disc prolapse

Intervertebral Disc Prolapse Investigations & Management

Lumbar Intervertebral Disc Prolapse-Clinical Features, Investigations & ManagementDr.PRASHANTH KUMAR JR ORTHOPEDIC RESIDENT

The intervertebral disc is a fibrocartilaginous structure whose principal function is to act as a shock absorber, transmitting compressive loads between vertebral bodies. Degeneration of the disc is associated with several clinical conditions, including herniation of the nucleus pulposus, mechanical back pain, spinal stenosis, and other spinal deformities such as scoliosis..

The human intervertebral disc is considered to undergo more dramatic degenerative changes than any other musculoskeletal tissue in the bodyand to undergo these changes at an earlier age

Normal Disc

Disc AnatomyThe intervertebral disc is composed of three main structures: the cartilaginous endplates, the central nucleus pulposus, and the peripherally located anulus fibrosus

Cartilaginous EndplatesThe intervertebral disc is separated from adjacent vertebral bodies by a cartilaginous endplate superiorly and inferiorly. In humans, the endplate serves as the growth plate for the vertebral bodies, having the typical structure of an epiphyseal growth plate.In infancy, this growth plate is thick and occupies a substantial fraction of the disc.

The endplates thin as growth progresses and eventually consist of only a 1-mm-thick, avascular layer of hyaline cartilage in adults.Similar to hyaline cartilage elsewhere in the body, the cartilaginous endplates are composed of rounded chondrocytes

Biomechanically, most compressive forces are transmitted through the superior vertebral body to the endplate, to the nucleus pulposus, and to the inferior endplate and vertebral body. The endplates and adjacent trabecular bone can undergo temporary deformation when a load is applied

Nucleus PulposusThe nucleus lies between adjacent endplates and forms the gel-like core of the disc. The nucleus consists of a proteoglycan and water matrix held together by an irregular network of collagen type II and elastin fibers. Proteoglycans have numerous highly anionic glycosaminoglycan (GAG) side chains (i.e., chondroitan sulfate and keratan sulfate), which allows the nucleus to imbibe water.

This composition is similar to articular cartilage, and the ability of the matrix to imbibe and release water in relation to applied stresses allows the disc to cushion against compressive loads. The primary proteoglycan is aggrecan, and the high concentration of this hydrophilic molecule provides the osmotic properties needed to resist compression.

Cells in the nucleus are initially notochordal, but their number declines after birth and they eventually become undetectable at about age 4 to 10 years.6The nucleus is gradually replaced during growth by rounded cells resembling the chondrocytes of articular cartilage.7These chondrocyte-like cells synthesize mostly proteoglycans and collagen type II in response to changes in hydrostatic pressure.

The nucleus functions as a shock absorber, acting as a pressurized, deformable sphere that dissipates compressive forces to the anulus and the adjacent vertebral bodies. As compressive forces on the spine increase, hydrostatic pressure within the nucleus pushes outward from its center in all directions.

Anulus FibrosusThe anulus fibrosus surrounds the nucleus and is composed of approximately 20 concentric rings (lamellae) of highly organized collagen fibers, primarily collagen type I. The collagen fibers are orientated approximately 60 degrees to the vertical axis of the spine and run parallel within each lamella but perpendicular between adjacent lamellae allowing for maximal tensile strength.8

Fibers of the outer anulus attach to the periphery of the vertebral bodies, whereas inner fibers pass from one endplate to another. Cells in the anulus are found between lamellae, arranged in parallel to the collagen fibers. Outer anulus cells are thin and elongated and phenotypically similar to fibroblasts, whereas cells of the innermost anulus are more spheroid similar to articular chondrocytes.1,9

The anulus contains the nucleus pulposus and maintains its pressurization under compressive loads. The tensile properties of the anulus allow the nucleus to recover its original shape and position when the compressive load is reduced.

Blood Supply, Nutrition, and Innervation

Blood SupplyIn early fetal life, vascular channels traverse the endplates, but they diminish in size starting at birth until complete disappearance by approximately 5 years of age. In adults, the blood supply of the disc arises from two capillary plexuses. One plexus penetrates 1 to 2 mm into the outer anulus, supplying only the periphery of the anulus.

The other capillary plexus begins in the vertebral body and penetrates the subchondral bone (seeFig. 61), terminating in capillary loops at the bone-cartilage junction.10The density of this capillary network varies in location across the endplate, being greatest in the center and lowest at the periphery. Cells in the center of the adult nucleus pulposus are 8 mm from the nearest blood source, making the disc one of the largest avascular structures in the body.

Nutrition

The limited vascularity of the intervertebral disc has important physiologic implicationsmainly that nutrition depends almost entirely on diffusion .The nutritional environment of the cells varies throughout the disc because of its size; cells in the nucleus are 6 to 8 mm from the nearest blood vessel. Small molecules necessary to maintain cellular function (i.e., glucose and oxygen) readily leave vertebral capillaries and diffuse across the thin cartilaginous endplate and the outermost layers of the anulus into the ECM.

