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Ldp& Cdp


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Ldp& Cdp

  1. 1. By Dr. Ashraf Shaker Lecturer of neurosurgery Mansora University
  2. 3. Low back pain <ul><li>Incidence: </li></ul><ul><li>About 90% of the population suffer from low back pain at some time. </li></ul><ul><li>30% of thesewill develop leg pain due to lumbar spine pathology. </li></ul><ul><li>The critical factor in assessing patients with LBP is whether there are also features of nerve root compression, such as leg pain or focal signs of neural compression in the lower limbs. </li></ul>
  3. 4. Sciatica <ul><li>Sciatica is the clinical description of pain in the leg due to lumbosacral nerve root compression which is usually in the distribution of the sciatic nerve . </li></ul><ul><li>The most common cause of sciatica is a lumbar disc prolapse . </li></ul><ul><li>It also occurs as a result of bony compression of the nerve root, usually by an osteophyte, and is often associated with lumbar canal stenosis or spondylolisthesis. </li></ul>
  4. 5. Lumbar disc prolapse <ul><li>Nearly 75% of the lumbar flexion–extension occurs at the lumbosacral junction ,20% at the L4/5 level and the remaining 5% is at the upper lumbar levels. </li></ul><ul><li>So it is not surprising that 90% of lumbar disc prolapses occur at the lower two lumbar levels; the most frequently affected disc is at the L5/S1 level. </li></ul><ul><li>The lumbar disc consists of an internal soft nucleus pulposus surrounded by an external laminar fibrous container, the annulus fibrosus. </li></ul>
  5. 6. <ul><li>A disc prolapse may consist of the nucleus pulposus bulging, with the annulus being stretched but intact. </li></ul><ul><li>Also the nucleus may rupture through the annulus and sequestrate as a free fragment . </li></ul><ul><li>Prolapse of the disc is usually in a posterolateral direction, as the posterior longitudinal ligament prevents direct posterior herniation . </li></ul><ul><li>Less frequently the disc may herniate laterally to trap the nerve in the neural foramen. </li></ul>
  6. 8. Patient assessment <ul><li>History taking: LBP & SCIATICA </li></ul><ul><li>The patient lies tilted to the side opposite to the sciatica, with the affected hip and knee slightly flexed taking pressure off the stretched nerve. </li></ul><ul><li>The pain is worse on movement, coughing, sneezing or straining </li></ul><ul><li>the patient may complain of sensory disturbance such as numbness or tingling in the leg or foot </li></ul><ul><li>History of sphincteric dysfunction, as a large disc prolapse may cause cauda equina compression. </li></ul>
  7. 9. <ul><li>Clinical assessment </li></ul><ul><li>Restricted lumbar movement </li></ul><ul><li>Scoliosis may be seen, usually concave to the side of the affected leg. </li></ul><ul><li>Straight leg raising :will be restricted on the affected side and, in severe cases, pain in the affected leg will be reproduced when the opposite leg is raised. </li></ul><ul><li>Wasting of certain muscle groups . </li></ul><ul><li>Motor power assessment according to The Medical Research Council (MRC) scale (M1-M5) </li></ul><ul><li>Deep tendon reflexes should be carefully tested. </li></ul><ul><li>Sensation should be tested in the foot and leg. </li></ul>
  8. 12. <ul><li>Summary of clinical features </li></ul><ul><li>L5/S1 prolapsed intervertebral disc </li></ul><ul><li>Pain along the posterior thigh with radiation to the heel </li></ul><ul><li>Weakness of plantar flexion (on occasion) </li></ul><ul><li>Sensory loss in the lateral foot </li></ul><ul><li>Absent ankle jerk. </li></ul><ul><li>L4/5 prolapsed intervertebral disc </li></ul><ul><li>Pain along the posterior or posterolateral thigh with radiation to the dorsum of the foot and great toe </li></ul><ul><li>Weakness of dorsiflexion of the toe or foot </li></ul><ul><li>Paraesthesia of the dorsum of the foot and great toe </li></ul><ul><li>Reflex changes unlikely. </li></ul>
