What is structure of lumber disc? What is disc bulge/prolapse/herniation? What is difference between disc bulge, disc prolapse, disc herniation or disc extrusion? What is criteria to diagnose lumber disc prolapse? How lumber disc herniation is treated medically or surgically? How lumber disc herniation is treated by conservative method? How lumber disc herniation is treated through physical therapy? What is physiotherapy after various disc surgeries? What is radiological method to diagnose disc prolapse?

1. Presented by: Dr. Zunaira Ahmad

2.  Learn anatomy of lumber disc bulge
 Types
 Find out causes of it.
 Elaborate differential diagnosis (DDs) for its signs and
symptoms
 Clinical tests
 Radiological findings or tests
 Treatment options

3.  What is Lumber region?
 What is disc?
 What is disc bulge and disc herniation?

5. It is a hydrostatic, load bearing structure between the vertebral bodies.
The intervertebral disc incorporates of:
 Annulus fibrosus
 Nucleus pulposus
 Endplate
A thick outer ring composed of fibrous cartilage called the annulus
fibrosus,
which surrounds a central gelatinous material known as the nucleus
pulposus.
Weight is transmitted to the nucleus through the hyaline cartilage plate.
The hyaline cartilage is ideally suited
to this function because it is avascular
The fibers of the annulus can be divided into three main groups:
outermost fibers
the middle fibers
innermost fibers
The anterior fibers are strengthened by the powerful anterior
longitudinal ligament.
The posterior longitudinal ligament affords only weak reinforcement,
especially at L4-5 and L5-S1, where it is a midline, narrow, unimportant
structure attached to the annulus. The anterior and middle fibers of the
annulus are most numerous anteriorly and laterally but are deficient
posteriorly, where most of the fibers are attached to the cartilage plate.

7.  Disc Bulge
Extension of the disc margin beyond the
margins of the adjacent vertebral endplates. Bulge
in the disc but not a complete rupture
 Protrusion / Bulging
Nucleus forced into outermost layer of annulus
fibrosus- not a
complete rupture
 Extrusion/ Disc herniation
The nuclear material emerges through the
annular fibers but the posterior longitudinal
ligament remains intact. A small hole in annulus
fibrosus and fluid moves into epidural space
 Sequestration or free fragment
The nuclear material emerges through the
annular fibers and the posterior longitudinal
ligament is disrupted. A portion of the nucleus
pulposus has protruded into the epidural space.

9. A bulging disc is that the nucleus does not
push out of the annulus in a bulging disc.
The disc simply bulges out of the space it
normally occupies in the spine.
Considered a normal part of aging, a
bulging disc may not even cause any
symptoms.
If it bulges enough to press on spinal
nerves or narrow the spinal canal, then it
can lead to symptoms including pain,
numbness, tingling, or weakness. A
bulging disc can sometimes be a
precursor to a herniated disc.

10. AGE: 30 – 40 years
MOST COMMON LEVEL: L4-L5 (next common level is L5-S1)
MOST COMMON TYPE: Postero-lateral type
WHY DISC PROLAPSE IS MOST COMMON POSTEROLATERALLY?
Incomplete annular lamellae in this quadrant (i.e) each lamellae end with
fusion to an adjacent lamellae not completely circular.
Fibers of annulus were deficient posteriorly.
Posterior fibers are only weakly reinforced by posterior longitudinal ligament
especially L4-5 and L5-S1

11. Repetitive mechanical activities – Frequent bending, twisting, lifting, and other
similar activities without breaks and proper stretching can leave the discs damaged.
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.
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. Sports/
Automobile injury
Obesity – Spinal degeneration can be quickened as a result of the burden of
supporting excess body fat.
Practicing poor posture – Improper spinal alignment while sitting, standing, or
lying down strains the back and neck. Sitting and bending forwards, lifting heavy
weight bending back.
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.

