NSAIDs
 Muscle relaxants
 Epidural corticosteroid injections

51. NON OPERATIVE TREATMENT
 Short-term rest (recommended 2
weeks)
**Conservative treatment should
continue for 6weeks, before other
measures are attempted

52. MYTH

53. NO EVIDENCE FOR:
 Short wave diathermy
 TENS
 Spinal manipulation
 Traction
 Acupuncture
 Exercises
 Spinal cortisone injections

54. LUMBAR BELT

56. MYTH

57. INDICATIONS FOR SURGERY
Ideal candidate
 History, physical examination, radiographic finding, are
consistent with one another
 Root tension sign (+)
 When discrepancy exist, the clinical picture should serve as the
principal guide.
Absolute surgical indications
 Definitive evidence for nerve root compression/myelopathy
(cervical disc)
 Cauda equina syndrome
 Severe paresis
 Paraparesis/paraplegia (thoracic disc herniation)
Relative indication
 Progressive weakness
 No response to conservative treatment > 6 weeks

58. OPERATIVE MANAGEMENT
 Open techniques
 Endoscopic techniques
 Microdiscectomy
 Minimally invasive techniques
 Chemonucleolysis
 Automated percutaneous lumbar discectomy
 Laser assisted percutaneous discectomy
 Arthroscopic microdiscectomy
 Intradiscal electrothermal therapy
 Percutaneous nucleoplasty

59. MICRODISCECTOMY

60. AUTOMATED PERCUTANEOUS LUMBAR
DISCECTOMY

61. LAMINECTOMY

62. DISC ARTHROPLASTY

63. LUMBAR FUSION
 lumbar fusion is
only indicated for
recurrent lumbar
disc herniations,
not primary
herniations

64. CHEMONUCLEOLYSIS
 Intradiscal injection of chymopapain which
causes hydrolysis of he cementing protein of
the nucleus pulposus.
 This causes decrease in water binding
capacity leading to reduction in size and
drying the disc.

65. INTRADISCAL ELECTROTHERMAL THERAPY
Heated at 194*c

66. NEUCLEOPLASTY

67. OUTCOME OF SPINAL SURGERY
•Non-Smoker/Normal BMI patients: 77 percent
• Normal BMI - all patients: 74 percent
• Obese with a BMI greater than 30: 59 percent
• Active Smokers: 58 percent
• Obese and litigator: 53 percent
• Obese, active smoker and litigator: 41
percent

68. PREVENTION
 Regular exercise.
 Weight loss if overweight.
 Safe lifting techniques.
 Correct sitting position and posture.

69. ANY QUESTIONS

70. THANK YOU