Lumbar disc presentation dr ajay bajaj neurosurgeon
1. Lumbar disc disease
Dr. Ajay Bajaj
MCh Neurosurgery, PGI, Chandigarh
Consultant Neurosurgeon
DR BALWANTSINGH HOSPITAL
GEORGETOWN
2. Very Important Talk!! -- LBP
• A major public health problem
• The leading cause of disability for people < 45
• 2nd leading cause for physician visits
• 3rd most common cause for surgical procedures
• 5th most common reason for hospitalizations
• Lifetime prevalence: 49%–80%
Pai et al. 2004, Orthop Clin N Am
3. Frequency
• United States
• Lifetime incidence of LBP is reported to
be 60-90% with annual incidence of 5%.
Each year, 14.3% of new patient visits to
primary care physicians are for LBP, and
nearly 13 million physician visits are
related to complaints of chronic LBP,
according to the National Center for
Health Statistics.
5. Disc
• Nucleus pulposus-
water rich,
gelatinous,axial load,
pivotal point,binds
vertebrae together
• Annulus fibrosus-
fibrous and tougher,
less water
content,contained the
nucleus pulposus
12. Natural disc ageing
• Loss of the proteoglycan molecule from
the nucleus of the disc.
• Progressive dehydration.
• Progressive thickening.
• Brown pigmentation formation.
• Increased brittleness of the tissue of the
disc.
33. ZONES OF ANTERIOR EPIDURAL
SPACE / HERNIATION ZONES
• Central region
• Paracentral region or
lateral recess
• Intraforaminal zone or
subarticular zone
• Extraforaminal zone
36. • The most common sites for a herniated
lumbar disc are L4-5 and L5-S1, resulting
in back pain and pain radiating down the
posterior and lateral leg, to below the knee
• Back pain caused by a herniated lumbar
disc is exacerbated by sitting and bending;
conversely, the pain of lumbar muscular
strain is aggravated by standing and
twisting movements.
37. PATHOPHYSIOLOGIC MECHANISM
OF NERVE ROOT INVOLVEMENT
• Mechanical deformation of the nerve root
• Biochemical activity if the disc tissue on
the nerve root
40. TREATMENT OPTIONS
• Surgery Vs conservative treatment.( Weber,peul
et al,)
• Same results with respect to over-all-long term
improvement.
• Advantage of surgery: if indicated:-faster pain
relief and back to work.
• Exception: severe pain with
radiculopathy,progressive neurological deficit,
development of cauda equina syndrome.
41. • Due to our findings, we recommend
conservative treatment for up to 2 months.
If there is no improvement in symptoms
and signs, surgery should then be
considered without further conservative
treatment options."
• if patients are improving slowly, then they
should continue conservative care.
45. Sciatica caused by referred pain from
a disc without neural compression
53 year old patient. Left sided buttock pain radiating
down left leg up to knee for 2 years.Recurring flare-
ups.
Pain aggravated on sitting.
Not sleeping well
Tried Physio for 7 months. On Gabapentin,
Amitrptilline, Oxyxontin .
Left L34 Nerve Root Block- no benefit
MRI- Degenerative changes at L34. No neural
compression.
?? Cause of Pain, and what are the treatment
options
46. F=53
L34 Analgesic Discogram. Local
Anesthetic and Omnipaque dye
injected into the disc space.
All her back and left thigh pain
eased for 4 weeks . Was able to
sleep comfortably for first time in
2 years
47. L34 Posterior Lumbar Interbody
Fusion- complete relief of pain
Reports complete
relief of pain 4
weeks after
surgery.
48. Messages
• Inflamed discs can cause referred leg pain
without neural compression by irritating the
sinu-vertebral nerve
• Mild disc degeneration can result in quite
severe pain- because of inflammatory
chemicals in the disc space- not seen on MRI
scans
• Analgesic Discography- a new technique –
offers a simple way to confirm the relevant
disc as the pain generator
• Interbody fusion can then be used to treat the
problem definitively.
49. Take Home Messages
• Know the natural history of the disease
• Know your patient
• Correlate clinical findings, MRI and
discograms if needed
• Until definitive evidence available, choose
the most cost-effective available treatment
option: cognitive therapy, exercise, fusion,
arthroplasty, dynamic stabilization
Four concentric layers of the intervertebral disc: (1) an outer anulus fibrosus, (2) a fibrocartilaginous inner anulus fibrosus, (3) a transition zone and (4) the central nucleus pulposus
Distribution of load in the intervertebral disc. (A) In the normal, healthy disc, the nucleus distributes the load equally throughout the anulus. (B) As the disc undergoes degeneration, the nucleus loses some of its cushioning ability and transmits the load unequally to the anulus. (C) In the severely degenerated disc, the nucleus has lost all of its ability to cushion the load, which can lead to disc herniation.
