Etiopathogenesis, types, clinical presentation and management of Intervertebral Disc Prolapse

1. Intervertebral Disc Prolapse
Dr. Achyut Ravi
Assistant Professor
Department of Orthopedics
SAIMS

2. h

6. .

10. • Is a hydrostatic, load
bearing structure between
the vertebral bodies from
C2-3 to L5-S1 .
• Nucleus pulposus +
annulus fibrosus
• Is relatively avascular.
Intervertebral Disc

11. Vital Functions of the IVD
• Keeping spine flexible
• Contribution to stability
• Resistance to axial, rotational, and bending load
• Preservation of anatomic relationship
The Biochemical Composition
• Water : 65 ~ 90% wet wt.
• Collagen : 15 ~ 65% dry wt.
• Proteoglycan : 10 ~ 60% dry wt.
• Other matrix protein : 15 ~ 45% dry wt.

12. Annulus Fibrosus
•
•
•
•
•
•
Outer boundary of the disc. More than
60 distinct, concentric
layer of overlapping lamellae of
type I collagen.
Fibers are oriented 30-degree angle to the disc
space.
Helicoid pattern.
Resist tensile, torsional, and radial
stress.
Attached to the cartilaginous and
bony end-plate at the periphery of the
vertebra.

13. Nucleus Pulposus
 Type II collagen
strand +
hydrophilic
proteoglycan.
 Water content 70 ~ 90%
Confine fluid within the
annulus.
 Convert load into tensile
strain on the annular fibers
and vertebral end-plate.

14. Distribution of load in the
Intervertebral disc.
(A)In the normal, healthy disc,
the nucleus distributes the load
equally throughout the
annulus.
(B)As the disc undergoes
degeneration, the nucleus loses
some of its cushioning ability
and transmits the load
unequally to the annulus.
(C)In the severely degenerated
disc, the nucleus has lost all of
its ability to cushion the load,
which can lead to disc
herniation.

15.  Affects the spine due to trauma, lifting injuries, or idiopathic, in
which a tear in the annulus fibrosus of an intervertebral disc allows
the nucleus pulposus to bulge out beyond the damaged outer
rings.
 This tear in the disc ring may result in the release of
inflammatory chemical mediators which may directly cause
severe pain, even in the absence of nerve root compression .
 Disc herniations are normally a further development of a
previously existing disc "protrusion", a condition in which the
outermost layers of the annulus fibrosus are still intact, but can
bulge when the disc is under pressure.
Spinal Disc Herniation

16. Anatomic classification
Disc protrusion: the herniated portion of the disc covered
with a thin layer of annulus
Disc extrusion: disc material herniated through annulus but
remains continuous with disc space
Disc sequestration: the disc fragment herniates through the
annulus and loses contact with the originating disc space

17. posterolateral disc herniation –
 Protrusion is usually posterolateral into vertebral
canal, compress the roots of a spinal nerve.
 central (posterior) herniation:
Lumbar level central disc herniation may result in cauda equina
syndrome
Foraminal disc herniation
Extraforaminal disc Herniation
Types of herniation

18. Schematic illustration
a) Normal
b) Bulging disk
c)Focal bulge or protrusion.
The nucleus material remains
within the outermost fibres of
the annulus fibrosus.
d)Prolapse or extrusion.
The nucleus material has
penetrated the annulus
fibrosus but is contained in
front of the posterior
longitudinal ligament.
e) Sequester or free fragment.

19. Cellular and Biochemical Changes of the
Intervertebral Disc
 Decrease proteoglycan
content.
 Loss of negative charged
proteoglycan side chain.
 Water loss within the
nucleus pulposus.
 Decrease hydrostatic
property.
 Loss of disc height.
 Uneven stress
distribution on the
annulus.