12.  Patient presents with LOW BACK
PAIN with or without buttock
involvement.
AGGRAVATING FACTORS Pain
will aggravate on bending, stooping,
lifting heavy weight.
RELIEVING FACTORS: Pain
relieved on lying or rest. No position of
comfort in case of high lumbar root
lesions.
MORNING STIFFNES
 Patient presents with lower leg pain more
dominated than low back pain. follows a
dermatomal pattern
 Weakness And Paresthesia (pins and needles
feeling)
 Numbness
 Difficulty / painful walking in case of herniated
disc causing stenosis
 Difficulty/ painful stepping down stairs in case of
herniated disc causing stenosis
AGGRAVATING FACTORS Pain will aggravate on
bending, stooping, lifting heavy weight, coughing,
sneezing, deep breathing or laughing. But in case of
stenosis aggravate on extension.
RELIEVING FACTORS Pain relieved on extension but
pain relieved on flexion posture if stenosis.
MORNING STIFFNES
BULGING HERNIATION

13.  AROM
• Flexion- Painful and restricted
• Lateral bending to same side- Painful and restricted
• If stenosis, extension painful and restricted
 PROM (carefully)
 Tenderness +ve on involved vertebra or Over The Spinous Process
 Paraspinal muscle spasm- Central Furrow sign
 Gait- Antalgic/ limping gait
 Loss of lumber lordosis
 Scoliosis in Lumbar spine/ Sciatic scoliosis
 Loss of Normal Lumbar Lordosis
 Perform clinical tests
 Dermatome and myotome examination

14. 1) SLR Test/ LASEGUE’S TEST
2) BRAGGARD’S SIGN
3) BOWSTRING SIGN
4) Contralateral SLR Positive/ Crossed Straight Leg Raise Test (Crossed
Lasègue test)/ CONTRALATERAL STRAIGHT LEG RAISING TEST
(FRAJERSZTAGN TEST)
5) NAFFZIGER’S TEST
6) Tripod Test/Flip Sign
7) Valsalva maneuver
8) Slump test
9) FEMORAL NERVE Traction TEST (REVERSE SLR TEST)
10) Prone knee bend (PKBI)

15. SLR (passive test)

16. Perform SLR, move out of painful
range and add dorsiflexion
Stretching of the sciatic nerve will
cause intense pain

18. Indicates a large central disc
herniation or sequestration
Contralateral side pain reproduction
on 40 to 60 degree hip flexion in
knee extended position

19. Here pressure applied on the
jugular vein for 10 seconds, the
patient face flush. Now patient
asked to cough which produce
pain in back indicate test is
positive.
Indication of thecal sac / spinal
theca compression

20. Shooting pain in entire leg in case of
nerve root involvement but muscular
tension in case of hamstring
contracture.

21. Pt. seated, asked to take a breath,
hold breath, and bear doen as if
evacuating stool.
Pain reproduce.
Indicate thecal sac compression

22.  Hands behind back, slump
back of pt. ,flex head, exert
over pressure to head in
flexion, extend involved knee
with added pressure in
dorsiflexion
 Neurological signs or
shooting pain reproduction

23.  Patient side lying, extent hip
15 degree flex knee
 Test for L2 to L4 nerve root
compression test
 Pain in groin or hip that radiate
down anterior medial thigh
indicate L3 nerve lesion
 Pain extending to midtibia
indicates L4 nerve root
problem

24. Pt. prone, flex knee to 90 degree pain,
maintain position for 45 to 60 seconds.
Pain provoke.
When taking heel to buttock indicate SI
or lumber pain.
Could indicate tight rectus femoris.
Maintaining position with careful
history and its modification lead to find
femoral nerve compression

29. MYOTOMES
L2: Hip Flexion
L3: Knee extension
L4: Ankle Dorsiflexion
L5: Great toe extension
S1: Ankle plantar flexion, eversion, hip extension
S2: Knee flexion

30. The diagnosis of disc rupture is dependent on
demonstration of root impairment as reflected by
signs of motor weakness, changes in sensory
appreciation or reflex activity.

