Is a hydrostatic, load bearing
structure between the
vertebral bodies from C2-3 to
Nucleus pulposus + annulus
Is relatively avascular.
L4-5, largest avascular
structure in the body.
Vital Functions of the IVD
Restricted intervertebral joint motion
Contribution to stability
Resistance to axial, rotational, and bending load
Preservation of anatomic relationship
Is a medical condition affecting the spine 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.
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.
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
TYPES OF HERNIATION
Loss of fluid in nucleus pulposus
Bulge in the disc but not a complete rupture
Nucleus forced into outermost layer of annulus fibrosus- not a
A small hole in annulus fibrosus and fluid moves into epidural space
Disc fragments start to form outside of the disc area.
CLASSIFICATIONS OF HERNIATIONS
b) Bulging disk
c) Focal bulge or protrusion. The
nucleus material remains within the
outermost fibres of the annulus
d) Prolapse or extrusion.
The nucleus material has penetrated
the annulus fibrosus but is contained in
front of the posterior
e) Sequester or free fragment.
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.
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.
symptoms of a herniated disc can
vary depending on the location
of the herniation and the types
of soft tissue that become
Herniated discs are not
diagnosed immediately, as the
patients come with undefined
pains in the thighs, knees, or
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-
The thoracic region accounts for only 0.15% to 4.0% of cases.
Diagnosis is based on the history, symptoms, and physical
X-Ray : lumbo-sacral spine;
Narrowed disc spaces.
Loss of lumber lordosis.
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.
BETWEEN L5 AND S1
INTERVERTEBRAL DISC -
A CLASSIC PICTURE
Physical therapy include modalities to
temporarily relieve pain (i.e. traction, electrical
Patient education on proper body mechanics.
Lumbosacral back support.
Surgery is generally considered only as a last resort,
or if a patient has a significant neurological deficit.
The presence of cauda equina syndrome is
considered a medical emergency requiring
immediate attention and possibly surgical
The indications for surgery
• persistent pain and signs of sciatic tension after 2–3
weeks of conservative treatment.
• a cauda equina compression syndrome – this is an
• neurological deterioration while under conservative
INTRADISCAL ELECTROTHERMIC THERAPY (IDET)
It is a fairly advanced procedure in
which electrothermal catheter is
inserted to the intervertebral disc heats
the posterior annulus of the disk,
causing contraction of collagen fibers
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
Nucleoplasty is the most
advanced form of
developed to date.
Tissue removal from the
nucleus acts to
“decompress” the disc and
relieve the pressure exerted
by the disc on the nearby
This procedure is
used to remove part
of an intervertebral
disc that is
spinal cord or a nerve
Chemonucleolysis is the term
used to denote chemical
destruction of nucleus pulposus
This involves intradiscal
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
Removes the lamina
part to relieve spinal
stenosis or nerve
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.
lumbar fusion is only
indicated for recurrent
lumbar disc herniations, not
Artificial Disc Replacement (ADR),
or Total Disc Replacement (TDR),
is a type of arthroplasty.
It is a surgical procedure in which
discs in the spinal column are
replaced with artificial devices in
the lumbar (lower) or cervical
Used for cases of cervical disc
determining the onset,
location, and radiation of pain,
paresthesias, limited movement,
diminished function of the neck, shoulders, and
explanations about the surgery and reassurance that surgery
will not weaken the back.
Preoperative assessment also includes an evaluation of
movement of the extremities as well as bladder and bowel
To facilitate the postoperative turning procedure, the patient
is taught to turn as a unit (called logrolling)
Encouraged to take deep breaths, cough
PROVIDING PREOPERATIVE CARE
Vital signs are checked frequently and the wound is
inspected for hemorrhage
IV morphine -24-48
Sensation and motor strength of the lower extremities
are evaluated at specified intervals, along with the
color and temperature of the legs and sensation
of the toes.
Assess for CSF leakage
ASSESSING THE PATIENT AFTER SURGERY
Assess for paralytic ileus
Assess for urinary retention
Acute pain related to the surgical procedure
The patient may be kept flat in bed for 12 to 24 hours in cervical
Pillow is placed under the head and the knee rest is elevated slightly
to relax the back muscles( cervical surgery)
Extreme knee flexion must be avoided
Administering the prescribed postoperative analgesic agent,
positioning for comfort, and reassuring the patient that the pain can
Impaired physical mobility related to the postoperative
provide cervical collar cervical collar
provide L-S binders
The neck should be kept in a neutral(midline) position
Patients are assisted during position changes(log rolling)
Deficient knowledge about the postoperative course and home
A cervical collar is usually worn for about 6 weeks.
Instructed about strategies for pain management and about signs
and symptoms of complications
The nurse assesses the patient’s understanding of these management
advised to avoid heavy work for 2 to 3 months after surgery.
Exercises are prescribed to strengthen the abdominal and erector
Avoid sitting/standing for prolonged periods
Avoid twisting movements
Regular follow up