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Lumbar Disc Prolapse Evaluation in 38 Characters
- 1. Lumbar Disc Prolapse Basic Evaluation Dr. Umesh Srikantha MBBS, M.Ch (Neuro (NIMHANS), FMISS (S.Korea) Consultant Neurosurgeon; Head of Spine services Center of Excellence: Brain and Spine Aster CMI Hospital, Bengaluru
- 2. History • Aurelianus (5th cent AD) - Earliest symptom description resembling sciatica • Andreas Vesalius (1543) - Described the Intervertebral disc • Elseberg and Dandy (1928/29) – Cartilaginous tumor of the spine • Mixter and Barr (1932) – First true intentional Discectomy (Transdural) • Love (1938) – Extradural approach for discectomy • Yasargil and Caspar (1977) – Microlumbar discectomy • Foley (1994) – MED • Yeung (1999) – Transforaminal discectomy
- 3. Etiology/ risk factors Non-modifiable • Age – 35-50 • Male gender • Family history • Congenital bony stenosis Modifiable • Excessive stress to the spine • Heavy manual labour • Irresponsible lifting/ repetitive lifting • Long hours of driving/ Vibrating machinery • Lack of exercise/ Poor core muscle strength • Sedentary lifestyle • Smoking • Obesity
- 4. Clinical localization Important to correlate MRI with clinical findings – Case selection Success of surgery
- 5. Clinical symptoms/ History (What to ask?) • Duration • Prior episodes and treatment taken • Interval symptoms • Pain pattern • Back (Discogenic/ Mechanical) • Referred (Discogenic/ Radicular) • Radicular • Aggravating factors Types of discogenic pain
- 6. Discogenic pain – referral patterns (Type B) Ohnmeiss et al
- 7. Discogenic referred pain vs Radicular pain Discogenic pain Radicular pain Narrow, sharp, lancinating, prominent Concentrates distally Broad, dull Concentrates proximally
- 8. Radicular pain – Dermatomal localization • Narrow band of sharp, lancinating pain, burning paresthesias with poorly localized areas in its course (specific to the dermatomal level involvement)
- 10. • Spinal tenderness • Paraspinal spasm • Loco-regional movements • Flexion • Extension • Rotation • Extension/ rotation Examination – Local/ Regional
- 11. Examination – Stress tests • SLR • Bragards • Crossed SLR • Femoral stretch • FABER (SIJ) • Facet stress (Kemp’s) • Piriformis (Fair)
- 12. Examination – Stress tests • SLR • Bragards • Crossed SLR • Femoral stretch • FABER (SIJ) • Facet stress (Kemp’s) • Piriformis (Fair)
- 13. Examination – Stress tests • SLR • Bragards • Crossed SLR • Femoral stretch • FABER (SIJ) • Facet stress (Kemp’s) • Piriformis (Fair)
- 14. Examination – Stress tests • SLR • Bragards • Crossed SLR • Femoral stretch • FABER (SIJ) • FAIR (Facet) • Piriformis (Fair)
- 15. Examination – Stress tests • SLR • Bragards • Crossed SLR • Femoral stretch • FABER (SIJ) • Facet stress (Kemp’s) • Piriformis (Fair)
- 16. Examination – Stress tests • SLR • Bragards • Crossed SLR • Femoral stretch • FABER (SIJ) • Facet stress (Kemp’s) • Piriformis (Fair)
- 17. Examination – Stress tests • SLR • Bragards • Crossed SLR • Femoral stretch • FABER (SIJ) • Facet stress (Kemp’s) • Piriformis (FAIR)
- 18. Examination - Neurology • Motor - • Tone • Bulk • Power • Reflexes - DTRs • Sensory • Fine touch • Pain • Position sense • Sphincteric (if needed)
- 19. Examination - Neurology • Motor - • Tone • Bulk • Power • Reflexes - DTRs • Sensory • Fine touch • Pain • Position sense • Sphincteric (if needed)
- 20. Examination - Neurology • Motor - • Tone • Bulk • Power • Reflexes - DTRs • Sensory • Fine touch • Pain • Position sense • Sphincteric (if needed) Knee jerk Ankle jerk
- 21. Examination - Neurology • Motor - • Tone • Bulk • Power • Reflexes - DTRs • Sensory • Fine touch • Pain • Position sense • Sphincteric (if needed)
- 22. Clinical localization based on positive findings
- 23. X-RAY – RELEVANCE/ WHAT TO SEE? Lumbar Disc prolapse
- 24. X-ray in LDH – what to see? • Disc and foraminal height • Osteophytes • Calcified disc prolapse/ annulus • Intradiscal vacuum • Pars lysis/ defect • Angular/ Translational instability • Limbus fractures • Spinal balance ?!
