The document discusses intervertebral disc diseases. It describes the normal structure of intervertebral discs and how aging, mechanical factors, and inflammation can alter disc structure and function. Common causes of disc herniation include trauma, genetic predisposition, and degeneration from aging. Herniated discs most commonly occur in the lumbar and cervical spine. Symptoms depend on the specific nerve root compressed and may include pain, weakness, sensory changes, and reflex abnormalities. Imaging like MRI is used to identify disc herniations. Conservative care includes rest, medication, and physical therapy, while surgery is considered if symptoms do not improve.

2. INTERVERTEBRALINTERVERTEBRAL
DISC DISEASESDISC DISEASES

3. WHAT IS A DISC?WHAT IS A DISC?
The structure of the normal intervertebral discThe structure of the normal intervertebral disc
includes:includes:
 A soft nucleus pulposus in the centreA soft nucleus pulposus in the centre
 An tough outer annulus fibrosisAn tough outer annulus fibrosis
The structure and function of the disc may be alteredThe structure and function of the disc may be altered
by processes including normal physiological aging,by processes including normal physiological aging,
mechanical factors including trauma and repetitivemechanical factors including trauma and repetitive
stress, segmental instability of the spine, andstress, segmental instability of the spine, and
inflammatory and biochemical factors.inflammatory and biochemical factors.

6.  PathogenesisPathogenesis ..
 The displaced disc material may create signs and symptoms by bulgingThe displaced disc material may create signs and symptoms by bulging
or protruding beneath an attenuated annulus fibrosis or the material mayor protruding beneath an attenuated annulus fibrosis or the material may
extrude through a tear in the annulus and project directly into the spinalextrude through a tear in the annulus and project directly into the spinal
canal. In either case disc material may irritate or compress nerve roots. Incanal. In either case disc material may irritate or compress nerve roots. In
the lumbar region the signs and symptoms relate to an individual rootthe lumbar region the signs and symptoms relate to an individual root
lesion (compressed laterally) or to compression of the cauda equinalesion (compressed laterally) or to compression of the cauda equina
 In the cervical region the levels most commonly affected are in the C5 toIn the cervical region the levels most commonly affected are in the C5 to
C7 segments. In the lumbar area most disc protrusions occur at L4—5 andC7 segments. In the lumbar area most disc protrusions occur at L4—5 and
L5—Sl. Thoracic disc protrusion, except at the lower thoracic levels,L5—Sl. Thoracic disc protrusion, except at the lower thoracic levels,
differs from the cervical and lumbar disorders in genesis. Motion plays nodiffers from the cervical and lumbar disorders in genesis. Motion plays no
role there because the thoracic vertebrae are designed for stability ratherrole there because the thoracic vertebrae are designed for stability rather
than motion.than motion.
 Although trauma has been accepted as the prime cause of herniation, it isAlthough trauma has been accepted as the prime cause of herniation, it is
not the only cause. There seems to be a genetic predisposition in manynot the only cause. There seems to be a genetic predisposition in many
cases. Trauma can aggravate and cause the ultimate rupture. There may becases. Trauma can aggravate and cause the ultimate rupture. There may be
multiple levels of severe disc degeneration throughout the spine, withmultiple levels of severe disc degeneration throughout the spine, with
progressive clinical involvement in different areas.progressive clinical involvement in different areas.

7.  Spinal StenosisSpinal Stenosis , which is an abnormally narrow, which is an abnormally narrow
spinal canal, is an example of inherited anomaly. Thesespinal canal, is an example of inherited anomaly. These
abnormal spinal configurations along with spondylosisabnormal spinal configurations along with spondylosis
are major contributors to compression syndromes of theare major contributors to compression syndromes of the
cord and cauda equina. Spinal stenosis may occur atcord and cauda equina. Spinal stenosis may occur at
one or frequently multiple spinal levels. Patient typicallyone or frequently multiple spinal levels. Patient typically
report an exercise-precipitated neurogenic anterior thighreport an exercise-precipitated neurogenic anterior thigh
or sciatic pain. Neurologic examination is usuallyor sciatic pain. Neurologic examination is usually
normal. Surgical decompression is usually successful.normal. Surgical decompression is usually successful.
 Rupture of an intervertebral disc is common, especiallyRupture of an intervertebral disc is common, especially
in the fourth to sixth decades of life.in the fourth to sixth decades of life.

