Downloaded 1,983 times
Uploaded byAnand Dev
Lumbar disc prolapse
The document discusses the history and anatomy of lumbar disc disease. Key points include: 1) Aurelianus in the 5th century described symptoms of sciatica and Andreas Vesalius in 1543 first described the intervertebral disc. 2) Mixter and Barr in 1934 described disc herniation as the cause of sciatica. 3) The lumbar spine has intervertebral discs that can prolapse and press on nerve roots, commonly occurring posterolaterally at L4-L5 and L5-S1 levels.
More Related Content
Similar to Lumbar disc prolapse
Lumbar disc prolapse
- 2. J.J.M MEDICAL COLLEGE DAVANGERE SEMINAR ON
- 3. HISTORY Aurelianus (5thcentury) clearly described the symptoms of SCIATICA. Andreas Vesalius (1543) first described the intervertebral disc. 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.
- 4. Stookey (1928)described cartilaginous compression thought as chondromas responsible for clinical prersentation. Dandy (1929) reported removal of a disc tumour or chondroma from patients with sciatica. Mixter and Barr (1934) described disc herniation as the cause of Sciatica.
- 5. 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.
- 6.
- 7. ANATOMY OF LUMBARSPINE
- 9.
- 11.
- 12.
- 13.
- 15. LIGAMENTS OF LUMBARSPINE
- 16. MOTION SEGMENT ANTERIOR POSTERIOR ELEMENT ELEMENT
- 17. DISC & NERVEROOT RELATION L5 is TRAVERSING NERVE ROOT L5 is EXITING NERVE ROOT
- 18. EFFECT OF AXIALLOADING
- 19.
- 20. RELATION OF INTRADISCAL PRESSURE AND POSTURE
- 21. IN RELATION TOPOSTURE
- 22.
- 23. IN RELATION TOMANUAL MATERIALS HANDLING
- 24. LUMBAR DISC PROLAPSE 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.
- 25. 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: Posterolateral type
- 26. WHY DISC PROLAPSEIS MOST COMMON POSTEROLATERALLY?
- 27.
- 29. EFFECT OF SMOKING Blood vessel get constricted Transport of nutrients & disposal of waste products decreased Disc cells get deficient nutrition or die Disc degenerates & results in DISC INSTABILITY
- 30.
- 31. STAGES OF DISCDEGENERATION Stage of dysfunction Stage of instability Stage of stabilization
- 32. STAGE OF DYSFUNCTION Episode of rotational Posterior facet joint Small capsular & or compressive trauma & annular strain annular tear occurs Small subluxation of posterior joint Posterior joint SYNOVITIS Posterior segment muscle protect joint by sustained hypertonic contraction
- 33. STAGE OF INSTABILITY FACET Degeneration Laxity of JOINT of cartilage capsule INCREASED ABNORMAL MOVEMENT Loss of nucleus DISC Coalescence Bulging of internal of tears annulus disruption
- 34. STAGE OF STABILIZATION Destruction Fibrosis in FACET JOINT of cartilage joint INCREASED STIFFNESS DISC Loss of Fibrosis in disc nucleus & osteophytes STABILIZATION
- 35.
- 36. PATHOPHYSIOLOGY OF LUMBAR INTERVERTEBRALDISC PROLAPSE With aging, vascular channels start to fail and vascular diffusion of nutrients decrease thus number of viable chondrocytes in the nucleus pulposus diminishes 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
- 37. Facet joints undergo ANNULUS Facet joints share degenerative IN TACT even more of the changes & develop axial load osteophytes FACET JOINT SYNDROME
- 39.
- 40. Extruded disc & degraded nuclear material impinge on the nerve roots Nucleus pulposus is an immunogenic which induce an inflammatory response Produces radicular pain syndrome & RADICULOPATHY
- 41. STAGES OF DISCPROLAPSE
- 43.
- 44.
- 45.
- 46.
- 49.
- 50.
- 51.
- 52.
- 53.
- 54.
- 55.
- 56.
