Any buldge around disc causing compression of nerve root. Herniation of disc is of 4 types:- Contact:- No rupture in outer layer of NP within their limit, discogenic pain & deep dull pain. Complete rupture /protruded disc :- Outer most layer is intact & inner layer of AF is ruptured. Herniated Sequestered disc:- Outer most layer is also ruptured & nerve root compression (NRC) is there. 4 No buldge:- Nuclear Matrix comes out but no rupture of AF, No NRC but sequestration NRC is there.

1. DISC HERNIATION
Dr. Niraj Kumar , Pt
BPT, MPT MHA & Ph.D Physiotherapy (Orthopaeducs)
Associate Professor Physiotherapy Dept.
Shri Guru Rai Institute Of Paramedical Sciences , Dehradun

2. IVD consist of AF,NP & CEP. The central core of the IVD is
composed of the NP. The AF surrounds the NP, occupying the
majority of the disc space. On the superior and inferior
surfaces of the IVD lies the cartilage end plates.
The spinal column has 23 IVDs, starting from the C2-3
interspace to the L5-S1 interspace. C= 6, T= 12 & L=5.
The IVD is generally considered to be an avascular tissue
structure. The IVD receives innervations primarily from two
sources: the sinuvertebral nerve and the sympathetic trunk
via the multiple gray rami.
The Biochemical Composition
• Water : 65 ~ 90% wet wt. • Collagen : 15 ~ 65% dry wt. •
Proteoglycan : 10 ~ 60% dry wt. • Other matrix protein : 15 ~
45% dry wt.

4. Function:-
1. Separate the vertebrae from each other.
2. provides the surface for the shock-absorbing gel of the
nucleus pulposus.
3. The NP distribute hydraulic pressure in all directions
within each IVD under compressive loads.
4. Restricted intervertebral joint motion •
5. Contribution to stability •
6. Resistance to axial, rotational, and bending load

5. DEFINATION:-
Any buldge around disc causing compression of nerve
root.
Herniation of disc is of 4 types:-
1. Contact:- No rupture in outer layer of NP within their
limit, discogenic pain & deep dull pain.
2. Complete rupture /protruded disc :- Outer most layer is
intact & inner layer of AF is ruptured.
3. Herniated Sequestered disc:- Outer
most layer is also ruptured & nerve root
compression (NRC) is there.
4 No buldge:- Nuclear Matrix comes out
but no rupture of AF, No NRC but
sequestration NRC is there.

6. Resinick & Niwayma etal classified into following
type:-
1) Annular buldge:- Weakened portion of AF is buldge
out, pain with or without radiation.
2) Protrusion:- Nuclear matrix protrudes periphery but
outer layer of periphery intact but inner layer of
periphery rupture.
3) Extrusion:- Outer layer also damages & nuclear matrix
comes out, NRC is there.
4) Sequestration:- Extruded material will give another
buldge. And +ve NRC.

7. 1) Repetitive mechanical activities – Frequent bending, twisting, lifting,
pushing , pulling and other similar activities causes discs damaged.
2) 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.
3) Degenerative changes:- Degeneration is the major cause of spinal disc
herniation mostly seen in old age pts. that weakened the disc causes
herniation.
4) 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.
4) Obesity – Spinal degeneration can be occurred dueto excess body fat.
5) Poor posture – Improper spinal alignment while sitting, standing, or lying
down strains the back and neck.
6) 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.
7) Mutation- in genes coding for proteins involved in the regulation of the
extracellular matrix, such as MMP2 and THBS2, has been demonstrate
8) Poor and inadequate strength of the trunk
9) Sitting for long hours.

8. INTRA-DISCAL PRESSURE
In supine/prone lying----25kg discal pressure.
Side lying—75kg, Standing---100kg
Sitting without support-----140kg
Sitting forward---185kg
Sitting forward without lifting weight on hand-----275kg
Standing lifting weight, hip bending---340kg
On coughing, laughing---120kg

9. Neck /Cervical region
*Severe Pain in back of neck & Arm muscle weakness
*Deep ach pain near or over the shoulder blades on the
affected side
*Increased pain when bending the neck or turning head to
the side
*Pain made worse with coughing, straining or laughing
*Neck pain, especially in the back and sides along with
spasm
*Burning pain radiating to the shoulder, upper arm,
forearm, and rarely the hand, fingers or chest
*Tingling or numbness in one arm

10. Lower Back /Lumbar area
*Severe low-back pain
*Pain radiating to the buttocks, legs, and feet.
*Pain worse with coughing, straining or laughing &
during spinal flexion.
*Muscle spasm
*Tingling or numbness in legs or feet*
*Muscle weakness or atrophy in later stages
*Loss of bladder or bowel control & numbness in the
genital area in case of cauda -equina syndrome