10. LUMBAR DISCLUMBAR DISC
PROLAPSEPROLAPSE
 Due to trauma nucleus herniates through aDue to trauma nucleus herniates through a
tear in the annulustear in the annulus
 Herniation usually occursHerniation usually occurs laterallylaterally andand
compresses adjacent nerve roots, if itcompresses adjacent nerve roots, if it
occursoccurs centrallycentrally it compresses caudait compresses cauda
equinaequina
 Associated hypertrophy of degeneratedAssociated hypertrophy of degenerated
facet joints is further source of back and legfacet joints is further source of back and leg
painpain

11. DISC PROTRUSION
TRAUMA
FACET JOINT
MALIGNMENT
ROOT
COMPRESSION
FACET JOINT
DEGENERATION
&HYPERTROPHY

12. FACET JOINT

13. Lateral disc herniationLateral disc herniation
 Compresses the nerveCompresses the nerve
root exiting throughroot exiting through
foramen below affectedforamen below affected
areaarea
 L3/4 disc lesion willL3/4 disc lesion will
compress L4 nervecompress L4 nerve
rootroot
 Lumbar disc lesionsLumbar disc lesions
occur at any level butoccur at any level but
L4/5 and L5/S1 are theL4/5 and L5/S1 are the
commonest sites(95%)commonest sites(95%)

14. CAUSESCAUSES
 AGEAGE
 GENETIC PREDISPOSITIONGENETIC PREDISPOSITION
 ACUTE AND CHRONIC TRAUMAACUTE AND CHRONIC TRAUMA
 CONGENITAL ANOMALIES OFCONGENITAL ANOMALIES OF
SPINESPINE
 ADDITIONAL RIBS AND VERTEBRAADDITIONAL RIBS AND VERTEBRA
(KYPHOSCOLIOSIS)(KYPHOSCOLIOSIS)
 PHYSICAL LABOURPHYSICAL LABOUR

15. CLINICAL FEATURES OFCLINICAL FEATURES OF
LATERAL DISCLATERAL DISC
PROTRUSIONPROTRUSION
 Pain (back and leg)-coughing andPain (back and leg)-coughing and
sneezing aggravates itsneezing aggravates it
 Muscle spasmMuscle spasm
 Limitation of movementsLimitation of movements
 Decreased lumbar lardosisDecreased lumbar lardosis
 ScoliosisScoliosis
 ParesthesiaParesthesia

16. SIGNSSIGNS
 STRAIGHT LEG RAISING: L5 & S1 rootSTRAIGHT LEG RAISING: L5 & S1 root
compression cause limitation to less than 60compression cause limitation to less than 60
degrees from the horizontal and produces paindegrees from the horizontal and produces pain
down the back of leg, dorsiflexion of foot when itsdown the back of leg, dorsiflexion of foot when its
elevated aggravates the painelevated aggravates the pain
 REVERSE LEG RAISING: test for irritation ofREVERSE LEG RAISING: test for irritation of
higher nerve roots( L4&above)higher nerve roots( L4&above)
 VASALVA MANEUVERS: coughing or sneezingVASALVA MANEUVERS: coughing or sneezing
causes paincauses pain