- 57.
- 58. CONTRALATERAL LEG RAISING TEST (FRAJERSZTAGN TEST)
- 59. WHY PAIN OCCURSON AFFECTED SIDE ON RAISING NORMAL LEG? AFFECTED SIDE NORMAL SIDE
- 60.
- 61.
- 62. FLIP TEST NEGATIVE POSITIVE
- 63.
- 64.
- 66. CAUDA EQUINA SYNDROME •Marked reduction in SLRT • Saddle anaesthesia • Bilateral ankle jerk depression • Involuntary overflow incontinence • Decreased tone in external sphincter
- 67. DIFFERENTIAL DIAGNOSIS INTRASPINAL CAUSES Proximalto 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
- 68. 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 Peripheral nerve lesions • Neuropathy (Diabetic, tumour, alcohol) • Local sciatic nerve conditions (Trauma, tumour) • Inflammation (herpes zoster)
- 69. KEY DIAGNOSTIC POINTS LUMBARDISC PROLAPSE Leg pain greater than back pain Neurological deficit present ANNULAR TEARS Back pain greater than leg pain Bilateral SLRT positive FACET JOINT ARTHROPATHY Localized tenderness present unilaterally over joint Pain occurs immediately on spinal extension Pain exacerbated with ipsilateral side bending
- 70. SPINAL STENOSIS Back and/or leg pain develops after walks a limited distance. Flexion relieves symptoms No neurological deficit Pain not reproduced on SLRT MYOGENIC OR MUSCLE RELATED Pain localised to affected muscle Pain increases on prolonged muscle use Pain reproduced with sustained muscle contraction against resistance Contralateral pain with side bending
- 71. INVESTIGATION THECORNERSTONE OF DIAGNOSIS OF LUMBAR DISC DISEASE IS THE HISTORY AND PHYSICAL EXAMINATION NOT THE INVESTIGTION.
- 72. PLAIN RADIOGRAPH OSTEOPHYTE DECREASED DISC SPACE
- 73. NORMAL RETROSPONDYLOLISTHESIS
- 74.
- 75. REDUCTION IN THE HEIGHT OF THE PEDICLE
- 76. FORWARD DISPLACEMEN T OF L3OVER L4
- 77.
- 78. DISADVANTAGE OF MYELOGRAPHY •Myelographyis 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 .
- 79.
- 80. USES OF DISCOGRAPHY •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
- 81. CT DISCOGRAPHY USES • Todetermine 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.
- 82. COMPUTED TOMOGRAPHY ADVANTAGES • CTis 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.
- 83. LIMITATIONS • It cannotdifferentiate between scar tissue and new disc herniation • It does not have sufficient soft tissue resolution to allow differentiation between annulus and nucleus.
- 84. MAGNETIC RESONANCE IMAGING •It allows direct visualization of herniated disc material and its relationship to neural tissue including intrathecal contents.
- 85. INDICATIONS FOR SPINEIMAGING • Presence ofunderlying systemic disease • Progressive neurological deficits • Cauda equine syndrome • Candidate for therapeutic intervention • Failed clinically directed conservative therapy
- 98. CONTRAST ENCHANCED 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.
- 99. OTHER DIAGNOSTIC TESTS •ELECTROMYOGRAPHY – to rule out peripheral neuropathy. • SOMATOSENSORY EVOKED POTENTIALS (SSEP) – to identify the level of root involvement • POSITRON EMISSION TOMOGRAPHY
- 100.
- 101. CONSERVATIVE 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.
- 102.
- 103.
- 104. EXERCISES GENERAL RULES FOREXERCISE • 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.
