J.J.M MEDICAL COLLEGE

DAVANGERE

SEMINAR ON

LUMBAR DISC PROLAPSE09/01/2013

MODERATORS

Dr. NAGABHUSHANA.D.M MS ORTHO,

Dr. PRASANNA ANNABERU MS ORTHO, PRESENTED BY

Dr.VIGNESHWARAN.P

PG IN ORTHOPAEDICS

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HISTORY

Aurelianus(5th century) clearly described the symptoms of SCIATICA. Andreas Vesalius (1543) first described the intervertebral disc. Forst(1811) described the Lasegue sign. He attributed it to Lasegue, his teacher. Virchow (1857), Kocher (1896) described acute traumatic rupture of the intervertebral disc that

resulted in death. Contugino(18th century) attributed the leg pain to the sciatic nerve. 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. Schmorl (1928) described Schmorl nodes. Dandy (1929) reported removal of a disc tumour or chondroma from patients with sciatica. Arnell&Lidstorm (1931) first used water soluble contrast medium. 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.

ANATOMY OF LUMBAR SPINE

There are five lumbar vertebrae making up the lumbar spine. Each vertebra has three functional components: the vertebral bodies, designed to bear weight; the neural arches, designed to protect the neural elements; and the bony processes (spinous and transverse), designed as out-triggers to increase the efficiency of muscle action.

The vertebral bodies are connected together by the intervertebral discs, and the neural arches are joined by the facet (zygapophyseal) joints. The discal surface of an adult vertebral body demonstrates on its periphery a ring of cortical bone. This ring, the epiphysial ring, acts as a growth zone in the young and in the adult as an anchoring ring for the attachment of the fibers of the annulus.

The hyaline cartilage plate lies within the confines of this ring. The size of the vertebral body increases from L1 to L5, which is indicative of the increasing loads that each lower lumbar vertebral level has to absorb.

The neural arch is composed of two pedicles and two laminae. The pedicles are anchored to the cephalad half of the vertebral body and form a protective cover for the caudaequina contents of the lumbar spinal canal. The ligamentum flavum (yellow ligament) fills in the interlaminar space at each level. The outriggers for muscle attachment are the transverse processes and spinous process.

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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. The anterior and middle fibers of the annulus are most numerous anteriorly and laterally but are deficient posteriorly, where most of the fibers are attached to the cartilage plate.

Weight is transmitted to the nucleus through the hyaline cartilage plate. The hyaline cartilage is ideally suited to this function because it is avascular. If weight were transmitted through a vascularized structure, such as bone, the local pressure would shut off blood supply, and progressive areas of bone would die. This

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THE INTERVERTEBRAL DISC The intervertebral disc consists of outer fibrous annulus, containing inner gelatinous nucleus pulposus.

ANNULUS FIBROSUS

The fibers of the annulus can be divided into three main groups: the outermost fibers attaching between the vertebral bodies and the undersurface of the epiphyseal ring; the middle fibers passing from the epiphyseal ring on one vertebral body to the epiphyseal ring of the vertebral body below; and the innermost fibers passing from one cartilage end-plate to the other.The anterior fibers are strengthened by the powerful anterior longitudinal ligament.

The fibers of the annulus are firmly attached to the vertebral bodies and arranged in lamellae, with the fibers of one layer running at an angle to those of the deeper layer. This anatomic arrangement permits the annulus to limit vertebral movements. This important function is reinforced by the investing vertebral ligaments.

NUCLEUS PULPOSUS The nucleus pulposus is gelatinous, the load of axial compression is distributed not only vertically but also radially throughout the nucleus. This radial distribution of the vertical load (tangential loading of the disc) is absorbed by the fibers of the annulus.

phenomenon is seen when the cartilage plate presents congenital defects and the nucleus is in direct contact with the spongiosa of bone. The pressure occludes the blood supply, a small zone of bone dies, and the nucleus progressively intrudes into the vertebral body this is known as SCHMORL’S NODE.

COMPOSITION

The nucleus consists of approximately 85% water, 10 to 20% of collagen and abundant amount of proteoglycans. The annulus fibrosus contains 78% of water, 60 to 70% of collagen. The collagen prevent the proteoglycans imbibing water and swell up. Thus collagen gives tensile property to the tissue and proteoglycan gives compressive stiffness.

FUNCTIONS

The nucleus pulposus acts like a ball bearing, and in flexion and extension the vertebral bodies roll over this incompressible gel while the posterior joints guide and steady the movements. The annulus acts like a coiled spring, pulling the vertebral bodies together against the elastic resistance of the nucleus pulposus.

NUTRITION TO THE DISC

The intervertebral discs of a person up to the age of 8 years have a blood supply, but thereafter they are dependent for their nutrition on diffusion of tissue fluids. This fluid transfer is through two routes: (a) the bidirectional flow from vertebral body to disc and from disc to vertebral body and (b) the diffusion through the annulus from blood vessels on its surface. This ability to transfer fluid from the disc to the adjacent vertebral bodies minimizes the rise in intradiscal pressure on sudden compression loading. This fluid transfer acts like a safety valve and protects the disc.

THE FACET JOINTS

The facet (zygapophyseal) joints are synovial joints that permit simple gliding movements. These are like miniature KNEE JOINT. The lax capsule of the zygapophyseal joints is reinforced to some extent by the ligamentum flavum anteriorly and the supraspinous ligament posteriorly, the major structures restraining movement in these joints are the outermost fibers of the annulus. When these annular fibers exhibit degenerative changes, excessive joint play is permitted due to this degenerative changes within the discs render the related posterior joints vulnerable to strain.

THE LIGAMENTS

The strongest ligaments in the spine are the anterior longitudinal ligament and the facet joint capsules. The interspinous-supraspinous ligament complex is of intermediate strength, and weakest of all is the posterior longitudinal ligament.

Anterior longitudinal ligament (ALL) runs the length of the anterior aspect of the spine. It is intimately attached to the anterior annular fibers of each disc and is a fairly strong ligament useful in fracture reduction.

Posterior longitudinal ligament (PLL). is the posterior mate to the anterior longitudinal ligament. It is a significant ligament in all areas of the spine except the lower lumbar region

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where it is flimsy and inconsequential thus lumbar disc problems are most common in this region.

