Lumbar Disc Herniation Naneria Part 1


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Lumbar Disc Herniation Naneria Part 1

  1. 1. Lumbar disc herniation Management of free fragments Part 1 Vinod Naneria Consultant orthopaedic surgeon Choithram Hospital & Research Centre Indore, India
  2. 2. <ul><li>A piece of nucleus pulposus with annulus fribrosus & fragments of cartilagenous end-plate, lying loose in the spinal canal. </li></ul><ul><li>It may migrate up or down a level or two, may migrate posterior to dura or perforate dura. Incidence - 9 to 15.5% </li></ul>Free fragment
  3. 3. Types of Disk Disease Disk Bulge Disk bulges into anterior epidural space without any area of focal-ness or out-pouching Disk Herniation General term used to describe different degrees of 'eccentric out-pouching' of IV disk. Protrusion contained herniation or sub-ligamentous herniation Extrusion non-contained herniation, or trans-ligamentous herniation Sequestration free fragment
  4. 4. Free Fragments Free Fragments
  5. 5. Loose Fragments
  6. 6. Literature – Free Fragment <ul><li>Incidence - 9 to 15.5% </li></ul><ul><li>Composition – N.P. / A.F. + fragments of end plate </li></ul><ul><li>Lateral migration – cranial & caudal </li></ul><ul><li>Posterior migration – cauda equina – mimic tumour </li></ul><ul><li>Intra dural more than 60 cases reported-world literature </li></ul><ul><li>Roof disc : central disc extrusion : contained by P.L.L. </li></ul>
  7. 7. Migration <ul><li>Since it is impossible to predict on MRI, that a migrated fragment have some continuity with the parent disc or not - it should be considered as loose fragment. </li></ul><ul><li>There is a real possibility of migration of the fragment and increase in the neuro-deficit. </li></ul><ul><li>It is immaterial where the migration is. </li></ul><ul><li>Migration may progress in the initial phase of extrusion, it may migrate one or two level – up or down. </li></ul>
  8. 8. Composition of extruded material <ul><li>Nucleolus pulposus </li></ul><ul><li>Annulus fibrosus </li></ul><ul><li>Fragments of cartilage end plate . </li></ul>
  9. 9. Pathophysiology of Absorption <ul><li>The disc formation takes place before the immune system develops in the embryonic life. </li></ul><ul><li>The proteins in the nucleosus pulposus are foreign to immune system in adults. </li></ul><ul><li>The free fragment is treated as foreign protein and a reactive granuloma forms, which absorbs the free fragment. </li></ul>
  10. 10. Absorption - Composition & Time <ul><li>Nucleolus Puplposus </li></ul><ul><ul><li>absorb by formation of granulation tissue possibly as an auto-immune reaction </li></ul></ul><ul><ul><li>3 months </li></ul></ul><ul><li>Annulus Fibrosus </li></ul><ul><ul><li>absorb by granulation tissue by vascular invasion </li></ul></ul><ul><ul><li>1 – 2 years </li></ul></ul><ul><li>Hyline cartilage of end-plate </li></ul><ul><ul><li>suppresses neo-vascularization </li></ul></ul><ul><ul><li>resistant to absorb </li></ul></ul>
  11. 11. <ul><li>The amount of hyaline cartilage, should be predictable on the basis of imaging data. </li></ul><ul><li>Vertebral endplate marrow signal intensity changes are associated with fissures in the vertebral end-plate. </li></ul><ul><li>Signal intensity changes may be regarded as osteo­cartilaginous fracture signs similar to other skeletal manifestations. </li></ul>
  12. 12. MRI – showing End-plate lesion, marrow signals Indicating a portion of end-plate avulsion in the extruded disc & Will take long time to absorbed or reduction in size. Early surgery may be contemplated.
  13. 13. Fate of Free Fragment – Complete absorption <ul><li>Sei A, Nakamura T et al 1994 </li></ul><ul><li>Coevoet V et al t.d. 1997 </li></ul><ul><li>Westmark RM et al c.d. 1997 </li></ul><ul><li>Miller S et al 1998 </li></ul><ul><li>Singh P, Singh AP. 1998 </li></ul><ul><li>Morandi X et al 1999 </li></ul><ul><li>Kobayashi N et al c.d. 2003 </li></ul>More than 55% of absorption is clinically significant Follow up MRI – every 3 months for one year
  14. 14. Spontaneous changes on MRI & Clinical Correlation - 42 cases treated conservatively. Takada & Takahashi <ul><li>MRI changes Cases Excellent Good Poor </li></ul><ul><li>Disappearance 08 06 02 00 </li></ul><ul><li>More  50% 29 11 18 00 </li></ul><ul><li>No reduction 05 00 01 04 </li></ul>50% involution in 3 – 6 months J.of Orthopaedic Surgery 2001, 9(1): 1–7
  15. 15. Upward behind body
  16. 16. Lateral Migration Case history – 2 - Monoradiculopathy L4 – L5 with loose fragment over L5 body EHL drop gr. 2 Complete relief 2 Yr FU
  17. 17. Downward Migration
  18. 18. Why conservative? <ul><li>Stable neurological deficit & Presented late > than one week. </li></ul><ul><li>Bearable radicular pain with negative root stretching test (SLRT). </li></ul><ul><li>No bladder or bowel dysfunction. </li></ul><ul><li>Patient not willing for surgery but gave consent for surgery as & when needed. Kept under strict watchful supervision. </li></ul>
  19. 19. R.K.- Absorption one month <ul><li>A 25 M </li></ul><ul><li>Acute agonizing pain 5 days duration </li></ul><ul><li>Spinal flexion 50%, EHL lt weak gr3 </li></ul><ul><li>No bladder – bowel dysfunction. </li></ul><ul><li>Pain minimal </li></ul><ul><li>MRI extruded disc at L5-S1 left </li></ul><ul><li>Repeat MRI after one month – extruded fragment (N.P.)absorbed completely. </li></ul>
  20. 20. Jan 2 0 0 7 Feb 2 0 0 7
  21. 21. Absorption within 3 months <ul><li>R.J. – 55 male, </li></ul><ul><li>Backache sciatica rt., acute onset. </li></ul><ul><li>Rt. Ankle jerk absent. </li></ul><ul><li>MRI-June 07- extruded fragment L5-S1 </li></ul><ul><li>Conservative </li></ul><ul><li>MRI – Aug 07- complete absorption </li></ul>
  22. 23. Complete absorption in three months.
  23. 24. N.K.- Complete absorption one year <ul><li>H/o backache sciatica 2005 – MRI degenerated discs at L4-L5, L5-S1. </li></ul><ul><li>Extruded disc in 2006 – with no neurological deficit. </li></ul><ul><li>Tx – conservatively with complete absorption of free fragment. </li></ul>
  24. 25. 2 0 0 5 2006 2006
  25. 26. 2006
  26. 27. 2 0 0 7
  27. 28. Case history – U.S. <ul><li>45 M, </li></ul><ul><li>Acute backache sciatica 15 days duration </li></ul><ul><li>Attended clinic as OPD patient. </li></ul><ul><li>L5 – S1 Rt. with loose fragment over L5 body </li></ul><ul><li>Measuring 2.4cm x 1.5cm </li></ul><ul><li>Full flexion spine and negative SLRT </li></ul><ul><li>Mild gr.4 weakness in EHL and Hypoasthesia in L5 distribution. </li></ul><ul><li>Tx conservatively </li></ul>