Prolapsed Intervertebral Disc

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Presentation Transcript

Slide 1: 

Dr. Aseem. N. Parekh Prof. and Head, Dept. of Orthopaedics B.Y.L.Nair Hospital

Slide 2: 

Lumbar Spine • Each lumbar vertebra is formed by a round block of bone, called a vertebral body, and a bony arch attached to the back of each vertebral body • The bony arch has two parts (a) two pedicle bones and two lamina bones • When the vertebrae are stacked on top of each other, they form a hollow tube that surrounds the spinal cord and nerves. The laminae provide a protective roof over these • The intervertebral disc sits between two adjacent vertebrae and is a cushion enclosed by thick a capsule

Lumbar Spine Disease : 

Lumbar Spine Disease 75-80% of all people have back pain at some time in their life Pain of Intervertebral disc orign includes disc herniation,internal disc disruption,DDD 5th most common cause of admission to the hospital

Degenerative Disc Disease: Herniation : 

Degenerative Disc Disease: Herniation Represents <2% of LBP More likely at L4-L5 and L5-S1 Increased risk if overweight Less common if <20 or >65 yrs

Slide 6: 

Lumbar Disc Degeneration • Due to natural loss of elasticity and / or injury over the years, the disc degenerates. The degenerated disc may herniate backwards into the spinal canal and press on a spinal nerve root • 90% occurs in either the L4-5 or L5-S1 region • Compression of the spinal nerves results in severe radiating pain or numbness or weakness of muscles • Severe compression can lead to permanent nerve damage

Spectrum of Pathological Changes in Facet Joints and Discs : 

Spectrum of Pathological Changes in Facet Joints and Discs Dysfunction Instability Stabilization   Modified from Kirkaldy-Willis WH, ed: Managing low back pain, New York, 1983, Churchill Livingstone.

Effects of discdegeneration• Healthy on top toseverely degenerateddiscs• Adams et al., 2002 : 

Effects of discdegeneration• Healthy on top toseverely degenerateddiscs• Adams et al., 2002

Clinical Presentation… : 

Clinical Presentation… A 30 y/o previously healthy male CC: “My back and leg hurts and it’s keeping me from working.” Onset 1 week ago; no inciting trauma recalled Pain is sharp and burning. Radiates to posterolateral leg (unilateral) Pain is worse with movements of back and sitting Gait is not affected

…Clinical Presentation : 

…Clinical Presentation Numbness and tingling along lateral leg, big toe and dorsum of foot after 30 seconds of sitting leg extension test Bladder/bowel fxn nml Lab tests? Differential Diagnosis?

Evaluation of Lumbar Spine Disease : 

Evaluation of Lumbar Spine Disease Patient History: Location of pain Duration of pain Character/quality of pain Weakness Numbness

Evaluation of Lumbar Spine Disease : 

Evaluation of Lumbar Spine Disease Physical Exam: Strength Sensation Reflexes Range of Motion Palpation

Evaluation of Lumbar Spine Disease : 

Evaluation of Lumbar Spine Disease Strength exam: L3 - iliopsoas muscle (hip flexion), adductor longus (hip adduction) L4 - quadriceps femoris (knee extension), tibialis anterior (dorsiflexion and inversion) L5 - gluteus medius/minimus (thigh abduction and medial rotation), extensor hallicus longus (big toe extension), peroneus longus and brevis (plantar flexion and eversion) S1 - gluteus maximus (thigh abduction), biceps femoris (hip extension), gastrocnemius (plantar flexion)

Lower Limb Dermatomes : 

Lower Limb Dermatomes

Evaluation of Lumbar Spine Disease : 

Evaluation of Lumbar Spine Disease Reflexes: L3 - iliopsoas reflex (meaningful?) L4 - knee jerk L5 - extensor hallicus reflex (meaningful?) S1 - ankle jerk Babinski - in adults, UMN lesion from motor strip to lower spinal cord

