Orthopaedics

1. PROLAPSED LUMBAR INTERVERTEBRAL DISC (PLID)
PROF. (DR.) MD. SHAH ALAM
MBBS, MS, FCPS, FRCS
Fellowship Training in Spine Surgery (USA)
Imperial Spine Course (UK)
Professor
Department of Ortho & Spine Surgery
National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR)
Dhaka, Bangladesh

3. FUNCTIONS

4. FUNCTIONS

9. • Secondary curves
Secondary curves develops in response to
weight bearing. Purpose of these curves
are to keep the spine balanced in sagittal
plane. The lordotic cervical & lumbar
curves are the secondary curves.

10. LUMBAR SPINE

11. ANATOMY OF LUMBAR
SPINE

13. INTERVERTEBRAL DISC

14. Intervertebr
al foramen

15. Intervertebral Disc
 Is a hydrostatic, load bearing structure between
the vertebral bodies from C2-3 to L5-S1.
 1/6th of vertebral column
 Nucleus pulposus + annulus fibrosus.
 Is relatively avascular.
 L4-5, largest avascular structure in the body.

16. Vital Functions of the IVD
 Restricted intervertebral joint motion
 Contribution to stability
 Resistence to axial, rotational, and bending
load
 Preservation of anatomic relationship.

17. Biochemical Composition
 Water : 65 ~ 90% wet wt.
 Collagen : 15 ~ 65% dry wt.
 Proteoglycan : 10 ~ 60% dry wt.
 Other matrix protein : 15 ~ 45% dry wt.

18. Annulus Fibrosus
 Outer boundary of the disc.
 Helicoid pattern, more than 60 distinct
concentric layer of overlapping lamellae of
type I collagen.
 Resist tensile, torsional and radial stress
 Attached to the cartilaginous and bony end-
plate at the periphery of the vertebra.

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

20. Intervertebral Disc

21. Disc Nutrition
Nutrition depends on
diffusion from
adjacent vertebral
body through porous
central concavity of
vertebral column

22. Diurnal Change
 During day time- disc shrinks by 20%
 Body height reduced by 15 – 25 mm
 In night- body height is increased.

23. Natural disc ageing: Degeneration starts as
early as at 16 years of age
 Loss of the proteoglycan molecule from the
nucleus of the disc.
 Progressive dehydration.
 Progressive thickening.
 Brown pigmentation formation.
 Increased brittleness of the tissue of the disc.

24. Factors Contributing To
Disc Ageing
 Idiopathic Blood Vessel/Nutrient Loss And
Dehydration/Decreased Proteoglycans
Production
 Vertebral end plate calcification
 Arterial stenosis
 Smoking
 DM
 Exposure to vibration

25. Disc pressure
 Normal intra-discal pressure: 10-15 kg/cm2
(Sitting)
 In lying: Pressure decreases by 50% than
sitting
 In standing: < 30% Of sitting.

26.  Is a medical condition affecting lumbar spine,
in which a tear in the outer fibrous ring
(annulus fibrosus) of an intervertebral disc that
allows the soft, central portion (nucleus
pulposus) to bulge out beyond the damaged
outer rings
Prolapsed Lumbar Intervertebral Disc
(PLID)

27.  This tear may result in the release of
inflammatory chemical mediators which cause
severe pain, even in the absence of nerve root
compression.
 Disc herniations are a condition in which the
outermost layers of the annulus fibrosus are
still intact, but can bulge when the disc is
under pressure.

28. NORMAL DISC
HERNIATED
DISC

29. Types of herniation
 Posterolateral disc herniation
 Central (posterior) herniation
 Lateral disc herniation

31. Disc prolapse (
lumbagosciatica)

33. Epidemiology
 Disc herniation can occur in any disc
 Two most common forms are lumbar and
cervical disc herniation.
 The former is the most common, causing
lower back pain (lumbago) and often leg pain
as well (sciatica).

34. Epidemiology
 Lumbar disc herniation occurs 15 times more
often than cervical disc herniation.
 Most disc herniations occur in thirties or
forties when the nucleus pulposus is still a
gelatin-like substance.
 With age the nucleus pulposus changes ("dries
out") and the risk of herniation is greatly
reduced
 Mostly at L4/5 level.

35. Epidemiology
 After age 50 or 60, osteoarthritic degeneration
(spondylosis) or spinal stenosis are more
likely causes of low back pain or leg pain.
 Of all individuals, 60% to 80% experience
back pain during their lifetime.
 Generally, males have a slightly higher
incidence than females.

