J.J.M MEDICAL COLLEGEDAVANGERESEMINAR ON

HISTORY Aurelianus (5th century) clearly described the symptoms of SCIATICA.

Andreas Vesalius (1543) first described the intervertebral disc.

Middleton & Teacher (1911) described a case of paraplegia following attempting to lift heavy weight from floor on postmortem they found fibrocartilage in extradural space.

Elseberg (1928) described Chondromas derived from disc of cervical region.

Stookey (1928) described cartilaginous compression thought as chondromas responsible for clinical prersentation.

Dandy (1929) reported removal of a disc tumour or chondroma from patients with sciatica.

Mixter and Barr (1934) described disc herniation as the cause of Sciatica.

Peet& Echols (1934) referred to as Chondroma or Ecchondrosis was really protrusion of intervertebral disc.

Lindblom(1948) first described DISCOGRAPHY.

Lyman Smith (1963) described CHEMONUCLEOLYSIS.

Kambin & Gellman (1983) reported percutaneous approach for lumbar discectomy.

LUMBAR SPINE

ANATOMY OF LUMBAR SPINE

INTERVERTEBRAL DISC

NUTRITION TO DISC

FUNCTION OF DISC

FACET JOINTS

LIGAMENTS OF LUMBAR SPINE

MOTION SEGMENT

ANTERIOR ELEMENT

POSTERIOR ELEMENT

DISC & NERVE ROOT RELATION

L5 is TRAVERSING NERVE ROOT

L5 is EXITING NERVE ROOT

EFFECT OF AXIAL LOADING

THREE JOINT COMPLEX

RELATION OF INTRADISCAL PRESSURE AND POSTURE

IN RELATION TO POSTURE

CORRECT SLEEPING POSTURE

IN RELATION TO MANUAL MATERIALS HANDLING

LUMBAR DISC PROLAPSEDEFINITION It is condition in which there is

outpouching of the disc Nucleus pulposus along with few annular fibres and end plate cartilage through the tears in annulus fibrosus into the extradural space.

EPIDEMIOLOGY• AGE: 30 – 40 years

• SEX: Male affected more than female

• MOST COMMON LEVEL: L4-L5 (next common level is L5-S1)

• MOST COMMON TYPE: Posterolateral type

WHY DISC PROLAPSE IS MOST COMMON POSTEROLATERALLY?

ETIOLOGY

EFFECT OF SMOKINGBlood vessel get

constricted

Transport of nutrients & disposal of waste products decreased

Disc cells get deficient nutrition or die

Disc degenerates & results in DISC

INSTABILITY

DISC DEGENERATION

STAGES OF DISC DEGENERATION

Stage of dysfunction

Stage of instability

Stage of stabilization

STAGE OF DYSFUNCTIONEpisode of rotational

or compressive trauma

Posterior facet joint & annular strain

Small capsular & annular tear occurs

Small subluxation of posterior joint

Posterior joint SYNOVITIS

Posterior segment muscle protect joint by sustained

hypertonic contraction

STAGE OF INSTABILITY

FACET JOINT

Degeneration of cartilage

Laxity of capsule

DISC Coalescence of tears

Loss of nucleus internal

disruption

Bulging of annulus

INCREASED ABNORMAL MOVEMENT

STAGE OF STABILIZATION

FACET JOINT

DISC

Destruction of cartilage

Fibrosis in joint

Loss of nucleus

Fibrosis in disc & osteophytes

INCREASED STIFFNESS

STABILIZATION

DISC DEGENERATION

PATHOPHYSIOLOGY OF LUMBAR INTERVERTEBRAL DISC PROLAPSE

With aging, vascular channels start to fail and vascular diffusion of nutrients decrease thus number of viable chondrocytes in the

nucleus pulposus diminishes

Synthesis rate & concentration of proteoglycans decreases & proportion of

collagen increase in nucleus pulposus

Water binding capacity of the nucleus decreases

Nucleus becomes more fibrous & stiffer

Nucleus is less able to bear & disburse load, transferring load to the posterior annulus