Evaluation of Lumbar Spine Disease : 

Evaluation of Lumbar Spine Disease Range of Motion: Straight leg raise - most sensitive for sciatic pain syndromes Pain in contralateral leg with straight leg raise is most specific for sciatic pain syndromes Lumbar flexion/extension (lumbar stenosis worse with extension, better with flexion)

Evaluation of Lumbar Spine Disease : 

Evaluation of Lumbar Spine Disease ROM to rule out other causes of back/leg pain: internal and external hip rotation Palpation over spine, SI joint, pelvis and hip

Evaluation of Lumbar Spine Disease : 

Evaluation of Lumbar Spine Disease Prior or current treatments including medication Smoking (smokers complain of more severe symptoms and have less improvement postsurgery) Obesity (carry more comorbidities) Diabetes (may need neurophysiology testing) Psychological factors: anxiety, depression, somatization symptoms, stressful responsibilities, job dissatisfaction, mental stress at work, negative body image.(prospective predictors of developing back pain) Activities that affect pain (e.g. leaning forward in spinal stenosis, sitting down, coughing, sneezing, Valsalva for herniated discs)

Differential Diagnosis : 

Differential Diagnosis Lumbar disc herniation: pain, paresthesias, weakness, depressed DTRs in an anatomic distribution (i.e. down lower extremity) Lumbar stenosis: diagnosis made mainly by history. neurogenic claudication

Differential Diagnosis.. : 

Differential Diagnosis.. Lumbar instability: pain with motion; improved with lying down; motion on flexion/extension x-rays indicates unstable motion segment; look for defects in neural arch (lamina, pedicle, pars interarticularis); 30% of patients with degenerative spondylolisthesis (subluxation) will have progressive slippage Compression fracture: acute to subacute onset of pain, pain to palpation; +/- history of trauma/cancer Musculoskeletal: pain with active but not passive motion; point tenderness over joint; +/- history of trauma

Approach : 

Approach Options when clinical suspicion of PID Observe (80-90% will resolve in <6 weeks) most common diagnosis of acute (i.e. <6 weeks) back pain = “lumbar strain” pathobiology may be any pain sensitive structure: muscle, tendon, ligaments, disc, facet joints, periosteum, meninges, blood vessels, or ‘degenerative changes’ Counsel the patient regarding the natural history . Educate the patient about the need to have a good posture and to avoid provocative activities

Imaging of Lumbar Spine Disease : 

Imaging of Lumbar Spine Disease If clinical suspicion high for intraspinal source of symptoms 1)Radiographs-loss of lordosis,scoliotic list,rarely reduced disc space can show infection, tumors, or other anomalies/pathologies. 2) MRI investigation of choice unless there is a contraindication (see next slide) Add contrast only if patient has had prior surgery or a history of cancer; perhaps with a demyelinating process like multiple sclerosis If not sure; order without contrast and radiology will pick up the ones that do need it

Imaging of Lumbar Spine Disease : 

Imaging of Lumbar Spine Disease 3) If there is a contraindication to MRI then CT myelogram (contraindications to MRI = heart stent < 2 weeks old, defibrillator, pacemaker, pain pump, spinal cord or deep brain stimulator, prior lumbar spine instrumentation, programmable shunt) If patient is too large for closed MRI then order open MRI CT is WAY OVERUTILIZED as a spine diagnostic test and delivers A LOT of radiation to the patient

MRI : 

MRI TIMING--Only indicated after 4-6 wks of conservative management(except when urgent surgery indicated) Confirms the clinical diagnosis; not the other way around Disc protrusion is found in 80% of asymptomatic people over age 60* Does not correlate with symptoms or severity Jensen, MC, Brant-Zawadzki, MN, Obuchowski, N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 1994; 331:69.

