Pathology of Intervertebral Disc

Injury
Annular Injury
Annular rings
Softened
Overstretched
Torn

Normal viscoelasticity is exceeded

Cannot stabilize or limit motion
Nucleus pulposus exerts pressure on weak
part
Buckling occurs - Disc Bulge

Pathology of Intervertebral Disc

Injury
Extrusion
Fragmentation of
nucleus pulposus
Nuclear material
dissects its way
through breaches in
annulus fibrosus

Pathology of Intervertebral Disc

Injury
Prolapses
Fissures provide
pathway for irritating
nuclear fluid to
escape onto
perineural tissue *
Persistent and
chronic back pain

* - Hampton et al

Prolapsed Intervertebral Disc (PID)

Clinical features
Any age, but commonly in fit adult of 20 -45
years
Sudden onset; while lifting ,felt severe back
pain
Then pain is felt in the buttock & lower limb.
Worst by coughing & straining
Paraesthesia in the leg;occasionally muscle
weakness.

Cauda Equina Syndrome:

Rare
Sudden, partial or complete loss of voluntary bladder
function
due to massive disc impingement on spinal nerves
Can include loss of sensation ( saddle anaesthesiaS3,4),& anal sphincter control

Treatment:
Urgent decompression is mandatory for prevention of
irreparable / irreversible bladder damage
12 hours is the maximum time prior to irreversible
changes

Prolapsed Intervertebral Disc (PID)

Clinical features

o/e- scoliosis +
Tenderness at affected site
Paravertebral muscle spasm
ROM is reduced
SLR positive on affected site
Bowstringing S/- (+)ve.
Cross sciatic tension +ve.
With high or mid-lumbar prolapse, femoral stretch test
+ve

Prolapsed Intervertebral Disc (PID)

Clinical features
CNS- power
L5=weak knee flexion & extension of EHL
S1=weak FHL, planter flexion & eversion of foot

Sensory
Loss on outerside of leg & dorsum of foot.
Loss on lateral border of foot
Reflex- L5= quadriceps reflex seem to increased
because of weak hamstrings
S1= depressed ankle jerk

Prolapsed Intervertebral Disc (PID)

Diagnosis
X-ray- to exclude bone disease.
Late cases may show narrowed disc space &
osteophytes

CT& MRI
Very useful for diagnosis.

Prolapsed Intervertebral Disc (PID)

Differential diagnosis
Infections- constitutional symptoms, severe
spasm, marked tenderness, raised ESR ,, Xray findings of bone destruction, joint space
narrowing
Ankylosing spondylitis- stiffness of all axial
skeleton, Typical x-ray finding of Bamboo
spine

Prolapsed Intervertebral Disc (PID)

Differential diagnosis
Vertebral tumours- severe continuous pain,
marked spasm, general illness, raised ESR,
bony destruction or sclerosis in X-ray.
Nerve tumours,eg neurofibroma of cauda
equina cause continuous pain. Ct & MRI
confirm the lesion.

Prolapsed Intervertebral Disc (PID)

Management

Rest
Reduction
Removal
Rehabilitation

Prolapsed Intervertebral Disc (PID)

Management
Rest
In bed with hip & knee in slight flexion.
NSAID

Reduction
Pelvic traction with 10kg x 2 weeks will reduce
herniation in 90%.
Epidural Depomedrol injection
Chemonucleolysis- harmful> effective

Prolapsed Intervertebral Disc (PID)

Management
Removal indication for operation.
Cauda equina syndrome not responding to traction
in 6to 12 hrs.(maximum)
Neurological deterioration while under conservative
Treatment
Persistant pain & S/ of cross sciatic tension after 6
wks of conservative treatment

 Physical therapy

electrical stimulation/TENS
Postural education / body mechanics
Massage / mobilization
Stretching / body work
Exercise / strengthening
Tract

Injections

Epidural blocks
Facet blocks
Trigger point
SI joint

 Surgery:

Laminectomy
Fusion
Discectomy
Percutaneous Lumbar Discectomy
Success rate variable 50 -85 %
Low rate of complications:
Infection
Peripheral nerve injury

Benefits:

Outpatient procedure
Minimal to no epidural scarring
No general anesthesia
Spine stability preservation
Decreased cost

Persistent post operative back pain & scitica

May be due to
1-residual disc material in spinal canal
2- disc prolapsed in another level
3-nerve root pressure by hypertrophic facet
joint
4-narrow lateral recess due to fibrosis

Spondylolysis
Spondylolisthesis