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PROLAPSE DISC (Slip Disc )
Herni...
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DEFINITION
Outpouching of disc
N...
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InterVertebral Disc
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NUTRITION TO DISC
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FUNCTION OF DISC
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EFFECT OF AXIAL LOADING
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Biochemical Change After Stress
...
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IN RELATION TO POSTURE
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WHY DISC PROLAPSE IS MOST COMMON...
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ETIOLOGY
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PATHOPHYSIOLOGY OF LUMBAR INTERV...
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!
Extruded disc &
degraded nucle...
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EFFECT OF SMOKING
Blood vessel g...
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ANNULUS
IN TACT
!
Facet joints s...
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STAGES OF DISC PROLAPSE
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Herniation v.s Bulge
Contained d...
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Types of Disc Herniation (Contai...
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Degree and location of disc
frag...
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Types of Disc Herniation

(Non-c...
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AXIAL LOCATION
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SAGITTAL SECTION
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LIST (SCIATIC SCOLIOSIS)
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RELATION OF INTRADISCAL PRESSURE...
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MOTION SEGMENT
ANTERIOR
ELEMENT
...
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DISC & NERVE ROOT RELATION
L5 is...
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Aging Disc
• Loss of cells
• Deh...
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HIVD
• Paracentral herniation is...
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• 95% involves L3-4 or L4-5
• Mo...
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• The likely of recovery of neur...
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Lumbar Disc Herniation

Pathophy...
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Pathophysiology of H.I.V.D.
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Ventral ramus, sympathetic chain...
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Lumbar Disc Herniation

Pathoana...
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Lumbar Disc Herniation
• Disc He...
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Symptoms of H.I.V.D.
• 1% of gen...
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CONTRALATERAL LEG RAISING TEST
(...
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WHY PAIN OCCURS ON AFFECTED SIDE...
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Symptoms
• Sudden onset back pai...
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Symptoms
• Radicular pain accomp...
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CAUDA EQUINA SYNDROME
• Marked r...
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KEY DIAGNOSTIC POINTS
LUMBAR DIS...
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SPINAL STENOSIS
➢ Back and/or le...
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Physical Examination
Motor, Sens...
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Sensory Dermatome
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Diagnosis of H.I.V.D.
• History ...
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L4
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L5
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S1
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DISCOGRAHY
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Lumbar Disc Herniation

Manageme...
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Nonsurgical Rx
• Bed Rest (80% r...
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CORRECT SLEEPING POSTURE
BED REST
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IN RELATION TO MANUAL MATERIALS
...
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FOR ACUTE STAGE
!
BRIDGING EXERC...
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FOR RECOVERY OR SUBACUTE STAGE
!...
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Lifestyle Changes That Help Elim...
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DO’S & DON’T’S
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EPIDURAL STEROID INJECTION
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What Is Muscle-Balance
Therapy?!...
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What Is Inversion Therapy?!
As t...
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Indication for Surgical Rx
•Prog...
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CONTRAINDICATIONS FOR SURGERY
...
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• Persistent intractable pain> 6...
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Surgical Rx of Lumbar HIVD
!
• T...
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•Limited open lumbar
laminotomy ...
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LAMINOTOMY & DISCECTOMY
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Percutaneous Endoscope Discectomy
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Indication
• Radicular pain
• Po...
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PED Procedures (Marking)
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PED Procedures (Discography)
PED...
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PELD Indications for good result...
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MED

(MicroEndoscopic Discectomy...
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Procedures
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Endoscope-guide Discectomy
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Scope Images
Disc
Lig. Flavum
Lo...
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Potential disadvantages
• Learni...
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PED & MED
PED
MED (laminotomy)
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Lumbar Disc Herniation

Prognosi...
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DISC REPLACEMENT
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Lumbar Disc Herniaiton
• Lumbar ...
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Recurrent Herniation and Reopera...
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Intervertebral Disc Surgery
• Th...
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Complications
• Incidental durot...
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Recurrent disc herniation
•Focal...
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Recurrent disc herniation
•Less ...
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FAILED BACK SYNDROME
It is a con...
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Key point of lumbar HIVD
• HIVD ...
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This presentation is for  doctor...
Life laughs at
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are unhappy...
Life smiles at you when you
are happy…

Life salutes you when
you make others h...
Every successful person has a
painful story.