20.  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.
CAUSES

21.  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.
 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.
 Mutation- in genes coding for proteins involved in the
regulation of the extracellular matrix, such
as MMP2 and THBS2, has been demonstrated to
contribute to lumbar disc herniation.
CAUSES

22. Normal Disc herniated Disc

23.  There is now recognition of the importance of
“chemical radiculitis” in the generation of back pain.
 A primary focus of surgery is to remove “pressure” or
reduce mechanical compression on a neural element: either
the spinal cord, or a nerve root.
 But it is increasingly recognized that back pain, rather than
being solely due to compression, may also be due to
chemical inflammation.
Pathophysiology

24.  There is evidence that points to a specific
inflammatory mediator of this pain.
 This inflammatory molecule, called tumor necrosis
factor-alpha (TNF), is released not only by the herniated
disc, but also in cases of disc tear (annular tear), by facet
joints, and in spinal stenosis.
 In addition to causing pain and
inflammation, TNF may also contribute to disc
degeneration

25.  symptoms of a herniated disc can
 Vary depending on the location of the
herniation and the types of soft tissue
that become involved.
 Degenerated disc can cause back pain
which exaggerates on forward bending.
 Lumbar disc protrusion can cause lower
limb radiating pain , tingling and
numbness.
Severe cases can present with
neurological deficit.

26.  sensory changes such as numbness, tingling, muscular
weakness, paralysis, paresthesia, and affection of
reflexes.
 If the disc protrudes to one side, it may irritate the dural
covering of the adjacent nerve root causing pain in the
buttock, posterior thigh and calf (sciatica).
 Unlike a pulsating pain or pain that comes and goes,
which can be caused by muscle spasm, pain from a
herniated disc is usually continuous or at least is
continuous in a specific position of the body.

27.  A large central rupture may cause compression
of the cauda equina.
 A posterolateral rupture presses on the nerve
root
 Sometimes a local inflammatory response with
oedema aggravates the symptoms.

28. CLINICAL FEATURE OF ACUTE DISC
PROLAPSE
• Acute disc prolapse may occur at any age, but is
uncommon in the very young and the very old.
• Typically, while lifting or stooping he has severe back pain and
is unable to straighten up.
• Either then or a day or two later pain is felt in the buttock and
lower limb (sciatica).
• Later there may be sensory or motor involvement.
• Cauda equina compression is rare but may cause urinary
retention and perineal numbness.

29. • The patient usually stands with a slight List to
one side.
• Sometimes the knee on the painful side is held
slightly flexed to relax tension on the sciatic nerve;
straightening the knee makes the skew back.
• All back movements are restricted, and during
forward flexion the list may increase.

30. • There is often tenderness in the midline of the low
back, and paravertebral muscle spasm.
• Straight leg raising is restricted and painful on
the affected side; dorsiflexion of the foot and
bowstringing of the lateral popliteal nerve may
accentuate the pain.
• Sometimes raising the unaffected leg causes acute
sciatic tension on the painful side (crossed SLR).
• With a high or mid-lumbar prolapse the femoral
stretch test may be positive.
• Neurological examination may show muscle
weakness and sensory loss corresponding to
the affected level.

31. • Normal reflexes at the knee and ankle are
characteristic of L5 root compression.
• Paradoxically, the knee reflex may appear to be
increased, because of weakness of the antagonists
(which are supplied by L5).
• S1 impairment causes weak plantar-flexion and
eversion of the foot, a depressed ankle jerk and
sensory loss along the lateral border of the foot.

32. FEATURES OF CAUDA EQUINA SYNDROME
Bladder and bowel incontinence
Perineal numbness
Bilateral Lower limb weakness
Crossed straight-leg raising sign
Note: Scan urgently and operate urgently if a large
central disc is revealed.

33. Signs and Symptoms
• Most common
sign or
symptom is
pain.
Pain located in
the buttock
that radiates
down the back
of the thigh
and possible
the calf.

34. Location
 The majority of spinal disc herniation cases occur
in lumbar region (95% in L4-L5 or L5-S1).
 The second most common site is the cervical
region (C5-C6, C6-C7).
 The thoracic region accounts for only 0.15% to 4.0%
of cases.

35. .
 Symptomatic posterolateral
herniation between two
vertebrae will actually
impinge on the nerve
exiting at
the next intervertebral
foramen down.
 for example, a herniation of
the disc between the L5 and
S1 vertebrae will impinge on
the S1 spinal nerve, which
exits between the S1 and S2
vertebrae.
 Occasionally an L4/5 disc
prolapse compresses both L5
and S1.

36. Cervical
 Cervical disc herniations occur in the neck, most often
between the fifth & sixth (C5-C6) and the sixth and
seventh (C6-C7) cervical vertebral bodies.
 Symptoms can affect the back of the skull, the neck,
shoulder girdle, scapula, shoulder, arm, and hand.
 The nerves of the cervical plexus and brachial
plexus can be affected.
Thoracic
 Thoracic discs are very stable and herniations in this
region are quite rare.
 Herniation of the uppermost thoracic discs can mimic
cervical disc herniations, while herniation of the other
discs can mimic lumbar herniations.

