Lumbar disc extrusion_ an observational study

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Presentation Description

conservative management of extruded disc. Fate of extruded disc, absorption, regression, recurrence, relationship of size and neurodeficit,

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Presentation Transcript

Inferences:

Inferences Extruded disc – disappears completely. Extruded fragment – complete absorption. Extruded disc – reduce in size. Extruded disc – can recur at same level, same side or other side. Extrusion of disc – can occur at other site.

Inferences:

Inferences Extrusion of disc – genetic predisposing. Extrusion of disc – more with multiple level disc bulges. Extruded disc – may not reduce in size. Extruded disc – mostly with single root radiculopathy . Extrusion of disc – usually acute onset – last for few hours and pain decreases with some neurological deficit with in 24 hours.

Inferences:

Inferences Contended disc remains same for long time. There is no co-relation between size of prolapse /extrusion with amount of pain or neurological deficit. Foraminal disc – protrusion/extrusion causes severe pain and compressive radiculopathy . Neurological status never deteriorate after initial insult(damage at the time of extrusion)

Inferences:

Inferences EHL – improve to gr 3- 5 power depends on initial damage. Ankle jerk – do not come back Functional recovery – complete Back pain – remain Patients own assessment – Happy Extrusion – may be considered as final stage in disc pathology.

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Case summary - 1

Comments:

Comments First attack in 2007 – with a large disc protrusion with EHL weakness. Improved clinically Recurrence in Feb 2011 without any deficit. Finally – disc extrusion occur in Sept 2011 without any deficit. Off duty for a month in Feb 2011 and another month in Sept 2011. Last follow up – Sept 2012 - Happy

Asraf Beg – case summary :

Asraf Beg – case summary 40 yr, M, short statured, obase DM + HT Acute PID L4 – L5 rt <1wk Nil neurology at admision MRI – Nov 2010 extruded disc Tx - Conservative Develop ankle jerk loss and EHL gr2 in one wk Follow up MRI – Feb 2011 Last follow up – Sept 2012 Case summary - 2

comments:

comments Patient was attended in acute attack. He had disc extrusion at L5 – S1 with proximal migration. He developed EHL – drop along with ankle jerk loss. His EHL still Gr 4 and ankle jerk absent. Follow up MRI in Feb 2011 showed near complete absorption.

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Case summary - 3

comments:

comments Six years follow up. Marginal reduction in size. No neurological deficit. Persisting with backache.

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Case summary - 4

comments:

comments Three years follow up First follow up MRI showed reduction in size and absorption a large piece of extruded disc in three months time. Recurrence of back pain and further extrusion at same level in Jan 2011. Some reduction in size in April 2011. Recurrence can occur at the same level.

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Complete absorption in three months Case summary - 5

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Reduction in size of disc with complete recovery in clinical symptoms Case summary - Case summary - 6

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Reduction in size of disc with complete recovery in clinical symptoms Case summary - 7

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Gr 4 EHL after 2 years with occasional backache Case summary - 8

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Persistence of same size, backache, no new deficit since 2004 Case summary - 9

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Oct 2004

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Oct 2004

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Dec 2008

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Dec 2008

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Oct 2010

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Oct 2010

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Oct 2010

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Significant decrease in the size of the disc Case summary - 10

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No changes in 3 years Case summary - 11

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Sept 2007

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Sept 2007

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May 2010

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May 2010

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No relationship between size of disc and functions Case summary - 12

Comments:

Comments In spite of huge disc size, there is no neurological deficit. There is limited straight leg raising on left side after 2 months of acute attack. Patient can still stand on his left toes indicating the power in the Gastrosoleus muscles.

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Yet another example of relationship of size of disc and clinical status Case summary - 13

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Contended disc – No appreciable changes in 7 years Case summary - 14

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Complete absorption Case summary - 15

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Case summary - 16

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July 2008

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July 2008

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Nov 2011

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Nov 2011

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Nov 2011

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Nov 2011

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May 2012

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May 2012

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May 2012

comments:

comments Initial MRI just had a contended disc at L5 – S1 in 2008. Recurrence with multiple level disc in Nov – 2011. No neurological deficit. Recurrence in May 2012 with extrusion of L5 – S1 disc and quadaequina with temporary loss of bladder control. Prompt surgery with removal of loose piece from L5 – S1 space and discoidectomy at L4 – L5 relieved her. Improving neurological status at last follow up Sept 2012.