Concentration gradients of glucose, oxygen, and other nutrients and metabolites exist across the disc, regulated by the rates of nutrient supply and consumption. The low oxygen tension in the nucleus leads to anaerobic metabolism (i.e., glycolysis), resulting in a high concentration of lactic acid and a lower pH in the nucleus compared with the periphery of the disc.13Metabolic by-products such as lactic acid are removed from the disc by diffusion in the opposite direction of nutrient entry.

InnervationUnder normal conditions, only the outer 1 to 2 mm of the anulus fibrosus is innervated in nondegenerated human discs. The remainder of the anulus and nucleus are uniquely avascular and lacking neurons under normal, nondegenerated conditions.

Disc CompositionThe function of the intervertebral disc depends greatly on the properties of the extracellular matrix (ECM). The ECM provides the biomechanical properties and acts as a filter to regulate the extracellular fluid composition and the rate at which nutrients and metabolites are exchanged. The ECM consists of a complex network of macromolecules whose composition varies in different regions of the disc .

ECM macromolecules are synthesized and maintained by a small population of cells (9000 cells/mm3in the anulus and 5000 cells/mm3in the nucleus) occupying less than 1% of the disc volume.Disc cells also produce a complex array of cytokines, growth factors, and proteases to maintain equilibrium between the rates of synthesis and degradation of ECM components.

WaterThe major component of the intervertebral disc is water, and its concentration is regulated by the GAG side chains of proteoglycans. The concentration of water varies with age, location within the disc, and body position.17The nucleus pulposus is most highly hydrated, and the water concentration may be 90% in an infant, declining to approximately 80% in nondegenerated young adult discs.18The water content of the anulus is lower than the nucleus, declining to 65% in the outer anulus in adult discs.

Water content varies with load, leading to diurnal changes in disc hydration.19During the diurnal cycle in young, highly hydrated lumbar discs, 25% of the discs water can be lost and regained.20Water is expressed from the disc during the day because of the increased forces of body weight and muscle contractions, and it is reimbibed at night when the compressive forces are removed. This diurnal cycle results in changes in disc height and affects the discs mechanical properties.

Macromolecules

Collagen is one major macromolecular component of the disc. The collagen content of the disc is highest in the outer anulus, and the dry weight decreases significantly in the nucleus of adult discs.The concentration of collagen type I is highest in the outer anulus and decreases toward the nucleus, where virtually none is present.Collagen type II follows the opposite gradient, with the highest concentration located in the nucleus. Along with collagen types I and II, the ECM contains many other collagens, including types III, V, VI, IX, and XI.

In addition to collagens and aggrecan, the disc contains lower concentrations of numerous other macromolecules,14including elastin, the smaller proteoglycans decorin and fibromodulin, cartilage oligomeric matrix protein, and cartilage intermediate layer protein. These molecules function either structurally or biomechanically and are important for normal disc function.

Intervertebral Disc: Aging and Degeneration

AgingHuman intervertebral discs undergo very early aging and degeneration, resulting in histomorphologic and functional changes .24Endplate permeability and vascular supply decrease throughout growth and aging, leading to altered metabolite transport.24Proteoglycans begin to fragment during childhood, and the overall proteoglycan content decreases with age, especially in the nucleus.

There is a corresponding increase in collagen content, with collagen type I fibers replacing collagen type II fibers in the inner anulus and nucleus. In addition, reduced matrix turnover in older discs enables collagen fibrils to become increasingly cross-linked,25leading to retention of damaged fibers and reduced tissue strength. Synthesis of ECM components decreases steadily throughout life, and this is partly attributable to decreased cell density, although synthesis rates per cell also decrease.

In infants, the nucleus contains approximately 90% water and appears translucent.18The disc dehydrates slowly with aging, with water content of the nucleus declining to around 80% in young adults.24The nucleus also accumulates yellow pigmentation and becomes less distinguishable from the surrounding anulus.18,24As the disc water content decreases, the nucleus becomes smaller and decompressed, often condensing into several fibrous lumps

. Dehydration of the nucleus leads to altered biomechanical properties of the disc, forcing the anulus to act as a fibrous solid to resist compression directly. The proteoglycan content of the anulus also decreases with aging, and the anulus becomes stiffer and weaker, resisting compressive loads in a haphazard manner

Degeneration

Intervertebral disc degeneration mimics age-related changes of the disc, but the process occurs prematurely or at an accelerated rate26,27and usually results in symptoms. There are no widely accepted definitions of disc degeneration in the literature, reflecting the difficulty in distinguishing degeneration from the physiologic processes of growth, aging, and remodeling.

