herniated nucleus pulposus

Prepared by: Roxanne Mae Birador SN

An intervertebral disk acts as shock absorber (24 disk)

protect the nerves that run down the middle of the spine and intervertebral disks

Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in the surrounding annulus fibrosus.

A herniated (slipped) disk occurs when

all or part of a disk is forced through a weakened part of the disk.

Alternative Names

Lumbar radiculopathyCervical radiculopathy

Herniated intervertebral disk/ discProlapsed intervertebral disk/ disc

Slipped disk/ discRuptured disk/ disc

deterioration and loss of function in the cells of a tissue or organ

slipping forward

process of pushing out

abnormal separation

ETIOLOGY

Most disc herniations occur when a person is in their 30’s or 40’s

After age 50 or 60, osteoarthritic degeneration (spondylosis) or spinal stenosis are more likely causes of low back pain or leg pain.

Then the disc does press on a nerve, symptoms may include:

Pain that travels through the buttock and down a leg to the ankle or foot because of pressure on the sciatic nerve. Low back pain (LUMBAGO) may accompany the leg pain.

Tingling ("pins-and-needles“ sensation) or numbness in one leg that can begin in the buttock or behind the knee and extend to the thigh, ankle, or foot.

Weakness in certain muscles in one or both legs. Pain in the front of the thigh. Severe deep muscle pain and muscle spasms.

Weakness in both legs and the loss of bladder and/or bowel control are symptoms of a specific and severe type of nerve root compression called CAUDA EQUINA SYNDROME.

If the herniated disc is in the lumbar region the patient may also experience SCIATICA due to irritation of one of the nerve roots of the sciatic nerve.

-The lower back (lumbar area) of the spine is the most common area affected by a slipped disk.

-The neck (cervical area) disks are the second most commonly affected area.

-The upper-to-mid-back (thoracic area) disks are rarely involved.

4.8% males and 2.5% females older than 35 experience sciatica during their lifetime.

Of all individuals, 60% to 80% experience back pain during their lifetime.

In 14%, pain lasts more than 2 weeks.

Generally, males have a slightly higher incidence than females.

DIAGNOSISPhysical examination - Straight Leg Raise

The straight leg raise, also called Lasègue's sign, Lasègue test or Lazarević's sign, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk, often located at L5 (fifth lumbar spinal nerve).

TECHNIQUE

With the patient lying down on his or her back on an examination table or exam floor, the examiner lifts the patient's leg while the knee is straight.

A variation is to lift the leg while the patient is sitting. However, this reduces the sensitivity of the test.

In order to make this test more specific, the ankle can be dorsiflexed and the cervical spine flexed. This increases the stretching of the nerve root and dura.

Lasègue's sign was named after Charles Lasègue (1816-1883).In 1864 Lasègue described the signs of developing low back pain while straightening the knee when the leg has already been lifted.

CHARLES LASÈGUE

In 1880, Serbian doctor Laza Lazarević described the straight leg raise test as it is used today, so the sign is often named Lazarević's sign in Serbia and some other countries.

LAZA LAZAREVIĆ

IMAGING

X-ray Computed tomography Magnetic resonance imaging Myelogram

X-RAY

COMPUTED TOMOGRAPHY

MAGNETIC RESONANCE IMAGING

Diagnosed with C5-C6 herniated disc via MRI

MYELOGRAM

Electromyogram and Nerve conduction studies (EMG/NCS)

These tests measure the electrical impulse along nerve roots, peripheral nerves, and muscle tissue.

This will indicate whether there is ongoing nerve damage, if the nerves are in a state of healing from a past injury, or whether there is another site of nerve compression. EMG/NCS studies are typically used to pinpoint the sources of nerve dysfunction distal to the spine.

The presence and severity of myelopathy (known as (acute) spinal cord injury) can be evaluated by means of Transcranial Magnetic Stimulation (TMS).

A neurophysiological method that allows the measurement of the time required for a neural impulse to cross the pyramidal tracts, starting from the cerebral cortex and ending at the anterior horn cells of the cervical, thoracic or lumbar spinal cord. This measurement is called Central Conduction Time (CCT).

MEDICATIONS

Acetaminophen (paracetamol) NSAIDs Muscle relaxants If the pain is still not managed adequately,

short term use of opioids such as morphine may be useful

Antidepressants may be effective for treating chronic pain associated with symptoms of depression, but they have a risk of side effects.

Antiseizure drugs gabapentin and carbamazepine are sometimes used for chronic low back pain and may relieve sciatic pain, there is insufficient evidence to support their use.

NON-SURGICAL METHODS 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)

Non-steroidal anti-inflammatory drugs (NSAIDs)

Weight control Spinal manipulation: Moderate quality evidence

suggests that spinal manipulation is more effective than placebo for the treatment of acute (less than 3 months duration) lumbar disc herniation and acute sciatica.

Contraindication: Spinal manipulation is contraindicated for disc herniations when there are progressive neurological deficits such as with cauda equina syndrome.

TRACTION BELT

PELVIC GIRDLE TRACTION

SURGICAL METHODS

Discectomy (the partial removal of a disc that is causing leg pain) can provide pain relief sooner

than nonsurgical treatments. Discectomy has better outcomes at one year but not at four to ten years.

DISCECTOMY

LUMBAR DISCECTOMY

NECK DISCECTOMY

The presence of cauda equina syndrome (in which there is incontinence, weakness and genital numbness) is considered a medical emergency requiring immediate attention and possibly Surgical Decompression.

PREVENTION There are various causes for back injuries, prevention must be comprehensive. Back injuries are predominant in manual labor so the majority low back pain prevention methods have been applied primarily toward biomechanics. Prevention must come from multiple sources such as education, proper body mechanics, and physical fitness.

EDUCATION Education should emphasize not lifting beyond one's capabilities and giving the body a rest after strenuous effort. Over time, poor posture can cause the IVD to tear or become damaged. Striving to maintain proper posture and alignment will aid in preventing disc degradation.

EXERCISE Exercises that are used to enhance back

strength may also be used to prevent back injuries. Back exercises include the prone press-ups, upper back extension, transverse abdominus bracing, and

floor bridges.

Other preventative measures are to lose weight and to not work oneself past fatigue. Signs of fatigue include shaking, poor coordination, muscle burning and loss of the transverse abdominal brace. Heavy lifting should be done with the legs performing the work, and not the back.

Swimming is a common tool used in strength training. The usage of lumbar sacral support belts may restrict movement at the spine and support the back during lifting.