11. 1. First no complain of radiation, when radiation occurs
then actually the disc is occurs i.e true herniation.
2. Neurogenic Pain in Cx & Lx area.
3. Paresthesia about 75% of pts.
4. Numbness, loss of sensation at dermatome level.
5. Tenderness over particular herniated discal level.
6. Spinal mobility- Pain aggravates on forwards bending
of Cx & Lx . Sometime lateral bending is also painful.
7. L5 nerve root compression causes difficulties of great
toes extension.
8. Inability to walk

13. DERMATOMES & MYOTOMES

14. Differential diagnosis
1.Mechanical pain
2.Discogenic pain
3. Osteoporosis
4. Osteomyelitis
5. Spondylosis
6. Spinal stenosis
7. Spondylolysthesis – Step
Deformity at particular level.
8.Neurofibroma- Nerve. Tumour
(paraperesis, Bladder & bowel)----LMNL

15. 9. Ankylosing spondylitis
10. Piriformis syndrome
11. Pott’s spine
12. Lumbar canal stenosis
13. Facet jt. syndrome
14. Any soft tissue injury of Cx & Lx area.
15. Mass lesion or malignancy-
Note-In PIVD pain is decrease during rest but tumour
pain is not diminished.

16. Special test for cervical spine
1. Foramina Compression Test, Spurling's Test
(Vertebral Compression Test) or Quadrant Test --- pt.-
sitting + therapist- applied gentle axial compression on top
of head neck in extension, lateral flexion .
2. Foramina Destruction Test- therapist places the one
hand under the chin & other hand around occiput area +
lifted or destructed in upward direction & distraction force
of up to approximately 14 kg.--- +ve –relief of pain.

18. 5. Shoulder Depression test--- Pt. - supine or in a
sitting position + patient laterally flexes her/his head
away from the side that is being tested. and presses
down on the patient’s shoulder any localized pain or
shoulder pain or arm pain indicates +ve NRC.
6. Brachial Plexus Tension Test
ULTT-1 (Radial nerve)
ULTT-2-a (Medial root of Median nerve)
ULTT-2-b ( Lateral root of Median nerve)
ULTT-3- Ulnar nerve

19. 1. Straight Leg Raise (Lasegue & sciatic nerve test):
POP:- Supine lying
POT:- Standing behind the tested side & therapist lifts or passively
flexes hip the patient's leg while the knee is straight.
Perform hold relax muscle stretch:-
A) If this increases the ROM most likely tight hamstrings
B) If this has no effect on pain -may be nerve root impingement or
irritation
ROM Interpretations:
0 –30°-----indicates hip pathology or severely inflamed nerve root.
30 - 50°-----indicates sciatic nerve involvement.
50 –70°---------indicates probable hamstring involvement
70 –90°---sacroiliac joint is stressed.

21. 2. Bowsting test:- SLR carried out until pain
reproduced ------knee is gradual flexed till pain
disappears ----- therapist rest his/ her limb on his
shoulder & palpate the sciatic nerve in popliteal fossa
–sudden firm pressure on nerve reproduces pain in
back or radiates down in leg ---indicate +ve Bowsting
sign
3. Kerning test
Femoral stretch test.
Prone Knee Bending Test
Slump Test

22. DRUG MANAGEMENT
1.NSAID:-
Diclofenac potassium (Cataflam), Diclofenac sodium
(Voltaren, Voltaren XR), Diclofenac sodium , Ibuprofen,
Indomethacin , Piroxicam
2. ANTACIDS:-
pantoprazole and rabeprazole , Aluminum and Magnesium
Hydroxide Oral Suspension , Ranitidine, Zantac, Zoton
3. Calcium therapy with vitamin D3
4. Common Muscle Relaxant Medications
Baclofen, Chlorzoxazone, Carisoprodol , Cyclobenzaprine,
Metaxalone, Methocarbamol , Tizanidine

23. 5. DRUGS USED IN PERIPHERAL NEUROPATHY
Methylcobalamin:- Methylcobalamin, also known as
Methyl-B12 or Mecobalamin, is a form of the common
vitamin B12. It differs from typical B12 in that it has an
additional methyl group, and contains metal-alkyl bonds. It
supports nerve function and neuron health in the brain and
contributes improved signalling in the central nervous
system. This is especially true in patients who have
degenerative neurological conditions such as those that
affect the myelin sheath like multiple sclerosis (MS).
Gabapentin:- anti-epileptic drug, also called an
anticonvulsan. Gabapentin is used in adults to treat
neuropathic pain (nerve pain)caused by herpes virus or
shingles (herpes zoster).
6. Chemonucleolysis: dissolution of the Nucleus Pulposus
by percutaneous injection of a proteolytic enzyme
(chymopapain). This enzyme has the property of dissolving
fibrous and cartilaginous tissue.