ANNULUS IN TACT

Facet joints share even more of the

axial load

Facet joints undergo degenerative

changes & develop osteophytes

FACET JOINT SYNDROME

ANNULUS FAILS

Extruded disc & degraded nuclear

material impinge on the nerve roots

Nucleus pulposus is an immunogenic which induce an inflammatory response

Produces radicular pain syndrome & RADICULOPATHY

STAGES OF DISC PROLAPSE

AXIAL LOCATION

SAGITTAL SECTION

ATTITUDE

LIST (SCIATIC SCOLIOSIS)

L4

L5

S1

L3

L2

L1

STRAIGHT LEG RAISING TEST

LASEGUE SIGN

LASEGUE TEST

CONTRALATERAL LEG RAISING TEST (FRAJERSZTAGN TEST)

WHY PAIN OCCURS ON AFFECTED SIDE ON RAISING NORMAL LEG?

AFFECTED SIDE NORMAL SIDE

BOWSTRING TEST

FEMORAL NERVE STRETCH TEST

FLIP TEST

NEGATIVE POSITIVE

NAFFZIGER TEST

VALSALVA MANEUVRE

CAUDA EQUINA SYNDROME

• Marked reduction in SLRT• Saddle anaesthesia• Bilateral ankle jerk depression• Involuntary overflow

incontinence• Decreased tone in external

sphincter

DIFFERENTIAL DIAGNOSIS

INTRASPINAL CAUSESProximal to disc: Conus and Cauda equine lesions (eg.

Neurofibroma, ependymoma)Disc level• Herniated nucleus pulposus• Stenosis (Canal or recess)• Infection: Osteomyelitis or discitis ( with nerve root pressure)• Inflammation: Arachnoiditis• Neoplasm: Benign or malignant with nerve root pressure

EXTRASPINAL CAUSESPelvis • Cardiovascular conditions (eg. Peripheral vascular disease)• Gynaecological conditions• Orthopaedic conditions ( osteoarthritis of hip, Muscle related disease,

Facet joint arthropathy)• Sacroiliac joint disease• Neoplasm

Peripheral nerve lesions• Neuropathy (Diabetic, tumour, alcohol)• Local sciatic nerve conditions (Trauma, tumour)

• Inflammation (herpes zoster)

KEY DIAGNOSTIC POINTSLUMBAR DISC PROLAPSE Leg pain greater than back pain Neurological deficit present

ANNULAR TEARS Back pain greater than leg pain Bilateral SLRT positive

FACET JOINT ARTHROPATHY Localized tenderness present unilaterally over joint Pain occurs immediately on spinal extension Pain exacerbated with ipsilateral side bending

SPINAL STENOSIS Back and/or leg pain develops after walks a limited distance. Flexion relieves symptoms No neurological deficit Pain not reproduced on SLRT

MYOGENIC OR MUSCLE RELATED Pain localised to affected muscle Pain increases on prolonged muscle use Pain reproduced with sustained muscle contraction against

resistance Contralateral pain with side bending

INVESTIGATION

THE CORNERSTONE OF DIAGNOSIS OF LUMBAR DISC DISEASE IS THE HISTORY AND

PHYSICAL EXAMINATION NOT THE INVESTIGTION.

PLAIN RADIOGRAPH

OSTEOPHYTE

DECREASED DISC SPACE

NORMAL RETROSPONDYLOLISTHESIS

MARKED RETROSPONDYL

OLISTHESIS

REDUCTION IN THE HEIGHT OF THE

PEDICLE

FORWARD DISPLACEMENT OF L3 OVER

L4

MYELOGRAPHY

DISADVANTAGE OF MYELOGRAPHY

• Myelographyis capable of showing the level at which the pathology lies but fails to show the nature of the lesion or its precise location in the anatomic segment .