36. Causes of PLID
 Unaccustomed work
 Bad posture
 Over weight
 Heavy weight lifting
 Prolong standing /sitting
 Pregnancy
 Strenuous activity ( sneezing , coughing,
chronic Constipation)

37. ETIOLO
GY

38. EFFECT OF SMOKING
Blood vessel get
constricted
Transport of nutrients
& disposal of waste
products decreased
Disc cells get
deficient nutrition or
die
Disc degenerates
& results in DISC
INSTABILITY

39. History
 Age : 20-45 yrs
 Pain starts while lifting/forward bending.
 Radiation :towards buttock ,lower limbs.
 It is worsen by coughing or straining.
 Later paraesthesia/numbness in legs/feet .
 Cauda equina : urinary retention & perineal
numbness.
 Muscle Weakness

40. STAGES OF DISC
DEGENERATION
Stage of dysfunction
Stage of instability
Stage of stabilization

41. Clinical Features
 Vary depending on the location of the
herniation and the types of soft tissue that
become involved.
 Often herniated discs are not diagnosed
immediately, as the patients come with
undefined pains in the thighs, knees, or feet.

42. Clinical Features
 Unlike a pulsating pain by muscle spasm, pain
from a herniated disc is usually continuous or
at least is continuous in a specific position of
the body.
 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).

43. Clinical Features
 Neurological changes such as numbness,
tingling, muscular weakness, paralysis,
paresthesia, and affection of reflexes.
 A large central rupture may cause
compression of the cauda equina.
 Sometimes a local inflammatory response with
oedema aggravates the symptoms

44. Clinical Features
 A posterolateral rupture presses on the nerve
root proximal to its point of exit through the
intervertebral foramen; thus a herniation at
L4/5 will compress the fifth lumbar nerve
root, and a herniation at L5/S1, the first sacral
root.

45. DISC & NERVE ROOT
RELATION
L5 is
TRAVERSIN
G NERVE
ROOT
L5 is
EXITING
NERVE
ROOT

46. Features Of Cauda Equina Syndrome
 Bladder and bowel incontinence.
 Perineal numbness.
 Bilateral sciatica .
 Lower limb weakness.
 Crossed straight-leg raising sign.

47. Physical Examinations
Straight Leg Raise Test
The straight leg raise test is
positive if pain in the sciatic
distribution is reproduced
between 30° and 70° passive
flexion of the straight leg.
Dorsiflexion of the foot
exacerbates the pain

48. Physical Examinations
Root Tension Signs
Straight-leg raising : L5, S1 root.
Contralateral SLR : sequestrated or
extruded disc.
Femoral stretching, reverse SLR : L3, L4
root.

49. Physical Examinations
 Fever – possible infection.
 Vertebral tenderness - not specific and not
reproducible between examiners.
 Limited spinal mobility – not specific.
 If sciatica or pseudoclaudication present – do
straight leg raise.

50. Physical Examinations
 Positive test reproduces the symptoms of
sciatica.
 Ipsilateral test sensitive – not specific: crossed
leg is insensitive but highly specific.

51. Diagnosis
Examination in a patient with suspected
lumbar (intervertebral) disk disease may
feature the following:
 Abnormal gait
 Abnormal postures
 Decreased lumbar range of motion
 Positive straight leg raising test: Indicative of
nerve root involvement

52. Diagnosis
 Usually negative nerve root stretch test results
 Perform the usual motor, sensory, and reflex
examinations (including perianal sensation
and anal sphincter tone when appropriate). It
is also mandatory to perform a careful
abdominal and vascular examination.

53. Differential diagnosis
Of PLID
 Mechanical Pain
 Discogenic Pain
 Myofascial Pain
 Spondylosis/spondylolisthesis
 Spinal stenosis
 Abscess
Hematoma
Discitis/osteomyelitis
Mass lesion/malignancy
Myocardial infarction
Aortic dissection

54. Investigations
 Laboratory tests are generally not helpful in
the diagnosis of lumbar disk disease.
 Indications for screening laboratory tests such
as the following include pain of a non
mechanical nature, atypical pain pattern,
persistent symptoms, and age older than 50
years.