  9. 13. <ul><li>L3/4 prolapsed intervertebral disc </li></ul><ul><li>Pain in the anterior thigh </li></ul><ul><li>Wasting of the quadriceps muscle </li></ul><ul><li>Weakness of the quadriceps function and dorsiflexion </li></ul><ul><li>of foot </li></ul><ul><li>Diminished sensation over anterior thigh, knee and medial aspect of lower leg </li></ul><ul><li>Reduced knee jerk. </li></ul>
  10. 14. Investigations <ul><li>X ray LSS: Which may reveal </li></ul><ul><li>Straight lumbar curve </li></ul><ul><li>Narrowing of disc spaces </li></ul><ul><li>Osteoarthritic changes </li></ul><ul><li>Associated spondylolisthesis &degenerative changes. </li></ul><ul><li>Lumbar myelography </li></ul><ul><li>was the time honoured investigation for lumbar disc prolapse. </li></ul><ul><li>Its invasive technique & invention of CT & MRI limited its use. </li></ul>
  11. 16. <ul><li>High-quality computerized tomography scanning </li></ul><ul><li>and magnetic resonance imaging have largely superseded myelography for the diagnosis of lumbar discprolapse. </li></ul><ul><li>The MRI is especially helpful in showing the size, configuration and position of the disc prolapse, as well as any associated nerve root or thecal compression. </li></ul><ul><li>In addition the MRI will also demonstrate pathology at other discs, such as degenerativechanges as evidenced by decreased signal in the disc on the T2-weighted scans. </li></ul>
  12. 19. Treatment <ul><li>Most patients with sciatica achieve good pain relief with simple conservative treatment and less than 20% will require surgery. </li></ul><ul><li>The likelihood of symptomatic relief without surgery is related to the pathology of the disc prolapse. </li></ul><ul><li>A‘bulging’ disc is likely to settle with simple conservative measures,. </li></ul><ul><li>But sciatica due to a nucleus pulposus that has herniated out of the disc space and ‘sequestrated’ outside the annulus will probably need surgery for satisfactory relief of symptoms. </li></ul>
  13. 20. <ul><li>Conservative treatment </li></ul><ul><li>Bed rest for a period of about 7–10 days` </li></ul><ul><li>Although traction is sometimes recommended it probably has only limited benefit and may resultin lower leg complications. </li></ul><ul><li>Simple analgesic agents and non-steroidal anti inflammatory medication. </li></ul><ul><li>High-dose corticosteroids. </li></ul><ul><li>Vitamin B complex. </li></ul><ul><li>Muscle relaxant. </li></ul>
  14. 21. <ul><li>Surgical treatment </li></ul><ul><li>Indications </li></ul><ul><li>a) Pain : especially Incapacitating pain not responding to conservative measures and recurrent episodes of pain </li></ul><ul><li>b) Neurological deficits </li></ul><ul><li>c) Central disc prolapse. Patients with bilateral sciatica or other features indicating a central disc prolapse, such as sphincter disturbance and diminished perineal sensation. </li></ul><ul><li>Aim of surgery : excision of the disc prolapse with decompression of the affected nerve root. </li></ul>
  15. 22. <ul><li>In the past the operation usually entailed a complete or partial laminectomy, identification of the compressed nerve root, its mobilization off the disc prolapse and excision of the herniated disc. </li></ul><ul><li>Recently disc prolapses can be excised with minimal disturbance to the normal bony anatomy and with the removal of only a small amount of bone. </li></ul><ul><li>A full laminectomy may occasionally be necessary prior to the disc excision of a large central disc prolapse causing cauda equina compression. </li></ul><ul><li>A percutaneous endoscopic lumbar discectomy can be done . </li></ul>
  16. 23. Cervical disc prolapse <ul><li>Cervical spine disorders predominantly cause neck pain and/or arm symptoms. </li></ul><ul><li>CDP is less common than LDP. </li></ul><ul><li>CDP occurs most frequently at the C6/7 level and slightly less commonly at the C5/6 level. </li></ul><ul><li>This is due to the force exerted at these levels which act as a fulcrum for the mobile spine and head. </li></ul>