DISCOGRAHY

USES OF DISCOGRAPHY

• To evaluate equivocal abnormality seen on myelography, CT or MRI

• To isolate a symptomatic disc among multiple level abnormality

• To diagnose a lateral disc herniation• To establish contained discogenic pain• To select fusion levels• To evaluate the previously operated spine

CT DISCOGRAPHY

USES• To determine whether the disc herniation is

contained, protruded, extruded or sequestrated.

• To evaluate previously operated lumbar spine to distinguish between mass effect from scar tissue or disc material.

COMPUTED TOMOGRAPHYADVANTAGES• CT is an extremely useful, highly accurate & noninvasive tool in

the evaluation of spinal disease.• CT provides superior imaging of cortical and trabecular bone

compared with MRI.• It provides contrast resolution and identify root compressive

lesions such as disc herniation.• It also helps to differentiate between bony osteophyte from

soft disc.• It helps to diagnose foraminal encroachment of disc material

due to its ability to visualize beyond the limits of the dural sac and root sleeves.

LIMITATIONS• It cannot differentiate between scar tissue

and new disc herniation• It does not have sufficient soft tissue

resolution to allow differentiation between annulus and nucleus.

MAGNETIC RESONANCE IMAGING• It allows direct visualization of herniated disc

material and its relationship to neural tissue including intrathecal contents.

INDICATIONS FOR SPINE IMAGING

• Presence ofunderlying systemic disease• Progressive neurological deficits• Cauda equine syndrome• Candidate for therapeutic intervention• Failed clinically directed conservative therapy

CONTRAST ENCHANCED MRI

• Here GADOLINIUM labeled diethylenetriaminepentaacetate (Gd-DTPA) administered intravenously and MRI scan done.

ADVANTAGES• Display the inflammatory reaction critical to the

pathophysiology of radicular pain or radiculopathy• Allows discrimination of scar from recurrent disc.

OTHER DIAGNOSTIC TESTS

• ELECTROMYOGRAPHY – to rule out peripheral neuropathy.

• SOMATOSENSORY EVOKED POTENTIALS (SSEP) – to identify the level of root involvement

• POSITRON EMISSION TOMOGRAPHY

TREATMENT

• CONSERVATIVE• SURGICAL

CONSERVATIVE

Majority of disc prolapse respond well to conservative therapy. Resolution of first disc prolapse takes place approximately 75% of patients over a period of 3 months.

BED REST

PHYSIOTHERAPY

EXERCISESGENERAL RULES FOR EXERCISE• Do each exercise slowly. Hold the exercise position for a slow

count of five.• Start with five repetitions and work up to ten. Relax

completely between each repetition.• Do the exercises for 10 minutes twice a day.• Care should be taken when doing exercises that are painful. A

little pain when exercising is not necessarily bad. If pain is more or referred to the legs the patient may have overdone it.

• Do the exercises every day without fail.

FOR ACUTE STAGE

BRIDGING EXERCISE KNEE HUGS

FOR RECOVERY OR SUBACUTE STAGE

EXTENSION CONTROLHAMSTRING STRETCH

KNEE ROLLS

YOGAASANAS

TADASANA(Mountain pose) MARICHYASANA III

(Marichi's Pose)BHARADVAJASANA(Bharadvaja's Twist)

VIRABHADRASANA II (Warrior II Pose)

ARDHA URDHVA MUKHA SVANASANA

(Half Upward-Facing Dog Pose)

BALASANA(Child's Pose)

UTTHITA PARSVAKONASANA(Side Angle Pose)

UTTHITA TRIKONASANA(Triangle Pose)

SHAVASANNA(Corpse Pose)

DO’S & DON’T’S

EPIDURAL STEROID INJECTION

CHEMONUCLEOLYSIS

Chymopapain injected into the

disc

Degrades the proteoglycans in the

nucleus

Water holding capacity of the disc

is decreased

Shrinkage of the disc

CONTRAINDICATION FOR CHEMONUCLEOLYSIS

• Sequestrated disc • Significant neurological deficit • Disc herniation with lateral stenosis • Cauda equine syndrome• Previous treatment with chymopapain• Spinal tumour• Recurrence of disc herniation • Spondylolisthesis• Pregnancy • Diabetic Neuropathy

SURGERY

GOAL To relive neural compression and

henceradiculopathy while minimizing complications.