demonstrates the 'pre-cursor' to a disc herniation. This type of disc lesion - that bulges into the anterior epidural space without any area of focal-ness or out-pouching - would be called a ' Disc Bulge ' on MRI (only because the MRI can NOT show the condition within the disc), although in reality it is a 'Grade 3 Radial Anular Tear' (you would need CT discography to identify the tear) that has disrupted the posterior annulus and allowed irritating nucleus pulposus material to enter into the outer fibers of the disc. Again, this in of itself (IDD) may cause severe and disabling pain in some unfortunate people; however, the subject of Internal Disc Disruption is not the focus of this page. Also note that the PLL, although bulged, continues to be intact and has not ruptured. As well shall see later, the PLL is the 'key' to differentiating between a disc protrusion and a disc extrusion. Finally, note that the Sinuvertebral nerves are irritated (red) and are sending pain signals on to the brain through the sympathetic nervous system (gray ramus communicans). Also note that this IDD may cause some referred lower leg pain as well (spinal nerve has some orange in it to indicate referred pain.) demonstrates the 'pre-cursor' to a disc herniation. This type of disc lesion - that bulges into the anterior epidural space without any area of focal-ness or out-pouching - would be called a ' Disc Bulge ' on MRI (only because the MRI can NOT show the condition within the disc), although in reality it is a 'Grade 3 Radial Anular Tear' (you would need CT discography to identify the tear) that has disrupted the posterior annulus and allowed irritating nucleus pulposus material to enter into the outer fibers of the disc. Again, this in of itself (IDD) may cause severe and disabling pain in some unfortunate people; however, the subject of Internal Disc Disruption is not the focus of this page. Also note that the PLL, although bulged, continues to be intact and has not ruptured. As well shall see later, the PLL is the 'key' to differentiating between a disc protrusion and a disc extrusion. Finally, note that the Sinuvertebral nerves are irritated (red) and are sending pain signals on to the brain through the sympathetic nervous system (gray ramus communicans). Also note that this IDD may cause some referred lower leg pain as well (spinal nerve has some orange in it to indicate referred pain.)
demonstrates a 4 millimeter disc protrusion and represents a worsening of our disc bulge. The posterior of the disc is 'focally' or 'eccentrically' pushing backwards into the anterior epidural space and has contacted, and even somewhat compressed, the traversing nerve root (white star) and right front corner of the thecal sac. Note that the PLL (blue) still has NOT be disrupted and is still "containing" the near-herniated nuclear material.
demonstrates a more serious progression of our pathologically degenerated disc: An 8 millimeter Disc Extrusion (aka: non-contained herniation, transligamentous herniation) is now present. The PLL (blue) has finally been defeated and has completely ruptured, hence allowing for further migration of the the nucleus pulposus into the anterior epidural space. Note the marked displacement of the traversing nerve root (white star) AND the exiting nerve root (green star) (which has now turned completely red with inflammation and venous congestion - the precursors for Radiculopathy). This Disc Extrusion is NOT typically seen in the asymptomatic person and is often an indication for surgical decompression; the sooner the better IF you're NOT improving with conservative care. Another interesting phenomenon about extrusions are the fact that these larger disc lesions have a greater ability to be 'reabsorbed' by the body! This ' shrinkage phenomenon ' has been demonstrated time and time again in the literature; in fact, you can expect that in 80% of large disc extrusions, there will be at least a 50% 'shrinkage' of size (5,6). Unfortunately, this doesn't always mean that the pain associated with the extrusion will fade! Some patients recover from disc extrusion yet demonstrate NO change in the size of their extrusion at all, where others fail to recover yet their extrusion has markedly decreased in size! That just goes to prove that we still have a lot to learn about the relationship between disc herniation and pain
represents the end-of-the-line for the cycle of disc herniation. Now we can see that a big 'chunk' or 'fragment' of nuclear material has detached itself from the main body of the extrusion is and loose in the epidural space. Note the resulting severe compression of the traversing nerve root (white star), the exiting nerve root (green star) and the lateral aspect of the Thecal Sac (blue star). Sequestration (aka: sequester, free-fragment) may be excruciatingly painful (back and leg pain - sciatica) and, if centrally located, may occasionally cause the patient to lose control of their bowl and bladder function, i.e., Cauda Equina Syndrome , which is considered a ' Medical Emergency '! As with the disc extrusion, the sequestration may also undergo a reduction in size from a combination of an immune attack {macrophage attack} and dehydration, although frequently the patient will need immediate decompressive surgery to beat this monster!
demonstrates a large 9mm disc extrusion (red star) as visualized on both the Axial (over-head) and Sagittal (side) views. Note that this extrusion has completely blotted out (can't see) the right traversing S1 nerve roots (left side of image) and has pinched it against the lamina (tiny green arrow). Note the thecal sac is moderately to severely compressed by this large herniation, as noted on both the axial and sagittal images (between blue arrow and red star). This young man (24 years) has avoid surgery and is doing fairly well, although his days of heavy work are probably over for good.
Relative increases and decreases in intradiscal pressure in relation to different body positions. Note that seated and bending postures apply more pressure to the disc than do standing and recumbent positions. This explains the exacerbation of symptoms of herniated disc when patients are in the former positions.