- 25. X-ray in LDH – what to see? • Disc and foraminal height • Osteophytes • Calcified disc prolapse/ annulus • Intradiscal vacuum • Pars lysis/ defect • Angular/ Translational instability • Limbus fractures • Spinal balance ?!
- 26. X-ray in LDH – what to see? • Disc and foraminal height • Osteophytes • Calcified disc prolapse/ annulus • Intradiscal vacuum • Pars lysis/ defect • Angular/ Translational instability • Limbus fractures • Spinal balance ?!
- 27. X-ray in LDH – what to see? • Disc and foraminal height • Osteophytes • Calcified disc prolapse/ annulus • Intradiscal vacuum • Pars lysis/ defect • Angular/ Translational instability • Limbus fractures • Spinal balance ?!
- 28. X-ray in LDH – what to see? • Disc and foraminal height • Osteophytes • Calcified disc prolapse/ annulus • Intradiscal vacuum • Pars lysis/ defect • Angular/ Translational instability • Limbus fractures • Spinal balance ?!
- 29. X-ray in LDH – what to see? • Disc and foraminal height • Osteophytes • Calcified disc prolapse/ annulus • Intradiscal vacuum • Pars lysis/ defect • Angular/ Translational instability • Limbus fractures • Spinal balance ?!
- 30. X-ray in LDH – what to see? • Disc and foraminal height • Osteophytes • Calcified disc prolapse/ annulus • Intradiscal vacuum • Pars lysis/ defect • Angular/ Translational instability • Limbus fractures • Spinal balance ?!
- 31. MRI EVALUATION Lumbar Disc Prolapse
- 32. What sequences? • T1W and T2W – Sagittal and Axial • GRE – Flash 2D – FISP • STIR • Complete abdominal circumference • T1-weighted images are generally considered to show the best anatomy • Although they are not that sensitive to pathology • Fat to neural contrast (Hypo to Hyper) good for delineation esp. Foramen • Better to visualize PLL, endplate, epidural fat during assessment of disc prolapse
- 33. What sequences? • T1W and T2W – Sagittal and Axial • GRE – Flash 2D – FISP • STIR • Complete abdominal circumference • T2-weighted images are the most sensitive to pathology • Single sequence to provide maximum information • Commonly used sequence in case of disc prolapse – Disc – Facet – Cysts – Ligament
- 34. What sequences? • T1W and T2W – Sagittal and Axial • GRE – Flash 2D – FISP • STIR • Complete abdominal circumference • Inflammation • Edema • Acute vs Chronic disc fragments • Calcifications
- 35. What sequences? • T1W and T2W – Sagittal and Axial • GRE – Flash 2D – FISP • STIR • Complete abdominal circumference
- 36. CLASSIFICATION GETTING THE TERMINOLOGY RIGHT Lumbar disc prolapse
- 37. Bulge Prolapse (?) Protrusion Extrusion Sequestration Contained Complete Sequestered Getting the Terminology right - Disc Herniation Focal (<25%) Broad-based (25-50%) Asymmetrical bulge (50-100%) Symmetrical bulge (100%)
- 38. Acute Intra-annular tear (Normal disc) Acute Extra-annular tear (Normal disc) Intra-annular herniation; Degenerate dsic Extra-annular herniation; Degenerate dsic Newer variables – Status of parent disc
- 39. Relation to PLL – Central vs Paracentral Central Paracentral
- 40. Location – Axial plane
- 41. Central Paracentral, pre-dural Paracentral, Axillary Paracentral, pre-radicular Paracentral – sub-classification
- 43. Posterior extent of herniation
- 44. Vertical extent of herniation
- 45. Disc degeneration Grade 1 Grade 4 Grade 2 Grade 3 Grade 5
- 46. Facet joint • 15 – 40% of chronic pain • Local pain; Referral pain • Early mornings or late evenings • Extension-rotation (looking over your shoulder) • Sciatica (more often at L5-S1)
- 47. Facet degeneration Pathria – 1987 (X-rays) Weishaupt – 1999 (CT)
- 48. Facet hypertrophy - Relevance to MIS Grade 1 Grade 2 Grade 3 • Mild hypertrophy • Facet and lamina in same plane • Mod. hypertrophy • Tube not sitting on the lamina • Severe hypertrophy • Lamina buried • Small gap between spinous process and facet
- 49. • 40-70% • L4-5 (MC) foll. by L5-S1 • Higher incidence of • Low back pain (L2-3) Ko et al, Clin Orthop Surg, 2019) • Disc herniation • LCS (Abbas et al, Biomed Res Int, 2020) • Degenerative Spondylolisthesis Facet tropism/ Facet angle Vanharanta et al Ko et al
- 50. • Limited facet resection • High chance of Iatrogenic instability • ? Inadequate ipsilateral decompression • Adequate facet resection • Less chance of Iatrogenic instability Facet angle/ tropism - Relevance to MIS