Interspinous/supraspinous ligament complex helps in flexion of lumbar spine. Ligamentum flavum (the yellow ligament). This ligament is so named because of the

yellowish color that is given to it by the high content of the elastin fibers. The ligamentum flavum bridges the interlaminar interval, attaching to the interspinous ligament medially and the facet capsule laterally. It has a broad attachment to the undersurface of the superior lamina and inserts onto the leading edge of the inferior lamina at each segment. Normally, the ligamentum maintains a taut configuration, stretching for flexion and contracting its elastin fibers in neutral or extension. In this way, it always covers but never infringes on the epidural space. With aging, the ligamentum flavum loses its elastin fibers and the collagen hypertrophies, which results in buckling of the ligamentum flavum and encroachment on the thecal sac, potentially contributing to spinal stenosis.

MOTION SEGMENT

Basic functional unit of spine is MOTION SEGMENT. It includes two adjacent vertebral bodies and intervening soft tissues. It is controlled actively by muscles and passively by ligaments. Disc is protected from both torsional and compressive loads when motion segment in extension.

HOW TO KNOW WHICH NERVE ROOT INVOLVED IN CASE OF DISC PROLAPSE?

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For example the fifth lumbar nerve root passes beneath the fifth lumbar pedicle and is also described as the exiting nerve root at the L5-S1 segment. Proximal to this, the L5 root passes across the L4-5 disc space. The L5 nerve root is the traversing root at the L4-5 disc space, where it can be encroached on by an L4-5 disc herniation in the common posterolateral position. Distal to the L5 pedicle, the fifth lumbar nerve root lies just lateral to the L5-S1 disc space, and a lateral disc herniation at L5-S1 can encroach on the fifth lumbar nerve root at this level.

MOTION SEGMENT

ANTERIOR ELEMENTS

It includes vertebral body, disc, anterior & posterior longitudinal ligaments.

Provides stability & Shock absorption

POSTERIOR ELEMENTS

It includes pedicles, facet joints, posterior ligamentous & muscular attachment.

Control the spinal movements

L5 is TRAVERSING NERVE ROOT

L5 is EXITING NERVE ROOT

BIOMECHANICS OF LUMBAR SPINE

LOAD BEARING

In axial compression load, there will be increase in intradiscal pressure which will be counteracted by annular fibre tension and disc bulge.

In axial rotation of lumbar spine,

Torsion of disc Annular fibres in one direction are stretched significantly and opposite side shortened stress concentration at region of postero-lateral annulus Fissures in postero-lateral annulus

Torsion of vertebral body segment cause only peripheral circumferential tear in annular fibres after damage to the posterior joints. But only lateral bending and flexion will cause acute rupture of lumbar intervertebral disc.

THREE JOINT COMPLEX

It includes intervertebral disc & Facet joints. It has load bearing function. Facet joints and disc normally resist 80% of torsion. 25% of axial compression load transmitted through the facet joints when the person is standing and the facet joints share 0% axial load on the spine in sitting. The primary function of the facet joints is to protect the disc from shear and rotational forces.

BIOMECHANICS OF LIGAMENTS

The ligaments of the lumbar spine act like rubber bands. They have an elastic physical property that allows the ligament to stretch and resist tensile forces. Under compression, the ligaments buckle and serve little function. In resisting tensile forces, ligaments allow just enough movement without injury to vital structures. Passively, they maintain tension in a segment so that muscles do not have to work as hard.

ROLE OF ABDOMINAL CAVITY

Abdominal cavity and its surrounding muscles stabilize the spine for activities such as lifting.

INTRADISCAL PRESSURE

The final determining factor in biomechanical injury to spine is the INTRADISCAL PRESSURE.

IN RELATION TO POSTURE

Disc pressure is higher in sitting without support than standing

With use of backrest with inclination of about 1200, arm rest and lumbar support of about 5cm reduces deformation of lumbar spine and decreases disc pressure.

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In recumbent position on firm bedding surface with flexion at hip and knee,

Decrease stress on spine due to relaxation of spinal musculature Decrease the stress on facet joints by decreasing lumbar lordosis.

IN RELATION TO MANUAL MATERIALS HANDLING

Lifting heavy weight with back stooped and legs straight more stressful than back straight lifting with legs because

Shear forces are greater when lifting with back flexed Articular facet capsules and posterior ligament are overstrained in flexed posture.

Heavy load held close to the body is much less hazardous to back than one lifted further away from the body.

DO & DONTS

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LUMBAR DISC PROLAPSE

SYNONYMS: Herniated disc, Prolapsed disc, Sequestrated disc, Soft disc, Slipped disc, Protruding disc, Bulging disc, Ruptured disc, Extruded disc, Disc.

DEFINITION

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: Postero-lateral type

WHY DISC PROLAPSE IS MOST COMMON POSTEROLATERALLY?

Incomplete annular lamellae in this quadrant (i.e) each lamellae end with fusion to an adjacent lamellae not completely circular.

Fibres of annulus were deficient posteriorly. Posterior fibres are only weakly reinforced by posterior longitudinal ligament especially L4-5 and L5-S1

where it is midline, narrow, unimportant structure attached to annulus.

