PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc   AGRASEN HOSPITAL Gondia Vidarbha DR SANDEEP C AGRAWAL www.drsandeepagrawal.com www.agrasenortho.com

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. 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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com

4. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com InterVertebral Disc

5. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com NUTRITION TO DISC

6. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com FUNCTION OF DISC

7. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com EFFECT OF AXIAL LOADING

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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com IN RELATION TO POSTURE

10. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com WHY DISC PROLAPSE IS MOST COMMON POSTEROLATERALLY? 

11. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com ETIOLOGY

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. 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. 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. 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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com STAGES OF DISC PROLAPSE

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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Types of Disc Herniation (Contained) Bulging Protrusion

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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Types of Disc Herniation  (Non-contained) Extrusion Sequestered

22. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com AXIAL LOCATION

23. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com SAGITTAL SECTION

24. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com LIST (SCIATIC SCOLIOSIS)

25. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com RELATION OF INTRADISCAL PRESSURE AND POSTURE

26. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com MOTION SEGMENT ANTERIOR ELEMENT POSTERIOR ELEMENT

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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Aging Disc • Loss of cells • Dehydration • Annular fissures • Mechanical incompetence • Osteophyte

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. 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. 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. 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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Pathophysiology of H.I.V.D.

34. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Ventral ramus, sympathetic chain, dorsal root ganglion

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. 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. 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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com CONTRALATERAL LEG RAISING TEST (FRAJERSZTAGN TEST)

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. 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. 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 )

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. 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. 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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Physical Examination Motor, Sensory, Reflex

47. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Sensory Dermatome

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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com L4

50. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com L5

52. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com S1

53. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com DISCOGRAHY

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. 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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com CORRECT SLEEPING POSTURE BED REST

59. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com IN RELATION TO MANUAL MATERIALS HANDLING

60. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com FOR ACUTE STAGE ! BRIDGING EXERCISE ! KNEE HUGS

61. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com FOR RECOVERY OR SUBACUTE STAGE ! EXTENSION CONTROL ! HAMSTRING STRETCH ! KNEE ROLLS

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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com DO’S & DON’T’S

65. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com EPIDURAL STEROID INJECTION

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. 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. 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. 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

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. 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. 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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com LAMINOTOMY & DISCECTOMY

75. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Percutaneous Endoscope Discectomy

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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com PED Procedures (Marking)

79. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com PED Procedures (Discography) PED Procedures (Wound)

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. 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

83. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Procedures

84. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Endoscope-guide Discectomy

85. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com Scope Images Disc Lig. Flavum Lower edge of L4

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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com PED & MED PED MED (laminotomy)

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. www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com DISC REPLACEMENT

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. 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. 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. 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. 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. 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. 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. 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.)

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. 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. Every successful person has a painful story.  Every painful story has a successful ending.  Accept the pain and get ready for success. 

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

PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc AGRASEN HOSPITAL Gondia Vidarbha DR SANDEEP C AGRAWAL www.drsandeepagrawal.com www.agrasenortho.com

AGRASEN Fracture Arthritis Hospital, Ganesh Nagar,Gondia,Maharashtra,INDIA