- 51. Perineural fat obliteration in 2 opposing directions Perineural fat obliteration in all 4 directions Morphologic changes of the nerve Grade 1 Grade 2 Grade 3 Foraminal imaging/ defining stenosis • Transforaminal Endoscopy • Ensuring adequacy of decompression (in presence of stenosis)
- 52. • Evaluation for Transforaminal endoscopic surgery • Choose Outside-in vs Inside- out • Target localisation • Measurement of parameters • Evaluation of iliac crest • Presence of osteophytes – posterior / lateral Foraminal imaging/ defining stenosis
- 53. Modic changes/ Endplate changes • Type 1 • Low back pain • Instability • ?? Infective • Type 2 • Android fat pattern • Reduced disc space Edema Fat Sclerosis Marrow ischemia – conversion of red marrow into fatty marrow Inflammation Acute Chronic
- 54. Limbus fractures Posterior Limbus Vertebral fractures Type 1 Type 2 Type 3 Type 4 Type I - an arcuate fragment without osseous defect. Type II - an avulsion fracture that includes a rim of bone. Type III - a localized fracture, The osseous defect anterior to the fragment is larger than the frag- ment. Type IV - a fracture that extends both beyond the margins of the disc and the full length of the vertebral body between the end plates. Epstein NE et al, Neurosurgery, 1987
- 55. Posterior Limbus Vertebral fractures Huang et al, Clin Imaging, 2012
- 56. Posterior Limbus Vertebral fractures Huang et al, Clin Imaging, 2012
- 57. Type 4 Type 1 Type 2 Type 3 Posterior Limbus Vertebral fractures Huang et al, Clin Imaging, 2012
- 58. Intravertebral herniation/ Schmorl’s node Samartzis et al , Osteoarth and Cartilage, 2016 • 4-70% ! • Unknown etiology (Traumatic, idiopathic, developmental, reduced BMD) • Low back pain ? • Uncertain clinical relevance Dip Sharp Round Rectangular Irregular, Multiple
- 59. Intravertebral herniation/ Schmorl’s node
- 60. Intravertebral herniation/ Schmorl’s node
- 61. Conjoined nerve root • 1.9-4% (imaging • 8-30% (Autopsy studies) • High index of suspicion • Look for it in pre-op MRI
- 62. Sagittal shoulder sign (open arrow) A vertical structure connecting 2 consecutive nerve roots and the overlying herniated disc on parasagittal MRI which represents a combinations of a protruded or extruded disc adjacent to a conjoined nerve root. Oh et al; J Anat Cell Biol, 2013 Signs on MRI Corner sign (solid arrowheads) Asymmetric structure of the anterolateral corner of the dural sac with one side being angulated compared with the other Fat crescent sign (open arrowheads) The presence of extradural fat between the conjoined nerve root and asymmetric dural sac
- 63. Schubert et al; Eurorad; 2011 Parallel sign (solid arrows) Unsual course of the entire nerve at disc level running parallel to the disc plane Thicker nerve root on one side Associated – Facet hypoplasia Signs on MRI
- 64. llustration of a lumbar nerve root anomaly mimicking a lumbar disc herniation on magnetic resonance imaging (MRI). A: Scheme of a nerve root anomaly at the lumbosacral level encountered during microsurgery for a supposed left-sided lumbosacral disc herniation. Contrary to a disc herniation an accessory L5 nerve root originating caudo-ventrally from an anatomically normal L5 nerve root was found. Both nerve roots exited the spinal canal through the left lumbosacral neuroforamen C: Sagittal T2-weighted MRI of the lower lumbar spine suggesting a cranially migrated lumbar disc herniation (white arrow) at the lumbosacral level. B,D: Corresponding transversal T2- weighted MRI also suggesting a disc herniation compressing the left nerve roots L5 and S1 (white arrow Fabio et al; J Clin Imaging, 2017
- 65. Intradural disc herniation • <1% (Lumbar) • 7% (Thoracic) • Recurrent herniation • Previous herniation (non surgical) • Large herniations • Often diagnosed during surgery
- 66. Fadon DF, Milette PC; Spine 2001 – Combined recommendation of task force of NASS, ASSR, ASNR Correct disc description L4-5 Paracentral, Pre-dural, pre-radicular [Acute] disc extrusion (grade 2 posterior extent) with low superior migration. Disc degeneration Gr. 2 Facet Gr 1 No modic changes
- 67. Re-cap • Clinico-Radiological correlation • Detailed clinical examination • Complete radiological assessment • Identify pain generator • Appropriate case selection • Correct terminology • Watch for anomalies/ variations
- 68. Differentiate acute vs chronic/ osteophyte
Editor's Notes
