By

Dr. Ashraf Shaker Lecturer of neurosurgery

Mansora University

Low back painIncidence: About 90% of the population suffer from

low back pain at some time.30% of thesewill develop leg pain due to

lumbar spine pathology.The critical factor in assessing patients

with LBP is whether there are also features of nerve root compression, such as leg pain or focal signs of neural compression in the lower limbs.

SciaticaSciatica is the clinical description of pain in

the leg due to lumbosacral nerve root compression which is usually in the distribution of the sciatic nerve .

The most common cause of sciatica is a lumbar disc prolapse .

It also occurs as a result of bony compression of the nerve root, usually by an osteophyte, and is often associated with lumbar canal stenosis or spondylolisthesis.

Lumbar disc prolapseNearly 75% of the lumbar flexion–extension occurs

at the lumbosacral junction ,20% at the L4/5 level and the remaining 5% is at the upper lumbar levels.

So it is not surprising that 90% of lumbar disc prolapses occur at the lower two lumbar levels; the most frequently affected disc is at the L5/S1 level.

The lumbar disc consists of an internal soft nucleus pulposus surrounded by an external laminar fibrous container, the annulus fibrosus.

A disc prolapse may consist of the nucleus pulposus bulging, with the annulus being stretched but intact.

Also the nucleus may rupture through the annulus and sequestrate as a free fragment .

Prolapse of the disc is usually in a posterolateral direction, as the posterior longitudinal ligament prevents direct posterior herniation .

Less frequently the disc may herniate laterally to trap the nerve in the neural foramen.

Patient assessmentHistory taking: LBP & SCIATICA The patient lies tilted to the side opposite to the

sciatica, with the affected hip and knee slightly flexed taking pressure off the stretched nerve.

The pain is worse on movement, coughing, sneezing or straining

the patient may complain of sensory disturbance such as numbness or tingling in the leg or foot

History of sphincteric dysfunction, as a large disc prolapse may cause cauda equina compression.

Clinical assessmentRestricted lumbar movement Scoliosis may be seen, usually concave to the

side of the affected leg.Straight leg raising :will be restricted on the

affected side and, in severe cases, pain in the affected leg will be reproduced when the opposite leg is raised.

Wasting of certain muscle groups .Motor power assessment according to The

Medical Research Council (MRC) scale (M1-M5) Deep tendon reflexes should be carefully tested.Sensation should be tested in the foot and leg.

Summary of clinical featuresL5/S1 prolapsed intervertebral discPain along the posterior thigh with radiation tothe

heelWeakness of plantar flexion (on occasion) Sensory loss in the lateral foot Absent ankle jerk.L4/5 prolapsed intervertebral discPain along the posterior or posterolateral thigh with

radiation to the dorsum of the foot and great toe Weakness of dorsiflexion of the toe or foot Paraesthesia of the dorsum of the foot and great toeReflex changes unlikely.

L3/4 prolapsed intervertebral discPain in the anterior thighWasting of the quadriceps muscleWeakness of the quadriceps function and

dorsiflexionof foot Diminished sensation over anterior thigh,

knee and medial aspect of lower legReduced knee jerk.

InvestigationsX ray LSS: Which may revealStraight lumbar curveNarrowing of disc spacesOsteoarthritic changesAssociated spondylolisthesis &degenerative

changes.

Lumbar myelographywas the time honoured investigation

for lumbar disc prolapse.Its invasive technique & invention of

CT & MRI limited its use.

High-quality computerized tomography scanning

and magnetic resonance imaging have largely superseded myelography for the diagnosis of lumbar discprolapse.

The MRI is especially helpful in showing the size, configuration and position of the disc prolapse, as well as any associated nerve root or thecal compression.

In addition the MRI will also demonstrate pathology at other discs, such as degenerativechanges as evidenced by decreased signal in the disc on the T2-weighted scans.

TreatmentMost patients with sciatica achieve good pain

relief with simple conservative treatment and less than 20% will require surgery.

The likelihood of symptomatic relief without surgery is related to the pathology of the disc prolapse.

A‘bulging’ disc is likely to settle with simple conservative measures,.

But sciatica due to a nucleus pulposus that has herniated out of the disc space and ‘sequestrated’ outside the annulus will probably need surgery for satisfactory relief of symptoms.

