The document discusses lumbar disc disease and degenerative disc disease. It begins by describing the anatomy of the lumbar spine including vertebrae, discs, and ligaments. It then discusses the intervertebral disc structure and how degeneration occurs due to loss of water content. Disc degeneration can lead to herniations which are classified as protrusions, extrusions, or sequestrations depending on the shape. Common signs and symptoms include low back pain and sciatica. Evaluation involves patient history, physical exam, and MRI to diagnose the specific herniation type. Treatment options may include conservative care or surgery depending on the severity of symptoms.

1. Lumbar Disc
Disease

2. Ligamentum
flavum
PLL
ALL
ISL
Inter
ANATOMY

4. Functional
spinal
unit
• Two adjacent
vertebrae
• Intervertebral
disc
• Spinal ligaments

5. INTERVERTEBRAL DISC
Nucleus pulposis
- Gelatenous substance
- Proteoglycan
- 80% water content
Annulus fibrosus
-Fibrocartilage
-Closely attach to the end plate
-Contain laminated Layers

6. OBJECTIVES
1. Identify the etiology of lumbar disc herniations.
2. Review the proper steps in the evaluation of lumbar disc
herniations.
3. Outline the management options available for lumbar disc
herniations.
4. Summarize interprofessional team strategies for improving
care coordination and communication to improve outcomes
of lumbar disc herniations

7. LOW BACK PAIN
• strain of the muscles
• ligaments and tendons
• Herniation of lumbar disc
• sciatica
• Various other conditions

8. ANATOMY

10. • In the normal, healthy disc, the
nucleus distributes the load equally
throughout the anulus
• As the disc undergoes
degeneration, the nucleus loses
some of its cushioning ability and
transmits the load unequally to the
anulus
• In the severely degenerated disc,
the nucleus has lost all of its ability
to cushion the load, which can lead
to disc herniation
Etiology of Disc Degeneration

11. HERNIATED NUCLEUS PULPOSUS
• Degeneration
• Prolapse
• Extrusion
• Sqeuestration

12. COMPLETE HISTORY
• Did you have an injury?
• Where is the pain?
• Do you have any numbness? Where?
• Do you have any weakness? Where?
• Have you had this problem or something like it before?
• Have you had any weight loss, fevers, or illnesses recently?

13. CAUDA EQUINA SYNDROME
• Most serious complication
• Ruptured disc material may press on
the nerves that control the bowels and
bladder
• It can cause permanent damage lead
to lose the ability to control bowels
and bladder
• Surgery immediately is recommend

14. PHYSICAL EXAMINATION
1. Motion of Spine
2. Weakness
3. Pain
4. Sensory Changes
5. Reflex changes
6. Motor skills
7. Special signs

15. FUNCTIONS
LUMBAR VERTEBRA
1. Weight transmission – L4/L5
and L5/S1
2. Multidirectional Movement
–T12/L1

16. LOCALIZING
NEUROLOGIC LEVELS

17. DEGENERATIVE DISC
DISEASE (DDD)
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7
DEFINITION
“Describes the natural breakdown of an intervertebral disc of
the spine.”

18. Degenerative changes of the disc
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8
Pathological changes
 Water and proteoglycan content decreases
 Collagen fibers of AF become distorted
 Tears may occur in the lamellae
 Results in:
 Decreased disc height and volume
 Impaired mobility
 Pain
 Inflammation
 Neurological signs and symptoms

19. DEGENERATIVE
INTERVERTEBRAL DISC
DISEASE
1
9
a. DISC BULGE
b. ANNULAR TEAR
c. HERNIATION
PROTUSION
EXTRUSION
INTRAVERTEBRAL

20. A) DISC BULGE
2
0
•Generalized or circumferential disc
displacement
• (involving 50% to 100% of the disc
circumference) is known as “bulging”
•and is not considered a form of herniation.
TYPES
•Bulging can be symmetrical (displacement
of disc material is equal in all directions)
•asymmetrical (frequently associated with
scoliosis)

21. 2
1

22. ). ANNULAR TEAR
2
2
Disruption of concentric collagenous fibers
comprising
the anulus fibrosus
TYPES:
1. Concentric tears
2. Radial tears
3. Transverse tears
MR Findings
• T1WI: Contrast-enhancing nidus in disc margin
• T2WI: High signal zone at edge of disc which has low
intrinsic signal

23. A. Concentric tears
•are circumferential lesions which are found in
the outer layers of the annular wall.
•They represent splitting between adjacent
lamellae of the annulus, like onion rings.
•Concentric tears are most commonly
encountered in the outer annulus fibrosus,
are believed to be of traumatic origin
especially from torsion overload injuries.
2
3
TYPES

24. B. RADIAL TEARS
2
4
• are characterized by an annular tear
• permeates from the deep central part of the disc (nucleus
pulposus)
• extends outward toward the annulus
• either a transverse or cranial-caudal plane.

25. C. TRANSVERSE TEARS
2
5
• also known as “peripheral tears” or “rim lesions”
• are horizontal ruptures of fibers, near the insertion in the bony
ring apophyses.
• Their clinical significance remains unclear.
• Transverse tears are believed to be traumatically induced and
are often associated with small osteophytes

26. 2
6

27. C). DISC HERNIATION
Herniation is defined as a localized displacement
of disc material (nucleus, cartilage, fragmented
apophyseal bone, fragmented annular tissue)
beyond the limits of the intervertebral disc space.
 Intravertebral
Herniations
 Protruded Disc
 Extruded Disc
2
7

28. •Are protrusions of
the nucleus pulposus of
the intervertebral
disc through
the vertebral
body endplate and into
the adjacent vertebra.
•(also known as
Schmorl’s nodes).
•They are often
surrounded by reactive
bone marrow changes.
INTRAVERTEBRAL HERNIATIONS
15

29. 16

30. “PROTRUDED DISC
• The terminology “protruded disc” is used
when the base of the disc is broader than
any other diameter of the displaced
material.
•Based on a two-dimensional assessment
of the disc contour in the transverse plane,
a protruded disc can be:
•focal (involving <25% of the disc
circumference)
•broad-based (involving 25%–50% of the
17
disc circumference).

31. • The terminology “extruded disc” is used for a focal disc
extension of which the base against the parent disc is narrower than
diameter of the extruded disc material, measured in the same plane.
EXTRUDED DISC HERNIATIONS
Extrusion: the base of the herniation is
narrower than the apex (toothpaste
sign) 18

32. •Extrusion is also used when
there is no continuity between
the herniated disc material
beyond the disc space and that
within the disc space
•If the displaced disc material
has no connection with the
parent disc, it is called a
“sequestrated fragment”.
•This is synonymous with a “free
fragment”.
3
2

33. 3
3

34. MIGRATION – SEQUESTRATION
Migration
indicates displacement of disc material away from the site
extrusion, regardless of whether sequestrated or not.
Sequestration
indicate that the displaced disc material has lost
any continuity with the parent disc
3
4

35. A. Small subligamentous herniation (protrusion) without significant
disk material migration.
B.Subligamentous herniation with downward migration of disk
material under the PLLC.
C.Sub-ligamentous herniation with downward migration of disk
material and sequestered fragment (arrow). 22

36. • X-ray: show spinal degenerative changes but
not a herniated disc; rule out obvious
underlying problems
• CT: relatively less used
• MRI: The best
DIAGNOSIS
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6

37. MANAGEMENT FOR DDD
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