Prolapsed Intervertebral Discs can be caused by chronic degeneration from normal aging or acute disc herniation which causes pain and compression effects on the nerve root. Imaging like x-rays, MRI, and CT scans are used to diagnose the condition. Treatment options include rest, gentle massage, bracing, anti-inflammatory medications, epidural blocks, and surgery like microdiscectomy if conservative treatments fail. Surgical treatment aims to decompress the nerve root while avoiding excessive scarring and early mobilization is emphasized.

1. Prolapsed Intervertebral Discs

3. Pathology 1-Chronic-Normal aging-disc degeneration-displacement of facet joint--2ndary effect-aquired SS 2-Acute disc herneation-pain---Effects of pressure on the nerve root -Compressive -Deformation-str,& fun, changes

8. Clinical picture

9. Clinical picture

10. Imaging X-ray MRI CT scans with or without myelography -intolerant to MRI -Unsuitable for MRI gadolinium-enhanced MRI This will help to delineate which part of the previous operation site is disc and which is epidural fibrosis (the latter enhancing).

12. DDX Good general condition,mild N/D,-ve Investigation,normalCSF,+veMRI,on.off,1-2 level, neither young nor old DDX -----Acute muscular&ST strain ------inflammatory ----Infection -----Vertebral and nerve Tumor

13. treatment REST- Reduce-traction Remove Rehablitate

14. rest First attack • Any attack, early period • 75 to 80% respond • Principle – rest – 3wks

15. GENTLE MASSAGE 􀂙 Helps to loosen tight muscles in spasm. 􀂙 Psychological well being effect

16. BRACES & CORSETS 􀂾 Helps to restrict movements 􀂾 Sense of well being 􀂾 Prevails tortional movements Not to be used for more than 3 wks.

17. Anti inflammatory Analgesics Muscle relaxant Small doses of diazepam to relieve apprehension Medicines for constipation

18. PRECAUTIONS 􀂉 Straining 􀂉 Wt lifting 􀂉 Jerky movements 􀂉 Torsion of back 􀂉 Forward flexion

19. EPIDURAL BLOCK Very valuable Immediate relief from pain Should not have neurological deficit SLR should be more than 45o Should not have bilateral signs

20. Indications for diskectomy -Progressive Neurological deficit Failure of conservative treatment-refractory Significant motor deficit Severe incapacitating pain - does not respond to any form of treatment Cauda equina syndrome

21. surgical treatment -lamenectomy --partial lamenectomy-fenstraion-tailor -percutanous- -endoscopic-spinoscope --Microdisectomy -LASER ---disc replacement

22. PRINCIPLES OF SURGERY Decompress the root Prevent further extrusion Avoid too much scarring Minimum handling of muscles Least excision of bone Early mobilization Early discharge

23. THE LAMINECTOMY 􀂙 Today there is no indication to laminectomy in PID 􀂙 May create instability 􀂙 Involves lot of scarring & morbidity 􀂙 Cannot return to work early 􀂙 Introduces restrictions on life

24. THE FENESTRATION The approach is good and adequate Unilateral exposure Minimum damage Ligamentum flavum removed Contiguous margins of laminae removed. 2/3 upper lamina and 1/3 lower lamina removed.

25. MICROLUMBAR DISCECTOMY Best ,Short paramedian incision – less than one inch Bone is not touched The approach is through lateral half of lig.flavum. Good illumination, magnificationVisualisation Meticulous haemostasis Same day mobilisation Discharge within 24 hours

27. Complications -mechanical intraop; dural tear nerve root injury vascular injury epidural haematomas.

28. -early postop Superficial wound infections Discitis Haematoma -late postop Non-union Instability deformity

32. Persistent post operative back pain and sciatica

33. Back Pain

34. 70-80% of population at least once 13% of sickness absences most common cause of work-related disability most expensive cause of work-related disability 7% chronic pain Men= women Most common between 30-50 yrs Epidemiology

35. Risk Factors Heavy lifting Bodily vibration Obesity High risk occupations :miscellaneous labor, warehouse work, and nursing

36. Aetiology Conginetal --Kyphoscoliosis --Spina bifida --Spondylolisthesis

37. Acquired Traumatic Vertebral fractures Ligamentous injury Joint strains Muscle tears

38. Infective Osteomyelitis-acute and chronic TB,Discitis

39. Inflammatory Ankylosing spondyolitis Rheumatology disorders

40. Neoplastic Primary tumors Secondary tumors

41. Degenerative Osteoarthritis Spondylosis

42. Metabolic Osteoporosis Osteomalacia

43. Endocrine Cushing's -osteoporosis

44. Idiopathic Paget's disease Scheuermann's disease

45. Psychogenic Psychosomatic backache

46. Visceral Penetrating peptic ulcer Carcinoma of the pancreas Carcinoma of the rectum

47. Vascular Aortic aneurysm Acute aortic dissection

48. Renal Carcinoma of the kidney Renal calculus Inflammatory kidney disease

49. Gynaecological Uterine tumors Pelvic inflammatory disease Endometriosis

50. Approach to diagnosis -Transiet back ache following musc,activity -sudden acute pain &scitica -intermittent low back pain --pain+claudication -sever constant, localized pain

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