2. .

3. h

4. .

6. .

7. .

9. .

12. U

13. .

14. .

15. • Is a hydrostatic, load bearing structure
between the vertebral bodies from C2-3 to L5-
S1 .
• Is relatively avascular structure and the
Essential minerals and fluids required for
regeneration enter the disks passively during
the night.

16. Vital Functions of the IVD
1-It supports the axial load on the column that is delivered by the
body mass.
2- Assist a limited range of motion at the spine.
3- Shock absorbing system.
4- Serve ligamental functions between vertebral bodies.
5- Assist to keep the normal shape & curvature of each spinal region
(cervical, thoracic, ..etc)
The Biochemical Composition
• Water : 65 ~ 90% wet wt.
• Collagen : 15 ~ 65% dry wt.
• Proteoglycan : 10 ~ 60% dry wt.
• Other matrix protein : 15 ~ 45% dry wt.

17. 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.

18. Nucleus Pulposus
 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.

19. Distribution of load in
the intervertebral disc.
(A) In the normal, healthy disc,
the nucleus distributes the load
equally throughout the anulus.
(B) As the disc undergoes
degeneration, the nucleus loses
some of its cushioning ability
and transmits the load
unequally to the anulus.
(C) In the severely degenerated
disc, the nucleus has lost all of
its ability to cushion the load,
which can lead to disc
herniation.

20.  Is a medical condition affecting
the spine due to trauma,
lifting injuries, or idiopathic, 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.
 This tear in the disc ring may result in
the release of inflammatory chemical
mediators which may directly cause
severe pain, even in the absence of
nerve root compression .
 Disc herniations are normally a
further development of a previously
existing disc "protrusion", a condition
in which the outermost layers of the
annulus fibrosus are still intact, but
can bulge when the disc is under
pressure.

21. Types of herniation
posterolateral disc herniation –
 protrusion is usually posterolateral into vertebral canal,
compress the roots of a spinal nerve.
 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.
 central (posterior) herniation:
 less frequently, a protruded disc above second lumbar vertebra
may compress spinal cord itself or or may result in cauda equina
syndrome.
 in the lower lumbar segments, central herniation may result in
S1 radiculopathy.
lateral disc herniation:
 may compress the nerve root above the level of the herniation
 L4 nerve root is most often involved & patient typically have
intense radicular pain.

22. Classifications Of Herniations
 Degeneration
 Loss of fluid in nucleus pulposus.
 Protrusion
 Bulge in the disc but not a complete rupture.
 Prolapse
 Nucleus forced into the outermost layer of the annulus
fibrosus- not a complete rupture.
 Extrusion
 the gel-like nucleus pulposus breaks through the tire-
like wall (annulus fibrosus) but remains within the disc.
 Sequestration
 Disc fragments start to form outside of the disc area.

24. Cellular and Biochemical Changes of the
Intervertebral Disc
 Decrease proteoglycan
content.
 Loss of negative charged
proteoglycan side chain.
 Water loss within the
nucleus pulposus.
 Decrease hydrostatic
property.
 Loss of disc height.
 Uneven stress
distribution on the annulus.

25. CAUSES
 Repetitive mechanical activities – Frequent bending,
twisting, lifting, and other similar activities without breaks
and proper stretching can leave the discs damaged.
 Living a sedentary lifestyle – Individuals who rarely if ever
engage in physical activity are more prone to herniated
discs because the muscles that support the back and neck
weaken, which increases strain on the spine.
 Traumatic injury to lumbar discs-
commonly occurs when lifting while bent at the waist,
rather than lifting with the legs while the back is
straight.

26. CAUSES
 Obesity – Spinal degeneration can be quickened as a
result of the burden of supporting excess body fat.
 Practicing poor posture – Improper spinal alignment while
sitting, standing, or lying down strains the back and neck.
 Tobacco abuse – The chemicals commonly found in
cigarettes can interfere with the disc’s ability to absorb
nutrients, which results in the weakening of the disc.
 Mutation- in genes coding for proteins involved in the
regulation of the extracellular matrix, such
as MMP2 and THBS2, has been demonstrated to
contribute to lumbar disc herniation.

28. Pathophysiology
 There is now recognition of the importance of
“chemical radiculitis” in the generation of back pain.
 A primary focus of surgery is to remove “pressure” or
reduce mechanical compression on a neural element:
either the spinal cord, or a nerve root.
 But it is increasingly recognized that back pain, rather
than being solely due to compression, may also be
due to chemical inflammation.