Every painful story has a
successful ending.

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Be bold when you loose

and be calm when you win.
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PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc

 AGRASEN HOSPITAL Gondia Vidarbha DR SANDEEP C AGRAWAL www.drsandeepagrawal.com www.agrasenortho.com

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Herniated Disk in the Lower Back
Sometimes called a slipped disc, a herniated disk most often occurs in your lower back. It is one of the most common causes of low back pain, as well as leg pain (sciatica).

Herniated Disc symptoms: sharp, burning or stabbing pain in back, may also run down leg; onset is often sudden.

Condition and Causes

Between 60% and 80% of people will experience low back pain at some point in their lives. A high percentage of people will have low back and leg pain caused by a herniated disk.

Although a herniated disk can sometimes be very painful, most people feel much better with just a few weeks or months of nonsurgical treatment.

Published in: Health & Medicine
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PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc

 AGRASEN HOSPITAL Gondia Vidarbha DR SANDEEP C AGRAWAL www.drsandeepagrawal.com www.agrasenortho.com

  1. 1. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc
 
 Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India drsandeep123@gmail.com Visit us at: www.drsandeepagrawal.com www,agrasenortho.com
  2. 2. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com DEFINITION Outpouching of disc Nucleus pulposus along with few annular fibres and end plate cartilage through tears in annulus fibrosus into the extradural space.
  3. 3. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  4. 4. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com InterVertebral Disc
  5. 5. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com NUTRITION TO DISC
  6. 6. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com FUNCTION OF DISC
  7. 7. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com EFFECT OF AXIAL LOADING
  8. 8. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Biochemical Change After Stress • Matrix protein loss • Loss of hydrostatic pressure • Bulking of annular lamellae • Annulus wall shear stress ↑, Tear • Axial back pain & dysfunction
  9. 9. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com IN RELATION TO POSTURE
  10. 10. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com WHY DISC PROLAPSE IS MOST COMMON POSTEROLATERALLY?