More recent definitions describe degeneration as an aberrant, cell-mediated response to progressive damage, with combined structural failure and accelerated or advanced signs of aging. These proposed definitions also suggest that structurally intact discs with accelerated age-related changes be classified asearly degenerative discs,whereas the termdegenerative disc diseaseshould be applied if the disc is also painful.26

Although the exact mechanism of disc degeneration has not been determined, it is known to involve a complex interaction of factors, including ECM macromolecule changes, decreased water content, altered enzyme activity, decreased endplate permeability, impaired metabolite transport, structural failure, cell senescence and death, and genetic factors. These biologic and biomechanical factors cause extensive histomorphologic changes of the disc leading to disorganization of the anulus, solidification of the nucleus, and thinning and calcification of the cartilaginous endplates.

Etiology of Intervertebral Disc Degeneration

AgingGenetic PredispositionNutritionEnvironmental Factors include heavy or repetitive mechanical loading (i.e., occupational physical loading and whole-body vibration),51,69obesity, and cigarette smoking.70Heavy physical loading, particularly related to occupation, was previously suspected to be a major risk factor for degeneration and commonly viewed as a wear and tear phenomenon

Facet Joints, Ligaments, and Vertebral Bodies

No discussion of intervertebral disc degeneration would be complete without consideration of the other elements of the spine. Degeneration of the spine has an impact not only on the disc, but also the surrounding structures, such as the facet joints, ligaments, and vertebral bodies. Degenerative changes occur simultaneously in each of these components, altering the ability of the spine to respond to normal physiologic loads. In addition, degeneration of the surrounding structures may cause pain and reduced mobility of the spine

Facet Joints

Degeneration of the facet joints resembles osteoarthritic changes occurring at other synovial joints, starting with synovitis and progressing to articular cartilage loss, capsular redundancy, and eventually degenerative spondylolisthesis. Hypertrophic osteophytes at the joint margins and periarticular fibrosis can also result in reduced mobility and pain at the facet joint. Osteoarthritis of the facet joints parallels degenerative changes of the disc, possibly resulting from abnormal loading and narrowing of the disc in the early stages of degeneration.71

Ligaments

The anterior longitudinal ligament and posterior longitudinal ligament contribute to the overall stability of the spine. The strong anterior longitudinal ligament buttresses the anulus anteriorly, whereas the posterior longitudinal ligament offers only weak reinforcement to the posterior anulus. Information regarding degenerative changes of these ligaments is minimal, but the anterior longitudinal ligament and the posterior longitudinal ligament become more redundant as disc height decreases, and ossification occurs in later stages. These changes may contribute to pain and reduced mobility of the spine.

Vertebral Bodies

Osteoarthritic changes of the vertebral body are also associated with intervertebral disc degeneration.The cartilaginous endplates are normally the weakest structure under compressive loads, and thinning and calcification with aging further compromise endplate strength. The endplates accumulate trabecular microdamage and undergo remodeling in response to altered loads, and the nucleus bulges into the vertebral body as degeneration progresses.

Endplate damage decompresses the nucleus further, and loss of disc height transfers forces onto the anulus, causing it to bulge into the nucleus.The nucleus may eventually herniate through a damaged endplate, and subsequent calcification of the herniated nucleus is called a Schmorl node. The loss of disc height and annular laxity leads to formation of osteophytes at the vertebral body margins, decreased separation of the posterior neural arches, and eventual bony ankylosis

Lumbar disc diseaseClinical Features

Clinical FeaturesAGE: 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

Clinical Features-Back PainMechanical midline, worse with activityInstability midline, gluteal, worse in morning.Radiculopathy Claudication heaviness of one or both legsInflammatory worse in morning better with activityInfection/Tumorsrest pain and night pain

Clinical features-Radiculopathy Radicle- rootShooting pain distributed along the dermatome of the involved nerve root biochemical mediators(TNF alpha, interleukins) or mechanical compression Pain typically radiates below the kneeLeg pain = or > than back pain Worse on activity or bending forwards

Clinical features- HistoryMay attribute to episode of traumaProlonged history of repetitive lower back and buttock painrelieved by a short period of rest. suddenly exacerbated, often by a flexion episode, with the appearance of leg pain. increasing with activity, especially sitting, straining sneezing decreased by rest, especially in the semi-Fowler position

Other SymptomsWeaknessCorresponding to level of neurological involvement

ParesthesiaDermatomal distribution

Cauda equina

Cauda EquinaEmergencyAggressive evaluation and managementmost consistent symptoms(Tay & Chacha)saddle anesthesiabilateral ankle areflexia bladder symptomsOther symptoms-numbness and weakness in both legs, rectal pain, numbness in the perineum, bowel disturbances

Clinical Features- SignsAntalgic gaitAffected hip more extended and knee more flexed than normal sideTrendelenberg gait (L5 nerve root)List abrupt planar shiftAxillary disc same sideShoulder disc- opposite sideThigh and calf muscle wastingLoss of lumbar lordosisParaspinal spasm- central furrow sign