ETIOLOGY

Congenital/ Developmental – Biochemical and structural abnormality in one or more disc Repetitive microtrauma Accumulated macrotrauma – Sports / Automobile injury Poor nutrition Poor Health habits – Lack of exercise, smoking Biomechanical factors – Rotational torsional stress, flexion and compression injury Poor posture habits – sitting and bending forwards, lifting heavy weight bending back Autoimmune inflammatory reaction Biochemical changes – In inner annulus and nucleus initiate/ potentiate the degradation of DISC

MATERIAL and predispose to herniation because of thinning or weakening of annulus. PhospholipaseA2 and arachidonic acid are suspected

NATURAL HISTORY OF DISC DEGENERATION

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The three stages of disc degeneration are:

Stage of dysfunction Stage of instability Stage of stabilization

STAGE OF DYSFUNCTION

STAGE OF INSTABILITY

STAGE OF STABILIZATION

PATHOPHYSIOLOGY OF LUMBAR INTERVERTEBRAL DISC PROLAPSE

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Episode of rotational or compressive trauma (uncoordinated muscle contraction)

Posterior facet joint & annular strain

Small capsular & annular tear occurs

Small subluxation of posterior joint

Posterior joint synovium injured & result in SYNOVITIS

Posterior segment muscle protect joint by sustained hypertonic contraction

Muscle become ischaemic & metabolites get accumulated cause pain

Muscle splint the posterior joint subluxation maintained

Increased dysfunction

FACET JOINT

DISC

Degeneration of cartilage

Attenuation of capsule

Laxity of capsule

Coalescence of tears

Loss of nucleus internal disruption

Bulging of annulus

INCREASED ABNORMAL MOVEMENT

FACET JOINT

DISC

Destruction of cartilage

Fibrosis in joint

Enlargement of facets

Locking facets Fibrosis around joint

Loss of nucleus

Approximation of bodies

Destruction of plates

Fibrosis in disc & osteophytes

INCREASED STIFFNESS

STABILIZATION

FATE OF DISC HERNIATION

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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 INTACT

ANNULUS FAILS

Facet joints share even more of the axial load

Facet joints undergo degenerative changes & develop osteophytes

FACET JOINT SYNDROME

Fissures develop across annular lamellae may extend upto disc periphery

Internal disc disruption cause AXIAL PAIN

Expression of this degraded nuclear material through these radial fissures

DISC HERNIATION

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

Nucleus pulposus is an immunogenic which induce an inflammatory response mediated by TNF alpha, IL, Phospholipase A2,

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

WHAT IS RADICULOPATHY?

Radiculopathy means the presence of objective signs of NEURAL DYSFUNCTION including motor weakness, sensory loss/ paresthesias or diminished deep tendon reflexes. It is typically accompanied by radiating limb pain which is intermittent, lanciating, electric or burning.

TYPES OF DISC PROLAPSE

Based on the intactness of annulus fibrosus

AXIAL LOCATION SAGITTAL LOCATION

Central R/L Central R/L Subarticular R/L Foraminal R/L Extraforaminal

Discal Pedicular Infrapedicular Suprapedicular

AREA OF THE DISC SHAPE OF THE DISC

<25%ExtrusionFocal Protrusion

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Extrude disc & degraded nuclear material impinge on the nerve roots

Nucleus pulposus is an immunogenic which induce an inflammatory response mediated by TNF alpha, IL, Phospholipase A2,

Produces radicular pain syndrome & RADICULOPATHY

CONTAINED (intact annular fibres)

NON CONTAINED (disruption of annular fibres)

PROTRUSION SUBANNULAR EXTRUSION

TRANSANNULAR EXTRUSION

SEQUESTERED

25-50% Broad based protrusion

CLINICAL FEATURES

STAGE OF DEGENERATIVE

DISEASE OF DISCSTAGE OF DYSFUNCTION STAGE OF INSTABILITY STAGE OF

STABILIZATION

SYMPTOMS

- Low back pain often localized or referred to groin/ greater trochanter/ posterior thigh- Aggravated on movement- Relieved on rest

- Catch in back on movement.- Pain on coming to standing position after flexion.

- Low back pain decrease in severity

SIGNS

- Local tenderness on one side & at one level-Hypomobility- Muscle activity abnormality- Extension painful- Neurological examination normal

-Abnormal movement of spine- Observation of catchsway or shift when coming erect after flexion-Reversal spinal rhythm

- Muscle tenderness- Stiffness- Reduced movements- Scoliosis

RADIOLOGICAL CHANGES

-Abnormal movement- Spinous process not rotate to the side of bend- On lateral bending disc height on concave side not reduced - Irregularity of posterior facets- Small osteophyte on anterior surface vertebral body- Slightly decreased disc

AP VIEW-Lateral shift- Rotation- Abnormal tilt- Malaligned spinous processOBLIQUE VIEW-Opening of facetsLATERAL VIEW-Spondylolisthesis on flexion-Retrospondylolisthesis on extension-Narrowing of foramen on

- Enlarged facets- Loss of disc height- Osteophytes- Small foramina- Reduced movement- Scoliosis

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AXIAL LOCATION SAGITTAL LOCATION

height extension-Abnormal opening of disc-Abrupt change in pedicle height

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CLINICAL FEATURES OF LUMBAR DISC PROLAPSE

NERVE ROOT COMPRESSED

L1 L2 L3 L4 L5 S1

LEVEL OF DISC PROLAPSE

T12 – L1 L1 – L2 L2 - L3 L3 – L4 L4 – L5 L5 – S1

PAIN Thoraco lumbar junction, groin, proximal part of thigh

Thoraco lumbar junction, groin, proximal part of thigh

Upper lumbar spine, anterior aspect of proximal thigh

Lower back, hip, postero lateral thigh, anterior leg

Sacroiliac joint, hip, lateral thigh & lateral leg

Sacroiliac joint, hip, postero lateral thigh & postero lateral leg to heel

PARESTHESIA Oblique band proximal 3rd of thigh anteriorly just below inguinal ligament

Oblique band mid 3rd of thigh anteriorly

Oblique band lower part of thigh anteriorly just above the knee

Medial to shin of tibia, medial aspect of the foot

Lateral leg, dorsum of foot, 1st web space

Posterior aspect of thigh, back of calf, lateral side and sole of foot

MUSCLE AFFECTED MAINLY

Iliopsoas (Hip flexion)

Iliopsoas (Hip flexion), Quadriceps (Knee extension), adductor brevis, longus, magnus (Hip adduction)

Iliopsoas (Hip flexion), Quadriceps (Knee extension), adductor brevis, longus, magnus (Hip adduction)

TIBIALIS ANTERIOR (Foot inversion), Quadriceps (Knee extension), adductor brevis, longus, magnus (Hip

EXTENSOR HALLUCIS LONGUS (Dorsiflexion of great toe), Extensor digitorum longus & brevis (Dorsiflexion of foot), Gluteus

PERONEUS LONGUS & BREVIS (Foot eversion), Flexor hallucis longus (Plantar flexion of great toe), Flexor digitorum longus & brevis