  11. 11. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com ETIOLOGY
  12. 12. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com PATHOPHYSIOLOGY OF LUMBAR INTERVERTEBRAL DISC PROLAPSE
 With aging, vascular channels start to fail and vascular diffusion of nutrients decrease thus number of viable chondrocytes in the nucleus pulposus diminishes ! Synthesis rate & concentration of proteoglycans decreases & proportion of collagen increase in nucleus pulposus ! Water binding capacity of the nucleus decreases ! Nucleus becomes more fibrous & stiffer ! Nucleus is less able to bear & disburse load, transferring load to the posterior annulus
  13. 13. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com ! Extruded disc & degraded nuclear material impinge on the nerve roots Nucleus pulposus is an immunogenic which induce an inflammatory response Produces radicular pain syndrome & RADICULOPATHY
  14. 14. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com EFFECT OF SMOKING Blood vessel get constricted Transport of nutrients & disposal of waste products decreased Disc cells get deficient nutrition or die Disc degenerates & results in DISC INSTABILITY
  15. 15. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com ANNULUS IN TACT ! Facet joints share even more of the axial load ! Facet joints undergo degenerative changes & develop osteophytes ! FACET JOINT SYNDROME
  16. 16. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com STAGES OF DISC PROLAPSE
  17. 17. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  18. 18. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Herniation v.s Bulge Contained disc : Herniation disc displacement of inner disc material => annulus fibrosus with focal asymmetric outer circumference • Bulge : generalized outpouch peripheral margin of annulus without focal displacement of inner disc material Herniation Bulge, Protrusion
  19. 19. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Types of Disc Herniation (Contained) Bulging Protrusion
  20. 20. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Degree and location of disc fragment displacement • Noncontained • Extrusion : remains in continuity with inner disc through annular defect • Sequestration : no direct continuity with inner disc
  21. 21. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Types of Disc Herniation
 (Non-contained) Extrusion Sequestered
  22. 22. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com AXIAL LOCATION
  23. 23. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com SAGITTAL SECTION
  24. 24. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com LIST (SCIATIC SCOLIOSIS)
  25. 25. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com RELATION OF INTRADISCAL PRESSURE AND POSTURE
  26. 26. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com MOTION SEGMENT ANTERIOR ELEMENT POSTERIOR ELEMENT
  27. 27. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com DISC & NERVE ROOT RELATION L5 is TRAVERSING NERVE ROOT ! L5 is EXITING NERVE ROOT
  28. 28. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Aging Disc • Loss of cells • Dehydration • Annular fissures • Mechanical incompetence • Osteophyte
  29. 29. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com HIVD • Paracentral herniation is the most common pattern and compress the lower existing nerve nerve root • Extraforaminal herniation is more likely compress the upper nerve root • The tumor necrosis factor-α may be a key factor of the pain process • The effects of mechanical deformation are compounded by chemical sensitization of nerve root • The inflammatory factors around the nerve root and dorsal root ganglion includes IL-1, IL-6, PGE-2 and phospholipase A2 • These factors incites vascular changes around nerve root and direct effect on the blood-nerve barrier, promoting intraneural edema and reducing neuronal perfusion
  30. 30. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com • 95% involves L3-4 or L4-5 • Most patients are between the ages of 20 and 50 years • In lumbar disc herniation, SLRT is sensitive and specific • The crossed straight leg raising test has a lower sensitivity, but much higher specificity • Nonsurgical treatments result in good resolution of symptoms in up to 80-90% patients • The surgical results are better in smaller disc herniation • Large extrusive disc herniation has greater likelihood of total resorption
  31. 31. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com • The likely of recovery of neurologic deficit is dependent of surgical intervention • Patients with painless neurologic deficit still require surgery • Patients with painless neurologic deficit require surgery only when functional weakness in a major muscle group and no return of function after 6 weeks • The sensory nerve fibers are affected first and recover last • Recurrent HIVD at the same level: 5% at 5-years F/U • HIVD in elder patient commonly combined with spinal stenosis or spondylolisthesis and more frequent in the upper lumbar levels. Spontaneous resorption and improvement is less likely • Neurologic deficit in young patients with HIVD is common and the herniation is frequently an avulsed ring apophysis • Foraminal epidural steroid injections may help in combating the chemical mediators of pain and inflammation associated with disc herniation • A positive nerve block response indicated by a reduction of leg pain by more than 50%