17. STRAIGHT LEG
RAISING
STRAIGHT LEG RAISING

18. REVERSE LEG RAISING

19. Neurological deficitNeurological deficit
 L4- quadriceps weakness, sensory impairment overL4- quadriceps weakness, sensory impairment over
medial calf,impaired knee jerk reflexmedial calf,impaired knee jerk reflex
 L5-weakness of dorsiflexion of big toe and foot,L5-weakness of dorsiflexion of big toe and foot,
difficulty walking on heels, foot drop may occur.difficulty walking on heels, foot drop may occur.
Numbness in lateral leg, first 3 toes. Pain overNumbness in lateral leg, first 3 toes. Pain over
sacro-iliac joint, hip, lateral thigh and leg. Reflexessacro-iliac joint, hip, lateral thigh and leg. Reflexes
changes are uncommon in knee and ankle jerks.changes are uncommon in knee and ankle jerks.
 S1- weakness of plantar flexors of foot and greatS1- weakness of plantar flexors of foot and great
toe. Numbness in the back of calf, lateral heel, foottoe. Numbness in the back of calf, lateral heel, foot
to toe. Pain over sacro-iliac joint, hip, postero-lateralto toe. Pain over sacro-iliac joint, hip, postero-lateral
thigh and leg to heel. Ankle jerk is diminished orthigh and leg to heel. Ankle jerk is diminished or
absent.absent.

21. CLINICAL FEATURES OFCLINICAL FEATURES OF
CENTRAL DISCCENTRAL DISC
PROTRUSIONPROTRUSION
 Usually bilateralUsually bilateral
 Leg pain: extend down back of thighsLeg pain: extend down back of thighs
 Sphincter paralysis:Sphincter paralysis:
bladder,urethral,rectumbladder,urethral,rectum
 Sensory loss: sacral area(saddleSensory loss: sacral area(saddle
anaesthesia)anaesthesia)
 Motor loss: foot dropMotor loss: foot drop
 Reflex lost: ankle jerkReflex lost: ankle jerk

23. BACK PAIN ON
THE SACRAL
REGION
EXTENDING
DOWN TO THE
BACK OF THE
THIGH IN
CENTRAL
DISC
PROTRUSION

24. Thoracic Disc RuptureThoracic Disc Rupture
 Because the thoracic spine is designed for rigidity rather thanBecause the thoracic spine is designed for rigidity rather than
excursion, wear and tear from motion and stress cannot causeexcursion, wear and tear from motion and stress cannot cause
thoracic disc protrusion and clinical disorders are rare. Thoracic discthoracic disc protrusion and clinical disorders are rare. Thoracic disc
disease may result from the chronic vertebral changes incident todisease may result from the chronic vertebral changes incident to
Scheuermann diseaseScheuermann disease oror juvenile osteochondritisjuvenile osteochondritis with laterwith later
traumatrauma. The radiographic changes of Scheuermann disease, when. The radiographic changes of Scheuermann disease, when
seen with thoracic cord compression. should raise the possibility ofseen with thoracic cord compression. should raise the possibility of
disc protrusion. Calcific changes in the intervertebral disc and thedisc protrusion. Calcific changes in the intervertebral disc and the
typical vertebral changes of that disease are diagnostic markers.typical vertebral changes of that disease are diagnostic markers.
This occurs rarely ( 0.2% of all lesionsThis occurs rarely ( 0.2% of all lesions
due to the relative rigidity of thedue to the relative rigidity of the
thoracic spine )thoracic spine )

25. CERVICALCERVICAL
RADICULOPATHRADICULOPATH
YY

26. Cervical Disc DiseaseCervical Disc Disease
Cervical radiculopathy, related to pressure on a cervicalCervical radiculopathy, related to pressure on a cervical
nerve root, is a common clinical problem. It affects most adultnerve root, is a common clinical problem. It affects most adult
age groups but is uncommon in adolescents and children.age groups but is uncommon in adolescents and children.
Although cervical root symptoms often begin spontaneously,Although cervical root symptoms often begin spontaneously,
clinical presentation less frequently begins with a specificclinical presentation less frequently begins with a specific
incident such as a mild twist, carrying a heavy briefcase orincident such as a mild twist, carrying a heavy briefcase or
significant acute trauma.significant acute trauma.
Cervical disc herniation may involve both the root and theCervical disc herniation may involve both the root and the
spinal cord depending on the volume of the canal and the sizespinal cord depending on the volume of the canal and the size
of the lesion. Cord compression is uncommon except withof the lesion. Cord compression is uncommon except with
spinal stenosis or massive rupture of a disc. The sites of thespinal stenosis or massive rupture of a disc. The sites of the
most frequent disc herniations are C5--6 and C6—7;most frequent disc herniations are C5--6 and C6—7;
C4--5 and C7—T1 are less frequently affected, and otherC4--5 and C7—T1 are less frequently affected, and other
levels are rarely involved.levels are rarely involved.

