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  • At night while we're sleeping the discs "reconstitute" and the nucleus fills with fluid which increases the pressure on the outer annulus. This is possibly why we feel stiff and are prone to injuries on sudden movements in the morning.
  • The discs form strong joints
  • In the normal, healthy disc, the nucleus distributes the load equally throughout the anulus. As the disc undergoes degeneration, the nucleus loses some of its cushioning ability and transmits the load unequally to the anulus. In the severely degenerated disc, the nucleus has lost all of its ability to cushion the load, which can lead to disc herniation.
  • Anterior longitudinal ligament limits extension Posterior longitudinal ligament limits flexion, supports to the discs except lumbar spine Interspinous limits flexion Supraspinous ligament limits flexion and rotation Ligamentum flavum exerts pull on joint capsule
  • Protrusion the disc bulges posteriorly without rupture of the annulus fibrosus proplase only the outer most fibers of the annulus fibrosus contain the nucleus Extrusion: rupture of the annulus fibrosus and part of the nucleus palposus moves into the epidural space Sequestration formation of discal fragments from the nucleus palposus outside the disc proper As a disc degenerates, it can herniate (the inner core extrudes) back into the spinal canal, which is known as a disc herniation (or a herniated disc) A herniation may develop suddenly or gradually over weeks or months. The four stages to a herniated disc include: Approximately 90% of disc herniations will occur at L4- L5 (lumbar segments 4 and 5) ,which causes pain in the L5 nerve or L5- S1 (lumbar segment 5 and sacral segment1), which causes pain in the S1 nerve.
  • spondylosis degeneration of the IVD spondylolysis defect in the pars interarticularis or the arch Sponylolisthesis forward displacement of one vertebra over another
  • The examiner should looks for limitation of movement and its possible causes, such as pain, spasm, stiffness, or blocking.
  • Prone knee bending test. examiner is pointing to where pain may be expected in the lumbar spine with positive test Sequence of subject postures in the slump test
  • radiographs have limited diagnostic value because degenerative changes are age-related and are equally present in asymptomatic and symptomatic persons.
  • The McKenzie exercise program is believed to be one of the most beneficial. Strengthening of the abdominal and back muscles Extension and isometric exercises are performed first and, after sufficient strength and pain relief are achieved, flexion exercises are allowed. Flexion exercises are delayed because flexion motions apply the greatest load to the intervertebral disc.
  • L H D

    1. 1. بسم الله الرحمن الرحيم
    2. 2. Lumbar Herniated Disc Prepared by: Hussain Alwi AlOlweyat
    3. 3. Outlines <ul><li>Anatomy of the lumbar spine </li></ul><ul><li>Biomechanics of the lumbar spine </li></ul><ul><li>Lumbar Disc Herniation </li></ul><ul><li>Causes </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Physical Examination & Diagnosis </li></ul><ul><li>Treatment (Medical & Surgical) </li></ul><ul><li>Physical Therapy </li></ul><ul><li>Prevention </li></ul>
    4. 4. <ul><li>The lumbar region contains five lumbar vertebrae that supports the lower back. </li></ul><ul><li>The lumber vertebrae (L1-L5) are the largest and strongest in the vertebral column. </li></ul><ul><li>Between the bodies of adjacent vertebrae are intervertebral discs. </li></ul>Vertebrae Anatomy
    5. 6. Inter-Vertebral Disc (IVD) <ul><li>Each disc has two layers: </li></ul><ul><li>Annulus fibrosus: is an outer fibrous ring consisting of fibrocartilage. </li></ul><ul><li>Nucleus pulposus: is an inner soft, pulpy, highly elastic substance. </li></ul><ul><li>Over time, the discs dehydrate and become stiffer . </li></ul>
    6. 8. The Functions of Intervertebral Disc <ul><li>Permit various movements of the vertebral column </li></ul><ul><li>Shock absorber. </li></ul>
    7. 9. Distribution of Load in The IVD <ul><li>In the normal, healthy disc </li></ul><ul><li>In the mild degenerated disc. </li></ul><ul><li>In the severely degenerated disc. </li></ul>