Conservative treatmentBed rest for a period of about 7–10 days`Although traction is sometimes recommended it

probably has only limited benefit and may resultin lower leg complications.

Simple analgesic agents and non-steroidal anti inflammatory medication.

High-dose corticosteroids.

Vitamin B complex.

Muscle relaxant.

Surgical treatmentIndications a)Pain: especially Incapacitating pain not

responding to conservative measures and recurrent episodes of pain

b) Neurological deficits c) Central disc prolapse. Patients with

bilateral sciatica or other features indicating a central disc prolapse, such as sphincter disturbance and diminished perineal sensation.

Aim of surgery: excision of the disc prolapse with decompression of the affected nerve root.

In the past the operation usually entailed a complete or partial laminectomy, identification of the compressed nerve root, its mobilization off the disc prolapse and excision of the herniated disc.

Recently disc prolapses can be excised with minimal disturbance to the normal bony anatomy and with the removal of only a small amount of bone.

A full laminectomy may occasionally be necessary prior to the disc excision of a large central disc prolapse causing cauda equina compression.

A percutaneous endoscopic lumbar discectomy can be done .

Cervical disc prolapseCervical spine disorders predominantly cause

neck pain and/or arm symptoms.

CDP is less common than LDP.

CDP occurs most frequently at the C6/7 level and slightly less commonly at the C5/6 level.

This is due to the force exerted at these levels which act as a fulcrum for the mobile spine and head.

The cervical disc consists of an internal nucleus pulposus surrounded by the external fibrous lamina, the annulus fibrosus.

The CDP is usually in the postero -lateral direction, because the strong posterior longitudinal ligament prevents direct posterior herniation.

Unlike the lumbar region, the nerves pass directly laterally from the cervical cord to their neural foramen,so that the herniation compresses the nerve at that level.

So aC5/6 disc prolapse will cause compression of the C6 nerve root, a C6/7 prolapse causes compression

of the C7 nerve roo

Clinical presentation The characteristic presenting features of these patients are neck and arm pain and the neurological manifestationsof cervical nerve root compression.Examination Restricted cervical spine movementsThe head is often moderately flexed, and tilted towards

the side ofthe pain in some patients but occasionally away from it in others.If the disc herniation is longstanding there may be

weakness &wasting in the appropriate muscle group.Sensation should be tested & the sensory loss will be

characteristic for the nerve root involved although theremay be some overlap.

The deep tendon reflexes provide objective evidence

of nerve root compression in the following distribution.

• Biceps reflex C5

• Brachioradialis (supinator) reflex C6

• Triceps reflex C7

A full neurological examination must be performed

and particular care taken to assess the lower limbs for

hypertonia hyperreflexia +ve babinski

C6/C7 prolapsed intervertebral disc (C7 nerve

root)• Weakness of elbow extension• Absent triceps jerk• Numbness or tingling in the middle or

indexFinger

C5/6 prolapsed intervertebral disc (C6 nerve root)

• Depressed supinator reflex• Numbness or tingling in the thumb or index

finger• Occasionally mild weakness of elbow flexion.

C7/T1 prolapsed intervertebral disc (C8 nerve root)

• Weakness may involve long flexor muscles,triceps, finger extensors and intrinsic muscles

• Diminished sensation in ring and little finger and on xthe medial border of the hand and forearm

• Triceps jerk may be depressed.

Investigations MRI cervical spine: is now the investigation

of choice and has almost completely replaced both myelography and CT .

The cervical myelogram using water-based non-ionic iodine contrast material was a most useful investigation for determining the presence and site of the disc herniation .

CT scanning by itself is frequently not helpful, but if performed following intrathecal iodine contrast it will demonstrate a disc herniation, and smaller volumes of intrathecal contrast are necessary than with myelography

ManagementConservative ttt

Most patients with cervical disc herniation achieve good pain relief with conservative treatment

Bed rest ,cervical collar, simple analgesic medication, non-steroidal anti-inflammatory medication and muscle relaxants.

Surgical tttSurgical tttThe most commonly performed operationsfor cervical disc prolapse are: Cervical foraminotomy with excision

of the disc prolapse.Anterior cervical discectomy, with

subsequentfusion.

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