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adduction) medius (Hip abduction)

(Plantar flexion of foot), Gastronemius, Soleus (Difficulty in walking on toes), Gluteus maximus (Hip extension)

WEAKNESS Hip flexion Hip flexion, Knee extension, Hip adduction

Hip flexion, Knee extension, Hip adduction

Foot inversion, Knee extension, Hip adduction, Difficulty in walking on heels

Dorsiflexion of great toe & foot, Difficulty in walking on heels, Hip abduction

Foot eversion, Plantar flexion of great toe & foot, Difficulty in walking on toes, Hip extension

ATROPHY - Quadriceps Quadriceps Quadriceps Minor Gastrocnemius, Soleus,

REFLEXES - Knee jerk slightly diminished

Knee jerk slightly diminished

Knee jerk diminished or absent

Changes uncommon ( Posterior tibial reflex diminished or absent

Ankle jerk absent or diminished

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NEUROLOGICAL CHANGES AT DIFFERENT LEVEL OF DISC HERNIATION

AGGRAVATING FACTORS

Pain will aggravate on bending, stooping, lifting heavy weight, coughing, sneezing and straining at stool.

RELIEVING FACTORS

Pain relieved on lying in hip-knee flexed position, pillow under the knees or on the asymptomatic side in fetal position. No position of comfort in case of high lumbar root lesions.

PHYSICAL EXAMINATION

ATTITUDE

INSPECTION

The SCIATIC SCOLIOSIS disappears on recumbency. The loss of lateral curvature of the lumbar spine on recumbency helps differentiates the sciatic scoliosis from fixed structural scoliosis in which there will be no change in curvature of lumbar spine on recumbency.

Loss of lumbar lordosis and paravertebral muscle spasm are seen in acute phase of the disease.

PALPATION

On applying lateral thrust to the spinous process may produce pain in the back at the affected level.

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The lumbar spine is flattened and slightly flexed, hip and knee slightly flexed on the affected side and hip rotates forward to relax Piriformis

GAIT – Slow and deliberate walk holding their loins with the hands. In gross nerve root tension, TIP-TOE WALK due to not able to put the heel to the floor.

Deviation of spine to one side to take the nerve away from the prolapsed disc is called SCIATIC SCOLIOSIS which become more obvious on bending forwards.

Deviation of spine depends on the type of disc prolapsed medial or lateral to nerve root,

Trunk deviated to opposite side – SHOULDER TYPE (lateral)

Trunk deviated to same side – AXILLARY TYPE (medial)

Tenderness on the adjacent paraspinal region due to muscle spasm and tenderness at the point between the ischial tuberosity and the greater trochanter, at the centre point of the posterior aspect of the thigh, just lateral to middle of the popliteal space, the middle of the calf and just behind the medial malleolus. Tender points in the myotome corresponding to the probable segmental level of nerve root involvement.

MOVEMENTS

Forward flexion and extension are restricted. But lateral flexion can be free and full to one side depends on the position of the protrusion in relation to the nerve root .If the patient feel leg pain on extension it is indicative of SEQUESTRATED OR EXTRUDED DISC.

The cardinal signs of lumbar root compromise are ROOT TENSION, ROOT IRRITATION & ROOT COMPRESSION

TEST FOR ROOT TENSION AND ROOT IRRITATION

These are the test which tighten the sciatic nerve and compress the inflamed nerve root against a herniated lumbar disc.

STRAIGHT LEG RAISING TEST

BRAGGARD’S SIGN: After a SLRT is done the limb is slightly lowered and the foot is dorsiflexed. Stretching of the sciatic nerve will cause intense pain

SICCARD’S TEST: It involves SLR along with extension of the big toe.

TURYN’S TEST: It involves only the extension of great toe.

CONTRALATERAL STRAIGHT LEG RAISING TEST (FRAJERSZTAGN TEST)

PROCEDURE: It is performed same manner as SLRT except that THE NON PAINFUL LEG is raised.

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PROCEDURE: Patient in supine position, there should be no compensatory lumbar lordosis. One of the examiner hand is placed over the knee firm pressure exerted to maintain knee in full extension and other hand of the examiner under the heel, the examiner slowly raises the leg until leg pain is produced.

FINDING: If reproduction of pain before reaching 60 to 70 degree, aggravated by dorsiflexion of ankle (LASEGUE’S SIGN)and relieved by flexion of the knee

IMPRESSION: Tension on the fifth lumbar or first sacral root.

In patient in whom paresthesia in foot is predominant on repetitive SLR intensifies the sensation of numbness.

FINDING: If patient develops reproduction of pain in opposite extremity then the test is positive.

IMPRESSION: Positive test is very suggestive of HERNIATED DISC & also an indication of the location of extrusion usually disc lies medial to the nerve root in the axilla.

Why reproduction of pain in affected limb occurs on elevation of the normal limb?

BOWSTRING SIGN

FEMORAL NERVE STRETCH TEST (REVERSE SLR TEST)

LASEGUE’S TEST: Here the patient in supine position, the hip and knee are gently flexed to 90degree, then the leg is gradually extended which reproduces the symptoms of sciatica.

CROSS OVER TEST

It is an important determinant of compression of lumbosacral roots in the midline.

PROCEDURE: The examiner gently raise the affected leg

FINDING: If patient develop symptoms in asymptomatic contralateral extremity

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On lifting the normal limb (e.g) Left limb

Nerve root on the left will move

Along with this right side root brought against herniated disc

Produce pain over right buttock

It is most important indication of root tension or irritation.

PROCEDURE: SLR is carried out until pain is reproduced at this level knee is slightly flexed until pain abates. Then examiner rests the limb on his or her shoulder and places the thumb in the poipliteal fossa over the sciatic nerve and sudden pressure applied on the nerve.

FINDING: If patient developed pain in the back or down the leg test is positive

IMPRESSION: Significant root tension and irritation of nerve root by ruptured disc

PROCEDURE: Patient is placed in prone position and the knee is flexed and the hip is extended.

FINDING: If the patient develops pain over unilateral thigh and which gets aggravated on further knee flexion indicates test is positive

IMPRESSION: Tension on the 2nd, 3rd or 4th lumbar roots.