27. Signs and SymptomsSigns and Symptoms
Symptoms of a cervical radiculopathySymptoms of a cervical radiculopathy
depend on the specific root involved. Neckdepend on the specific root involved. Neck
or interscapular pain commonlyor interscapular pain commonly
accompanies cervical root compression.accompanies cervical root compression.
Occasionally shoulder or arm pain isOccasionally shoulder or arm pain is
present. Evidence of arm weakness andpresent. Evidence of arm weakness and
sensory disturbances are typical clinicalsensory disturbances are typical clinical
findings. These symptoms are worsened byfindings. These symptoms are worsened by
movements of the head and neck and oftenmovements of the head and neck and often
by stretching the dependent arm.by stretching the dependent arm.

28. C5 lesionsC5 lesions cause pain radiating into the medial scapula and the uppercause pain radiating into the medial scapula and the upper
arm. Muscle weakness manifests as difficulty performing tasks witharm. Muscle weakness manifests as difficulty performing tasks with
the arm elevated. Mild sensory loss in the shoulder.the arm elevated. Mild sensory loss in the shoulder.
C6 lesionsC6 lesions cause pain at the medial scapula, frequently radiating intocause pain at the medial scapula, frequently radiating into
the arm and the lateral hand. Weakness in the proximal arm muscles,the arm and the lateral hand. Weakness in the proximal arm muscles,
particularly with difficulty flexing the arm. Classic paresthesias in theparticularly with difficulty flexing the arm. Classic paresthesias in the
thumb and index finger. Depression of the biceps reflex withthumb and index finger. Depression of the biceps reflex with
weakness and atrophy of that muscle.weakness and atrophy of that muscle.
InIn C7C7 lesionslesions, paresthesias may involve the index and middle finger., paresthesias may involve the index and middle finger.
Atrophy and weakness in triceps, wrist extensors. and pectoralAtrophy and weakness in triceps, wrist extensors. and pectoral
muscles, and a parallel reflex depression.muscles, and a parallel reflex depression.
C8C8 (between C7 and T1 vertebrae) -(between C7 and T1 vertebrae) - pain radiates from thepain radiates from the
neck into the medial arm and forearm. Paresthesias affect the fourthneck into the medial arm and forearm. Paresthesias affect the fourth
and fifth fingers. May be significant weakness of intrinsic handand fifth fingers. May be significant weakness of intrinsic hand
function with sensory loss appropriate to the paresthesiasfunction with sensory loss appropriate to the paresthesias..

29. INVESTIGATIONINVESTIGATION
 X-RAY examination (osteofites, osteoporosis,X-RAY examination (osteofites, osteoporosis,
anatomy of spine with its degenerativeanatomy of spine with its degenerative
changes, instability, destructive lesions in thechanges, instability, destructive lesions in the
vertebral bodies and disc space)vertebral bodies and disc space)
 CT SCANCT SCAN
 MRI (disc herniation, spinal stenosis)MRI (disc herniation, spinal stenosis)
 MYELOGRAPHYMYELOGRAPHY

