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prolapsed intervertebral disc explanation

Prolapsed intervertebral disc explanation with treatment

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References : Campbell’s Operative Orthopaedics , Macnab’s backache 4th edition PROLAPSED INTERVERTEBRAL DISC
ANATOMY • Central axis of human skeleton is formed by the vertebral column . • Each vertebral column has three functional components: ~ Vertebral bodies ~ Neural arches ~ Bony processes
Intervertebral disc • It is a complicated structure both anatomically and physiologically. • It has outer annulus and inner nucleus pulposus . • Hydrostatic, load bearing structure between vertebral bodies . • Thicker anteriorly in the cervical and lumbar regions - anterior convexity .
Annulus • It has three main groups. • Outermost fibres : between the vertebral bodies and the undersurface of the epiphysial ring . • Middle fibers : from the epiphysial ring on one vertebral body to the epiphysial ring of the vertebral body below . • Innermost fibers passing from one cartilage endplate to the other
Nucleus pulposus • In lower lumbar spine,it is placed eccentrically near the posterior margin. • Water binding capacity and elasticity- property of protein content . • With ageing , the water bond capacity with progressive desiccation of disc • Type II collagen strand + hydrophilic priteoglycan
• The anterior fibers are strengthened by the powerful anterior longitudinal ligament. • The posterior longitudinal ligament affords only weak reinforcement, especially at L4-5 and L5–S1, where it is a midline, narrow, unimportant structure attached to the annulus.
Blood supply • In adults , it is avascular . • They sustain by diffusion of nutrients into disc through porous central concavity of end plate . • Diffusion is maintained by - Motion and weight bearing .
Factors affecting incidence of disc herniation • Age • Sex • Body build ( Anthropometry ) • Posture • Spine mobility and strength • Smoking • Occupational • Emotional • Radiographic factors
FREQUENCY • Two most common forms of: • I) Lumbar disc herniation • ii) Cervical disc herniation LEVEL PERCENTAGE L5-S1 40 L4-L5 49 L3-L4 7.5 L2-L3 3 L1-L2 0.5
CAUSES • Repetitive mechanical activities • Living a sedentary lifestyle • Traumatic injury to lumbar discs • Obesity • Practising poor posture • Tobacco abuse
Clinical features • I) Low back pain : atleast 4 types are associated with • a) Typical ligamentous or deep pain . Dull aching , poorly localised,varies in intensity.It occurs due to degenerative changes in nucleus . • b) Deep pain due to stretching of the posterior interspinous ligament . • c) Direct irritation of nerve root by posterior protrusion produces pain referred to cutaneous distribution of affected root . • d) Late stages of disc lesion , is when affected joint is undergoing arthritic changes .
• REFERRED PAIN : begins in lower limb and referred to sacroiliac region or posterior thigh . • RADICULAR PAIN : extends below knee and follows dermatome of involved nerve root . • SCIATICA • MOTOR CHANGES • REFLEX CHANGES • SENSORY CHANGES • BOWEL AND BLADDER CHANGES
Dematomes and Myotomes
PHYSICAL EXAMINATION • PALPATION • Tenderness on palpation : at level of symptomatic degenerative disc. • Paraspinal muscle spasm . • Patients with radiculopathy have tender motor points corresponding to probable segmental level of nerve root .
• NEUROLOGICAL EXAMINATION • weakness or paralysis of muscle group • Wasting or atrophy • Reflexes- diminished or lost .
• SCIATIA TENSION SIGNS : I) Valsalva manoeuvre ii) SLRT iii) contralateral SLRT Femoral nerve stretch test Cross over test
Radiographs • Simplest and most readily available. • Anteroposterior and lateral radiographs. • Oblique view - spondylolisthesis and spondylolysis . • Lateral flexion and extension views - segmental instability. • Ferguson view - far out syndrome • Angled caudal views - facet or laminar pathology .
