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  • Thanks a ton for sharing slide. Disc herniations can result from general wear and tear, such as when performing jobs that require constant sitting, herniations can result from jobs that require lifting, Traumatic injury to lumbar discs commonly occurs when lifting and benting at the waist.
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  1. 1. SPINE<br />Prolapseintervertebral disc<br /> Spinal Stenosis<br />Spondylosis<br />Spondylolysthesis<br />spondylolysis<br />
  3. 3. In PID, gelatinous nucleus pulposus squeezes through the fibres of the annulus fibrosusand bulges posteriorly or postrolaterallybeneath the posterior longitudinal ligament<br />Causes: Herniation of intervertebral disc, senile degeneration of disc, obesity, sudden jerk, sprain, trauma to spine.<br /> History of: Over-straining of lumber spine, lifting weight, violent coughing, sudden stooping or twisting.<br />
  4. 4. Because intervertebral disc are largest in the lumbar and lumbosacral region, where movement are consequently greater, posterolateralherniation of nucleus pulposus are common here.<br />Common site: disc at L4/L5, L5/S1 , L3/L4(rare)<br />
  5. 5. Types of herniation (Anatomy)<br />posterolateral disc herniation – <br />protrusion is usually posterolateral into vertebral canal, compress the roots of a spinal nerve<br />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 of L5)         <br />central (posterior) herniation:<br />in the lower lumbar segments, central herniation may result in S1 radiculopathy<br />less frequently, a protruded disc above second lumbar vertebra may compress spinal cord itself or or may result in caudaequinasyndrome<br />lateral disc herniation:<br />may compress the nerve root above the level of the herniation<br />L4 nerve root is most often involved & patient typically have intense radicular pain<br />
  6. 6.
  7. 7. CLINICAL FEATURES<br />Young adult<br />Back pain – Location: in lower back, radiates to gluteal region, back of thigh, calf, foot ; worse by: flexion (bending forwards) movement, coughing, stooping, turning, walking ; better by: rest, extension.<br /><ul><li>Compensatory scoliosis</li></ul>Symptoms depend on the structure involved and degree of compression: <br /><ul><li> pressure on ligament – backache
  8. 8. pressure on dural envelope of the nerve root – severe pain referred to the buttock and lower limb (sciatica)
  9. 9. pressure to the nerve itself – numbness, parasthesia,and muscle weakness
  10. 10. Compression of caudaequina – urinary retention</li></li></ul><li>Signs<br />Midline tenderness of the low back<br />Paravertebral muscle spasm – compensatory scoliosis<br />Straight leg raising test (SLR) +ve<br />Sciatic strecth test +ve<br />Cross SLR maybe +ve<br />Femoral strecth test maybe +ve (indicate prolapse at L3/L4)<br />
  11. 11. Investigation<br />X-Ray : lumbo-sacral spine<br /> • Narrowed disc spaces.• Loss of lumber lordosis.• Compensatory scoliosis.<br />CT scan lumber spine<br /> • Outline of soft tissues.• Bulging out disc.<br />MRI lumber spine<br /> • Intervertebral disc protrusion.• Compression of nerve root.<br />
  12. 12. Management Rest, Reduction, Removal & Rehabilitation<br />Conservative<br />Heat therapy, NSAIDs<br />Bed rests – During Acute attack<br />In severe cases- traction is applied to leg or pelvis, provided there is no cord compression.<br />Reginmobility gradually.<br />Advice on spinal postural<br />Restrict jerky movements, avoid forward bending, lifting weight, reduce weight if obese.<br />Operative<br />Indication : <br />Caudaequina syndrome does not clear up within 6hours of starting bed rest and traction <br />( emergency!)<br />Failed of conservative treatment<br />Neurological deterioration<br />Frequently recurring attack<br />Nerve decompression- Laminotomy+Diskectomy<br />(through post approach between adjacent vertebral laminae, dural sac is retracted to one side and bulging disc exposed. The friable partially shredded material is removed. )<br />
  13. 13. SPINAL STENOSIs<br />
  14. 14. Definition : Narrowing of spinal canal results in cord/root compression.<br />Causes:<br />Congenital stenosis - Idiopathic, osteopetrosis, achondroplasia<br />Spine degenerative - OA- narrowing spinal canal d/t hypertrophy of facet and ligflavum associated with osteophyte.<br />Spine instability - supporting lig torn/ stretched from severe back injury- bone move forward<br />Disc herniation<br />Degenerative spondylolisthesis- decreases its AP diameter <br />Trauma<br />
  15. 15. CLINICAL FEATURES<br /><ul><li>Elderly – late 5th / 6th decade
  16. 16. Back pain - worse by extension, relieved by sitting/ forward leaning
  17. 17. Numbness and paraesthesia in thighs, legs or feet
  18. 18. Spinal (neurological) claudication
  19. 19. Neurological symptom exercebrated by walking / standing</li></li></ul><li>Differentiating claudication<br />
  20. 20. Investigation<br />Lateral view XRAYs- Look for degenerative changes like spondylolisthesis, disc degeneration and disc height lost with osteophytes formation<br />CT scans (with myelogram): canal narrowing<br />MRI: evaluate cord/ root compression, extent of spinal cord narrowing<br />
  21. 21.