55. Investigations
 Complete blood count with differential
 Erythrocyte sedimentation rate
 Alkaline and acid phosphatase levels
 Serum calcium level
 Serum protein electrophoresis

56. Imaging studies
 Plain radiograph
 MRI: Imaging modality of choice
 CT scanning
 Myelography:
 Dynamic L/S spine X-ray . : to rule out the
instability .
 Bone scanning: To rule out tumors, trauma, or
infection

57. Imaging studies
 X-Ray : lumbo-sacral spine
Loss of lumber lordosis
Narrowed disc spaces
 CT scan : lumber spine
Shape and size of the spinal canal
Its contents and the structures around it

58. Imaging studies
 Myelogram
pressure on the spinal cord or nerves,
such as herniated discs, tumors, or bone spurs
 MRI : lumbar spine
Intervertebral disc protrusion
Bulging out disc
Compression of nerve root

59. X-ray findings

60. MRI findings
Normal central
Right Left

61. Treatment options
Conservative
&
Surgery

62. Conservative
 Non-steroidal anti-inflammatory drugs
(NSAIDs)
 Patient education on proper body mechanics
 Oral steroids
 Physical therapy (i.e. traction, electrical
stimulation massage

63. Conservative
 Anti-depressants
 Lumbosacral back support
 Tobacco cessation
 Weight control
 Intravenous sedation, analgesia-assisted
traction therapy (IVSAAT)
 Epidural cortisone injection.

64. Epidural Steroid Injection (ESI)
 The ESI is usually reserved for more severe
pain due to a herniated disc.

 It is not usually suggested if surgery is
indicated
 The ESI is probably only successful in
reducing the pain in about half the cases that it
is used.

65. Indications Of Surgery
 Cauda equina syndrome
 Progressive neurologic deficit
 Profound neurologic deficit and
 Severe and disabling pain refractory to four to
six weeks of conservative treatment.

66. The objectives of surgery
 Relief of nerve compression.
 Allowing the nerve to recover.
 Relief of associated back pain.
 Restoration of normal function

67. Surgical Options
Discectomy/Microdiscectom:
This procedure is used to
remove part of an
intervertebral disc that is
compressing the spinal cord
or a nerve root.

68. Surgical Options
The Tessys method:
The Tessys method
(transforaminal endoscopic
surgical system) is a
minimally invasive surgical
procedure to remove
herniated discs .

69. Surgical Options
Laminectomy:
To relieve spinal stenosis
or nerve compression

70. Surgical Options
Hemilaminectomy :
Hemilaminectomy is
surgery to help alleviate the
symptoms of an impinged
or irritated nerve root in the
spine

71. Surgical Options
 Chemonucleolysis:
 Chemical destruction
of nucleus pulposus.
 Intradiscal injection
ofchymopapain , causes
hydrolysis of protein of
the nucleus pulposus.
 Indicated in disc
herniation not responding
to conservative therapy

72. Surgical Options
Intradiscal electrothermic
therapy (IDET) :
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

73. Surgical Options
Lumbar fusion:
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

74. Surgical Options
Disc arthroplasty:
Artificial Disc Replacement
(ADR) or Total Disc
Replacement (TDR) is a
type of arthroplasty.
Degenerated intervertebral
discs in the spinal column
are replaced with artificial
devices in the lumbar
(lower) or cervical

75. Surgical Options
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.

76. Surgical Options
Nucleoplasty:
The most advanced form of
percutaneous discectomy
developed to date. Tissue
removal from the nucleus
acts to “decompress” the
disc and relieve the pressure
exerted by the disc on the
nearby nerve root . As
pressure is relieved the pain
is reduced

77. Future treatment
(stem cell therapy)
Substantial progress has been made in the
field of stem cell regeneration of the
intervertebral disc. Autogenic mesenchymal
stem cells in animal models can arrest
intervertebral disc degeneration or even
partially regenerate it and the effect is
suggested to be dependent on the severity of
the degeneration.

78. Persistent pain after disc surgery ?
 Wrong disc surgery
 Recurrent disc Prolapse
 Double root in same space
 Spare of root in a space
 Segmental instabilty
 Incomplete removal of disc
 Injury to root ( Iatrogenic )

80. PLID ….?
Is a medical condition affecting lumbar spine
due to trauma, lifting injuries, or idiopathic, in
which a tear in the outer fibrous ring (annulus
fibrosus) of an intervertebral disc that allows
the soft, central portion (nucleus pulposus) to
bulge out beyond the damaged outer rings