  32. 32. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Lumbar Disc Herniation
 Pathophysiology • TNF-α: sensitizing the nerve root after mechanical deforming force. • Inflammatory cytokines in the nerve root and dorsal root ganglion • Promoting intraneural edema and reducing neuronal perfusion
  33. 33. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Pathophysiology of H.I.V.D.
  34. 34. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Ventral ramus, sympathetic chain, dorsal root ganglion
  35. 35. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Lumbar Disc Herniation
 Pathoanatomy • Disc material: nucleus pulposus, cartilage, annulus fibrosis, apophyseal bone • Herniated disc <-> disc bulge • Herniated disc: protrusion, extrusion, sequestration • Containment • Location: central, paracentral, foraminal, extraforaminal • Axillary vs Shoulder • L4-L5 disc compressing L5 root (paracentral), compressing L4 root
  36. 36. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Lumbar Disc Herniation • Disc Herniation in the Elderly – Spinal stenosis, spondylolisthesis – Upper lumbar spine – SLRT commonly negative – Chronic fibrosis of the roots – Spontaneous improvement is less likely • Disc Herniation in Young Patients – 1% to 3% of all HIVD – Herniation: an avulsed apophysis
  37. 37. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Symptoms of H.I.V.D. • 1% of general population annually • L4-L5, L5-S1 disc • 20 – 50 years old • Aggravated by coughing, sneezing, sitting • SLRT – Sensitive, not specific • Crossed SLRT – Lower sensitivity, higher specificity • Nerve root tension: develops at 35° - 70° • 1% to 10% (underwent surgery) with cauda equina syndrome Lumbar Disc Herniation
 Clinical Features
  38. 38. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com CONTRALATERAL LEG RAISING TEST (FRAJERSZTAGN TEST)
  39. 39. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com WHY PAIN OCCURS ON AFFECTED SIDE ON RAISING NORMAL LEG? AFFECTED SIDE NORMAL SIDE
  40. 40. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Symptoms • Sudden onset back pain => highly innervated outer annular fibers tear • Back pain abate shortly => depressurization and relief annular tension • Back pain persist => large central disc irritation of PLL
  41. 41. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Symptoms • Radicular pain accompanied by paresthesias and varying degree motor, sensory and reflex loss • Activity accentuate pain ( cough, sneeze ) => intraspinal and intradiskal pressure ⇑ • Cauda equian syndrome : incontinence of bowel and bladder, bilateral leg motor weakness, saddle anesthesia ( triad )
  42. 42. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  43. 43. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com CAUDA EQUINA SYNDROME • Marked reduction in SLRT • Saddle anaesthesia • Bilateral ankle jerk depression • Involuntary overflow incontinence • Decreased tone in external sphincter
  44. 44. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com KEY DIAGNOSTIC POINTS LUMBAR DISC PROLAPSE ➢ Leg pain greater than back pain ➢ Neurological deficit present ! ANNULAR TEARS ➢ Back pain greater than leg pain ➢ Bilateral SLRT positive ! FACET JOINT ARTHROPATHY ➢ Localized tenderness present unilaterally over joint ➢ Pain occurs immediately on spinal extension ➢ Pain exacerbated with ipsilateral side bending
  45. 45. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com SPINAL STENOSIS ➢ Back and/or leg pain develops after walks a limited distance. ➢ Flexion relieves symptoms ➢ No neurological deficit ➢ Pain not reproduced on SLRT MYOGENIC OR MUSCLE RELATED ➢ Pain localised to affected muscle ➢ Pain increases on prolonged muscle use ➢ Pain reproduced with sustained muscle contraction against resistance ➢ Contralateral pain with side bending
  46. 46. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Physical Examination Motor, Sensory, Reflex
  47. 47. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Sensory Dermatome
  48. 48. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Diagnosis of H.I.V.D. • History ,Symptom,sign, and P.E. 90% • SLRT(straight leg raising test) + • Image study •Computer Tomogram •Magnetic Resonance Image
  49. 49. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com L4
  50. 50. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com L5
  51. 51. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  52. 52. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com S1
  53. 53. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com DISCOGRAHY
  54. 54. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  55. 55. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  56. 56. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Lumbar Disc Herniation
 Management • Conservative treatment – Alters the natural history ? • Foraminal epidural steroid injection – Positive response: more than 50% leg pain improvement – 3 to 4 times in one year • Absolute indication for surgery – Bladder and bowel symptoms – Progressive neurologic deficit • Relative indication for surgery – Intractable pain more than 6 weeks • Three sciatica episodes -> 100% future episodes • Gold standard: laminotomy + discectomy • Extraforaminal disc: Wiltse paraspinal approach
  57. 57. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Nonsurgical Rx • Bed Rest (80% resolution within 6 weeks), herniated disc reduced in size over time ( water content loss, inflammatory cytokines reduction) • Medication • Activity modification • Steroid injection => improved symptoms • Chymopapain –Possible anaphylatic shock Lyman Smith, 1963
