This document provides information on spinal disc herniation, including: - Disc herniation occurs when the nucleus pulposus is pushed through tears in the annulus fibrosus into the spinal canal. - Common causes are age-related degeneration, trauma, and straining. It progresses from internal disruption to instability. - Diagnosis is typically made using MRI, which can identify protrusions, extrusions, and sequestrations. - Treatment involves initial conservative measures like rest, ice, and NSAIDs. Surgery such as discectomy or microdiscectomy may be required for persistent or severe cases. - A case study describes the successful surgical treatment of a 29-year

1. DISC HERNIATION
PRESENTED BY
DR ANSHUL SETHI

2. INTRODUCTION
Spinal disc herniation (commonly called
slipped disc ) is a medical condition in
which there is outpouching of nucleus
pulposus along with few annular fibers
and end plate cartilage through tears in
annulus fibrosus into extradural space.

3. • William Kirkaldy –willis described the spectrum of disc – degeneration
& pathologic progression of lumbar disc degeneration and herniation.
• Genes related to disc degeneration :
1. Aggrecan gene
2. Metalloproteinase-3 gene
3. Collagen type 1 & 3

4. INTERVERTEBRAL DISC
• IT IS A FIBROCARTILAGENOUS STUCTURE WHICH CONTRIBUTES TO
25% OF THE HEIGHT OF THE SPINAL COLOUMN.
• ITS MAIN FUNCTION IS TO ACT AS A SHOCK ABSORBER ,
TRANSMITTING COMPRESSIVE LOADS BETWEEN VERTEBRAL BODIES.
• INTERVERTEBRAL DISC COMPOSED OF CENTRAL NUCLEUS PULPOSES
(NP) AND THE PERIPHERAL ANNULUS FIBROSUS (AF) AND THE END
PLATE (EP) WHICH ACT AS GROWTH PLATE OF VERTEBRAL BODY

6. Causes of disc herniation
1. Age related degeneration of the spine
2. Trauma to spine
3. Strain to spine

7. Natural history of disc disease
• Recurrent strains produce small circumfrential tears in annuus
fibrosus which later on enlarge and combone to form radial tears
• These tears further increases in size until disc is completely disrupted
internally
• As a result disc height reduces due to loss of proteoglycan and water
from nucleus , anulus become lax and bulges out which will later on
represent as thin slit between vertebral body filed with fibrous tissue.

8. SPECTURUM OF CHANGES IN DISC
HERNIATION
• INTERNAL DISC DISRUPTION
• DISC HERNIATION WITH DECREASE IN INTERVERTEBRAL DISC SPACE
• OVERLOADING OF FACET JOINT , LIGAMENTS INSTABILITY
• DEGENRATIVE SPONDYLOLISTHESIS
• LIGAMENT HYPERTROPHY
• SPINAL DEFORMOTY

9. THEORY OF DISC DEGENRATION
• Stage 1 – stage of dysfunction
Seen in 15 year to 45 year old individual
Showing circumferential and radial tears of the disc annulus and
localized synovitis of facet joints.

10. • Stage 2- stage of INSTABILITY/EXTRUSION
• Seen in 35 to 70 year old
• Showing features of internal disruption of the disc
• Progressive disc resorption
• Degeneration of facet joint with capsular laxity
• Subluxation and joint erosion

11. • STAGE 3 - stage of STABILIZATION/FIBROSIS
• Seen in older than 60 year
• Progressive development of hypertrophic bone around the disc and
facet joint leading to segmental stiffening or frank ankylosis

12. STAGES OF DISC HERNIATION
1. DISC DEGENRATION
WEAKING OF DISC BUT NO HERNIATION
WITH DISC SHOWING DEHYDRATION , DESSICATION AND EARLY
DEGENRATION OF DISC MATERIAL.

13. 2. PROTUSION
• NUCLEAR MATERIAL CAUSES BULGING OF OUTERMOST ANNULAR
FIBERS.
• REFERRED AS PIVD.

14. 3. EXTRUSION
NUCLEAR MATERIALS BREAK THROUGH ALL ANNULAR FIBERS BUT STILL
REMAIN CONNECTED TO NUCLEAR MATERIAL WITHIN DISC

15. 4. SEQUESTRATION
NUCLEUS PULPOSUS BREAKS THROUGH ANNULUS FIBROSUS AND LIES
OUTSIDE THE DISC IN SPINAL CANAL

16. CLASSIFICATION OF DISC HERNIATION ON THE
BASIS OF LOCATION
1. POSTEROLATERAL/ PARACENTRAL PROLAPSE :
• this is commonest type of disc herniation
• Post. Longitudnal ligament is weakest in this area
• Herniated disc impinges on the traversing nerve roots
2. CENTRAL PROLAPSE :
• Present as back pain only
• Or as cauda equina in severe cases