29.  There is evidence that points to a specific
inflammatory mediator of this pain.
 This inflammatory molecule, called tumor necrosis
factor-alpha (TNF), is released not only by the
herniated disc, but also in cases of disc tear (annular
tear), by facet joints, and in spinal stenosis.
 In addition to causing pain and
inflammation, TNF may also contribute to disc
degeneration.

30. Epidemiology
• Disc herniation can occur in any disc in the spine, but
the two most common forms are lumbar disc
herniation and cervical disc herniation.
• The former is the most common, causing lower back
pain (lumbago) and often leg pain as well, in which
case it is commonly referred to as sciatica.
• Lumbar disc herniation occurs 15 times more often
than cervical (neck) disc herniation, and it is one of
the most common causes of lower back pain.
• The following locations have no discs and are
therefore exempt from the risk of disc herniation: the
upper two cervical intervertebral spaces, the sacrum,
and the coccyx.

31. Epidemiology
 Most disc herniations occur when a person is in their thirties or
forties when the nucleus pulposus is still a gelatin-like substance.
 With age the nucleus pulposus changes ("dries out") and the risk
of herniation is greatly reduced.
 After age 50 or 60, osteoarthritic degeneration (spondylosis)
or spinal stenosis are more likely causes of low back pain or leg
pain.
 4.8% males and 2.5% females older than 35
experience sciatica during their lifetime.
 Of all individuals, 60% to 80% experience back pain during their
lifetime.
 In 14%, pain lasts more than 2 weeks.
 Generally, males have a slightly higher incidence than females.

32. Diagnosis & management
 Diagnosis is based on the history, symptoms, and physical
examination.
 At some point in the evaluation, tests may be performed to
confirm or rule out other causes of symptoms such
as spondylolisthesis,degeneration, tumors, metastases and
space-occupying lesions.

33.  symptoms of a herniated disc can
 vary depending on the location of the
herniation and the types of soft
tissue that become involved.
 They can range from little or no pain
if the disc is the only tissue injured,
to severe and unrelenting neck
or low back pain that will radiate into
the regions served by affected nerve
roots that are irritated or impinged
by the herniated material.
 Often, herniated discs are not
diagnosed immediately, as the
patients come with undefined pains
in the thighs, knees, or feet.

34.  sensory changes such as numbness, tingling, muscular
weakness, paralysis, paresthesia, and affection of
reflexes.
 If the disc protrudes to one side, it may irritate the dural
covering of the adjacent nerve root causing pain in the
buttock, posterior thigh and calf (sciatica).
 Unlike a pulsating pain or pain that comes and goes,
which can be caused by muscle spasm, pain from a
herniated disc is usually continuous or at least is
continuous in a specific position of the body.

35.  A large central rupture may cause compression of the
cauda equina.
 A posterolateral rupture presses on the nerve root
proximal to its point of exit through the intervertebral
foramen; thus a herniation at L4/5 will compress the
fifth lumbar nerve root, and a herniation at L5/S1, the
first sacral root.
 Sometimes a local inflammatory response with oedema
aggravates the symptoms.
 …………………………………………………………………..

36. ACUTE DISC PROLAPSE
• Acute disc prolapse may occur at any age,commonly
between 20-45 but is uncommon in the extreme of
ages.
• Typically, while lifting or stooping .

37. CLINICAL FEATURES
• The patient has severe back pain and is unable to
straighten up.
• Radiating pain to the buttock and lower limbs and is
associated with paraesthesia or numbness in the legs
or foot( sciatica) and occasionally there is muscle
weakness.
• Both backache and sciatica are made worse by
coughing or straining.
• Cauda equina compression is rare but may cause
urinary retention and perineal numbness.

38. CLINICAL FEATURES
• The patient usually stands with a slight list to one
side(‘sciatic scoliosis’).
• Sometimes the knee on the painful side is held
slightly flexed to relax tension on the sciatic nerve;
straightening the knee makes the skew back more
obvious.
• All back movements are restricted, and during
forward flexion the list may increase.

39. CLINICAL FEATURES
• There is often tenderness in the midline of the low
back, and paravertebral muscle spasm.
• Straight leg raising is restricted and painful on the
affected side; dorsiflexion of the foot and
bowstringing of the lateral popliteal nerve may
accentuate the pain.
• Sometimes raising the unaffected leg causes acute
sciatic tension on the painful side (‘crossed sciatic
tension’).
• With a high or mid-lumbar prolapse the femoral
stretch test may be positive.

40. CLINICAL FEATURES
• Neurological examination may show muscle weakness
(and, later, wasting), diminished reflexes and sensory
loss corresponding to the affected level.
• L5 impairment causes weakness of knee flexion and
big toe extension as well as sensory loss on the outer
side of the leg and the dorsum of the foot.