Flat back deformity of chronic IVDP

50

ATTITUDE

LIST (SCIATIC SCOLIOSIS)

Clinical features- Tests

Straight Leg RaisingLasegues testr/o hamstring tightness

Clinical Features- Tests

CONTRALATERAL LEG RAISING TEST (FRAJERSZTAGN TEST)

AFFECTED SIDENORMAL SIDE

Clinical Features -TestsFemoral nerve stretch testL2,3 and 4 nerve roots

Bowstring sign

Clinical features Flip test

NEGATIVEPOSITIVE

Clinical features-Slump test

Clinical features

VALSALVA MANEUVRE

Clinical features- ROMFlexion- Painful and restricted

Lateral bending to the same sidePainful and restricted

Clinical features -NeurologyL1L2

Clinical Features- NeurologyL3


62


Clinical Features- NeurologyS1

Clinical Features- Red FlagsExtremes of age (55yr)Neurological deficitsFeverUnexplained weight loss(10lb in 6months)MalaiseRest pain/ night painSignificant traumaDrug and alcohol abuse

Non Organic Signs Of WaddellDescribed by Waddel in post op patients

Non anatomic tenderness

Simulation sign

Distraction sign

Regional sensory or motor disturbance

Overreaction(most sensitive)

Clinical features-Never forget

Sacroiliac and hip joint examination

Examination of peripheral pulses

Differential Diagnosis- Lumbar Disc DiseaseINTRASPINAL CAUSESProximal to disc: Conus and Cauda equine lesions (eg. Neurofibroma, ependymoma)Disc levelHerniated nucleus pulposusStenosis (Canal or recess)TraumaInfection: Osteomyelitis or discitis ( with nerve root pressure)Inflammation: Arachnoiditis, ankylosing spondylitisNeoplasm: Benign or malignant with nerve root pressure(multiple myeloma, extradural tumors)Other degenerative causes

Differential Diagnosis- Lumbar Disc DiseaseEXTRASPINAL CAUSESPelvis Cardiovascular conditions (eg. Peripheral vascular disease)Gynaecological conditionsOrthopaedic conditions ( osteoarthritis of hip, Muscle related disease, Facet joint arthropathy)Sacroiliac joint diseaseNeoplasmPeripheral nerve lesionsNeuropathy (Diabetic, tumour, alcohol)Local sciatic nerve conditions (Trauma, tumour)Inflammation (herpes zoster)

KEY DIAGNOSTIC POINTSLUMBAR DISC PROLAPSELeg pain greater than back painSLRT +Neurological deficit present ANNULAR TEARSBack pain greater than leg painBilateral SLRT positiveFACET JOINT ARTHROPATHYLocalized tenderness present unilaterally over jointPain occurs immediately on spinal extensionPain exacerbated with ipsilateral side bending

SPINAL STENOSISHeaviness(no pain) develops after walks a limited distance.Flexion relieves symptomsNo neurological deficit SLRT -veMYOGENIC OR MUSCLE RELATEDPain localised to affected musclePain increases on prolonged muscle usePain reproduced with sustained muscle contraction against resistanceContralateral pain with side bending

Investigations

THE CORNERSTONE OF DIAGNOSIS OF LUMBAR DISC DISEASE IS THE HISTORY AND PHYSICAL EXAMINATION NOT THE INVESTIGTION

Investigations- Plain RadiographsSimplest and most readily availableAP and Lateral viewsLoss of lumbar lordosisIndicationsPositive SLR Red FlagsUnresponsive to conservative treatment

Other viewsOblique viewsSpondylolisthesis and lysisHypertrophic changes around foramina in cervical spineLateral flexion/ extension viewsFerguson View20 degrees caudocephalic AP far out syndrome, fifth root compression by a large transverse process of the L5 vertebra against the ala of the sacrum. Angled caudal views facet or laminar pathological conditions.

X ray- Signs of InstabilityIndirect SignsDisc space narrowing, Sclerosis of end plates OsteophytesTraction spur Vacuum Sign Direct signsTranslational abnormalities on dynamic films

Investigations RadiographyFeatures of Instability-Traction spurs

Tensile stresses by ALL or outer annulus fibres on body periosteum

2-3mm from end plate 75

Vacuum signKnuttsons signradiolucent defect presence of nitrogen gas accumulations in annular and nuclear degenerative fissurestypical central vacuum phenomenon gas collection that fills large neo-cavity occupying both the nucleus and annulus indicative of advanced disc degeneration. Other typeGas at outermost part of the annulus fibrosus close to the vertebral cornerrupture of the insertion of Sharpeys fibres

Reduction in Height of Pedicle

REDUCTION IN THE HEIGHT OF THE PEDICLE

Flexion Extension Views Forward translation of one vertebra over the other - anterior sliding instability.Backward translation - posterior sliding instability. Excessive angular movement of a motion segment / rotation - angular instability. Abnormal axial rotation in which posterior margin of the vertebral body has a focal double contour during bending.