- In a prospective study conducted in 187 patients with LBP scheduled for diagnostic CT-diskography, Ohnmeiss and coworkers found that L3-4 diskograms were likely to be positive if patients described their pain as involving the lumbar region with radiation into the anterior but not the posterior aspect of the thigh and often into the anterior aspect of the leg. For L4-5 disks, the most common pain referral pattern was lumbar pain involving more equivalent proportions of the anterior and posterior thigh pain. In L5-S1 discogenic pain, the pain description generally encompassed the lumbar and posterior thigh regions, with fewer patients reporting anterior thigh or leg pain. Pain in the absence of disk pathology tended to be limited to the low back region and buttocks
- In contrast, lumbar radicular pain is classically an intense narrow band of lancinating, sometimes burning pain that refers down the limb, and often to the foot.77 The leg pain is typically more prominent than any LBP (indeed, LBP frequently is absent), and the leg pain tends to concentrate distally. Coughing, sneezing, straining at the toilet, and lifting will all classically exacerbate radicular pain, but such aggravating features are not specific to radicular pain. Pain is not limited to the dermatome and it may also be experienced in deep tissues innervated by the nerve.78
- Symmetrical or asymmetrical bulging discs are not considered a form of herniation
- Figure 1: Acute Intra-Annular Tear (T1) This is the rupture of a normal disc where the protruding nuclear material is contained within the annular wall. Figure 2: Acute Extra-Annular Tear (T2) This is rupture of a normal disc where the nuclear material extrudes through the annulus and may be a free fragment. Figure 4: Intra-Annular Herniation (T4) This is a degenerated disc with weakend annular where the herniated nuclear fragment is contained within the annular wall. Figure 5: Extra-Annular Herniation, Degenerated Disc (T5) This is a degenerated disc which weakened annular wall. The nuclear material has extruded through the annulus and may migrate caudally or cranially.
- Relationship of typical posterior disc herniations with the posterior longitudinal ligament. A, Midline sagittal section: Unless very large, a posterior midline herniation usually remains entrapped underneath the deep layer of the PLL and sometimes a few intact outer anulus fibers joining with the PLL to form a “capsule.” The deep layer of the PLL (arrow) also attaches to the posterior aspect of the vertebral body so that no potential space is present underneath. B, Sagittal para-central section: The PLL extends laterally at the disc level (arrowhead) but, above and below the disc, an anterior epidural space (as), where disc frag- ments are frequently entrapped, is present between the lateral (peridural) membranes and the posterior aspect of the vertebral bodies. (Adapted with permission from Milette PC. Classification, diagnostic imaging and imaging characterization of a lumbar her- niated disc. Radiol Clin North Am 2000;38:1267–1292.)
- Figure 6: Central Herniation (L1) This may be a normal or degenerated disc which ruptures into the center of the spinal canal, directly ventral to the posterior longitudinal ligament. The herniated nuclear material may be contained with the annular wall (intra-annular) or extruded though the annulus (extra-annular). Figure 7: Paracentral, Predural Herniation (L2) The herniation is paracentral and may be on the right or the left side of the midline. Topographically it is found ventral to the dura and may extend to the midline. Figure 8: Paracentral, Axillary (L3) The herniation is paracentral and is lodged between the dura, medially, and the traversing nerve root laterally. The herniated material may be intra-annular or extra-annular (i.e. extruded). Figure 9: Paracentral, Pre-Radicular Herniation (L4) The herniation is paracentral and situated ventral to the traversing nerve. The nerve is usually draped around the herniated material making it vulnerable to injury when approached posterior
- Mixed-type 1/2 and 2/3 Modic changes have also been reported, suggesting that these changes can convert from one type to another and that they all present different stages of the same pathologic process
- Originally believed to occur only in adolescents and young adults, the latest reports show that such fractures can occur in adults over the age of 25. In these cases, type III and type IV fractures seem to be more common and are accompanied by a high risk of neurological damage.