    8. 10. Nutrition of Intervertebral Disc <ul><li>The discs are primarily avascular, with only the periphery receiving a blood supply. </li></ul><ul><li>The remainder of the disc receives nutrition by diffusion. </li></ul>
    9. 11. Ligaments <ul><li>Anterior longitudinal ligament </li></ul><ul><li>Posterior longitudinal ligament </li></ul><ul><li>Interspinous ligament </li></ul><ul><li>Supraspinous ligament </li></ul><ul><li>Ligamentum flavum </li></ul>
    10. 12. Muscles of The Lumbar Spine <ul><li>Flexion: psoas major, rectus abdominis, external abdominal oblique, internal abdominal oblique and transverse. </li></ul><ul><li>Extension: latissimus dorsi, erector spinae, transversospinalis, interspinalis, quadratus lumborum </li></ul><ul><li>Side flexion: latissimus dorsi, erector spinae, transversalis, external abdominal oblique, quadratus lumborum </li></ul>
    11. 15. <ul><li>The lumber spine support the upper body and transmits the weight of the upper body to the pelvis and lower limbs. </li></ul><ul><li>The greatest motion in the lumbar spine occurs between the L4 and L5 vertebrae and between L5 and S1. </li></ul>Biomechanics
    12. 16. Types of Forces Acting on Spine <ul><li>There are four types of forces acting on spinal structures: </li></ul><ul><li>Compression. </li></ul><ul><li>Tension. </li></ul><ul><li>Shearing force. </li></ul><ul><li>Torsional force. </li></ul>
    13. 17. Compression <ul><li>A downward force on the vertebrae compresses the discs and causes them to bulge or shorten and widen </li></ul>
    14. 18. Tension <ul><li>Tensions pull apart the structures being loaded. </li></ul><ul><li>In the spine it is the ligaments that are usually under tension, causing lengthening and narrowing </li></ul>
    15. 19. Shearing Force <ul><li>Shear forces involve the application of a load parallel to the vertebral surface </li></ul>
    16. 20. Torsional Force <ul><li>Twisting movements of the spine cause soft tissue strain through the generation of large muscle forces and loads on the intervertebral discs </li></ul><ul><li>These types of movements </li></ul><ul><li>cause the soft tissues to </li></ul><ul><li>be exposed to a combination </li></ul><ul><li>of compression, shear and </li></ul><ul><li>tension forces. </li></ul>
    17. 21. Relative increases and decreases in intradiscal pressure in relation to different body positions
    18. 22. Lumbar Disc Herniation <ul><li>Disc Degeneration or protrusion. </li></ul><ul><li>Disc Prolapse. </li></ul><ul><li>Extrusion. </li></ul><ul><li>Sequestration </li></ul>
    19. 23. <ul><li>Developmental Disorders </li></ul><ul><li>Inflammatory & Infectious Disorders </li></ul><ul><li>Trauma </li></ul><ul><li>Tumors </li></ul><ul><li>Mechanical Causes </li></ul>Causes of Herniated Disc
    20. 24. Mechanical Causes <ul><li>Common causes of annular disc tears include : </li></ul><ul><li>Prolonged sitting </li></ul><ul><li>Poor postural habits </li></ul><ul><li>Poor lifting habits </li></ul><ul><li>Improper workstation setup and ergonomics </li></ul><ul><li>Other factors have been shown to increase the susceptibility of disc injury : </li></ul><ul><li>Inadequate diet and nutrition </li></ul><ul><li>Smoking </li></ul><ul><li>Obesity </li></ul><ul><li>Lack of physical activity </li></ul>
    21. 26. Differential Diagnosis <ul><li>Spondylosis </li></ul><ul><li>Spondylolysis </li></ul><ul><li>Osteoporosis compression fractures </li></ul><ul><li>Spinal stenosis </li></ul><ul><li>Spondylolisthesis </li></ul><ul><li>Traumatic fracture </li></ul><ul><li>Congenital disease </li></ul><ul><li>Tumors </li></ul>
    22. 28. Anger/ anxiety/ stress Depression Back Pain Low mood Psychological Cycle Muscles further weakened Fear of pain/ damage (activities avoided) Muscles weakened by lack of activities Pain progresses Activities further avoided Physical cycle The Cycles of Back Pain
    23. 29. History <ul><li>Age: 30-50 years </li></ul><ul><li>Low back and leg pain (Radiated pain) </li></ul><ul><li>The onset of symptoms is characterized by a sharp, burning, stabbing pain. </li></ul><ul><li>Onset is acute (prior episodes) </li></ul><ul><li>Pain is often associated with numbness or tingling. </li></ul><ul><li>Pain is worse in positions (such as sitting) that produce increased pressure on the annular fibers. </li></ul>Clinical Assessment