41. CLINICAL FEATURES
– Normal reflexes at the knee and ankle are characteristic of L5 root
compression.
– Paradoxically, the knee reflex may appear to be increased, because of
weakness of the antagonists (which are supplied by L5).
– S1 impairment causes weak plantar-flexion and eversion of the foot, a
depressed ankle jerk and sensory loss along the lateral border of the
foot.

42. FEATURES OF CAUDA EQUINA SYNDROME
Bladder and bowel incontinence
Perineal numbness
Bilateral sciatica .
Lower limb weakness
Crossed straight-leg raising sign
Note: Scan urgently and operate
urgently if a large central disc is revealed.

43. The radiating pain

44. 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.

45. .
 posterolateral
herniation
between two
vertebrae will
actually impinge on
the nerve exiting at
the next interverte
bral foramen
down.
 Occasionally an
L4/5 disc prolapse
compresses both
L5 and S1.

46. Cervical
 Cervical disc herniations occur in the neck, most often
between the fifth & sixth (C5/6) and the sixth and
seventh (C6/7) cervical vertebral bodies.
 Symptoms can affect the back of the skull, the neck,
shoulder girdle, scapula, shoulder, arm, and hand.
 The nerves of the cervical plexus and brachial
plexus can be affected.
Thoracic
 Thoracic discs are very stable and herniations in this
region are quite rare.
 Herniation of the uppermost thoracic discs can mimic
cervical disc herniations, while herniation of the other
discs can mimic lumbar herniations.

47. Lumbar
 Lumbar disc herniations occur in the lower back, most
often between the fourth and fifth lumbar vertebral
bodies or between the fifth and the sacrum.
 Symptoms can affect the lower
back,buttocks, thigh, anal/genital region (via
the Perineal nerve), and may radiate into the foot
and/or toe.
 The sciatic nerve is the most commonly affected
nerve, causing symptoms of sciatica.
 The femoral nerve can also be affected and cause the
patient to experience a numbness, tingling feeling
throughout one or both legs and even feet or even a
burning feeling in the hips and legs.

48. DISC LOAD IN DIFFERENT BODY POSTURE
When the spine is straight, such as in standing or lying down,
internal pressure is equalized on all parts of the discs.
 While sitting or bending to lift, internal pressure on a disc can
move from 17 (lying down) to over 300 psi (lifting with a
rounded back).

49. Physical Examinations
 Finding include
positive straight leg
raise (lasegue sign)
which is the most
predictive finding if
it reproduces leg
pain for HNP with
L5 or S1
radiculopathy.
 as this finding has
low specificity;
however, it has
high sensitivity.
 Thus the finding of
a negative SLR sign
is important in
helping to "rule
out" the possibility
of a lower lumbar
disc herniation.

50. Examination With the
patient standing upright
look at his general posture
and note particularly the
presence of
any asymmetry or frank
deformity of the spine .

51. Then ask him to lean
backwards
(extension)

52. Forwards to touch
his toes
(flexion)

53. Then sideways as
far as possible

54. Hold the pelvis
stable and ask the
patient to twist first
to one side and then
to the other
(rotation).

55. With the patient upright, select two bony points 10 cm apart
and mark the skin as
the patient bends forward, the two points should separate by
at least a further 5 cm.

56. Examination with the patient prone
(a) Feel for tenderness, watching the patient’s face for any reaction.
(b) Performing the femoral stretch test.
You can test for lumbar root sensitivity either by hyperextending the hip or by
acutely flexing the knee with the patient lying prone.
Note the point at which the patient feels pain and compare the two sides.
(c) While the patient is lying prone, take the opportunity to feel the pulses. The
popliteal pulse is easily felt if the
tissues at the back of the knee are relaxed by slightly flexing the knee.

57. Sciatic stretch tests
(a) Straight-leg raising. The A B
knee is kept absolutely
straight while the leg is
slowly lifted (or raised by the
patient himself); note where
the patient complains of
tightness and pain in the
buttock – this normally
occurs around 80 or 90°.
(b) At that point a more
acute stretch can be applied
by passively dorsiflexing the
foot – this may cause an
added stab of pain. C D
(c) The‘bowstring sign’ is a
confirmatory test for sciatic
tension. At the point where
the patient experiences pain,
relax the tension by bending
the knee slightly; the pain
should disappear. Then apply
firm pressure behind the
lateral hamstrings to tighten
the common peroneal nerve
(d); the pain recurs with
renewed intensity.