30. Treatment.Treatment.
Bed rest, restricting of heavy activity, immobilization of the neck by aBed rest, restricting of heavy activity, immobilization of the neck by a
collar, benzodiazepine muscle relaxant, NSAID or both, vitamins B.collar, benzodiazepine muscle relaxant, NSAID or both, vitamins B.
Physiotherapy, acupuncture, massage (but not at the acute period).Physiotherapy, acupuncture, massage (but not at the acute period).
With this approach patients improve within 1 to 3 months. Surgery for aWith this approach patients improve within 1 to 3 months. Surgery for a
lumbar disc disorder is indicated when there is no improvement afterlumbar disc disorder is indicated when there is no improvement after
conservative treatment, or when a severe neurologic disorder is found onconservative treatment, or when a severe neurologic disorder is found on
examination.examination.
Cauda equina syndromeCauda equina syndrome – large herniation, compresses routs: severe– large herniation, compresses routs: severe
bilateral leg pains, sensory loss in dermatome distirbution, sphincterbilateral leg pains, sensory loss in dermatome distirbution, sphincter
disorder, foot drop, absence of ankle jerk. Absolute indication for surgery.disorder, foot drop, absence of ankle jerk. Absolute indication for surgery.

31. CERVICAL SPONDYLOTICCERVICAL SPONDYLOTIC
MYELOPATHYMYELOPATHY
Cervical spondylosisCervical spondylosis
Spondylosis is a normal aging process, is theSpondylosis is a normal aging process, is the
most common cause of a cervical myelopathy.most common cause of a cervical myelopathy.
It results from disc degeneration followed byIt results from disc degeneration followed by
reactive osteophyte formation, spondyloticreactive osteophyte formation, spondylotic
transverse bars, facet hypertrophy andtransverse bars, facet hypertrophy and
thickening of the ligamentum flavum causingthickening of the ligamentum flavum causing
spinal canal narrowing. Spinal cordspinal canal narrowing. Spinal cord
compression may occur. A herniated nucleuscompression may occur. A herniated nucleus
pulposus can produce cervical myelopathy.pulposus can produce cervical myelopathy.

32. Symptoms and SignsSymptoms and Signs . Neck pain may be. Neck pain may be
prominent. Root pain is uncommon butprominent. Root pain is uncommon but
paresthesias may indicate the most affectedparesthesias may indicate the most affected
root. The most common symptom is spasticroot. The most common symptom is spastic
gait disorder. Weakness and wasting of thegait disorder. Weakness and wasting of the
hands may be seen. Fasciculations also mayhands may be seen. Fasciculations also may
be noted. Urinary sphincter symptoms occur inbe noted. Urinary sphincter symptoms occur in
a minority of patients. The course of thea minority of patients. The course of the
disorder is slowly progressive. Study of patientsdisorder is slowly progressive. Study of patients
who were not treated surgically indicates thatwho were not treated surgically indicates that
the condition may become arrested or eventhe condition may become arrested or even
improve spontaneouslyimprove spontaneously

33. Differential DiagnosisDifferential Diagnosis . There are two types of problems of. There are two types of problems of
differential diagnosis. In one group, there is compression ofdifferential diagnosis. In one group, there is compression of
the cervical spinal cord but not by spondylosis (or at least notthe cervical spinal cord but not by spondylosis (or at least not
by spondylosis alone). Cervical spinal tumors are the bestby spondylosis alone). Cervical spinal tumors are the best
example of this category. Such lesions are revealed by MRI.example of this category. Such lesions are revealed by MRI.
in other compressive lesions the primary bony changes arein other compressive lesions the primary bony changes are
congenital (anomalies of the craniocervical junction) orcongenital (anomalies of the craniocervical junction) or
acquired (rheumatoid arthritis or basilar impression), and mayacquired (rheumatoid arthritis or basilar impression), and may
be further complicated by spondylosis. These disorders arebe further complicated by spondylosis. These disorders are
recognized by CT or MRI. Arteriovenous malformations mayrecognized by CT or MRI. Arteriovenous malformations may
also be found.also be found.
Another group of myelopathies presents more of a diagnosticAnother group of myelopathies presents more of a diagnostic
problem: cervical spondylosis is so common in the generalproblem: cervical spondylosis is so common in the general
population that it may be present by chance and harmless in apopulation that it may be present by chance and harmless in a
person with another disease of the spinal cord.person with another disease of the spinal cord.

34. MRI of CERVICAL SPINEMRI of CERVICAL SPINE
showing a large central dicsshowing a large central dics
prolapse impinging on theprolapse impinging on the
spinal cord (arrow) at thespinal cord (arrow) at the
C6/7 level.C6/7 level.