37. DISC LOAD IN DIFFERENT BODY POSTURE
When the spine is straight, such as in standing or lying down,
internal pressure is equalized on all parts of the discs.
While sitting or bending to lift, internal pressure on a disc can
move from 17 (lying down) to over 300 psi (lifting with a
rounded back).

38.  Diagnosis is based on the
history, symptoms, and physical examination.
 At some point in the evaluation, tests may be
performed to confirm or rule out other causes of
symptoms such
as spondylolisthesis, degeneration, tumors, metastasis
and space-occupying lesions, as well as to evaluate the
efficacy of potential treatment options.
Diagnosis

39.  Main article: Straight leg raise
 The Straight leg raise may be positive, as this finding
has low specificity; however, it has high sensitivity.
 Thus the finding of a negative SLR sign is important in
helping to "rule out" the possibility of a lower lumbar
disc herniation.
Physical
Examination

40. Examination With the
patient standing upright
look at his general posture
and note particularly the
presence of
any asymmetry or frank
deformity of the spine.

41. Then ask him to lean
backwards
(extension)

42. forwards to touch
his toes
(flexion)

43. then sideways as
far as possible

44. hold the pelvis
stable and ask the
patient to twist first to
one side and then to
the other (rotation).
Note that rotation
occurs almost
entirely in the thoracic
spine (e) and not in the
lumbar spine.

45. With the patient upright, select two bony points 10 cm apart
and mark the skin as
the patient bends forward, the two points should separate by
at least a further 5 cm

46. Provocative tests
– Straight leg raise test (SLR)
• a nerve root tension sign
• technique
– Supine position
– reproduces pain and paresthesia in leg at 30-70 degrees passive hip flexion
• sensitivity/specificity
– most important and predictive physical finding for identifying nerve
root compression
– contralateral SLR
• crossed straight leg raise is less sensitive but more specific
– Lasegue sign
• SLR aggravated by forced ankle dorsiflexion
– Bowstring sign
• SLR aggravated by compression on popliteal fossa
– Kernig test
• pain reproduced with neck flexion, hip flexion, and legextension

48. Examination with the patient prone (a) Feel for tenderness, watching the patient’s face
for any reaction.
(b) Performing the femoral stretch test. You can test for lumbar root sensitivity either by
hyperextending the hip or by
acutely flexing the knee with the patient lying prone.
Note the point at which the patient feels pain and compare the two sides.
(c) While the patient is lying prone, take the opportunity to feel the pulses. The
popliteal pulse is easily felt if the
tissues at the back of the knee are relaxed by slightly flexing the knee.

49. X.Ray : lumbo-sacral spine
 Narrowed disc spaces.
 Loss of lumber lordosis.
 Compensatory scoliosis.
MRI lumbar spine;
 Helps to visualize the disc, nerve root, thecal sac.
 Compression of nerve root.
CT scan lumbar spine;
 It can show the shape and size of the spinal canal and bony anatomy
better delineated by CT scan.
Myelogram;
 pressure on the spinal cord or nerves, such as herniated discs, tumors,
or bone spurs.

53. Treatment options
Pain medications.
Bed rest
Oral steroids .
Nerve root block .
Surgery

54.  Non-steroidal anti-inflammatory drugs (NSAIDs).
 Patient education on proper body mechanics.
 Physical therapy, to address mechanical factors, and may
include modalities to temporarily relieve pain
(i.e. traction, electrical stimulation massage).
 Oral steroids (e.g. prednisone or methylprednisolone).
 Epidural cortisone injection.
 Intravenous sedation, analgesia-assisted traction therapy
(IVSAAT).
 Weight control.
 Tobacco cessation.
 Lumbosacral back support.
 anti-depressants.
Indicated treatment.