Investigations- CT

Assessment of fractures spondylolysis preoperative planning,Alternative for assessing a patient with instrumentation

Investigations- CTADVANTAGESExtremely useful, highly accurate & noninvasive tool in the evaluation of spinal disease.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.

LimitationsIt cannot differentiate between scar tissue and new disc herniationIt does not have sufficient soft tissue resolution to allow differentiation between annulus and nucleusLiteratureEnd plate avulsions in CT scan by Rajasekaran et al

AXIAL LOCATION

SAGITTAL SECTION

Investigations- MRIMost accurate and sensitive modality for the diagnosis of subtle spinal pathology, test of chice It allows direct visualization of herniated disc material and its relationship to neural tissue including intrathecal contents.Advantages over myelographyNo radiationOp procedureNo intrathecal contrast More accurate in far lateral discDisc disease of LS junctionEarly disc disease

Advantages over CTimaging the discdirectly images neural structures. shows the entire region of study (i.e., cervical, thoracic, or lumbar). ability to image the nerve root in the foramenLimitationsShowing abnormal anatomy in asymptomatic patientClinical exam is paramount

which is difficult even with postmyelography CT because the subarachnoid space and the contrast agent do not extend fully through the foramen

85

Stages of Disc Prolapse

CONTRAST ENCHANCED MRIHere GADOLINIUM labeled diethylenetriaminepentaacetate (Gd-DTPA) administered intravenously and MRI scan done.ADVANTAGESDisplay the inflammatory reaction critical to the pathophysiology of radicular pain or radiculopathyAllows discrimination of scar from recurrent disc.

MyelographyUnnecessary if clinical and CT or MRI findings are in complete agreement.Indicationssuspicion of an intraspinal lesion, patients with spinal instrumentation, questionable diagnosis resulting from conflicting clinical findings and other studies . previously operated spine marked bony degenerative change that may be underestimated on MRIarachnoiditis

MyelographyDyesAir, oil contrast, water-soluble (absorbable) metrizamide (Amipaque)-higher complication ratesiohexol (Omnipaque)- approved for thoracic and lumbar myelographyiopamidol (Isovue-M). Water-soluble contrast media -standard agents for myelographyAdvantages: absorption by the body, enhanced definition of structures, tolerance, and the ability to vary the dosage for different contrastsDisadvantages : 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 Complications: nausea, vomiting, confusion, and seizures. Rare complications include stroke, paralysis, and death.Arachnoiditis- iophendylate(oil contrast). Not noted in water contrast.

PrecautionsClear explanation of the procedureHydration of the patient using the lowest possible dose discontinuation of phenothiazines and tricyclic drugs before, during, and after the procedure30-degree elevation of the patient's head until the contrast material is absorbedProper equipmentSmaller gauge needles (22-gauge or 25-gauge) Whitacre-type needle with a blunter tip and side port opening

, including a fluoroscopic unit with a spot film device, image intensification, tiltable table, and television monitoring96

Air contrast is used rarely -Only in situations in which the patient is extremely allergic to iodized materials

Electrodiagnostic studies

Applied when clinical examination and imaging fail to provide a clear diagnosis or perhaps conflicting diagnosesMay include needle electromyelography, somatosensory evoked potentials or cervical root stimulationOperator dependedMay help differentiate primary cervical disorders from peripheral nerve entrapments syndromes or pain eminating from the intrinsic shoulder pathology

Electromyographythe identification of

peripheral neuropathy

diffuse neurological involvement

Investigations-Injection studiesEpidural steroidFacet joint injectionsDiscographyFocused and controlled anesthesia of particular anatomic structures to help define loci of pain (excl discography)

Used whendiagnosis is in doubt pathological condition diffuseIdentification of pain generator difficultTherapeutic as well as diagnostic

Other diagnostic testsSOMATOSENSORY EVOKED POTENTIALS (SSEP) to identify the level of root involvementPOSITRON EMISSION TOMOGRAPHYBone scan & SPECTuseful for localizing a pain generator when multiple radiographic abnormalities presentBlood investigationsRheumatoid screening

TreatmentThere are many treatment options for patients with low back pain and neck pain, but, although there is a plethora of literature,there is very little conclusive evidence for any of them. The treatment options are usually used in combination

TreatmentConservativeBed restMedicationsPhysical therapyLifestyle modificationsChiropractic manipulationLumbo-sacral orthosisSelective injectionsIntradiscal Electrothermal Therapy ( IDET )

Operative

Bed Restno data to suggest that bed rest alters the natural history of lumbar disc herniations or improves outcomes.Consensus of 2 days (if used)

Semi Fowlers Position

MedicationsNSAIDs Selective COX-2 inhibitorsPreferential COX-2 inhibitorsNonselectiveAcetamenophenOpiodsSteroidsMuscle relaxantsAnti depressantsAnti Seizure