  58. 58. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com CORRECT SLEEPING POSTURE BED REST
  59. 59. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com IN RELATION TO MANUAL MATERIALS HANDLING
  60. 60. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com FOR ACUTE STAGE ! BRIDGING EXERCISE ! KNEE HUGS
  61. 61. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com FOR RECOVERY OR SUBACUTE STAGE ! EXTENSION CONTROL ! HAMSTRING STRETCH ! KNEE ROLLS
  62. 62. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  63. 63. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Lifestyle Changes That Help Eliminate Pain :! Tip #1:
 Use Your Body Symmetrically! Tip #2:
 Make Your Work Area Posture Friendly! Tip #3:
 Use a Telephone Headset! Tip #4:
 Make Your Car Seat Posture Friendly! ! Tip #5:
 Use Posture Support Devices! Tip #6:
 For Women: Limit the Use and Height of High Heels! !
  64. 64. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com DO’S & DON’T’S
  65. 65. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com EPIDURAL STEROID INJECTION
  66. 66. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com What Is Muscle-Balance Therapy?! Muscle-Balance Therapy is an innovative approach to eliminating back pain (and just about any other ailment) by addressing the imbalances in your muscles.! The Muscle-Balance Therapy approach begins by assessing the strength and flexibility of your muscle pairs—in your hips, pelvis, spine, and throughout the body.!
  67. 67. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com What Is Inversion Therapy?! As the name states, inversion therapy actually “inverts” the body to an upside-down position.! Imagine a balloon, for instance, one of those long ones that can be twisted into different shapes to make balloon animals. If you were to squish one side with your fist, all the air in the balloon would form a bulge at the other side. Keep pressing and eventually you could force the other end of the balloon to burst.! Discs operate much the same way. As muscle imbalances— and gravity—apply uneven pressure on a disc, the disc bulges to one side. This is what happens in the case of a herniated disc.! How Does Inversion Therapy Help?! Inversion therapy literally reverses the compression caused by gravity— and in part, muscle imbalances. In essence, it reverses the pressure on the spine that is a result of gravity and muscle imbalances. Instead of compressing your discs and making you shorter, inversion therapy—by allowing you to hang upside down—actually stretches the spine out, as well as the muscles supporting the spine and torso, giving the discs room to reabsorb fluids and move back into their proper positions—eliminating pressure on nearby nerves.!
  68. 68. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Indication for Surgical Rx •Progressive neurological deficit •Cauda equina syndrome •Persistent radiculopathy with 6 weeks conservative treatment •Recurrent sciatica •Motor defect with tension sign and pain •Pseudoclaudication ( activity related leg pain )
  69. 69. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com 
 CONTRAINDICATIONS FOR SURGERY
 • Wrong patient ( poor potency for recovery) • Wrong diagnosis • Wrong level • Painless HNP (do not operate for primary complaint of weakness or paresthesia, in the absence of pain) • Inexperienced surgeon applying poor technical skills • Lack of adequate instruments
  70. 70. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  71. 71. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com • Persistent intractable pain> 6 weeks ! surgery • Disc herniation into stenotic cannal, patients can not comply with dictates of conservative regimen, numbers of csiatica episodes are also surgical indications • Absolute surgical indications are bladder and bowel involvement and progressive neurologic deficit • The laminotomy and diskectomy is the gold standard for surgical treatmentof posterolateral HIVD • Wiltse paraspinal approach is for extraforaminal HIVD • Endoscopic discectomy – PED – MED Surgical Treatment
  72. 72. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Surgical Rx of Lumbar HIVD ! • Traditional Open Discectomy • Microscopic Discectomy) (AMD) • AMD(Arthroscopic MicroDiscectomy) PED (Percutaneous Endoscopic Discectomy) - Hijikata and Kambin, early 1970’s • MED (MicroEndoscopic Discectomy
  73. 73. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com •Limited open lumbar laminotomy and disectomy – remove only the displaced fragment and nearby loose intradiscal fragment - 90 % success •Unilateral partial medial facetectomy – lateral recess preexisting stenosis Open Discectomy
  74. 74. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com LAMINOTOMY & DISCECTOMY
  75. 75. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Percutaneous Endoscope Discectomy
  76. 76. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  77. 77. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Indication • Radicular pain • Positive root tension sign • Positive imaging study • Persisted symptom at least 6 weeks of proper conservative treatment
  78. 78. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com PED Procedures (Marking)
  79. 79. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com PED Procedures (Discography) PED Procedures (Wound)