35. LUMBAR SPONDYLOSISLUMBAR SPONDYLOSIS
The same pathologic changes that define cervical spondylosis may affect the lowerThe same pathologic changes that define cervical spondylosis may affect the lower
spine. Here, however, the roots of the cauda equina are affected rather than thespine. Here, however, the roots of the cauda equina are affected rather than the
spinal cord. The spinal cord becomes narrow because of age-related degenerativespinal cord. The spinal cord becomes narrow because of age-related degenerative
changes that affect the vertebral column articulations, including disc bulging and spurchanges that affect the vertebral column articulations, including disc bulging and spur
formation, facet joint enlargement, and hypertrophy of the ligamentum flavum andformation, facet joint enlargement, and hypertrophy of the ligamentum flavum and
facet capsule.facet capsule.
The stenosis caused by spondylosis may be diffuse, but it is usually confined to one orThe stenosis caused by spondylosis may be diffuse, but it is usually confined to one or
two lumbar levels.two lumbar levels. Isolated L4-5 disorder with unilateral or bilateral L5 radiculopathyIsolated L4-5 disorder with unilateral or bilateral L5 radiculopathy
is the most common syndromeis the most common syndrome. The L3-4 segment is affected less often, either alone. The L3-4 segment is affected less often, either alone
or in combination with L4-5 stenosis. Other levels are rarely affected.or in combination with L4-5 stenosis. Other levels are rarely affected.
The resulting syndrome differs from acute herniation in many respects. Most patients areThe resulting syndrome differs from acute herniation in many respects. Most patients are
older than 40; many are older than 60. Progression of symptoms is likely to beolder than 40; many are older than 60. Progression of symptoms is likely to be
gradual rather than acute; twisting the back, lifting, or falling are precipitating factorsgradual rather than acute; twisting the back, lifting, or falling are precipitating factors
in less than a third of cases. and back pain is not the dominant symptom but may bein less than a third of cases. and back pain is not the dominant symptom but may be
reported in more than half. Leg pain, when present. is as often bilateral as unilateral.reported in more than half. Leg pain, when present. is as often bilateral as unilateral.
Weakness of the legs and urinary incontinence are symptoms in a minority ofWeakness of the legs and urinary incontinence are symptoms in a minority of
patients, but many show weakness of isolated muscles and loss of re flexes onpatients, but many show weakness of isolated muscles and loss of re flexes on
examination. Straight leg-raising is limited in a few cases.examination. Straight leg-raising is limited in a few cases.

36. MRI of LUMBARMRI of LUMBAR
SPINE showing aSPINE showing a
central disccentral disc
prolapse at the L4/5prolapse at the L4/5
level (arrow).level (arrow).
The signal from theThe signal from the
L4/5 and L5/S1L4/5 and L5/S1
indicatesindicates
dehydration, whiledehydration, while
the L3/4 signalthe L3/4 signal
appearance isappearance is
normal.normal.

37. INDICATION FORINDICATION FOR
OPERATIONOPERATION
 Progressive neurological deficitsProgressive neurological deficits
 Intractable pain when this fails toIntractable pain when this fails to
respond to conservative measuresrespond to conservative measures
 Acute disc protrusionsAcute disc protrusions

38. SPONDYLOLISTHESISPONDYLOLISTHESI
SS Forward shift of one of the vertebra body onForward shift of one of the vertebra body on
anotheranother
 Slip occurs due to degenerative disease ofSlip occurs due to degenerative disease of
the facet joint (always at L4/5) or due to athe facet joint (always at L4/5) or due to a
developmental break or elongation of the L5developmental break or elongation of the L5
laminalamina
 Treatment is usually conservative but if signsTreatment is usually conservative but if signs
of root compression are present thenof root compression are present then
decompression of root canal is necessarydecompression of root canal is necessary

39. DEGENERATIVE
DISEASE OF
FACET JOINT

40. THE ENDTHE END
Thank you for your attention.Thank you for your attention.