- 105. FOR ACUTE STAGE BRIDGINGEXERCISE KNEE HUGS
- 106. FOR RECOVERY ORSUBACUTE STAGE EXTENSION CONTROL HAMSTRING STRETCH KNEE ROLLS
- 108. YOGAASANAS TADASANA (Mountainpose) MARICHYASANA III BHARADVAJASANA (Marichi's Pose) (Bharadvaja's Twist)
- 109. VIRABHADRASANA II ARDHA URDHVA MUKHA (Warrior II Pose) SVANASANA (Half Upward-Facing Dog Pose) BALASANA (Child's Pose)
- 110. UTTHITA PARSVAKONASANA UTTHITA TRIKONASANA (Side Angle Pose) (Triangle Pose) SHAVASANNA (Corpse Pose)
- 111.
- 112.
- 113. CHEMONUCLEOLYSIS Chymopapain Degrades the Water holding injected into the proteoglycans in the capacity of the disc disc nucleus is decreased Shrinkage of the disc
- 114. CONTRAINDICATION FOR CHEMONUCLEOLYSIS • Sequestrated disc • Significant neurological deficit • Disc herniation with lateral stenosis • Cauda equine syndrome • Previous treatment with chymopapain • Spinal tumour • Recurrence of disc herniation • Spondylolisthesis • Pregnancy • Diabetic Neuropathy
- 115. SURGERY GOAL To relive neural compression and henceradiculopathy while minimizing complications.
- 116. INDICATIONS ABSOLUTE • Bladder andbowel involvement: The cauda equine syndrome • 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
- 117. CONTRAINDICATIONS FOR SURGERY • Wrong patient ( poor potency for recovery) • Wrong diagnosis • Wrong level • Painless HNP (do not operate for primary complaint of weakness or paresthesia, in the absence of pain) • Inexperienced surgeon applying poor technical skills • Lack of adequate instruments
- 118.
- 119. HEMI OR PARTIALLAMINECTOMY
- 120.
- 121.
- 122.
- 123. COMPLICATIONS OF LAMINECTOMY ANDDISCECTOMY • 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 equine lesions • Neurological damage or nerve root injury • Urinary retention and urinary tract infection
- 124. FAILED BACK SYNDROME It is a condition characterized by persistent postoperative backache and sciatica. VERY COMMON CAUSES • Recurrent/ Persistent disc material at operated site • Herniated Nucleus Pulposus at other site • Epidural scar / Fibrosis • Facet arthrosis / Spinal stenosis
- 125. COMMON CAUSES –Neuritis, Referred pain from nonspinous site UNCOMMON CAUSES • Discitis / Osteomyelitis/ Epidural abscess • Arachnoiditis • Conus tumour • Thoracic, High lumbar Herniated Nucleus Pulposus • Epidural haematoma
- 126. The recurrence ofpain after disc surgery should be treated with all available conservative treatment modalities initially. The surgery should be tailored to the anatomic problem only.
- 127.
- 128.
- 129. PERCUTANEOUS SUCTION DISCECTOMY
- 131.
- 132. PERCUTANEOUS LASER DISCECTOMY
- 133. LUMBAR ARTIFICIAL DISC REPLACEMENT
- 134. Patient not suitablefor artificial disc replacement are • Osteoporosis • Spondylolisthesis • Infection or tumour of spine • Spine deformities from trauma • Facet arthrosis
- 135.
- 138. 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.
- 139. PROGNOSIS • Extruded disc,Large herniations, Sequestrations have a greater tendency to resolution than small herniations& disc bulges. • Recurrence of disc prolapse can be prevented by a proper exercise programme and avoidance of stress to the lower part of back.
- 140. REFERENCES • MACNAB’S BACKACHEby DavidA.Wong 4th edition • THE LUMBAR SPINE by Sam W Wiesel 2nd edition • MANAGING LOW BACK PAIN by W.H.Kirkildy – Willis 3rd edition • ORTHOPAEDIC PHYSICAL ASSESSMENT by David Magee 5th edition • ORTHOPAEDIC PRINCIPLE AND THEIR APPLICATION by TUREK 4TH Edition • CAMPBELL’S OPERATIVE ORTHOPAEDICS 11TH EDITION • INTERNET
- 141. “LEARN TO BE GOOD TO YOUR BACK AND YOUR BACK WILL BE GOOD TO YOU….”