    24. 30. Location of Pain in Association with Nerve Root Involvement at Each Lumbar Disc Level <ul><li>L1-L2: Pain in anterior and medial aspect of upper thigh </li></ul><ul><li>L2-L3: Pain in anterolateral thigh </li></ul><ul><li>L3-L4: Pain in posterolateral thigh and anterior tibial area </li></ul><ul><li>L4-L5: Pain in dorsum of foot </li></ul><ul><li>L5-S1: Pain in lateral aspect of foot </li></ul>
    25. 31. Physical Examination <ul><li>Observation: </li></ul><ul><li>includes Body type, Gait, Total spinal posture. </li></ul><ul><li>Palpation: </li></ul><ul><li>The spinous processes and interspinous ligaments should be palpated for tenderness. </li></ul>
    26. 32. <ul><li>AROM is performed with the patient standing. </li></ul><ul><li>Measuring ROM using Tape measure. </li></ul><ul><li>All movement should be tested </li></ul>Range of Motion (ROM)
    27. 33. Lower Limb Scanning Examination <ul><li>Should includes: </li></ul><ul><li>Sacroiliac joints </li></ul><ul><li>Hip joints </li></ul><ul><li>Knee joints </li></ul><ul><li>Ankle joints </li></ul>
    28. 34. Myotomes (MMT) <ul><li>The examiner tests the patient’s muscle power. </li></ul><ul><li>With the patient lying supine, the myotomes are assessed individually. </li></ul><ul><li>Myotomes of the lumber: </li></ul><ul><li>L1-L2: hip flexion </li></ul><ul><li>L3: knee extension </li></ul><ul><li>L4: ankle dorsiflexion </li></ul><ul><li>L5: big toe extension </li></ul>
    29. 35. <ul><li>Sensory examination includes light touch, pressure, pain….etc </li></ul>Sensations
    30. 36. <ul><li>The reflexes should be checked for difference the two sides. </li></ul><ul><li>Reflexes of the lower limb: </li></ul><ul><li>Patellar: L3-L4 </li></ul><ul><li>Posterior Tibial: L4-L5 </li></ul><ul><li>Medial hamstring: L5-S1 </li></ul><ul><li>Achilles: S1-S2 </li></ul>Reflexes
    31. 37. Special Tests <ul><li>Tests commonly performed on the lumbar spine: </li></ul><ul><li>Slump test. </li></ul><ul><li>Straight leg rising test (SLR). </li></ul><ul><li>Prone knee bending (Nachlas) test. </li></ul><ul><li>Other tests: Naffziger’s test, Fermoral nerve traction test, Valsalva maneuver ….etc. </li></ul>
    32. 38. SLR Test
    33. 39. <ul><li>The major finding on plain radiographs of patients with a herniated disc is decreased disc height . </li></ul><ul><li>Radiographs have limited diagnostic value for herniated disc. </li></ul><ul><li>The best modality for visualizing the herniated disc is magnetic resonance imaging ( MRI). </li></ul>Diagnostic Imaging
    34. 40. Magnetic Resonance Imaging ( MRI)
    35. 41. Conservative Treatment <ul><li>Nonsteroidal anti-inflammatory drugs (NSAID’s). </li></ul><ul><li>Narcotic Pain Relievers. </li></ul><ul><li>Muscle Relaxants . </li></ul>Medications
    36. 43. Physical Therapy Passive modalities Exercises Education Specific Techniques Strengthening Stretching
    37. 44. Electrotherapy
    38. 45. Education
    39. 46. Traction
    40. 47. Extension exercise
    41. 48. Swiss ball exercise
    42. 49. Strengthening Exercises
    43. 50. Stretching Exercises
    44. 51. Surgical Options <ul><li>Surgery may be considered if the patient is experiencing bowel or bladder dysfunction, increased nerve impairment, progressive weakness, incapacitating pain, or spinal instability. Surgical options are: </li></ul><ul><li>Laminectomy </li></ul><ul><li>Microdiscectomy </li></ul><ul><li>Posterior Lumbar Fusion </li></ul>
    45. 53. Prevention <ul><li>Practicing good body mechanics. </li></ul><ul><li>Regular exercise. </li></ul><ul><li>Weight management. </li></ul><ul><li>Avoid activities that require heavy lifting, trunk twisting. </li></ul><ul><li>Good nutrition </li></ul>
    46. 54. References <ul><li>Therapeutic Exercise, Foundations and Techniques </li></ul><ul><li>Orthopedic Physical Assessment. Magee D.J. </li></ul><ul><li>Basic Biomechanics of The Musculoskeletal System. Nordin M. & Frankel V.H. </li></ul><ul><li>www.spine-health.com </li></ul>
    47. 55. Thank You