LIMITATION: Difficult to assess in the presence of hip or knee pathology

IMPRESSION: A large central disc protrusion

FLIP TEST

NAFFZIGER’S TEST: Here pressure applied on the jugular vein until the patient face flush. Now patient asked to cough which produce pain in back indicate test is positive.

VALSALVA MANEUVER: Ask the patient to bear down as if he were trying to pass stools. If bearing down causes pain in the back or radiating down to the leg it indicates test is positive.

The diagnosis of disc rupture is dependent on demonstration of root impairment as reflected by signs of motor weakness, changes in sensory appreciation or reflex activity.

CAUDA EQUINA SYNDROME

The syndrome is a true spine surgical emergency that is often missed due to its rare occurance. The condition is usually caused by a massive midline disc sequestration into the spinal canal, usually at L4-L5 but also at L5-S1 and L3-L4. Higher disc ruptures are a rare cause of this syndrome.

The presentation is fairly classic. The patient usually has a prodromal stage of back pain and some leg symptoms.Without much in the way of intervening trauma, there is a dramatic increase in back pain and the occurrence of bilateral leg pain and perineal numbness. The numbness usually extends to the penis in men. The patient then notices an inability to void because of the paralysis of the S2, 3, and 4 roots in the cauda equina.

On examination, marked reduction in SLR; numbness to pinprick in the perineal region (S2, 3, 4 dermatomes) SADDLE ANAESTHESISA; and weakness corresponding to the level of the disc rupture. Reflexes will usually be depressed (e.g., bilateral ankle reflex depression with either an L4-L5 or L5-S1 sequestered disc). The bladder will be full to palpation/percussion, and any passage of urine will be due to involuntary overflow incontinence.On rectal examination, decreased tone in the external sphincter will be noted.If there is any suspicion at all that bladder and bowel function are impaired, in a back pain patient, an immediate diagnostic study like EMERGENCY MRI is indicated. It should operated as early as possible because delay in surgery increases the risk of permanent impairment of bowel and bladder function.

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PROCEDURE: Patient is made to sit with knees dangling over the side of the bed, the hip and knee are both flexed at 90degrees. Now extend the knee joint fully.

FINDING: If patient develops sudden, severe pain, and patient will throw his or her trunk backwards to avoid tension the nerve indicates that the test is positive.

IMPRESSION: Root compromise

DIFFERENTIAL DIAGNOSIS OF SCIATICA

INTRASPINAL CAUSES

Proximal 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 CAUSES

Pelvis

Cardiovascular conditions (eg. Peripheral vascular disease) Gynaecological conditions Orthopaedic conditions ( osteoarthritis of hip, Muscle related disease, Facet joint arthropathy) Sacroiliac joint disease Neoplasm

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CRITERIA FOR THE DIAGNOSIS OF THE ACUTE RADICULAR SYNDROME ( SCIATICA DUE TO A HERNIATED NUCLEUS PULPOSUS)

Peripheral nerve lesions

Neuropathy (Diabetic, tumour, alcohol) Local sciatic nerve conditions (Trauma, tumour) Inflammation (herpes zoster)

KEY DIAGNOSTIC TIPS FOR DISTINGUISHING AMONG FIVE IMPORTANT CAUSES OF SCIATICA

HERNIATED NUCLEUS PULPOSUS

H/o specific trauma Leg pain greater than back pain Neurologic deficit present; Nerve tension signs present Pain increases with sitting & leaning forwards, coughing, sneezing, and straining Pain reproduced with ipsilateral straight leg raising and sciatic stretch tests, contralateral legraising test Radiologic evidence of nerve root impingement

ANNULAR TEARS

H/o significant trauma Back pain usually greater than leg pain; Leg pain bilateral or unilateral Nerve tension signs are present ( But no radiologic evidence of impingement) Pain increases with sitting & leaning forwards, coughing, sneezing, and straining Back pain is exacerbated with bilateral straight leg raising and sciatic stretch tests Discography is diagnostic ( neither CT nor Myelogram shows abnormality)

FACET JOINT ARTHROPATHY

H/o injury Localized tenderness present unilaterally over joint Pain occurs immediately on spinal extension Pain exacerbated with ipsilateral side bending Pain blocked by intrajoint injection of local anaesthetic or corticosteroid

SPINAL STENOSIS

Back and/or leg pain develops after patient walks a limited distance; symptoms worsen with continued walking

Leg weakness or numbness present, with or without sciatica Flexion relieves symptoms No neurological deficit present Pain not reproduced on straight leg raising; pain reproduced with prolonged extension of spine and

relieved afterwards when spine flexed Radiologic evidence: Hypertrophic changes, disc narrowing, interlaminar space narrowing, facet

hypertrophy, degenerative spondylolisthesis L4-L5

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MYOGNIC OR MUSCLE - RELATED DISEASE

H/o Injury to muscle, recurrent pain symptoms related to its use Lumbar paravertebral myositis produce back pain; gluteus maximus myositis causes buttock and thigh

pain Pain is unilateral or bilateral, rather midline; does not extend below knee Soreness or stiffness present on rising in the morning and after resting; is worse when muscles are

chilled or when the weather changes ( arthritis like symptoms) Pain increases with prolonged muscle use ; is most intense after cessation of muscle use( directly

afterward and on following day) Symptom intensity reflects daily cumulative muscle use Local tenderness palpable in the belly of the involved muscle Pain reproduced with sustained muscle contraction against resistance, and passive stretch of the muscle Contralateral pain present with side-bending No radiologic evidence

INVESTIGATION

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

CT and MRI are ordered for two reasons: (a) almost always to verify the clinical diagnosis as correct and at the same time to plan a surgical approach to the problem and (b) infrequently to solve a differential diagnosis problem.

PLAIN RADIOGRAPH

It is not of much value in the diagnosis of disc herniation It is mainly used to rule out other causes like ankylosing spondylitis, neoplasms. Most commonly the herniation occurs at the end of phase I or in early phase II. Thus features of phase II

disc degeneration maybe seen

Radiological features are

Narrowing of disc space Osteophyte formation along the peripheries of the adjacent vertebral bodies Sclerosis or condensation of subchondral bone of the adjacent vertebral bodies above and below

the affected disc Loss of lumbar lordosis Translation of vertebral bodies

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MYELOGRAPHY

Technique: water-soluble contrast agent is injected into the epidural space.