MRI.. : 

MRI.. Site, Side ,Size, Type, Associated findings Can be used for prognosis/counseling any Disc >6mm on MRI-patient has significant postoperative immediate relief. Disc<6mm –usually no immediate relief

Conservative Management : 

Conservative Management Even with radicular symptoms 70% will resolve within 4 weeks Bed rest for 2 Days (any longer does not improve outcome) NSAIDs, COX-2 inh, Walking to the point of pain Physio-Torso stabilizing,paraspinal Ms.,Abdominal Ms strenghthening Whitman, JM, Flynn, TW, Childs, JD, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine 2006; 31:2541. Faas A, Chavannes AW, van Eijk JT, Gubbels JW. A randomized, placebo-controlled trial of exercise therapy in patients with acute low back pain. Spine 1993;18:1388-95.

Slide 28: 

Ultrasound/Electrical Stimulation /Massage ??Bracing/Traction Correction of posture Osteopathic/chiropractic manipulations Oral steroids (e.g. prednisone or methylprednisolone) An epidural (cortisone) injection ??Ozone therapy

Surgical Management of Lumbar Disc Herniation : 

Surgical Management of Lumbar Disc Herniation

Indications for Surgery : 

Indications for Surgery Absolute Cauda Equina Syndrome Recent Onset, Severe and Progressive Motor Deficit Relative Failure of “adequate trial” of non operative treatment for radicular pain Severe intractable radicular pain Herniation into an already stenotic spinal or nerve root canal Significant motor deficits with positive nerve root tension signs Large extruded fragments Recurrent radicular pain after successful trial of non operative treatment The presence of a mild or moderate motor deficit does not necessarily affect the indication for operative or non operative treatment

Timing of Surgery : 

Timing of Surgery Cauda Equina Syndrome ASAP Relative Indications Lack of scientific evidence on optimal timing Rarely <6 weeks Period in which improvement in symptoms generally known to occur Should not be delayed beyond 6 weeks Chances of improvement in radicular pain are slight and decrease further with time

Available Surgical Interventions : 

Available Surgical Interventions Open Discectomy(Laminectomy,Hemilaminectomy,Fenestration) Microdiscectomy ?? Chymopapain chemonucleolysis Automated Percutaneous Nucleotomy Manual Percutaneous Discectomy Percutaneous Endoscopic Discectomy Endoscopic or Percutaneous Laser Discectomy ??Intradiscal Electrothermal Therapy

Complications of Surgery : 

Complications of Surgery Wrong Level 1.2 – 3.3 % Durotomy 0.8 – 7.2 % Nerve Root injury 0.2 % Infection 2 – 3 % Recurrent Herniations 2-12% Epidural Fibrosis Difficult to distinguish from recurrent herniation Contrast MRI investigation of choice No correlation between extent and symptoms No intervention or material shown to alter incidence Epidural Haematoma Cauda Equina Syndrome Iatrogenic Instability

Results of Surgery : 

Results of Surgery 85 – 95 % good to excellent short term results Long Term good to excellent results diminish to 55 – 70 % 10 – 18 % having required additional surgery Lower back pain usually the cause of dissatisfaction No difference between surgery or conservative Microdiscectomy Shorter hospital stay Faster return to sedentary work No difference c/w open discectomy after 8 –12 weeks No statistically significant difference in established motor deficit recovery after 3-4 months with or without surgery

Patient Factors Predicting Favourable Outcomes : 

Patient Factors Predicting Favourable Outcomes Absence of Lower Back Pain Radicular pain distribution with positive tension signs Compliance to post operative rehabilitation protocols Non work-related injury Higher socioeconomic status/Literate Minimal psychosocial stressors

Recurrent Disc Prolapse : 

Recurrent Disc Prolapse Defined as re-herniation at the same level after a pain free interval of 6 months or more(Suk et al) Up to 2-12 % of the cases. Presentation is recurrent sciatic pain Most common same level and same side,same level> opposite side same level Investigation-MRI Gd enhanced Fusion may have to be considered after first or second recurrent disc



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