58. X-Ray : lumbo-sacral spine;
 Narrowed disc spaces.
 Loss of lumber lordosis.
 Compensatory scoliosis.
CT scan lumber spine;
 It can show the shape and
size of the spinal canal, its
contents, and the structures
around it, including soft tissues.
 Bulging out disc.
MRI lumber spine;
 Intervertebral disc protrusion.
 Compression of nerve root.
Myelogram;
 pressure on the spinal cord or
nerves, such as herniated discs,
tumors, or bone spurs.

59. Normal MRI

61. .

62. ..

64. medical treatments.
 Bed rest.
 Non-steroidal anti-inflammatory drugs (NSAIDs).
 Patient education on proper body mechanics.
 Physical therapy, to address mechanical factors, and may
include modalities to temporarily relieve pain
(i.e. traction, electrical stimulation massage).
 Oral steroids (e.g. prednisone or methylprednisolone).
 Epidural cortisone injection.
 Intravenous sedation, analgesia-assisted traction therapy
(IVSAAT).
 Weight control.
 Tobacco cessation.
 Lumbosacral back support.
 anti-depressants.

65. Indication of Surgery
Ideal candidate
• history, physical examination, radiographic finding, are
consistent with one another
• when discrepancy exist, the clinical picture should serve as the
principal guide.
Absolute surgical indication
• cauda equina syndrome.
• acute urinary retension/incontinence,
saddle anesthesia, back/buttock/leg pain, weakness, difficulty
walking.
Relative indication
• progressive weakness.
• no response to conservative treatment.

66. The objectives of surgical treatment
1. relief of nerve compression.
2. allowing the nerve to recover.
3. relief of associated back pain.
4. restoration of normal function.

67. Chemonucleolysis-
• Chemonucleolysis is the term
used to denote chemical
destruction of nucleus pulposus .
• This involves 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.
• Chemonucleolysis is one of the
methods to treat disc herniation
not responding to conservative
therapy.

68. Intradiscal electrothermic therapy (IDET)
 IDET is a minimally invasive outpatient
surgical procedure developed over
the last few years to treat patients
with chronic low back pain that is
caused by tears or small herniations
of their lumbar discs.
 provides a new alternative and a
dvanced procedure made possible by
the development of electrothermal
catheters that allow for careful and
accurate temperature control.
 The procedure works by cauterizing
the nerve endings within the disc
wall to help block the pain signals

69. Discectomy/Microdiscectomy -
• This procedure is used
to remove part of an
intervertebral disc that
is compressing the
spinal cord or a nerve
root.

70. The Tessys method
• The Tessys method
(transforaminal
endoscopic surgical
system) is a minimally
invasive surgical
procedure to remove
herniated discs .

71. Laminectomy-
to relieve spinal
stenosis or nerve
compression

72. Hemilaminectomy -
Hemilaminectomy is
surgery to help alleviate
the symptoms of an
impinged or irritated
nerve root in the spine

73. Lumbar fusion
• Anterior lumbar fusion is an
operation done on the
front (the anterior region) of the
lower spine.
• Fusion surgery helps two or more
bones grow together into one solid
bone.
• Fusion cages are new devices,
essentially hollow screws filled with
bone graft, that help the bones of the
spine heal together firmly.
• Surgeons use this procedure when
patients have symptoms from disc
degeneration, disc herniation, or
spinal instability.
• lumbar fusion is only indicated for
recurrent lumbar disc herniations,
not primary herniations

74. Disc arthroplasty
• Artificial Disc Replacement
(ADR), or Total Disc Replacement
(TDR), is a type of arthroplasty.
• It is a surgical procedure in which
degenerated intervertebral
discs in the spinal column are
replaced with artificial devices in
the lumbar (lower) or cervical
(upper) spine.
• The procedure is used to treat
chronic, severe low back pain and
cervical pain resulting
from degenerative disc disease.
• Used for cases of cervical disc
herniation.

75. Dynamic stabilization
• Dynamic stabilization is a surgical
technique designed to allow for
some movement of the spine,
while maintaining enough
stability to prevent too much
movement.
• If you need to undergo surgery
for spinal disc problems, you may
also need added stabilization of
the spine to prevent additional
problems

76. Nucleoplasty
• Nucleoplasty is the most
advanced form of
percutaneous discectomy
developed to date.
• Nucleoplasty uses a unique
technology to remove tissue
from the center of the disc.
• Tissue removal from the
nucleus acts to “decompress”
the disc and relieve the
pressure exerted by the disc
on the nearby nerve root .
• As pressure is relieved the
pain is reduced

