LUMBAR DISC HERNIATION.pptx

LUMBAR DISC HERNIATION.pptx

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  LUMBAR DISC HERNIATION TEAM:SPINE NO/YA MODERATOR:VI SUPERVISOR: dr. Jainal Arifin, MKes, SpOT (K) Spine Tuesday, 24th September 2019
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  PATIENT IDENTITY Name :IC Age : 31 years old Registration : 672070
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  History Taking  Chiefcomplaint Low back pain  History of illness Suffered since two years ago before admitted to the hospital. Initially, pain intermitten. But the three weeks ago the raight, pain felt getting worse and pain radiated to the lower limb. Pain occurred by activity, and decreased by rest. Cough(-), sneeze(-), straining at stool, History of fever (-).  History of trauma (+) : patients had a motorcycle accident two years ago and the patient falls in the sitting position. After that, the patient can walk and move as usual. History of lifting heavy weight (-)  History of chronic cough(-), history of loose weight (-), history of night sweat (-), history of TB treatment (-).  History of same complain in his family (-). Hipertension (-), Diabetic (-).
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  Composmentis/well nourished VITAL SIGN BP: 120/80 mmHg HR: 88x/mnt, regular RR: 20x/mnt, thoracoabdominal type T : 36,6˚C General Status
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  Vertebra Region : •I : deformity (-), hematome (-), swelling (-), wound (-) • P : tenderness as level as vertebra L5 (+), step off sign (-) Localized Status
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  Clinical picture
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  5 5 5 5 5 5 5 0 5 5 5 5 5 5 5 5 5 5 5 5 5 yes Motoric Examination
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  2 2 2 2 2 2 2 2 2 2 2 2 22 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 → Absent 1 → Impaired 2 → Normal NT → Not testable Any anal sensation Y 2
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  Physiologic reflex R L •Biceps (+) (+) • Triceps (+) (+) • Achilles (+) (+) • Patellar (+) (+) Pathologic Reflex R L • Babinski (-) (-) • Chadock (-) (-) • Openheim (-) (-) • Hoffmentromner(-) (-) Reflex
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  Special test R L •Straight leg raise : (+) (-) • Laseque sign : (+) (-) • Femoral stretch test : (-) (-)
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  RBC: 5,13 x10^3/µL Hb : 15,6 g/dl WBC : 4,34 x 1o^6/µl HCT: 44,5% PLT : 226 x 10^3/µL HbsAg : Negatif Laboratory
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  toracolumbal AP Lumbosacral AP
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  toracolumbal lateral Lumbosacral lateral
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  A man 31years old come to the hospital with chief complaint of low back pain, Suffered since two years ago before admitted to the hospital. Pain occurred by activity, cough (-), sneeze(-), straining at stool, and decreased by resing, pain radiated to lower limbs. History of trauma (+) : patients had a motorcycle accident two years ago and the patient falls in the sitting position. After that, the patient can walk and move as usual. History of lifting heavy weight (-)  From physical examination, there is no deformity at the region of vertebra. The motoric strength of upper and the lower extremities are normal. Special test straight leg raise(+), laseque sigh(+), bowstring sign(+) at right lower extremity.  The laboratory findings are in normal limit. Summary
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  Diagnosis • Low BackPain due to herniation nucleus pulposus L3-L4, L4-L5
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  •Analgesic •Plan for discectomy Treatment
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  Introduction • 95 %L4-L5 or L5-S1 (most common) • 4th and 5th decades of life • 3:1 male:female ratio and 5% symptomatic • 90 % patient will have improvement of symptoms within 3 monts w/o surgery Orthobullets.com
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  Pathoanatomy • The discis the anterior border of the spinal canal at the facet joint level • Posterolateral (or paracentral) herniations are the most frequent location • Cumulative degenerative changes occur from:  Concentration of torsional  Axial loading  Flexion-induced biomechanical strains Rothman, The Spine
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  Pathoanatomy Rothman, The Spine
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  Pathophysiology Disc Degeneration andHerniation • Anulus fibrosus tear – compression the nucleus – herniation • Nucleus must be fluid/well-hydrate (younger age) to be herniated through the anulus Disc Herniation and Sciatica • Usually occur with radicular pain following dermatomal distribution • Sciatic-type pain is produced only if the nerve root is concurrently irritated or inflamed Disc Herniation and Back Pain • Most patients with symptomatic disc herniations present with leg and back pain • Nociceptive pain transmission from disc degeneration Rothman, The Spine