Abnormalities in myelography indicative of an Herniated nucleus pulposus (HNP) are as follows:

FALSE NEGATIVE MYELOGRAM SEEN IN

Foraminal HNP Unscanned area (high lumbar disc not scanned). Insensitive space at L5-S1 Short or narrow dural sac at L5-S1 Conjoint nerve roots distorting the contrast column

DISADVANTAGE

Myelography is 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 .

CT MYELOGRAPHY

CT myelography is minimally invasive modality here CT scan taken after myelography is done.

INDICATIONS

Patient with contraindication for MRI Postoperative spine in which metal artifacts present

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Normal myelogram

Double density Distortion of sac

S1 root sleeve absent

Root sleeve shortening

ADVANTAGE: Accurate detection of root impingement and central lateral recess and foraminal stenosis

DISCOGRAPHY

Definition: The discogram is physiologic evaluation of the disc that consists of a manometric, volumetric, radiographic and pain provocative challenge.

Technique: Done by injecting saline or water soluble contrast into the disc through extradural or transdural approach under fluoroscopic guidance.

PARAMETERS NORMAL DISC ABNORMAL DISCVOLUME 0.5 – 1.5ml >1.5ml

END POINT PRESSURE Firm SpongyRADIOGRAPHIC Contrast confined to nucleus Contrast extend beyond the nucleusPAIN RESPONSE None/Pressure Typical/ Atypical/ Painless

USES

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

Post discography CT should be performed within 4hours of discography both axially and sagitally reformatted images are obtained.

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.

NORMAL ANNULAR TEAR PROTRUSION EXTRUSION SEQUESTRATION

SCHEMATIC DIAGRAM

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CT DISCOGRAP

HY

COMPUTED TOMOGRAPHY

ADVANTAGES

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.

In Lumbar disc prolapse, disc herniation usually focal, asymmetric and dorsolateral in position and is seen to lie directly under the nerve root traversing that disc causing demonstrable nerve root compression or displacement indicating nerve root compression.

MRI

MRI is a single best diagnostic test for imaging the cervical, thoracic and lumbar disc herniation. It allows direct visualization of herniated disc material and its relationship to neural tissue including intrathecal contents.

IMAGE SEQUENCE

T1 weighted image T2 weighted image

FAT Bright Less brightFLUID Dark BrightUSES Study the anatomy of cord and nerve

roots and spinal cordStudy the pathologic changes in spine Differentiate the nucleus from annulus fibrosus

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INDICATIONS FOR SPINE IMAGING

Presence of underlying systemic disease Progressive neurological deficits Cauda equina syndrome Candidate for therapeutic intervention Failed clinically directed conservative therapy

In Lumbar disc herniation, MRI shows disc herniation and their effect on the thecal sac and nerve roots, particularly on T2 weighted images.

Disc extrusions and sequestrated disc fragments on T2 weighted images shows greater signal intensity than the parent disc due to reflection of inflammation and matched T1 images reveals the lesion hypointense against the bright intra-foraminal fat.

CONTRAST ENHANCED 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

These tests are done to rule out diseases other than primary disc herniation.

ELECTROMYOGRAPHY – to rule out peripheral neuropathy. SOMATOSENSORY EVOKED POTENTIALS (SSEP) – to identify the level of root involvement POSITRON EMISSION TOMOGRAPHY

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T1 weighted image T2 weighted image

TREATMENT

CONSERVATIVE TREATMENT

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

In very acute condition patient must be hospitalized and kept on bed rest. Adequate analgesic relive the pain and this helps the muscle spasm to subside. Patient should not be kept in bed rest for not more than 3 to 4 days. The amount of straight leg raising obtained without pain is a useful indication of recovery. During bed rest, pelvic or skin traction can applied.

DRUG THERAPY

Bed rest can be supplemented with Non steroidal anti-inflammatory drugs, analgesics, muscle relaxants and night sedation.

PHYSIOTHERAPHY

In acute condition, traction should not be applied, only short wave diathermy and ultrasonic massage, infrared therapy can be used. In chronic disc prolapsed, skin traction or pelvic traction with 5 to 10 pounds can be applied.

EXERCISES

For the patients with loss of lumbar lordosis, extension exercise are important. For the patient with weak abdominal muscle, flexion exercise must be adviced.

GENERAL 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.

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FOR ACUTE STAGE

FOR SUBACUTE OR RECOVERY STAGE

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BRIDGING EXERCISE

Here lie on the floor, knees bent, feet flat on the floor, palms down and raise lower back and buttocks.

KNEE HUGS

Lie flat on the floor, pull left knee towards chest firmly and at the same time straighten right leg. It helps to passively stretch erector spinae and the contracted fascia and ligaments over the posterior aspect of the lumbosacral junction. Thus unload posterior disc

PELVIC TILT

Lie on the floor, knees bent, feet flat on floor, palms down. Push lower back flat against the floor. This decrease the lumbar lordosis and increase the anterior aspect of pelvis.

HAMSTRING STRETCH

Lie on your back, bring your knee towards your chest so your hip is at 90º.

Place your hands around your thigh; straighten your leg towards the ceiling until you feel a comfortable stretch in the back of the thigh.

Hold up to 30 seconds, repeat x3 – 5 times on both legs

YOGAASANAS FOR LUMBAR DISC PROLAPSE

These should performed only after the pain had relieved and should not be performed in acute state.

Recommend poses for Lumbar Disc Prolapse:

Tadasana (Mountain Pose) Marichyasana III (Marichi's Pose) Bharadvajasana (Bharadvaja's Twist) Virabhadrasana II (Warrior II Pose)Utthita Parsvakonasana (Side Angle Pose)

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KNEE ROLLS

Lie on your back with your knees bent, place your arms out to the side, level with your shoulders and palms turned upwards. Slowly roll your knees to the right, trying to keep your knees and ankles together.