• Changes consistent with disc degeneration , including • I) osteophytes • ii) disc space narrowing or • iii) subtle changes in translation , facet hypertrophy ,or • iv) changes in Sagittal alignment
Myelography • It has the ability to check all spinal regions for abnormality and defines intraspinal lesions • It is valuable in previously operated spine and in marked bony degenerative changes. • It It involves injection of intrathecal contrast material to outline the boundaries of the subarachnoid space . • Extradural compression caused by a foraminal or extraforaminal disc can be missed . • Dynamic test - patient standing.
Magnetic Resonance Imaging • Identification of infections , tumors and degenerative changes in discs. • It can image the nerve root in the foramen • The disc and fragments that are herniated are readily visualised . • Free fragments ( sequestered ) - extruded disc herniations .
MRI grading of disc Normal • Well hydrated disc • Central dark band = central fibrous Degeneration • Desiccation • Narrowing • Bulging • Endplate changes • Osteophytes
Computed Tomography
Other diagnostic tests • The advantage is to rule out diseases other than primary disc herniation , spinal stenosis and spinal arthritis . • Electromyography • Bone scans • Laboratory tests • Rheumatoid screening studies • Lumbar venography • Ultrasonography
TREATMENT • CONSERVATIVE : 90% respond to conservative management I) bed rest ii) drug therapy iii) physiotherapy iv) epidural steroid injections
Physiotherapy • Patients with acute back pain eased by passive extension of spine can benefit with extension exercises. • Should not be forced in extreme pain . • Education should be given regarding posture and biomechanics • Some respond to TENS , pelvic and skin traction, back braces .
Epidural steroid injection • INDICATIONS • painful SLRT • patients with neurological deficits • Patients with acute on chronic symptoms, with different level of disc pathology. • CONTRAINDICATIONS: • Infection • Haemorrhaging and bleeding diasthesis
• COMPLICATIONS • Bacterial meningitis • Transient hypotension • Headache • CHEMONUCLEOSIS : Enzymatic dissolution of disc
INDICATIONS OF SURGERY • IDEAL CANDIDATE : • History, physical examination,radiographic finding , are consistent with one another • Root tension sign + • When discrepancy exist , the clinical picture should serve as principal guide . • ABSOLUTE SURGICAL INDICATION • cauda equina syndrome • Acute urinary retention/ incontinence ,saddle anaesthesia,back/buttock/leg pain , weakness , difficulty in walking.
• RELATIVE INDICATION • Progressive weakness • No response to conservative management
LAMINECTOMY AND DISCECTOMY • HEMI OR PARTIAL LAMINECTOMY: Lamina and ligamentum flavum on one Side is removed taking care not to remove facet joint. • TOTAL LAMINECTOMY: Removal of all of the lamina.
DISCECTOMY Fenestration and discectomy • Micro discectomy • Endoscopic discectomy • Arthroscopic microdiscectomy • Automated percutaneous lumbar discectomy • Intradiscal electrothermal annuloplasty
LASER DISCECTOMY ADVANTAGES • Performed in an outpatient setting • Requires no general anesthesia, • Results in no scarring or spinal instability, • Reduces rehabilitation time, • Is repeatable
Lumbar fusion for disc herniation • Patients with preoperative lumbar instability may benefit from fusion at the time of lumbar discectomy; incidence instability - very low (5%) • Patients who suffer from chronic low-back pain, or are heavy laborers or athletes with axial low-back pain, in addition to radicular symptoms may also be candidates for fusion at the time of lumbar disc excision. • Recurrent lumbar disc herniation with associated spinal deformity, instability, or associated chronic low backpain, consideration of fusion in addition to reoperative discectomy is recommended.
COMPLICATIONS 1. Infection 2. Thrombophlebitis/ DVT 3. Pulmonary embolism 4. Dural tears resulting in: Pseudomeningocele, CSF leak, meningitis. 5. Post-op cauda equina lesions 6. Nerve-root injury 7. Urinary retention
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