17. 3. FORAMINAL/ FARLATERL HERNIATION :
• LESS COMMON TYPE OF HERNIATION
• HERNIATED DISC IMPINGES ON THE EXITING NERVE ROOTS

18. RED FLAG SIGN IN CASE OF BAK PAIN
1. AGE MORE THAN 50 YEAR
2. SIGNIFICANT TRAUMA
3. NEUROMUSCULAR DEFICIT
4. UNEXPLAINED WEIGHT LOSS
5. SUSPICION OF ANKYLOSING SPONDYLITIS
6. DRUG OR ALCHOL ABUSE
7. HISTORY OF CANCER
8. USE OF CORTICOSTEROIDS FOR LONG TERM

19. INVESTIGATIONS :
1. SKIGRAM
skigram of the specific level of spine in both AP and LATERAL view in order
to rule out other associated causes and to see the degenerative changes
2. Melography :
It is done in suspicion of intra-spinal lesion of the spine
3. Computed Tomography (CT
4. MAGNETIC RESONANCE IMAGING (MRI) on of the definitive investigation
to diagnose disc herniation

20. SIGN AND SYMPTOMS OF DISC HERNIATION
1. Back pain radiating to sacroiliac region and buttock
2. Weakness
3. Paraesthesia
4. Loss of bladder , bowel movements
5. Marked paraspinal muscle spasm
6. Loss of lumbar lordosis
7. Point tenderness at the level of involved spinous process

21. Diffrential diagnosis
1. Ankylosing spondylitis
2. Multiple myeloma
3. Arthritis of hip
4. Osteoprosis with stress fracture
5. Extradural tumors
6. Synovial cyst
7. Vascular insufficiency

22. TREATMENT
• BROADLY DIVIDED INTO TWO PARTS
NON OPERATIVE OPERATIVE

23. NON OPERATIVE
• BED REST FOR 3 -4 DAYS (IN SEMIFLOWER POSITION WITH PILLOW IN
BETWEEN LEGS )
• ICE PACK APPLICATION TO RELIEVE SPASM OF PARASPINAL MUSCLE IN
ACUTE BACK PAIN
• NSAID’S
• FOLLOWED BY ISOMETRIC ABDOMINAL , LOWER EXTERMITY AND
SPINAL EXTENSION EXERCISES TO STRENGTHEN THE MUSCLES.

24. OPERATIVE
• DISC SURGERY PROVIDE SYMPTOMATIC RELIEF , IT DOES NOT STOP THE
PATHOLOGIC PROCESS OF THE DISEASE
INDICATIONS FOR SURGERY
1. UNILATERAL LEG PAIN EXTENDING BELOW KNEE FOR MORE THAN 6 WEEKS
2. REOCCURENCE OF PAIN AFTER CONSERVATIVE MANAGEMENT (EPIDURAL,
PHYSIOTHERAPHY ) AFTER A GAP OF 2 MONTHS
3. EVIDENCE OF LOCALIZING NEUROLOGIC IMPAIRMENT
4. CT , MRI OR MYELOGRAPHY CONFIRMING THE LEVEL OF INVOLVEMENT

25. SURGICAL OPTIONS :
1. DISSECTOMY : surgical removal of the whole or part of an intervertebral
disc.
2. MICRO- DISSECTOMY : also known as MICRODECOMPRESSION in hich
portions of herniated disc will be removed to relieve pressure on spinal
nerve coloumn.
3. LAMINOTOMY : remove part of the lamina of a vertebral arch to relieve
pressure in vertebral canal
4. LAMINECTOMY : removal of whole lamina to ease the pressure from
spinal cord

26. 5. HEMI LAMINECTOMY : in this only a part of lamina or part of facet
joint is removed to allow more space of nerve root
6. INTER LAMINAR FENESTRATION

27. STEPS :
• PATIENT MADE TO LIE IN THE PRONE POSTION AFTER GIVING G.A
WITH ENDOTRACHEAL INTUBATION WITH THE HELP OF BOLISTERS
PLACED LONGITUDNALLY UNDER THE PATIENTS SIDES ALONG WITH
PADDING DONE FOR PRESSURE POINTS AND KNEE
OR
PATIENT MADE TO LIE IN PRONE POSITION IN A SPECIAL SPINAL
FRAME WHICH ALLOWS THE ABDOMEN TO HANG FREE RESULTING IN
DECREASING INTRAVENOUS PRESSURE AS A RESULT THERE WILL BE
COLLAPSE OF EPIDURAL VENOUS PLEXSUS