Repeat x6 times each side, hold the stretch for as long as is comfortable for you.

EXTENSION CONTROL

Position yourself on all fours.

Lift your opposite arm and leg into a horizontal position. Hold for 5 -10 seconds. Try to keep your body still.

Repeat on the other side.

PARTIAL CURL (MODIFIED SIT UPS)

Lie on your back raise your upper back off the floor as you reach with both hands for your knees. Touch the top of your knees with your fingers. Lower your upper back slowly on the floor. Relax your arms and take a deep breath before repeating the exercise.

EXTENSION EXERCISE (PRESS UP)

Lying face down, leaning on your elbow/forearms. Arch the small of your back. Keep your knees and shoulders relaxed. Repeat x6 –10 hold for 4 -6 seconds. This helps to increase the extension flexibility and relaxes the muscles of back and abdomen.

Utthita Trikonasana (Triangle Pose) Ardha Urdhva Mukha Svanasana (Half

Upward-Facing Dog Pose) Balasana (Child's Pose) Shavasana (Corpse Pose)

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BALASANAARDHA URDHVA MUKHA SVANASANA

VIRABHADRASANA II UTTHITA PARSVAKONASANA UTTHITA TRIKONASANA

TADASANA MARICHYASANA III BHARADVAJASANA

EPIDURAL STEROID

Epidural steropid injections are useful for breaking the cycle of pain in acute lumbar disc herniations. This injection relieves pain by suppressing the inflammatory component of nerve root irritation.

INDICATIONS OF EPIDURAL STEROID

Painful SLRT or femoral stress test Patient with appropriate neurological deficit Patient with acute on chronic symptoms, with a different level of disc pathology

CONTRAINDICATIONS

- Infection -Hemorrhagic & Bleeding diasthesis- Evolving neurological disease - Cauda equina syndrome- Uncontrolled diabetes mellitus - Hypertension

TECHNIQUE: Methylprednisolone (80-120mg) mixed with 2% xylocaine and normal saline made into 10ml and injected into the epidural space through interlaminar approach and patient in lateral decubitus position using a glass syringe.

COMPLICATIONS OF EPIDURAL STEROID INJECTION

Failure inject drug into epidural space

Bacterial meningitis, Transient hypotension, Severe paresthesia, Headache, Transient corticoidism

SURGICAL TREATMENT

GOAL: To relive neural compression and hence radiculopathy while minimizing complications.

SURGICAL OPTIONS

POSTERIOR APPROACH

Standard laminectomy and discectomy Fenestration operation – Limited laminotomy Microsurgical laminotomy with disc fragment excision

ANTERIOR APPROACH with or without interbody fusion

PERCUTANEOUS APPROACH – Suction, laser or arthroscopic discectomy

INDICATIONS FOR SURGERY

ABSOLUTE

Bladder and bowel involvement: The cauda equina syndrome

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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

o Wrong patient ( poor potency for recovery)o Wrong diagnosis o Wrong levelo Painless Disc Prolapse (do not operate for primary complaint of weakness/paresthesia)o Inexperienced surgeon applying poor technical skillso Lack of adequate instruments

CHEMONUCLEOLYSIS

It is technique in which enzymatic dissolution of the disc done using CHYMOPAPAIN. Other substances used are collagenase, apoproteinin, chondrotininase and cathepsins.

INDICATION – Low back with radicular pain

CONTRAINDICATION OF CHEMONUCLEOLYSIS

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

MOA: Chymopapain injected into the intervertebral disc degrades the proteoglycan of the disc thus decrease the water holding property of the disc and result in shrinkage of the disc.

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LAMINECTOMY AND DISCECTOMY

Anaesthesia: Usually general

Position: Prone in knee chest position (Jack knife position)

Incision: Midline vertical incision over affected interspace usually 6 -8cms.

Exposure: Subcutaneous and deep tissue deepened – Lumbodorsal fascia divided – Supraspinous ligament incised –

LumboDorsal fascia divided – Supraspinous ligament incised – Paravertebral muscles reflected – Spinous process of 2 or more vertebra removed - Lamina and ligamentum flavum exposed – Cord exposed –Dura retracted – Nerve root inspected and retracted to expose the disc – Nick is made for any loose fragments of annulus – rest of disc material removed using disc forceps.

Closure: In layers

Post operatively: Patient allowed to turn in the bed and allowed out of the bed by 1st week

Discharged in 10 to 15 days

Advice on Discharge: Not to do stretching exercises for 6 months

HEMI OR PARTIAL LAMINECTOMY: Lamina and ligamentum flavum on one side is removed taking care not to damage facet joint.

FENESTRATION: Removal of a part of the lamina by inter-laminar approach

TOTAL LAMINECTOMY: Removal of all of the lamina

FREE FAT GRAFTING: Before closure fat is excised from the subcutaneous tissue, soaked in dexamethasone and placed over the exposed dura and the spinal nerves. This helps to prevent muscle from adhering to the exposed dura and in patients who required re-operation later.

COMPLICATIONS OF LAMINECTOMY AND DISCECTOMY

The complications associated with standard laminectomy and discectomy are

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 equina 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.

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VERY COMMON CAUSES

-Recurrent/ Persistent disc material at operated site

- Disc prolapse 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- Conustumour- Thoracic, High lumbar HNP- 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

It is technique in which microscope used in performing the disc excision.

TECHNIQUE

Pt in kneeling position – Level disc herniation palpated – A 2 to 3 cm incision directly over disc herniation about 1cm to the side of midline – A power burr used to remove few mm of cephalad lamina & 2 to 3mm of medial aspect of inferior facet – release Ligamentum flavum – With Kerrison rongeur 2 to 3mm of medial aspect of superior facet removed – Decompress the lateral recess stenosis to the level of pedicle – exposure of lateral disc space – Nerve root, ligamentum flavum, epidural fat are retracted towards midline – cauterize the bleeding epidural veins over the herniated disc –Herniated disc removed – Disc space irrigated with a catheter – The pituitary forceps used to remove the remaining loose fragments – spinal canal palpated for any residual disc fragments - Bleeding controlled – Wound closed in layers.

