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Disc lesions & Nerve Root Pain
Lesion is a non-specific term used in medicine to refer to a pathology of tissue. It indicates an area of tissue that has been injured, destroyed, altered (for the worse) or has a problem.
Disc lesion refers to disc degeneration Leads to reduced water content and
therefore reduced shock absorption Leads to nucleus pulposes collapsing
through annulus fibrosis to adjacent vertebra (known as Schmorl’s nodules)
Definition of Disc lesion
Trauma Flexion rotation injuries- heavy object is
lifted (gives rise to tear of the posterior longitudinal ligament and results in bulging of the disc)
Degeneration Disc loses elasticity due to collagen
changes and decrease in water content results in inability to handle compression forces
Increased pressure Nucleus absorbs moisture during physical
illness or emotional stress, swells and presses against annulus fibrosis
Causes
Age: Most common in middle age, especially between 35 and 45, due to aging-related degeneration of the discs.
Weight: excess body weight causes extra stress on the disks in your lower back.
Occupation: People with physically demanding jobs have a greater risk of back problems. Repetitive lifting, pulling, pushing, bending sideways and twisting also may increase your risk of a herniated disk. Working night shift has also been found to increase your risk.
Pregnancy
Risk factors
Changes start asymptomatically but causes weak link
Most injuries occur at L4,5 and L5, S1
Prolapse to anterior or lateral causes osteophytes which later attach to each other, resulting in loss of movement
Posterior prolapse causes more problems
Disc itself or osteophytes exert pressure on spinal cord or nerve roots
Pathology
Sudden pain when picking up heavy object- initially slight but worsens and can impair movement.
Repeated attacks occur suddenly e.g. sneezing or coughing
Pain after a prolonged sustained position Central or referred symptoms- not always clearly
defined Proximal worse than distal Pain diminishes when lying down with knees
supported or hanging in a specific position
Symptoms
Young, healthy patient Lateral tilt of the pelvis Increased lumbar lordosis Gluteal area sensitive to palpation Protective muscle spasm Sitting, coughing and sneezing painful Decreased intervertebral movements
Signs
AP- Sometimes shows tilt of vertebra Lateral- Narrowed disc space
X-Rays
OMT Rotation (grade 4-) Longitudinal Static traction Palpation techniques (except when ext.
comparable sign) Electrotherapy Exercises
Abdominal stabilisation Strengthening quadriceps and gluteal
mm. Neural mobilisation Posture correction and kinetic handling Surgery http://
www.youtube.com/watch?feature=player_embedded&v=i6r5ivym8Ug
Treatment
Avoid sitting positions (driving or bathing) Sit with knees lower than hips and use lumbar cushion Avoid sustained positions Avoid rotation movements when picking up objects Avoid sudden, jerky movements (sporting activities) Do not pick up heavy objects Swimming is good exercise- strengthens erector spinae Wear a brace during activities which aggravate
backache
Advice
Pressure on the nerve root causing pain
Pain not from nerve itself but as result from venous congestion
First sign is pins and needles in distal region of affected dermatome, pain intensifies and arterial blood circulation restricted
Nerve conduction suspended and nerve fall-out develops
Nerve Root Pain
Depends on: Strength of initial impulse Duration of abnormal pressure (longer, the
worse it becomes)
Degree of impairment
Disc prolapse Disc protrusion Osteophytes Traction injuries Swelling in intervertebral canal Stenosis Deep-seated muscle spasms Hypertrophic capsule
Causes
Nerve root irritation: Increased reflexes Abnormal sensation or paraesthesia
Nerve root pressure: Decreased reflexes Loss/ no sensation Muscle weakness- long term atrophy
Physical manifestations
Pressure on spinal cord: Gait disturbances Bilateral pins and needles Bladder dysfunction Increased reflexes below level of lesion Clonus and Babinski (+)
Pressure on cauda equina Saddle anaesthesia Urine retention
Manifestations cont.
Area: Well defined throughout
dermatome or dominates distal part of dermatome
Nature: Severe pain, sometimes total
loss of function, may be latent, often undulent and builds up.
Sharp, shooting pain which may paralyse patient
Root pain of C7 refers to medial border of scapula with cervical movements (Cloward areas)
S1 refers to medial buttock Acute phase, pain severe, sub-
acute and chronic, pain is intermittent
Characteristics of nerve root pain
Movement: Either distal or latent pain
in distal segment More distal pain is caused,
more careful the management
Deformities: Protective deformities
occur Patient stands on one leg
with other leg bent and toes resting on the floor
Severe nerve root pain: Hospital traction or traction as out
patient (Neurological examination is an
ABSOLUTE prerequisite, palpation techniques are CONTA-indicated)
Steroid injections As soon as symptoms improve,
mobilisation techniques (Gr. 4) may be added to traction
Treatment suspended after 85% improvement
If symptoms extremely severe, surgery is indicated
Treatment
Cervical root pain: Constant traction Collar for support to restrict movement Advice regarding sleeping positions
Lumbar root pain: Complete bed-rest Constant traction Takes longer to react to treatment
Specific treatment
Chronic: History of prolonged pain in back and leg Strong treatment techniques indicated (e.g traction and SLR)
Intermittent: Pain only occurring in one dermatome e.g the knee Local hypertrophy and palpation tenderness of interspinal
ligament Quick active tests and palpation techniques do not
reproduce symptoms Treatment:Trigger pointsNeural mobilisationUltrasound
Chronic and intermittent nerve root pain
OBJECTIVE: To evaluate the effect of therapeutic transforaminal lumbar epidural steroid injections in managing low back and lower extremity pain.
OUTCOME MEASURES: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake.
Effectiveness of therapeutic lumbar transforaminal epidural steroid injections
in managing lumbar spinal pain.
RESULTS: 27 studies met inclusion criteria, 15 randomized trials and 10 non-randomized studies. For lumbar disc herniation, the evidence is good for transforaminal epidural with local anesthetic and steroids, whereas it was fair for local anesthetics alone and the ability of transforaminal epidural injections to prevent surgery. For spinal stenosis, the available evidence is fair for local anesthetic and steroids. The evidence for axial low back pain and post lumbar surgery syndrome is poor, inadequate, limited, or unavailable.
CONCLUSION: In summary, the evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids and fair with local anesthetic only. Evidence is limited for axial pain and post surgery syndrome using local anesthetic with or without steroids.
Barnes,R.2011.NEUROMUSCULAR-SKELETAL REHABILITATION DICTATE.(Unpublished dictate.) University of the Free State , Free State.
Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, Christo PJ. 2012. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain.(http://www.ncbi.nlm.nih.gov/pubmed/22622912)
Retrieved 22 August 2012
South Wales Osteopathic Society. Disc lesions. (http://osteopathywales.com/index.php?option=com_content&view=article&id=204:disc-lesions&catid=22:medical-conditions)
Retrieved 19 August 2012.
References
Asher, A. 2006. Lesion (http://backandneck.about.com/od/l/g/lesion.htm).
Retrieved 19 August 2012.
Health on Care. 2012. Disc Herniation, Prolapse Disc : Definition, Causes, Symptoms, Diagnosis, Prevent and Treatment (http://www.healthoncare.com/disc-herniation-prolapse-disc.html).
Retrieved 19 August 2012.
References cont.