The document summarizes lumbar herniated discs, including the anatomy and biomechanics of the lumbar spine, causes of herniated discs like prolonged sitting and lifting, symptoms like low back and leg pain, diagnostic tests like MRI, and treatment options like medications, physical therapy, and surgery. Conservative treatments include medications, physical therapy with modalities like traction and exercises, while surgery may be considered for severe or progressive cases. Prevention involves good posture, exercise, weight management, and avoiding heavy lifting.

1. بسم الله الرحمن الرحيم

2. Lumbar Herniated Disc Prepared by: Hussain Alwi AlOlweyat

3. Outlines Anatomy of the lumbar spine Biomechanics of the lumbar spine Lumbar Disc Herniation Causes Differential Diagnosis Physical Examination & Diagnosis Treatment (Medical & Surgical) Physical Therapy Prevention

4. The lumbar region contains five lumbar vertebrae that supports the lower back. The lumber vertebrae (L1-L5) are the largest and strongest in the vertebral column. Between the bodies of adjacent vertebrae are intervertebral discs. Vertebrae Anatomy

6. Inter-Vertebral Disc (IVD) Each disc has two layers: Annulus fibrosus: is an outer fibrous ring consisting of fibrocartilage. Nucleus pulposus: is an inner soft, pulpy, highly elastic substance. Over time, the discs dehydrate and become stiffer .

8. The Functions of Intervertebral Disc Permit various movements of the vertebral column Shock absorber.

9. Distribution of Load in The IVD In the normal, healthy disc In the mild degenerated disc. In the severely degenerated disc.

10. Nutrition of Intervertebral Disc The discs are primarily avascular, with only the periphery receiving a blood supply. The remainder of the disc receives nutrition by diffusion.

11. Ligaments Anterior longitudinal ligament Posterior longitudinal ligament Interspinous ligament Supraspinous ligament Ligamentum flavum

12. Muscles of The Lumbar Spine Flexion: psoas major, rectus abdominis, external abdominal oblique, internal abdominal oblique and transverse. Extension: latissimus dorsi, erector spinae, transversospinalis, interspinalis, quadratus lumborum Side flexion: latissimus dorsi, erector spinae, transversalis, external abdominal oblique, quadratus lumborum

15. The lumber spine support the upper body and transmits the weight of the upper body to the pelvis and lower limbs. The greatest motion in the lumbar spine occurs between the L4 and L5 vertebrae and between L5 and S1. Biomechanics

16. Types of Forces Acting on Spine There are four types of forces acting on spinal structures: Compression. Tension. Shearing force. Torsional force.

17. Compression A downward force on the vertebrae compresses the discs and causes them to bulge or shorten and widen

18. Tension Tensions pull apart the structures being loaded. In the spine it is the ligaments that are usually under tension, causing lengthening and narrowing

19. Shearing Force Shear forces involve the application of a load parallel to the vertebral surface

20. Torsional Force Twisting movements of the spine cause soft tissue strain through the generation of large muscle forces and loads on the intervertebral discs These types of movements cause the soft tissues to be exposed to a combination of compression, shear and tension forces.

21. Relative increases and decreases in intradiscal pressure in relation to different body positions

22. Lumbar Disc Herniation Disc Degeneration or protrusion. Disc Prolapse. Extrusion. Sequestration

23. Developmental Disorders Inflammatory & Infectious Disorders Trauma Tumors Mechanical Causes Causes of Herniated Disc

24. Mechanical Causes Common causes of annular disc tears include : Prolonged sitting Poor postural habits Poor lifting habits Improper workstation setup and ergonomics Other factors have been shown to increase the susceptibility of disc injury : Inadequate diet and nutrition Smoking Obesity Lack of physical activity

26. Differential Diagnosis Spondylosis Spondylolysis Osteoporosis compression fractures Spinal stenosis Spondylolisthesis Traumatic fracture Congenital disease Tumors

28. Anger/ anxiety/ stress Depression Back Pain Low mood Psychological Cycle Muscles further weakened Fear of pain/ damage (activities avoided) Muscles weakened by lack of activities Pain progresses Activities further avoided Physical cycle The Cycles of Back Pain

29. History Age: 30-50 years Low back and leg pain (Radiated pain) The onset of symptoms is characterized by a sharp, burning, stabbing pain. Onset is acute (prior episodes) Pain is often associated with numbness or tingling. Pain is worse in positions (such as sitting) that produce increased pressure on the annular fibers. Clinical Assessment

30. Location of Pain in Association with Nerve Root Involvement at Each Lumbar Disc Level L1-L2: Pain in anterior and medial aspect of upper thigh L2-L3: Pain in anterolateral thigh L3-L4: Pain in posterolateral thigh and anterior tibial area L4-L5: Pain in dorsum of foot L5-S1: Pain in lateral aspect of foot

31. Physical Examination Observation: includes Body type, Gait, Total spinal posture. Palpation: The spinous processes and interspinous ligaments should be palpated for tenderness.

32. AROM is performed with the patient standing. Measuring ROM using Tape measure. All movement should be tested Range of Motion (ROM)

33. Lower Limb Scanning Examination Should includes: Sacroiliac joints Hip joints Knee joints Ankle joints

34. Myotomes (MMT) The examiner tests the patient’s muscle power. With the patient lying supine, the myotomes are assessed individually. Myotomes of the lumber: L1-L2: hip flexion L3: knee extension L4: ankle dorsiflexion L5: big toe extension

35. Sensory examination includes light touch, pressure, pain….etc Sensations

36. The reflexes should be checked for difference the two sides. Reflexes of the lower limb: Patellar: L3-L4 Posterior Tibial: L4-L5 Medial hamstring: L5-S1 Achilles: S1-S2 Reflexes

37. Special Tests Tests commonly performed on the lumbar spine: Slump test. Straight leg rising test (SLR). Prone knee bending (Nachlas) test. Other tests: Naffziger’s test, Fermoral nerve traction test, Valsalva maneuver ….etc.

38. SLR Test

39. The major finding on plain radiographs of patients with a herniated disc is decreased disc height . Radiographs have limited diagnostic value for herniated disc. The best modality for visualizing the herniated disc is magnetic resonance imaging ( MRI). Diagnostic Imaging

40. Magnetic Resonance Imaging ( MRI)

41. Conservative Treatment Nonsteroidal anti-inflammatory drugs (NSAID’s). Narcotic Pain Relievers. Muscle Relaxants . Medications

43. Physical Therapy Passive modalities Exercises Education Specific Techniques Strengthening Stretching

44. Electrotherapy

45. Education

46. Traction

47. Extension exercise

48. Swiss ball exercise

49. Strengthening Exercises

50. Stretching Exercises

51. Surgical Options Surgery may be considered if the patient is experiencing bowel or bladder dysfunction, increased nerve impairment, progressive weakness, incapacitating pain, or spinal instability. Surgical options are: Laminectomy Microdiscectomy Posterior Lumbar Fusion

53. Prevention Practicing good body mechanics. Regular exercise. Weight management. Avoid activities that require heavy lifting, trunk twisting. Good nutrition

54. References Therapeutic Exercise, Foundations and Techniques Orthopedic Physical Assessment. Magee D.J. Basic Biomechanics of The Musculoskeletal System. Nordin M. & Frankel V.H. www.spine-health.com

55. Thank You