Physical TherapyExcercisesBack SchoolOthers : IFT, SWD, TENS, Traction

Excercises

Better than medical care aloneFlexion-based isometric exercises appear to have the most support in the literatureOffer benefit by decreasing local muscle spasm and stabilizing the spine.Begin when acute pain diminishes

It has been shownto be better than medical care aloneover a six-month period, especiallywhen the program is medically supervised37,38.It is also better than chiropracticmanipulation for the treatment ofchronic pain39. Specific types of backflexion and extension stretching havebeen thought to have beneficial effectsfor patients with low back pain40. Flexion-based isometric exercises appear tohave the most support in the literature,although extension-based exercises,progressive-resistance exercises, anddynamic stabilization training are usefuladjuncts30,41. Th108

ExercisesGENERAL RULES FOR EXERCISEDo 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 CONTROL

HAMSTRING 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)

Physical therapyTENSTranscutaneous electrical nerve stimulationrelease of endogenous analgesic endorphinsCentral nervous system process in which a control center is altered to block transmission of painDeyo RA et al TENS is no different from a placebo

Reduce intradiscal pressure by 20-30%115

Intermittent Pelvic TractionGoal- distract the lumbarvertebrae.enlargement of the intervertebral foramen, creation of a vacuum to reduce herniated discs,placement of the PLL under tension to aid in reduction of herniated discs, relaxation of muscle spasm, freeing of adherent nerve rootsDoes not alter natural history of disease

Back SchoolEducation in proper posture and body mechanics Helpful in returning the patient to the usual level of activity Individual or Group instruction. Now referred to as back school. Quality and quantity of information provided may vary widely.

Bergquist-Ullman et al beneficial in decreasing the amount of time lost from work initially, does little to decrease the incidence of recurrence of symptoms or length of time lost from work during recurrences.

The combination of back education and combined physical therapy is superior to placebo treatment.

Lifestyle ModificationsAvoidance ofRepetitive bending /twisting/ liftingContact sportsHeavy weights2wheelers, Auto rickshawsSoft mattress( Spring, foam)Posture training Back support while sittingFirm mattress (rubberised foam, coir )

Chiropractic Manipulations15% of the United States population seeks chiropractic help each yearSkargren et al. found chiropractic treatment to be more effectivefor acute low back pain (less than oneweek in duration) physical therapy more effective for pain of longer duration

A chiropractic adjustment, also known as chiropractic manipulation, manual manipulation, or spinal manipulation, is a common therapeutic treatment for lower back pain.18A chiropractic adjustment refers to a chiropractor applying manipulation to the vertebrae that have abnormal movement patterns or fail to function normally.The objective of this chiropractic treatment is to reduce thesubluxation, with the goals of increasing range of motion, reducing nerve irritability and improving function.

Chiropractic Adjustment Description

A chiropractic adjustment typically involves:A high velocity, short lever arm thrust applied to a vertebraAn accompanying, audible release of gas (joint cavitation) that is caused by the release of oxygen, nitrogen, and carbon dioxide, which releases joint pressure (cavitation)19A relieving sensation most of the time, although minor discomfort has been reported (that usually lasts for a short time duration) if the surrounding muscles are in spasm or the patient tenses up during this chiropractic care.

Lumbo-Sacral OrthosisPurpose is to stabilize and immobilizeIndicationsvertebral body fracturespondylolysis with spondylolisthesisPostoperative supportTheir use in low back pain is doubtfulNot prescribedlack of compliance on the part of the patient, creating psychological dependence, validating the disability.weakening of postural back and abdominal muscles (not proven)Does not alter natural history of the disease

Intradiscal Electrothermal TherapyLow back pain of discogenic originNot useful in radiculopathyposterolateral placement of a probe around the inner circumference of the annulus followed by heating of the probe.? Collagen alterationPre RequisitesNormal neurology Negative SLR. absence of compressive lesions on MRI positive concordant discogram Conflicting outcomes requiring refinement of indications

Novel Therapy

InfliximabTNF alfa inhibitor

Injection of Ozone into disc and around nerve roots

Operative ManagementPrerequisitessurgeon sure of diagnosisPatient feels that pain is debilitating enough to warrant surgeryUnderstand that surgery does not stop the pathological process Nor does it restore disc to normal stateMay only provide symptomatic reliefPhysiotherapy and activity restrictions may be needed post op

Operative treatmentPatient selection is the Keypredominant (if not only) unilateral leg pain extending below the knee present for at least 6 weeks. Not decreased by rest, antiinflammatory medication, or even epidural steroidsreturned to the initial levels after a minimum of 6 to 8 weeks of conservative carePhysical signs: Positive SLR, neurological deficitsImaging should confirm the level of involvement consistent with the patient's examination