55. Surgical Management
 Surgery is generally considered only as a last resort, or
if a patient has a significant neurological deficit.
 The presence of cauda equina syndrome is considered
a surgical emergency requiring immediate attention
and possibly surgical decompression.
 Regarding the role of surgery for failed medical
therapy in patients without a significant neurological
deficit, a meta-analysis of randomized controlled
trials by the Cochrane Collaboration concluded that
"limited evidence is now available to support some
aspects of surgical practice".
 More recent randomized controlled trials refine
indications for surgery as follows:

56.  The Spine Patient Outcomes Research Trial (SPORT)
 Patients studied "intervertebral disk herniation and
persistent symptoms despite some nonoperative
treatment for at least 6 weeks...radicular pain (below
the knee for lower lumbar herniations, into the
anterior thigh for upper lumbar herniations) and
evidence of nerve-root irritation with a positive
nerve-root tension sign (straight leg raise–positive
between 30° and 70° or positive femoral tension sign)
or a corresponding neurologic deficit (asymmetrical
depressed reflex, decreased sensation in a
dermatomal distribution, or weakness in a myotomal
distribution)

57.  Conclusions.
 "Patients in both the surgery and the nonoperative
treatment groups improved substantially over a 2-
year period.
 Because of the large numbers of patients who crossed
over in both directions, conclusions about the
superiority or equivalence of the treatments are not
warranted based on the intent-to-treat analysis"

58. • The Hague Spine Intervention Prognostic Study
Group
• Patients studied "had a radiologically confirmed
disk herniation...incapacitating lumbosacral
radicular syndrome that had lasted for 6 to 12
weeks...Patients presenting with cauda equina
syndrome, muscle paralysis, or insufficient strength
to move against gravity were excluded."
• Conclusions. "The 1-year outcomes were similar for
patients assigned to early surgery and those
assigned to conservative treatment with eventual
surgery if needed, but the rates of pain relief and of
perceived recovery were faster for those assigned
to early surgery.

59. The objectives of surgical treatment
1. relief of nerve compression.
2. relief of associated back pain.
3. restoration of normal function.

60. Chemonucleolysis-
• Chemonucleolysis is the term
used to denote chemical
destruction of nucleus pulposus
[Cehmo+nucleo+lysis].
• This involves intradiscal injection
ofchymopapain which causes
hydrolysis of he cementing
protein of the nucleus pulposus.
• This causes decrease in water
binding capacity leading to
reduction in size and drying the
disc.
• Chemonucleolysis is one of the
methods to treat disc herniation
not responding to conservative
therapy

61. Intradiscal electrothermic therapy (IDET)
• provides a new alternative to other
surgical procedures for patients who
suffer from back pain caused by certain
types of disc problems.
• It is a fairly advanced procedure made
possible by the development of
electrothermal catheters that allow for
careful and accurate temperature control.
The procedure works by cauterizing the
nerve endings within the disc wall to help
block the pain signals
• IDET is a minimally invasive outpatient
surgical procedure developed over the last
few years to treat patients with chronic
low back pain that is caused by tears or
small herniations of their lumbar discs.

62. Discectomy/Microdiscectomy -
• This procedure is used
to remove part of an
intervertebral disc that
is compressing the
spinal cord or a nerve
root.

63. The Tessys method
• The Tessys method
(transforaminal
endoscopic surgical
system) is a minimally
invasive surgical
procedure to remove
herniated discs .

64. Laminectomy-
to relieve spinal
stenosis or nerve
compression

65. Hemilaminectomy -
Hemilaminectomy is
surgery to help alleviate
the symptoms of an
impinged or irritated
nerve root in the spine

66. Lumbar fusion
• Anterior lumbar fusion is an
operation done on the
front (the anterior region) of the lower
spine. Fusion surgery helps two or more
bones grow together into one solid bone.
Fusion cages are new devices, essentially
hollow screws filled with bone graft, that
help the bones of the spine heal together
firmly. Surgeons use this procedure when
patients have symptoms from disc
degeneration, disc herniation, or spinal
instability.
• Lumbar fusion is only indicated
for recurrent lumbar disc
herniations, not primary
herniations

67. Disc arthroplasty
• Artificial Disc Replacement
(ADR), or Total Disc Replacement
(TDR), is a type of arthroplasty.
• It is a surgical procedure in which
degenerated intervertebral
discs in the spinal column are
replaced with artificial devices in
the lumbar (lower) or cervical
(upper) spine.
• The procedure is used to treat
chronic, severe low back pain and
cervical pain resulting
from degenerative disc disease.
• Used for cases of cervical disc
herniation

68. Dynamic stabilization
• Dynamic stabilization is a surgical
technique designed to allow for
some movement of the spine,
while maintaining enough
stability to prevent too much
movement.
• If you need to undergo surgery
for spinal disc problems, you may
also need added stabilization of
the spine to prevent additional
problems

69. THANK YOU