  17. 24. <ul><li>The cervical disc consists of an internal nucleus pulposus surrounded by the external fibrous lamina, the annulus fibrosus. </li></ul><ul><li>The CDP is usually in the postero -lateral direction, because the strong posterior longitudinal ligament prevents direct posterior herniation. </li></ul><ul><li>Unlike the lumbar region, the nerves pass directly laterally from the cervical cord to their neural foramen,so that the herniation compresses the nerve at that level. </li></ul><ul><li>So aC5/6 disc prolapse will cause compression of the C6 nerve root, a C6/7 prolapse causes compression </li></ul><ul><li>of the C7 nerve roo </li></ul>
  18. 26. <ul><li>Clinical presentation </li></ul><ul><li>The characteristic presenting features of these patients </li></ul><ul><li>are neck and arm pain and the neurological manifestations </li></ul><ul><li>of cervical nerve root compression. </li></ul><ul><li>Examination </li></ul><ul><li>Restricted cervical spine movements </li></ul><ul><li>The head is often moderately flexed, and tilted towards the side ofthe pain in some patients but occasionally away </li></ul><ul><li>from it in others. </li></ul><ul><li>If the disc herniation is longstanding there may be weakness &wasting in the appropriate muscle group. </li></ul><ul><li>Sensation should be tested & the sensory loss will be characteristic for the nerve root involved although theremay be some overlap. </li></ul>
  19. 27. <ul><li>The deep tendon reflexes provide objective evidence </li></ul><ul><li>of nerve root compression in the following distribution. </li></ul><ul><li>• Biceps reflex C5 </li></ul><ul><li>• Brachioradialis (supinator) reflex C6 </li></ul><ul><li>• Triceps reflex C7 </li></ul><ul><li>A full neurological examination must be performed </li></ul><ul><li>and particular care taken to assess the lower limbs for </li></ul><ul><li>hypertonia hyperreflexia +ve babinski </li></ul>
  20. 30. <ul><li>C6/C7 prolapsed intervertebral disc ( C7 nerve root) </li></ul><ul><li>• Weakness of elbow extension </li></ul><ul><li>• Absent triceps jerk </li></ul><ul><li>• Numbness or tingling in the middle or indexFinger </li></ul><ul><li>C5/6 prolapsed intervertebral disc ( C6 nerve root) </li></ul><ul><li>• Depressed supinator reflex </li></ul><ul><li>• Numbness or tingling in the thumb or index finger </li></ul><ul><li>• Occasionally mild weakness of elbow flexion. </li></ul>
  21. 31. <ul><li>C7/T1 prolapsed intervertebral disc ( C8 nerve root) </li></ul><ul><li>• Weakness may involve long flexor muscles,triceps, finger extensors and intrinsic muscles </li></ul><ul><li>• Diminished sensation in ring and little finger and on xthe medial border of the hand and forearm </li></ul><ul><li>• Triceps jerk may be depressed. </li></ul>
  22. 32. Investigations <ul><li>MRI cervical spine: is now the investigation of choice and has almost completely replaced both myelography and CT . </li></ul><ul><li>The cervical myelogram using water-based non-ionic iodine contrast material was a most useful investigation for determining the presence and site of the disc herniation . </li></ul><ul><li>CT scanning by itself is frequently not helpful, but if performed following intrathecal iodine contrast it will demonstrate a disc herniation, and smaller volumes of intrathecal contrast are necessary than with myelography </li></ul>
  23. 36. Management <ul><li>Conservative ttt </li></ul><ul><li>Most patients with cervical disc herniation achieve good pain relief with conservative treatment </li></ul><ul><li>Bed rest ,cervical collar, simple analgesic medication, non-steroidal anti-inflammatory medication and muscle relaxants. </li></ul>
  24. 37. <ul><li>Surgical ttt </li></ul><ul><li>The most commonly performed operations </li></ul><ul><li>for cervical disc prolapse are: </li></ul><ul><li>Cervical foraminotomy with excision of the disc prolapse. </li></ul><ul><li>Anterior cervical discectomy, with subsequent </li></ul><ul><li>fusion. </li></ul>
  25. 38. THANK YOU