Gourav Kapoor:

Gourav Kapoor 26/M Acute on chronic PID L4 – L5 rt. EHL – N Ankle jerk – N MRI – Feb. – 2005 contended disc Tx – conservative Recurrence in July 2007 EHL – weak Ankle jerk - N MRI – extruded disc at L4 – L5 Tx – conservative Last follow up – Sept 2012 - improved Case summary - 17

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Complete absorption Case summary - 18

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Marked reduction in size Case summary - 19

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Marked reduction in size Case summary - 20

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May 2012

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May 2012

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Aug 2012

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Aug 2012

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Aug 2012

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30/8/2012 5/5/2012

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Complete recovery Case summary - 21

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Sept 2004

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Sept 2004

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Sept 2004

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Gradual absorption in process Case summary - 22

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Complete absorption Case summary - 23

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Marked reduction in size Case summary - 25

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Complete regression Case summary - 27

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Marked regression Case summary - 29

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Nov 2011

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Nov 2011

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Dec 2011

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Dec 2011

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April 2012

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April 2012

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April 2012

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April 2012

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Case summary - 31

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Aug 2008

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Dec 2008

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Dec 2008

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Case summary - 32

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July 2008

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July 2008

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July 2009

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July 2009

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July 2009

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Regression in size Case summary - 33

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Marked reduction in size Case summary - 36

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Multiple discs, extrusion , complete regression Case summary - 37

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March 2008

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March 2008

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Case summary - 40

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March 2010

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March 2010

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Nov 2010

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Nov 2012

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Case summary - 41

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May 2007

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May 2007

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June 2011

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Case summary - 44

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Aug 2009

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Aug 2009

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Jan 2010 Jan 2010

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Jan 2010

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Complete regression Case summary - 46

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Absorption of loose piece within one month Case summary - 47

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Case summary - 49

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Case summary - 50

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Case summary - 51

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Case summary - 52

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Case summary - 53

Santosh Neema:

Santosh Neema 42/M Acute PID L4 – L5 lt >1wk EHL – weak Ankle jerk – N MRI –Dec 2004 extruded disc Tx – conservative Follow up MRI – May 2005 Last follow up Case summary - 54

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Dec 2004

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Dec 2004

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May 2005

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May 2005

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Regression of extrusion Case summary - 55

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Case summary - 56

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Case summary - 57

Suresh Neema:

Suresh Neema 60/M Acute PID rt L4 – L5>2wks EHL – weak Ankle jerk – N MRI – Feb 2009 Tx – Conservative Follow up MRI – June 2010 Recurrence No neurological deficit MRI – Aug 2012 – extrusion at L2 – L3 Case summary - 58

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Sept 2012, Tx – Conservative +epidural Case summary - 59

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No change in size , clinically OK Case summary - 60

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March 2002

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March 2002

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May 2007

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May 2007

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Case summary - 61

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Case summary - 63

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Case summary - Case summary - 64

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Total regression Case summary - 65

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Total regression of loose piece Case summary -66

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Total regression Case summary - 67

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Case summary - 68

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Case summary - 69

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Marked regression in size Case summary - 70

Purpose of presentation:

Purpose of presentation Conservative treatment is well accepted method of treatment of PID. There is no need to frighten the patient for possible hypothetical complications. In our experience, a mono radiculopathy never deteriorates to poly neuropathy. Poly neuropathy is a separate incident in the cases of pre-existing disc pathology.

References – same authors :

References – same authors http://www.slideshare.net/naneria/t1-t2-extruded-disc-case-report-14076043 http://www.slideshare.net/naneria/lumbar-disk-update-presentation http://www.slideshare.net/naneria/free-fragments-lumbar-spine-148466 http://www.slideshare.net/orthonet/lumbar-disc-herniation-naneria-part-1 http://www.slideshare.net/orthonet/lumbar-disc-herniation-naneria-part-2 http://www.authorstream.com/Presentation/naneria-23060-Free-fragments-lumbar-canal-LumbarCanal-fragment-Literature-Migration-Composition-extruded-materia-Education-ppt-powerpoint/

Disclaimer :

Disclaimer All photographs were taken with the consent of the all patients. Clinical photos were also put with due verbal permission. This presentation strictly for students of orthopedics with the sole idea of propogating knowledge. Any objection as for photographs or x-rays, please inform naneria@yahoo.com for prompt deletion. Material collected from C.H.& R.C., Indore and from private clinics of the authors.

DISCLAIMER :

DISCLAIMER Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 25 years. It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal opinion. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. For any correction or suggestion please contact naneria@yahoo.com

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