29. • A SPINAL NEEDLE OR OTHER RADIO-OPAQUE MARKER IS PLACED AT
THE DESIRED LEVEL BY PALPATING THE SPINOUS PROCESSES AND IS
CONFIRMED UNDER C-ARM IN LATERAL VIEW
• A MIDLINE LONGITUDNAL INCISION GIVEN OVER THE SPINOUS
PROCESS OF APPROXIMATELY 5 CM EXTENDING FROM 1 SPINOUS
PROCESS ABOVE AND BELOW THE DESIRED LEVEL

30. Confirming intervertebral disc space L5-S1
with spinal needle

31. • INCISION WILL BE THEN DEEPENED THROUGH FAT AND FASCIA IN THE
LINE OF SKIN INCISION AND SUBPERIOSTEAL DISSECTION IS
PERFROMED TO DETACH THE ERECTOR SPINAE MUSCLE FROM THE
LAMINA
(IT IS IMPORTANT TO BE IN THE SUBPERIOSTEAL PLANE TO LIMIT
BLEEDING IF PARASPINAL MUSCLES ARE VIOLATED)
• DISSECTION CARRIED DOWN TO THE SPINOUS PROCESS REMOVING
THE INTERSPINOUS LIGAMENT ALOMG THE LAMINA OF THE FACET
JOINT AND LIGAMENTUM FLAVUM REMOVED WITH THE HELP OG
PENFIELD AND RETRACTED TO ITS ATTACMENT SUPERIORLY
EXPOSING THE DURA COVERING NERVE ROOT

32. • THAT EXPOSED NERVE ROOT WAS THEN CAREFULLY SECURED AND
RETRACTED AWAY FROM DISSECTION FIELD EXPOSING THE THECAL
SAC WHERE BULGING EXTRUSION DISC WAS IDENTIFIED
• DISC LEVEL AGAIN CONFIRMED WITH THE HELP OF A SPINAL NEEDLE
UNDER C-ARM IN LATERAL VIEW
• BULGING DISC REMOVED WITH THE HELP OF RONGEURS AND DISC
FORECEPS TO ATTAIN DECOMPRESSION
• ENSURE TIGHT FASCIAL CLOSURE AND CLOSE THE SKIN IN SIMILAR
FASHION

33. CASE
• NAME : MOHD MUNEER
• AGE/SEX – 29 YEAR/ MALE
• PRESENTED WITH COMPLAIN OF :
1. PAIN IN LOWER BACK RADIATING TO RIGHT LOWER LIMB FROM
LAST 4 MONTHS
AGGRAVATING FACTIORS : SUDDEN FLEXION , PROLONGED SITTING ,
SNEEZING , COUGHING
RELIVED BY TAKING REST

34. NEUROLOGICAL STATUS PRE-OPERTAIVE
RIGHT LEFT
STRAIGHT LEG RAISE TEST 20 DEGREE 80 DEGREE
EHL 4/5 5/5
ANKLE REFLEX MUTE ++
KNEE REFLEX ++ ++
CLONUS - -
SENSORY DIMINSION AT ANTERO-LATERAL OF LEG, DORSUM OF FOOT AND GREAT TOE SUGESSTIVE OF L5
ROOT COMPRESSION

35. RADIOLOGICAL IMAGES
SKIAGRAM SHOWING
STRAIGHTING OF LUMBAR
SPINE WITH NEARLY
NORMAL INTERVERTEBRAL
DISC SPACE

36. MRI OF THE SAME PATIENT SHOWING ANNULAR TEAR
WITH DISC BULGE WITH POSTEROLATERAL DISC
EXTRUSION WITH CAUDAL MIGRATION AT L5-S1 LEVEL
CAUSING MODERATE THECAL SAC INDENTATION

37. INTRA –OP FINDINDS
• EXCESSIVELY THICKNED NERVE ROOT
• EXTRUSION OF DISC
CEPHALIC END
CAUDAL END
RIGHT
LEFT
DURA COVERING
THE NERVE ROOT
EXCESSIVELY
THICKNED
NERVE ROOT

38. ZOOM VIEW OF PREVIOUS PICTURE SHOWING
EXCESSIVELY THICKNED NERVE ROOT COVERED
WITH DURA

39. PEN FIELD RETRACTING
NERVE ROOT AND
SHOWING BULGING DISC

40. REMOVED EXTRUSION DISC

42. POST OPERATIVE NEUROLOGICAL STATUS ON
POD 1
RIGHT LEFT
STRAIGHT LEG RAISING TEST 50 DEGREE 80 DEGREE
EHL 4/5 5/5
ANKLE JERK MUTE ++
KNEE JERK ++ ++
CLONUS - -

43. • THANK YOU