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  Morphology • Degeneration: Decreasedor absent T2-weighted signal is noted from the intervertebral disc. It is not possible to distinguish symptomatic from asymptomatic degeneration based on MRI • Disc bulge: Disc material is noted to extend beyond the disc space with a diffuse, circumferential, nonfocal contour. Disc bulges are caused by early disc degeneration and infrequently cause symptoms in the absence of spinal stenosis • Protrusion: Displaced disc material extends focally and asymmetrically beyond the disc space. The displaced disc material is in continuity with the disc of origin. The diameter of the base of the displaced portion, where it is continuous with the disc material within the disc space of origin, has a greater diameter than the largest diameter of the disc tissue extending beyond the disc space • Extrusion: Displaced disc material extends focally and asymmetrically beyond the disc space. The displaced disc material has a greater diameter than the disc material maintaining continuity (if any) with the disc of origin • Sequestration: Refers to a disc fragment that has no continuity with the disc of origin. By definition all sequestered discs are extruded. However, not all extruded discs are sequestered Spine Secret Plus
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  Morphology Spine Secret Plus Rothman,The Spine
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  Morphology Spine Secret Plus Thelocation of a disc herniation within the spinal canal is described in terms of a three-floor anatomic house: • story 1: disc space level • story 2: foraminal level • story 3: pedicle level The spinal canal is also divided in terms of zones: • The central zone is located between the pedicles. • The foraminal zone is located between the medial and lateral pedicle borders • The extraforaminal zone is located beyond the lateral pedicle border
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  Symptoms Cauda equina syndrome(present in 1-10%) • Bilateral leg pain • LE weakness • Saddle anesthesia • Bowel/bladder symptoms Radicular pain (buttock and leg pain) • Often worse with sitting, improves with standing • Symptoms worsened by coughing, valsalva, sneezing Axial back pain (low back pain) • This may be discogenic or mechanical in nature Orthobullets.com
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  Physical Examination • LowerExtremity sensorics and motoric examination • Gait analysis • Provocative test:  Straight leg test  Contralateral SLR  Lesegue sign  Bowstring sign  Kernig test  Naffziger test  Milgram test Orthobullets.com
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  Imaging Radiographs: • loss oflordosis (spasm) • loss of disc height • lumbar spondylosis (degenerative changes) Orthobullets.com
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  Imaging • MRI withoutgadolinium modality of choice for diagnosis of lumbar disc herniations • highly sensitive and specific • helpful for preoperative planning • useful to differentiate from synovial facet cysts However high rate of abnormal findings on MRI in normal people Indications: • pain lasting > one month and not responding to nonoperative management or • red flags are present • infection (IV drug user, h/o of fever and chills) • tumor (h/o or cancer) • trauma (h/o car accident or fall) • cauda equina syndrome (bowel/bladder changes) Orthobullets.com
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  Imaging MRI with gadolinium •Useful for revision surgery • Allows to distinguish between post-surgical fibrosus (enhances with gadolinium) vs. recurrent herniated disc (does not enhance with gadolinium) Orthobullets.com
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  Treatment Non Operative: • Initialtreatment options include a short period of bedrest (not to exceed 3 days) • Oral medications ( NSAIDs, aspirin, mild opioids) • Progressive ambulation, return to activity, and patient reassurance • Epidural injections can be considered. • As acute pain subsides, physical therapy and aerobic conditioning are advised. If a patient fails to improve with 4 to 6 weeks of nonsurgical care, further evaluation is indicated. The optimal time for nonsurgical treatment ranges from a minimum of 4 weeks to a maximum of 6 months Spine Secret Plus
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  Treatment Operative: Appropriate criteria forsurgical intervention include: • Functionally incapacitating leg pain extending below the knee within a nerve root distribution • Nerve root tension signs with or without neurologic deficit • Failure to improve with 4 to 8 weeks of nonsurgical treatment • Confirmatory imaging study (preferably MRI), which correlates with the patient’s physical findings and pain distribution Spine Secret Plus
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  Treatment Operative: Laminotomy and discectomy(microdiscectomy) Indication: • Persistent disabling pain lasting more than 6 weeks that have failed nonoperative options (and epidural injections) • Progressive and significant weakness • Cauda equina syndrome Far lateral microdiscectomy Indication: • Far-lateral disc herniations Orthobullets.com
