This document summarizes information from a spine conference on lumbar disc disorders. It describes two patient cases - a 39-year-old woman with right buttock and leg pain and numbness, and a 45-year-old woman with severe right sciatica and thigh numbness. It also discusses various non-operative and surgical treatment options and natural history of lumbar disc herniations. Several topics are covered including anatomy of intervertebral discs, classification of disc pathology, nerve innervation of discs, and healing of disc herniations.

1. Lumbar
Discectomy
Spine Conference
May 2020

2. 39 year old woman with pain in the R buttock,
posterior thigh, posterior leg, dorsum foot second
and third toes. Onset 2 months prior started as
intermittent. One month ago the pain became
constant. Pain and numbness. Failed chiro, worse
with sitting, failed NSAID. LBP in the past.
Numbness where the thigh meets the groin.

6. Non-operative
• Meds: steroids,
NSAID, m relaxers,
opiates
• Therapy
• Chiropractic
• Massage
• Acupuncture
• Injections

7. 45 year old woman with severe R sciatica and posterior thigh numbness

8. Why are there so many low quality blurry MRI scans?

23. Note lumbar kyphosis in quadrups

26. Outerlayers are composed of tightly packed circumferential sheets of interlocked type 1 collagen f
Inner layer less organized and has a greater number of proteoglycans( NP) type 2 collagen

37. Herring

39. Why are annular disc tears so incapacitating?
Fine fiber nerve ending staining in a rabbit disc
The outer 3mm is innervated

40. Why are there standing desks?
Load with respect to posture of spine

41. How do HNP heal?

48. What is the usual natural history of a lumbar disc herniation ?

49. Probably 90% of all disc herniations are dissolved by the body

56. Success!!

57. Who gets the credit for resolution?

68. Enzymatic phagocytosis initiated by inflammatory cytokines released by disc material
Explains spontaneous regression of disc herniations

71. Most disc herniations are posterior lateral

72. The PLL is thicker in the midline and thinner posterior laterally, which contributes to higher
Incidence of paracentral herniations

74. • SPINE Volume 26, Number 5, pp E93–E113
• ©2001, Lippincott Williams & Wilkins, Inc.
• Nomenclature and Classification of Lumbar
• Disc Pathology
• Recommendations of the Combined Task Forces of the North
• American Spine Society, American Society of Spine Radiology, and
• American Society of Neuroradiology
• David F. Fardon, MD,* and Pierre C. Milette, MD†

77. Extrusion is
present when, in at least one
plane, any one distance
between the edges of the
disc material beyond the
disc
space is greater than the
distance between the edges
of
the base, or when no
continuity exists between
the disc
material beyond the disc
space and that within the
disc
space

78. 5

83. The DRG is very sensitive

85. Age versus degenerative changes on MRI on
ASx patients

89. Teenagers still grow

90. Pfirmann: Spine 2001 Sep 1;26(17):1873-8.

91. Sagittal T2-weighted MR images
(repetition time msec/echo time msec, 4000/80) of
lumbar disks illustrate five grades of degeneration
on the Pfirrmann scale. A and B are normal disks
in child and adult, respectively. C is a degenerated
disk, with diminished T2 signal intensity. D and E
have additional degenerative changes and height
loss.

92. Wide Geographical variation of spinal surgery per Medicare beneficiaries

94. Single center, random, 6 months versus surgery, VAS at 6 months
Surgery 3 wks after decision, crossover 34%, L4S1 PL HNP
London Health Sciences Center, Ontario, Canada
At 6 months VAS surgery 2.8 (+/-0.4), nonop 5.2 (+/-0.4)
At 12 months VAS surgery 2.6 (+/-0.4), nonop 4.7 (+/-0.4)

95. 45 year old woman with severe R sciatica and posterior thigh numbness

96. 39 year old woman with pain in the R buttock,
posterior thigh, posterior leg, dorsum foot second
and third toes. Onset 2 months prior started as
intermittent. One month ago the pain became
constant. Pain and numbness. Failed chiro, worse
with sitting, failed NSAID. LBP in the past.
Numbness where the thigh meets the groin.

102. Why should
laminotomy be
round?

103. The de Havilland DH 106 Comet
was the world's first commercial
jet airliner. Worlds first
commercial airliner debut in
1952. Within the first year
three exploded in midair, due to
stress risers from square
windows.

121. Prone Position

122. OSI Jackson Table 1

135. Adjustable speed from 200-75,000 rpm

137. Wilder Graves Penfield
(January 26, 1891 – April
5, 1976)
Canadian neurosurgeon

145. Thanks!

162. newborn

164. 11 months 7 years

171. Collagen fibrils 140,000x mag

172. Collagen: most abundant protein
• Table 22-3Major Collagen Molecules
• Type Molecule Composition Structural Features Representative Tissues
• Fibrillar Collagens
• I [α1(I)]2[α2(I)] 300-nm-long fibrils Skin, tendon, bone, ligaments, dentin,
interstitial tissues
• II [α1(II)]3 300-nm-long fibrils Cartilage, vitreous humor
• III [α1(III)]3 300-nm-long fibrils; often with type I Skin, muscle, blood vessels
• V [α1(V)]3 390-nm-long fibrils with globular N-terminal domain; often with type I Similar to type I; also cell cultures, fetal
tissues
• Fibril-Associated Collagens
• VI [α1(VI)][α2(VI)] Lateral association with type I; periodic globular domains Most interstitial tissues
• IX [α1(IX)][α2(IX)][α3(IX)] Lateral association with type II; N-terminal globular domain; bound glycosaminoglycan
Cartilage, vitreous humor;
• Sheet-Forming Collagens
• IV [α1(IV)]2[α2(IV)] Two-dimensional network All basal laminaes
• SOURCE: K. Kuhn, 1987, in R. Mayne and R. Burgeson, eds., Structure and Function of Collagen Types, Academic Press, p. 2; M. van der Rest and
R. Garrone, 1991, FASEB J. 5:2814.

176. http://www.valleylab.com/education/poes/poes_03.html