INDICATIONS

ABSOLUTE • Bladder and bowel involvement: The cauda equine syndrome• Increasing neurological deficit

RELATIVE• Failure of conservative treatment• Recurrent sciatica• Significant neurological deficit with significant SLR reduction• Disc rupture into a stenotic canal• Recurrent neurological deficit

CONTRAINDICATIONS FOR SURGERY

• Wrong patient ( poor potency for recovery)• Wrong diagnosis • Wrong level• Painless HNP (do not operate for primary complaint

of weakness or paresthesia, in the absence of pain)• Inexperienced surgeon applying poor technical skills• Lack of adequate instruments

KNEE CHEST POSITION

HEMI OR PARTIAL LAMINECTOMY

FENESTRATION

TOTAL LAMINECTOMY

LAMINOTOMY & DISCECTOMY

COMPLICATIONS OF LAMINECTOMY AND DISCECTOMY• Infection – Superficial wound infection , Deep disc space

infection• Thrombophlebitis/ Deep vein thrombosis• Pulmonary embolism• Dural tears may result in Pseudomeningocoele, CSF leak,

Meningitis• Postoperative cauda equine lesions• Neurological damage or nerve root injury• Urinary retention and urinary tract infection

FAILED BACK SYNDROME

It is a condition characterized by persistent postoperative backache and sciatica.

VERY COMMON CAUSES• Recurrent/ Persistent disc material at operated site• Herniated Nucleus Pulposus at other site• Epidural scar / Fibrosis• Facet arthrosis / Spinal stenosis

COMMON CAUSES – Neuritis, Referred pain from nonspinous site

UNCOMMON CAUSES• Discitis / Osteomyelitis/ Epidural abscess• Arachnoiditis• Conus tumour• Thoracic, High lumbar Herniated Nucleus Pulposus• Epidural haematoma

The recurrence of pain after disc surgery

should be treated with all available conservative treatment modalities initially. The surgery should be tailored to the anatomic problem only.

MICRODISCECTOMY

PERCUTANEOUS DISCECTOMY

PERCUTANEOUS SUCTION DISCECTOMY

MICROENDOSCOPIC DISCECTOMY

PERCUTANEOUS LASER DISCECTOMY

LUMBAR ARTIFICIAL DISC REPLACEMENT

Patient not suitable for artificial disc replacement are

• Osteoporosis• Spondylolisthesis• Infection or tumour of spine• Spine deformities from trauma• Facet arthrosis

TECHNIQUE

INTRADISCAL ELECTROTHERMAL THERAPY

• It is a new minimally invasive technique done as an outpatient procedure.

• Done in patients with low back pain caused by tears in the outer wall of the intervertebral disc.

PROGNOSIS

• Extruded disc, Large herniations, Sequestrations have a greater tendency to resolution than small herniations& disc bulges.

• Recurrence of disc prolapse can be prevented by a proper exercise programme and avoidance of stress to the lower part of back.

REFERENCES

• MACNAB’S BACKACHE by DavidA.Wong 4th edition• THE LUMBAR SPINE by Sam W Wiesel 2nd edition• MANAGING LOW BACK PAIN by W.H.Kirkildy – Willis 3rd

edition• ORTHOPAEDIC PHYSICAL ASSESSMENT by David Magee 5th

edition• ORTHOPAEDIC PRINCIPLE AND THEIR APPLICATION by TUREK

4TH Edition• CAMPBELL’S OPERATIVE ORTHOPAEDICS 11TH EDITION• INTERNET

“LEARN TO BE GOOD TO

YOUR BACK AND YOUR

BACK WILL BE GOOD TO YOU….”