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  Treatment Operative complication: • Vascularinjury • Nerve root injury • Dural tear • Infection • Increased back pain • Recurrent disc herniation • Cauda equina syndrome • Medical complications (e.g. throm-bophlebitis, urinary tract infection) Spine Secret Plus
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  QUESTION AND ANSWER
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  1. Which ofthe following would most likely explain the physical examination finding of decreased achilles tendon reflex and positive straight-leg-raise: 1. Lumbar arachnoiditis 2. L4/L5 paracentral disc herniation 3. L5/S1 paracentral disc herniation 4. L3/L4 far lateral (foraminal) disc herniation 5. L5/S1 far lateral (foraminal) disc herniation
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  Preferred Response 3.L5/S1 paracentral disc herniation • The clinical presentation is consistent with a S1 radiculopathy. A L5/S1 paracentral disc herniation would compress the descending nerve root (S1) and cause this physical finding. The location of a prolapsed lumbar disc determines its symptoms. Central disc herniations may give rise to back pain or cauda equina syndrome. Posterolateral (paracentral) disk herniations are the most common type of lumbar disk herniation, and affect the descending/lower nerve root (90- 95% of cases). For example, an L5/S1 paracentral disc herniation will cause S1 symptoms. Far lateral disc herniations (5-10%) affect the exiting nerve root. For example, an L5/S1 far lateral (foraminal) disc herniation will cause L5 symptoms.
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  2. Figure Ais an axial MR image of the L4-5 disc space. A patient with the pathology seen in this image would be expected to have all of the following signs and symptoms EXCEPT 1. Numbness over dorsum of foot 2. Decreased patellar tendon reflex 3. Weakness to hip abduction 4. Weakness of great toe extension 5. Positive straight leg raise
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  Preferred Response 2.Decreased patellar tendon reflex Figure A is an axial MR image demonstrating a paracentral disc herniation at L45/5. This would compress the L5 nerve root leading to symptoms that would likely include 1) numbness over dorsum of foot 3) weakness to hip abduction 4) weakness of great toe extension 5) positive straight leg raise. A L5 radiculopathy would not be expected to lead to decreased patellar tendon reflex In the lumbar spine a paracentral disc herniation typically compresses the descending nerve root (at L4/5 this is the L5 nerve root which exits under the L5 pedicle). This is in contrast to a far lateral herniation which compresses the exiting nerve root (at L4/5 this is the L4 nerve root which exits under the L4 pedicle). In the cervical spine, the nerve roots do not "descend" before they exit the foramen, and therefore a disc, whether central or lateral, always affects the exiting nerve root (a C4/5 disc hernation compresses the C5 nerve root which exits above the C5 pedicle). In the cervical spine the exiting nerve root travels above the corresponding pedicle (C5 exits above the C5 pedicle) whereas in the lumbar spine the exiting nerve root exits below the corresponding pedicle (L5 exits below the L5 pedicle). The transition from above the corresponding pedicle to below occurs because there is a C8 nerve root but no C8 pedicle (no C8 vertebral body).
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  3. A 56-year-oldman presents with 6 weeks of worsening back and left sided lower extremity pain and weakness. He has severe pain that radiates from the back to the groin and anteromedial thigh. His axial MRI image is shown in Figure 1. Which of the following physical examination findings would be most consistent with his imaging? 1. Decreased sensation on the lateral aspect of the foot 2. Weakness of quadriceps 3. Weakness of hip adduction 4. Weakness of extensor hallucis longus 5. Normal physical examination at rest, but leg heaviness after ambulation
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  Preferred Response 3.Weakness of hip adduction • The patient is presenting with a left-sided far lateral disc herniation at L3- L4 level. This pathology impinges on the exiting L3 nerve root, and more specifically the dorsal root ganglion, leading to severe pain in the groin and anteromedial thigh. L3 nerve root compression would be most associated with hip adduction weakness. Examination of the hip can be useful for differentiating hip versus spine pathology and involvement of different nerve roots. Typically hip flexion is mediated by the L2 nerve root, hip adduction by L3, hip abduction by L5 and hip extension by S1. Provocative maneuvers of the hip, including flexion adduction internal rotation (FADIR) and flexion abduction external rotation (FABER) testing as well hip internal and external rotation testing should be performed to evaluate the hip joint as a cause of pain. When the source of pain is still indeterminate, diagnostic injections should be attempted.
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