  22. 22. Management<br />Conservative: Control the symptoms<br /><ul><li>activity modification
  23. 23. Physiotherapy - Instruction in spinal posture, flexion exercise
  24. 24. Analgesia - NSAIDs, epidural injection
  25. 25. Protect neurological function – Vitamin B complex</li></ul>Operative:<br /><ul><li>Endoscopic spine decompression (laminectomy +/- facetectomy)</li></li></ul><li>Degenerative Disc Disease<br />
  26. 26. Degenerative disc disease involves the degeneration of intervertebraldiscs. <br />Disc properties change lead to decrease mechanical properties<br /><ul><li>With increasing age, the discs can lose flexibility, elasticity, and shock absorbing characteristics. They also become thinner as they dehydrate. When all that happens, the discs change from a supple state that allows fluid movement to a stiff and rigid state that restricts your movement and causes pain.
  27. 27. Tiny tears or cracks in the annulus fibrosus may forced out the nucleus pulposus through the tears or cracks, which causes the disc to bulge, break or rupture.</li></ul>It can take place throughout the spine, but it most often occurs in the discs in the lower back (lumbar region) and the neck (cervical region).<br />
  28. 28. CF - chronic back or neckpainw/out radiculopathy<br />High risk : smoke cigarettes ,heavy physical work (repeated heavy lifting), obese<br />A sudden (acute) injury leading to a herniated disc (such as a fall) may also begin the degeneration process.<br />As the space between the vertebrae gets smaller, there is less padding between them, and the spine becomes less stable. The body reacts to this by constructing bony growths called bone spurs (osteophytes). Bone spurs can put pressure on the spinal nerve roots or spinal cord, resulting in pain and affecting nerve function.<br />
  29. 29. Osteophyte on intervertebral foramina compress spinal nerve <br />Hypertrophic changes at vertebral margins with spur formation<br />Degeneration of lumbar IV disc<br />
  30. 30. Disc Problems<br />
  31. 31. Management<br />Conservative: <br /> Rest, activity modification, NSAIDs, +/- muscle relaxants<br /> Physical therapy: stretching, strengthening, weight control<br /> Lumbar bracing<br />Operative: <br /> Lumbar fusion, disc replacement<br />
  32. 32. Spondylosis<br />
  33. 33. Spondylosis (spinal OA) - degenerative disorder that may cause loss of normal spinal structure and function.<br />Degenerative changes in discs, facets, and uncovertebral joint<br />may affect the cervical (neck), thoracic (mid-back), or lumbar (low back) regions of the spine.<br />CF: <br /><ul><li>Cervical (Neck) : axial, neck pain, UL pain (spread into the shoulder or down the arm), paresthesia +/- weakness. Site: disc at C5/C6, C6/C7
  34. 34. Thoracic (Mid-Back) : pain triggered by forward flexion and hyperextension
  35. 35. Lumbar (Low Back) : >40, Pain and morning stiffness , worse by movement</li></ul>Can result in cord or root compression : myelopathy/radiculopathy<br />
  36. 36. Extensive thinning of cervical disc and hyperextension deformity with narrowing of intervertebral foramina<br />
  37. 37. Management<br />Conservative<br />Physiotherapy<br /> Advice on lifestyle modification<br />NSAIDS<br />Surgery<br />Surgical Indications:    - intractable pain    - progressive neurological deficit    - severe deltoid or wrist extensor weakness    - myelopathy<br />Laminectomy, removal of osteophytes, discectomy, laminaplasty<br />
  38. 38. spondylolysis<br />
  39. 39. Defect or fracture of pars interarticularis(without slip)<br />Pars interarticularis : portion of the neural arch that connects the superior and inferior articularfacet<br />Causes: hyperextension sports ( gymnasts, karate)<br />Common in paediatrics<br />Common site : L5<br />Common cause of spondylolisthesis<br />CF: insidious onset low back pain, worse with activity<br />XRAY : L-spine oblique view: “ scottydog has a collar neck”<br />Tx: rest, activity modification, physiotherapy, lumbar brace.<br />
  40. 40. Scotty dog sign<br />
  41. 41. spondylolisthesis<br />Def: Slippage/ displacement of one vertebra on adjacent vertebra<br />Spondylolisthesiscan lead to a deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) or compression of the exiting nerve roots (foraminalstenosis)<br />
  42. 42. Types of spondylolisthesis<br />Type 1: The dysplastic (congenital) type represents a defect in the upper sacrum or arch of L5.Commonly associated with spinabifida occulta and have nerve root involvement.<br />Type 2: The isthmic (early) type results from a defect in pars interarticularis, which permits forward slippage of the superior vertebra, usually L5.<br />Type 3: The degenerative (late) type is an acquired condition resulting from chronic disc degeneration and facet incompetence, leading to long-standing segmental instability and gradual slippage, usually at L4-5. Spondylosisis a general term reserved for acquired age-related degenerative changes of the spine that can lead to this type of spondylolisthesis. <br />Type 4: The traumatic (any age) type results from fracture of any part of the neural arch or pars that leads to listhesis.<br />Type 5: The pathologic type results from a generalized bone disease, such as Paget disease or osteogenesisimperfecta or tumor<br />
  43. 43. Management<br />XRAY - lateral view use to determine grade based on percentage of vertebral body slipped<br /><ul><li>Grade 1: 0- 25%
  44. 44. Grade 2: 25- 50%
  45. 45. Grade 3: 50- 75 %
  46. 46. Grade 4 : >75%</li></ul>Treatment<br /><ul><li>Low grade (1-2)- rest, activity modification, physiotherapy, lumbar bracing
  47. 47. High grade (3-4) – decompression and posterolateral fusion</li></li></ul><li>Isthmic type <br />Anterior subluxation of L5 on sacrum d/t fracture of isthmus<br />Note that gap is wider and dog appear decapitated<br />