  80. 80. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com PELD Indications for good result • Soft disc content (CT) • Contained or not sequestrated (MRI) • Without spinal stenosis • Without instability • Young age (<40 Y/O) • Shorter S/S duration (3-6Ms)
  81. 81. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com MED
 (MicroEndoscopic Discectomy) • 1997 , Smith & Foley • Minimal damage • Direct visualization by
 a. Muscle-splitting dilators
 b. Endoscope and Video monitor
  82. 82. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  83. 83. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Procedures
  84. 84. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Endoscope-guide Discectomy
  85. 85. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Scope Images Disc Lig. Flavum Lower edge of L4
  86. 86. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Potential disadvantages • Learning curve • Limited visualization • Inadequate exposure • Incomplete decompression • Vessel & nerve damage • Limited ability to treat lateral recess and foraminal stenosis
  87. 87. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com PED & MED PED MED (laminotomy)
  88. 88. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Lumbar Disc Herniation
 Prognosis and Outcome Following Intervention • 80% - 90% obtains satisfactory recovery • Resorption is possible • Favorable nonsurgical treatment – Less than 6 months – Younger patients – No litigation • Recovery of neurologic deficit is independent of surgical intervention • After recovery of motor deficit, 30% sensory deficit despite resolution of pain
  89. 89. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com DISC REPLACEMENT
  90. 90. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Lumbar Disc Herniaiton • Lumbar radicular pain and concordant myelogram – 1-year follow-up : Surgery is superior – 4-year follow-up : Surgery is slightly better – 10-year follow-up: similar, 60% symptoms free • Long-term success rate following open discectomy 76% - 93%
  91. 91. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Recurrent Herniation and Reoperation • Recurrent: 5% in 5 years, 14% in 10 years • Reoperation – Discectomy – Decompression (laminectomy) – Fusion
  92. 92. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Intervertebral Disc Surgery • Three classical surgical steps conservative! treatment percutaneous! surgeries open! surgeries fusion! surgeries I II III
  93. 93. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Complications • Incidental durotomy, pseudomeningocele • Wrong-level and wrong-side surgery • Abdominal organ injury ( Vessel, ureter…..) • Disc space infection • Postoperative instability • Recurrent disc herniation, ( D.D. Post-op scar and recurrent disc )
  94. 94. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Recurrent disc herniation •Focal mass lesion without central enhance •Reherniation – 5 % ( same level and side ) •Reherniation – 20 % ( include opposite side)
  95. 95. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Recurrent disc herniation •Less favorable nonsurgical treatment •Predominant leg pain – revision discectomy •Predominant back pain – fusion for instability
  96. 96. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com FAILED BACK SYNDROME It is a condition characterized by persistent postoperative backache and sciatica. VERY COMMON CAUSES • Recurrent/ Persistent disc material at operated site • Herniated Nucleus Pulposus at other site • Epidural scar / Fibrosis • Facet arthrosis / Spinal stenosis
  97. 97. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com Key point of lumbar HIVD • HIVD can be categorized as prolapsed, extruded, or sequestered. MRI is the best image tool for Dx. • About 80% symptomatic lumbar herniation can be treated by nonoperatively. • If a disc causes significant neurologic deficit or remitting, profound pain, surgery may be indicated (esp. in adolescent.)
  98. 98. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com
  99. 99. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA  www.agrasenortho.com This presentation is for  doctors and students in general.! . Graphics,Images and jpeg files are taken from Google and yahoo  Image  to heighten the specific points in this presentation. ! • If there is any objection/or copyright violation, please inform drsandeep123@gmail.com for prompt deletion. ! • It is intended for use only by the doctors of orthopaedic surgery.! . Views expressed in this presentation are personal. • .For any confusion please contact the sole author for clarification. ! • Every body is allowed to copy or download and use the material best suited to him. ! There is no financial involvement.!  • For any correction or suggestion please contact drsandeep123@gmail.com or www.agrasenortho.com!
  100. 100. Life laughs at you when you are unhappy... Life smiles at you when you are happy…
 Life salutes you when you make others happy...
  101. 101. Every successful person has a painful story.
 Every painful story has a successful ending.
 Accept the pain and get ready for success.

  102. 102. Be bold when you loose
 and be calm when you win. Heated gold becomes ornament.  Beaten copper becomes wires.   Depleted 
 stone becomes statue.  So the more pain you get in life you become more JADA ‘08

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