ADVANTAGES OF MICRODISCECTOMY

Allows more magnification & illumination Surgery done through a small incision Decreased tissue trauma Less blood loss Shorter hospital stay Quick recovery

DISADVANTAGES OF MICRODISCECTOMY

Increased incidence of missed pathologic changes ( eg: Lateral recess stenosis, recurrent disc herniations)

Increased rate of infection Limited field of vision with a small incision

MICROENDOSCOPIC DISCECTOMY

It blends percutaneous procedures and the best of microdiscectomy It allows for a minimum of tissue injury while optimizing the visualization. The 1.5cm incision disrupts minimal muscle. Direct observation of the nerve root maximizes the success of the procedure. The surgical outcomes in terms of pain relief similar to Microdiscectomy. Return to activites and work is accelerated due to less tissue trauma. Improvement in outcome is found by lessening scar tissue (epidural fibrosis) and by enhanced

visualization of the nerve root compression.

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PERCUTANEOUS DISCECTOMY To avoid the problem due to open disc excision an new technique was developed, PERCUTANEOUS DISCECTOMY. It can be done manually or by suction or laser or under arthroscopic guidanceCandidate for percutaneous discectomy should meet the following criteria:

Contained disc herniation Major complaint of unilateral leg pain more than back pain Positive SLRT Specific neurological deficit Failure of conservative measures

CONTRAINDICATIONS OF PERCUTANEOUS DISCECTOMY Sequestrated disc Previous lumbar spine surgery

POSITION: Prone / Lateral decubitusTECHNIQUEMANUAL With image intensification under local anaesthesia, Cannula is introduced into affected disc space through posterolateral approach after adequate visualization of cannular placement within the disc. Through this cannula, elongated rongeurs were introduced and manually disc material were removed thus decompress the affected nerve root.

PERCUTANEOUS LASER DISCECTOMY

Here ablative laser energy delivered through an optical fiber to the interior of the disc space.The disc material removed by vaporization. The volume of disc material removal depends on the wavelength of laser energy and the amount of energy utilized. A variety of laser are utilized like carbondioxide, Holmium: Yttrium-aluminium-garnet (YAG), neodymium:YAG, argon.

PERCUTANEOUS ARTHROSCOPIC DISCECTOMY

In this technique, the spinal nerve root and offending disc material can be visualized directly and free fragments of extruded disc material can be removed. Thus subannular and sequestrated disc can be removed.

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SUCTION DISCECTOMY It is also known as AUTOMATED PERCUTANEOUS DISCECTOMY. Here similar to manual method, instead of elongated rongeurs, a thin 2mm cutting aspiration probe that connected to a negative pressure of 600mmhg. The device morselizes the nucleus and carries it away in saline irrigant.

COMPLICATIONS OF PERCUTANEOUS DISCECTOMY

Discitis, Psoas hematoma, Vasovagal reaction. Neurological and vascular injury are uncommon.

ARTIFICIAL DISC

The implant is designed to bear the load through the spine at that level and prevent further collapse of the affected vertebral segments thus protect the remaining disc.

Patient not suitable for artificial disc replacement are

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

The estimated life span of an artificial disc prosthesis is over 80years.

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.

TECHNIQUE: Patient awake and under a local anaesthesia with mild sedation, a special wire known as Electrothermal catheter is inserted into the disc – Electrical current passed through the wire – Heating of the disc theoretically modify the collagen fibres of the disc - Destroy the pain receptors in the area of disc

SPECIAL SITUATION WITH LUMBAR DISC PROLAPSE

LUMBAR DISC PROLAPSE with Spondylolisthesis

Patients with a spondylolisthesis may suffer from a disc rupture, which causes an acute radicular syndrome. Most of these will occur at the level above the spondylolisthesis. A disc herniation at the same level of the slip usually occurs into the foramen. For the disc herniation above the slip level, simple disc excision or chemonucleolysis. For the disc herniation at the slip level, discectomy should be accompanied by a stabilization procedure.

LUMBAR DISC PROLAPSE in Spinal Stenosis

Spinal stenosis can occur in the central canal or lateral zones. It can be an asymptomatic or a mildly symptomatic condition that can suddenly convert to a significant disability when a disc herniation occurs. The presenting symptoms will be mainly leg. Simple microscopic removal of the disc herniation along with a local decompression of the stenotic segment is the proposed method of treatment. If, on

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history, the stenotic component was significantly symptomatic before the occurrence of the HNP, a wider decompression is needed to treat both the stenosis and the HNP.

LUMBAR DISC PROLAPSE in Instability

Patients with a long history of back pain and significant DDD revealed on plain radiograph may suffer from a disc herniation at the degenerative level. If the disc degeneration and HNP are confined to one level, consider fusion. If the disc degeneration is present at multiple levels, either on plain radiograph, discography, or MRI, simple disc excision is the best choice.

LUMBAR DISC PROLAPSE in the Adolescent Patient

The younger patient with a disc herniation is a special problem. Because of the high incidence of protrusions rather than disc extrusions, it is proposed that in this age group the optimal treatment is chemonucleolysis rather than surgical intervention.

Recurrent LUMBAR DISC PROLAPSE (After Discectomy)Reherniation of discal material occurs in approximately 2% to 5% of patients. The recurrence may occur at any interval after surgery (days to years) and is most often at the same level/same side. If the recurrence is at the same level/opposite side or another level, it can be considered a virgin HNP. But, most recurrences are same level/same side, and scar tissue from the previous surgery introduces a whole new element to diagnosis and treatment.

REFERENCES

1. MACNAB’S BACKACHE by David A.Wong 4th edition2. THE LUMBAR SPINE by Sam W Wiesel 2nd edition3. MANAGING LOW BACK PAIN by W.H.Kirkildy – Willis 3rd edition4. ORTHOPAEDIC PHYSICAL ASSESSMENT by David Magee 5th edition5. ORTHOPAEDIC PRINCIPLE AND THEIR APPLICATION by TUREK 4TH Edition6. CAMPBELL’S OPERATIVE ORTHOPAEDICS 11TH EDITION7. INTERNET

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“LEARN TO BE GOOD TO YOUR BACK AND YOUR BACK WILL BE GOOD TO YOU….”