24. Acute Stage:-
Conservative Management :- Aim of physiotherapy---
►To accelerate healing .
►To relief pain.
► To restore mobility.
► To restore posture & strength
► Prevention
►To accelerate healing :-
●Rest:- 1 – 2 days but in severe cases 7 to 10 days
(1 to 2wks.)
● Corset or lumber belt (L-S belt).
●If severe disabling pain crutches are advised
●Elastic adhesive strapping applied over the back to
immobilised the spine. It should be used up
to 10 days & replace the tape 2 to 3 times.
Elastic Adhesive
strapping

25. ►To relief pain:-
1. Traction :- ICT & ILT is used for relives intradiscal
pressure & increase the disc space.
2. Electrotherapy modalities---
Cryotherapy: reduces muscle spasm and inflammation in
acute phase.
TENS: relieves pain in both acute and chronic phases.
UST: as phonophoresis increases extensibility of connective
tissues
Moist heat: used as an adjunct before applying specialised
techniques to decrease muscle spasm.
SWD- pulsed SWD in acute condition and continuous SWD in
chronic cases for 20 to 25 mints .
LWD pulsed SWD in acute condition and continuous SWD in
chronic cases. 08 to 12 mints.
IFT – 20 to 25 mints
LASER:- Laser therapy treatment is very advance method for
pain relief and decrease inflammation,

26. ► To restore mobility.
1. Mobility exe.:- Mobility exe. of SI & hip can also include.
2. AROM exercises within pain free range to the lower limb
can be done e.g.- ankle toe movements, heel drag, hip
abduction/adduction.
3. Mobilization of thoracic spine Mobilization of segments
above and below the affected segmental level.
4. Piriformis/ Hams/ Calf muscle stretching
5. Maintain/ improve mobility of neural tissues- SLR with foot
dorsiflexion.
► To restore posture & strength
a) Spinal extension/ strengthening exe:- In initial stage
movt. of spine is contraindicated but after subside of pain can
start the isometric spinal exe & then isotonic spinal exe.
c) Local support in the form of corset (lumbosacral belt),
abdominal binder, tape etc.

27. ► Prevention:- Posture and activity modification- Avoid
forward bending, sitting for long duration or lifting
activities,

28. A) Soft tissue flexibility :-
1) Hamstring m/s tendinous unit stretching
2) Quads m/s tendinous unit stretching
3) Iliopsoas m/s tendinous unit stretching
4) Gastrosoleus m/s tendinous unit stretching
5) External & Internal hip rotators .
B) Joint mobility:-
1. Lumber spine segmental mobility
2. Hip ROM
3. Thoracic segmental mobility

29. C) Stabilisation Programme :-
1) Prone Gluteal squeeze
with arm raise
with alternate arm raise
with leg raise
with alternate leg raise
alternate arm & leg raises
2) Supine pelvic bracing
3) Bridging programme
● Basic Position
● One leg raised with ankle wt.
● Stepping
● Balancing with Gymball
4. Quadruped with alternate one arm & leg movement
5. Kneeling stabilisation.
6. Wall slide quadriceps strengthening

30. 7. Abdominal Programme
♦ Curl ups
♦ Diagonal curl up
♦ Diagonal curl up with inclined board.
♦ Straight leg lowering.
8. Gym Programme
♦ Latissimus pull down
♦ Angled leg press
♦ Lunges Hyperextension bench
9. Aerobic Programme
♦ Progressive walking
♦ Swimming
♦ Stationary bicycling
♦ Running on treadmill.

31. The disc is removed by following techniques.
a) Hemilaminectomy/Partial laminectomy- Part of
the lamina and ligamentum flavum on one side is
removed, taking great care not to damage the facet
joint.
b) Laminectomy- Laminae on both sides with spinous
process are removed. Such wide exposure is required for
big, central disc producing cauda equina syndrome.
c) Microdiscectomy- done with an operating
microscope. Exposure is very limited. Morbidity and
hospitalisation is less.
d) Fenestration- Ligamentum flavum bridging the two
adjacent laminae is excised and spinal canal at affected
level exposed.
e) Laminotomy- In addition to fenestration, a hole is
made in the lamina for wider exposure.