31.  X-Ray MRI

32.  Lumbar strain, spasm (70%)
 Facet joint pain
 Degenerative processes of disc and facets, usually age-related(10%)
 Spinal stenosis
 Osteoporotic compression fracture
 Spondylolisthesis
 Traumatic fracture
 Congenital disease
 Cauda equina
 Inflammatory/metabolic causes: Diabetes, Ankylosing spondylitis, Paget’s disease,
Arachnoiditis, Sarcoidosis
 Intraspinal synovial cysts
 Severe kyphosis, Severe scoliosis, Internal disk disruption
 Non mechanical- systemic cause

34. Majority of disc prolapse respond well to conservative therapy. Resolution of
first disc prolapse takes place approximately 75% of patients over a period of
3 months ( 12 weeks) surgery should not be recommended for at least 6
weeks of treatment.
BED REST In very acute condition patient must be kept on bed rest.
Adequate analgesic relive the pain and this helps the muscle spasm to
subside. Patient should not be kept in bed rest for not more than 2 to 3days.

36. Modalities
Cold or hot pack
TENS
Ultrasound therapy
Hydrotherapy
Lumbar Traction
Manual treatment

38.  Pain control
 Ambulation and resumption of exercise
 Education maintaining healthy weight
 restoration of functional deficit
 Restoration of neurological deficits associated with symptomatic disc
herniation.

39.  Acute/ protection phase- 0 to 4 weeks
 Subacute/ Controlled motion phase- 4 to 12 weeks
 Chronic/ Return to function phase- >12 weeks (6
months in some cases)

40. Educate patient- encourage to engage in activities
Pain control – modalities, soft tissue mobilization, traction, mobilization, rest
for 2 days if needed to settle nerve root irritation
Lumber traction for relieving paresthesia
Educate good posture - add braces or lumber support if needed
Initiate neuromuscular activation and control of stabilizing muscles-
Core strengthening – drawing in maneuver , bridging ,
Start extension bias protocol (McKenzie protocol)
Teach safe performance of ADLs- add adjacent muscle strengthening

43. BIDGING

44.  Educate patient – engage in all activities in safe mechanics, home exercise
program , ergonomics adaptation of work
 Progress control of stabilizing muscles- Lifting one leg in crawling position
Lifting crossed arms and legs in crawling position Lunges
 Flexibility exercises (eg, yoga and stretching)
 Proprioception/coordination/balance (medicine ball and wobble/tilt board)
 strengthening exercises
 Trunk curls
 SLR
 aerobic activity (eg, walking, cycling)

47.  Educate patient – engage in all activities in safe mechanics, home exercise program ,
ergonomics adaptation of work - progression
 Progress control of stabilizing muscles- Lifting one leg in crawling position Lifting
crossed arms and legs in crawling position, Lunges progress
 Flexibility exercises (eg, yoga and stretching)
 Proprioception/coordination/balance (challange balance progress)
 strengthening exercises- progression
 aerobic activity (eg, walking, cycling)
 (McKenzie approach progression)
 motor control exercises MCEs
 Endurance , agility, strength
 Lumber Traction

50. Post Surgical Rehab - In case of surgery, program start regularly 4-6 weeks
post-surgery.
 Patient education about the rehabilitation program they will follow the
next few weeks. Rehabilitation programs that start four to six weeks post-
surgery with exercises versus no treatment found that exercise programs
are more effective.
 The patients are instructed and accompanied in daily activities such as:
coming out of bed, going to the bathroom and clothing
 Patients have to pay attention on the ergonomics of the back.
 Home exercise programs.

51. Duration of rehabilitation program: 4 weeks
Frequency: every day
Duration of one session: approximately 60 minutes
Treatment: dynamic lumbar stabilization exercises + home exercises
Exercises: Prior to the DLS training session patients are provided with instruction or
technique to ensure and protect a neutral spine position. During the first 15 minutes of
each session stretching of back extensors, hip flexors, hamstrings and Achilles tendon
should be performed.
(DLS consists of: Quadratus exercises Abdominal strengthening Bridging with ball
Straightening of external abdominal oblique muscle Lifting one leg in crawling position
Lifting crossed arms and legs in crawling position Lunges)
Home Exercises - should be added to the treatment. These should be performed every
day. 5 repetitions during the first week up to 10-15 reps in the following weeks