Broad IndicationsABSOLUTE Bladder and bowel involvement: The cauda equine syndromeIncreasing neurological deficit RELATIVEFailure of conservative treatmentRecurrent sciaticaSignificant neurological deficit with significant SLR reductionDisc rupture into a stenotic canalRecurrent neurological deficit

ContraindicationsPredominantly back pain rather than leg painClinical findings and imaging do not correlateLack of adequate instrumentsBulging or protruding discs not ruptured through the annulus

Disc excision is an Elective procedure

only cauda equina syndrome warrants emergency management

Surgical OptionsStandard discectomyLimited DiscectomyMicrosurgical Lumbar discectomyEndoscopic discectomyAdditional ExposureHemilaminectomyTotal LaminectomyFacetectomyPercutaneous DiscectomyChemonucleolysisArthrodesisDisc replacement

Standard PrecautionsInfiltrate the operative field with 30 mL of 0.25% bupivacaine with epinephrineRadiographic confirmation of level . protect neural structures. Epidural bleeding should be controlled with bipolar electrocautery. Any sponge, pack, or cottonoid patty placed in the wound should extend to the outside.

at a point equal to the maximal allowable disc depth to prevent injury of viscera or great vessels.

131

Standard DiscectomyEstablished procedure of proved efficacyAbsolute Indicationscauda equina syndrome progressive neurological deficit despite non-operative treatment.Relative Indicationsintolerable pain,severe postural list, persistent pain that markedly compromises the ability to work, perform household tasks, engage in recreational activities.

no long-term difference in the improvement of static deficits among those treated operatively or non-operatively.

Patients who have the relative indications improve morerapidly after surgical treatment, but their long-term resultsare reportedly not significantly different than those after nosurgical treatment35.132

Positioning Prone positionWith bolstersKnee chest positionAllows abdomen to hang free, minimizing epidural venous dilation and bleedingLateral position with affected side up

Salient PointsLamina exposed cephalad and caudad to the level of the herniated disc1-2 sqcm area of lamina removed exposing dura and nerve rootVisualise lateral edge of nerve rootRemove sequestered discIncise Annulus and remove central and lateral part of nucleusNerve root must freely move 1cm inferomediallyForaminotomy Free fat graft to reduce post op scarring

A oneto two-square-centimeter area of lamina is removed to exposethe dura and nerve root at and caudad to the level ofthe herniated disc. In general, as much bone is removed asis necessary to allow visualization of the lateral edge of thenerve root. Any sequestered disc fragment that is encounteredis removed. An incision is made in the anulus fibrosus,and as much of the central and lateral regions of the nucleuspulposus is removed as possible, using pituitary rongeursand curets. The nerve root is assessed for tension; if it doesnot move freely, a partial or complete foraminotomy isperformed until it can be easily moved one centimeterinferomediahly20. Occasionally, the inferior and medial portionsof the pedicle must be removed to achieve this degreeof laxity. A free fat graft is used to cover the exposed duraand nerve root, to minimize postoperative scarring6.In one study of the results after standard discectomy,134

Limited DiscectomyOnly the extruded or sequestered portion of the disc is removed. The central or lateral portion of nucleus is not removed from the disc space.One study only with a short term follow upGood resultsNo recurrenceOnly 2% had persistent pain

Of the fifty-four patientsin that series, 83 per cent had only occasional painin the back or lower limbs postoperatively; 15 per cent hadintermittent pain in either the back or the lower limbs, orboth; and 2 per cent had persistent complaints of pain. Noherniation of the disc recurred.135

Lumbar Microsurgical Discectomy first reported by Williams in 1978procedure of choice for herniated lumbar discDecompression of the involved nerve root with minimum trauma to the adjacent structures.Advantagesdecreased operative time, Decreased morbidity, less loss of blood, shorter stay in the hospital, earlier return to work.Visibility for assistant

Put pic of microscope136

Lumbar Microsurgical DiscectomyDrawbacksinadequate exposure incomplete decompressionCostly equipmentContraindicationsPreviously operatedSpinal Canal Stenosis

Microsurgical Lumbar DiscectomyRequirementsoperating microscope with a 400-mm lens,small-angled Kerrison rongeurs of appropriate length, microinstruments, combination suctionnerve root retractor

Microsurgical Lumbar DiscectomyOriginal GuidelinesAvoidance of laminectomy and of trauma to the facets, Preservation of all extradural fat, Blunt perforation of the anulus fibrosus rather than incision with a scalpel, Preservation of healthy, non-herniated intervertebral disc material,Remove only as much disc as is necessary to relieve the neural elements from visible and palpable compression.New GuidelinesSubtotal discectomy through an incision, made with a scalpel,in the anulus fibrosus; using bipolar coagulation; Removing the medial portion of the facet for exposure when necessary

Post opImmediate post opMonitor neurologyTurn in bed , semi fowler positionWalk with assistance to toiletOral analgesics and muscle relaxants for painBladder stimulants to assist in voidingDischarge- after walking and voiding(day of surgery in microscopic discectomy)minimize sitting and riding in a vehicle to comfortIncrease walking on a daily basisAvoid stooping bending lifting