77. Complications
Cauda equina syndrome
Chronic pain
Peminant nerve injury
Paralysis

78. 1-Spine: 15 January 2012 - Volume 37 - Issue 2 - p 140–149
Who Should Have Surgery for an Intervertebral Disc Herniation?:
• Comparative Effectiveness Evidence From the Spine Patient Outcomes Research
Trial Pearson, Adam MD, MS; Lurie, Jon MD, MS; Tosteson, Tor ScD; Zhao, Wenyan
MS; Abdu, William MD, MS; Mirza, Sohail MD, MPH; Weinstein, James DO, MS
 Abstract
• Study Design. Combined prospective randomized controlled trial and
observational cohort study of intervertebral disc herniation (IDH), an as-treated
analysis.
 Objective.
• To determine modifiers of the treatment effect (TE) of surgery (the difference
between surgical and nonoperative outcomes) for intervertebral disc herniation
(IDH) using subgroup analysis.
 Methods.
• IDH patients underwent either discectomy (n = 788) or nonoperative care (n = 404)
and were analyzed according to treatment received.
• Thirty-seven baseline variables were used to define subgroups for calculating the
time-weighted average TE for the Oswestry Disability Index (ODI) across 4 years (TE
= ΔODIsurgery −ΔODInonoperative).
• Variables with significant subgroup-by-treatment interactions (P < 0.1) were
simultaneously entered into a multivariate model to select independent TE
predictors.

79. Results.
All analyzed subgroups improved significantly more with
surgery than with nonoperative treatment .
In minimally adjusted univariate analyses, being married,
absence of joint problems, worsening symptom trend at
baseline, high school education or less, older age, no worker's
compensation and longer duration of symptoms were
associated with greater Tes.
Conclusion.
• IDH patients who met strict inclusion criteria improved more
with surgery than with nonoperative treatment, regardless of
specific characteristics.
• However, being married, without joint problems, and
worsening symptom trend at baseline were associated with a
greater TE.
• © 2012 Lippincott Williams & Wilkins, Inc

80. 2-The impact of the Spine Patient Outcomes Research
Trial (SPORT) results on orthopaedic practice.
2012 Mar;20(3):160-6
Department of Orthopaedic Surgery, University of Cincinnati College of
Medicine, Cincinnati, OH, USA.
• Abstract
The benefits of spinal surgery for relief of low back and leg pain in patients
with degenerative spinal disorders have long been debated.
• The trial studied the outcomes of the surgical and nonsurgical management
of three conditions: intervertebral disk herniation, degenerative
spondylolisthesis, and lumbar spinal stenosis.
• Result;
• Both surgical and nonsurgical care of intervertebral disk herniation resulted
in significant improvement in symptoms of low back and leg pain.
• Still, the treatment effect of surgery for intervertebral disk herniation was
less than that seen in patients who underwent surgical versus nonsurgical
treatment of degenerative spondylolisthesis and lumbar spinal stenosis.
• Across SPORT, more significant degrees of improvement with surgery were
noted in chronic conditions of lumbar spinal stenosis and lumbar spinal
stenosis with spondylolisthesis.
• In addition, no catastrophic progressions to neurologic deficit occurred as a
result of watchful waiting.

81. 3-[Lumbar epidural steroid injection: Is the success rate predictable?].
Department of Orthopedics and Traumatology, Başkent University, Adana
Medical
Center, Ankara, Turkey.march 2012
 OBJECTIVES:
 The aim of this study was to determine the relation between the percent of
canal compromise and success rate of epidural steroid injection (ESI) in
patients with symptomatic lumbar herniated intervertebral discs.
 RESULTS:
 39 patients (14 male, 25 female) were included in this study.
 The mean age was 50.2±11.6 years (27-76).
 Twenty-one cases (51%) also had back pain.
 The mean percent canal compromise ratio was 36.1±2.4%.
 The mean duration of symptoms was 19.4±6.6 months.
 There was also a significant negative correlation between percent canal
compromise and post-injection VAS (p=0.042). However, there was no
correlation between post-injection VAS and age, sex, or location or type of
herniation (p>0.05).
 CONCLUSION:
 It has been demonstrated that higher benefits of ESI were achieved in
patients with short duration of symptoms and high percent of canal
compromise.

82. 4-Future treatments may include stem cell
therapy.
• Doctors Victor Y. L. Leung, Danny Chan and Kenneth
M. C. Cheung have reported in the European Spine
Journal
• that "substantial progress has been made in the field
of stem cell regeneration of the intervertebral disc.
• Autogenic mesenchymal stem cells in animal models
can arrest intervertebral disc degeneration or even
partially regenerate it and the effect is suggested to
be dependent on the severity of the degeneration.