Post opDelayedCore strengthening between week 1 & 3Lifting bending stooping gradually after 3 weeksLong trips avoid for 4-6weeksWalking jobs with minimal lifting 2-3weeksProlonged sitting jobs 4-6 weeksHeavy labor, long driving 6-8weeksExceptionally heavy manual labour- AVOID

Endoscopic Discectomy advantage of shortened hospital stay and faster return to activityNot provedEndoscope instead of microscope

Additional Exposure TechniquesLarge disc herniation, lateral recess stenosis or foraminal stenosis, may require a greater exposure of the nerve root. If the extent of the lesion is known before surgery, the proper approach can be planned

Hemilaminectomyrequired when identifying the root is a problem.

Eg. Conjoined root

Total LaminectomyReserved for patients with spinal stenoses that are central in nature,

Occurs typically in cauda equina syndrome.

Facetectomyreserved for foraminal stenosis severe lateral recess stenosis

If more than one facet is removed, a fusion should be considered

Especially in a young, active individual with a normal disc height at that level.

COMPLICATIONS OF LAMINECTOMY AND DISCECTOMYInfection Superficial wound infection , Deep disc space infectionThrombophlebitis/ Deep vein thrombosisPulmonary embolismDural tears may result in Pseudomeningocoele, CSF leak, MeningitisPostoperative cauda equine lesionsNeurological damage or nerve root injuryUrinary retention and urinary tract infection

FAILED BACK SYNDROME It is a condition characterized by persistent postoperative backache and sciatica.VERY COMMON CAUSESRecurrent/ Persistent disc material at operated siteHerniated Nucleus Pulposus at other siteEpidural scar / Fibrosis Facet arthrosis / Spinal stenosis

COMMON CAUSES Neuritis, Referred pain from nonspinous siteUNCOMMON CAUSESDiscitis / Osteomyelitis/ Epidural abscessArachnoiditisConus tumourThoracic, High lumbar Herniated Nucleus PulposusEpidural 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.

Chemo nucleolysis

treatment of lesions of the intervertebral disc by intradiscal injection of a lysing agent.satisfactory results in 77 per cent of patientsIndication: prolapsed herniated disc

Chemo nucleolysisContraindicationsSequestered discSpinal stenosisprevious injection of chymopapain allergy to papaya or its derivatives; Previous surgical treatment of the lumbar spine; herniation of more than two discs; a rapidly progressive neurological deficit;neurogenic dysfunction of the bowel or the bladder, or both;spondylohisthesis. Spinal tumourPregnancyDiabetic neuropathy

CHEMONUCLEOLYSIS

Chymopapain injected into the discDegrades the proteoglycans in the nucleusWater holding capacity of the disc is decreasedShrinkage of the disc

Chemo nucleolysisComplicationsNeurologicalcerebral hemorrhage, paraplegia,paresis, quadriplegia, Guillain-Barre syndrome, seizure disorder.AnaphylaxisProcedure is not in favour now

Discography cause for complications154

Percutaneous DiscectomyMechanically decompress a herniated lumbar disc via a posterolateral cannulaReduced morbidity Reduced hospital stayNo anaphylactic reactions and neurological complications associated with chemonucleolysisIndication: prolapsed herniated discContraindicationsPresence of sequestered fragmentsLumbar canal stenosisLumbosacral discs

The procedure is generally performed with the patientunder local anesthesia and prone. A c-arm image-intensifieris used to identify the proper level and to monitor anddocument the course of the operation. A trocar is insertedeight to nine centimeters from the midline on the symptomaticside and is advanced into the disc space. If the patient reports radicular pain, the trocar is redirected. When thetrocar is properly positioned, a 4.9-millimeter-diameter cannulais placed over the trocar and held firmly against theanulus fibrosus as the trocar is removed. A window is madein the anulus fibrosus with a cutting instrument that has beeninserted into the cannula, and the fragments of disc areevacuated with punch forceps and suction9. In addition toproviding access to the disc space, the posterolateral anularpenetration is believed to decompress the disc space andperhaps to decrease the chance of a recurrent posteriorherniation8.155

Disc Excision & ArthrodesisFirst suggested by Mixter and BarrIndicated forMarked segmental instabilityDone when facets are destabilized bilaterally to prevent Iatrogenic SpondylolisthesisFrymoyer J et al no significant difference in the results of patients who had discectomy and arthrodesis compared with the results in those who had discectomy alone

Lumbar Artificial Disc Replacement

Disc Replacement Patient not suitable for artificial disc replacement areOsteoporosisSpondylolisthesisInfection or tumour of spineSpine deformities from traumaFacet arthrosis

THANK YOU

LEARN TO BE GOOD TO YOUR BACK AND YOUR BACK WILL BE GOOD TO YOU.