HERNIA NUCLEUS

PULPOSUS

BOBBY FAHMI MULDAN PAHLEVI

20174011007
h
.
• Is a hydrostatic, load
bearing structure
between the vertebral
bodies from C2-3 to
L5-S1 .
• Nucleus pulposus +
annulus fibrosus
• Is relatively avascular.
• L4-5, largest avascular
structure in the body.
Vital Functions of the IVD

• Restricted intervertebral joint motion

• Contribution to stability
• Resistence to axial, rotational, and bendingload
• Preservation of anatomic relationship

The Biochemical Composition

• Water : 65 ~ 90% wet wt.

• Collagen : 15 ~ 65% dry wt.
• Proteoglycan : 10 ~ 60% dry wt.
• Other matrix protein : 15 ~ 45% drywt.
Distribution of load in the
intervertebral disc.
(A)In the normal, healthy disc,
the nucleus distributes the load
equally throughout the anulus.
(B)As the disc undergoes
degeneration, the nucleusloses
some of its cushioning ability
and transmits the load
unequally to the anulus.
(C)In the severely degenerated
disc, the nucleus has lost all of
its ability to cushion the load,
which can lead to disc
herniation
 Is a medical condition affecting the spinedue
to trauma, lifting injuries, or idiopathic, in which a tear in the
outer, fibrous ring (annulus fibrosus) of an intervertebral
disc allows the soft, central portion (nucleus pulposus) to bulge
out beyond the damaged outer rings.
 This tear in the disc ring may result in the release of inflammatory
chemical mediators which may directly cause severe pain, even in
the absence of nerve root compression.
 Disc herniations are normally a further development of a
previously existing disc "protrusion", a condition in which the
outermost layers of the annulus fibrosus are still intact, but can
bulge when the disc is under pressure.
 Degeneration
 Lossof fluid in nucleuspulposus
 Protrusion
 Bulge in the disc but not a
completerupture
 Prolapse
 Nucleus forced into outermost
layer ofannulus fibrosus- not a
complete rupture
 Extrusion
 Asmall hole in annulus fibrosus
and fluid moves into epidural
space
 Sequestration
 Disc fragments start to form
outside of the disc area.
 Cellular and Biochemical Changes of the
Intervertebral Disc

 Decrease proteoglycan
content.
 Loss of negative charged
proteoglycan side chain.
 Water loss within the
nucleus pulposus.
 Decrease hydrostatic
property.
 Loss of disc height.
 Uneven stress
distribution on the
annulus.
CAUSES
 Repetitive mechanical activities – Frequent bending,
twisting, lifting, and other similar activities without breaks
and proper stretching can leave the discsdamaged.
 Living a sedentary lifestyle – Individuals who rarely if ever
engage in physical activity are more prone to herniated
discs because the muscles that support the back and neck
weaken, which increases strain on the spine.
 Traumatic injury to lumbar discs-
commonly occurs when lifting while bent at thewaist,
rather than lifting with the legs while the back is
straight.
CAUSES

 Obesity – Spinal degeneration can be quickened as a

result of the burden of supporting excess body fat.
 Practicing poor posture – Improper spinal alignmentwhile
sitting, standing, or lying down strains the back and neck.
 Tobacco abuse – The chemicals commonly found in
cigarettes can interfere with the disc’s ability to absorb
nutrients, which results in the weakening of the disc.
 Mutation- in genes coding forproteins involved in the
regulation ofthe extracellular matrix, such
as MMP2 and THBS2, has been demonstrated to
contribute to lumbar discherniation.
 EPIDEMIOLOGI

• 1-2 % Population
• The most frequent ages are 30-50 years
• 80 % cases herniation is in L4-L5
Normal Disc herniated Disc
Pathophysiology
 History Taking

1. History of illness
2. Mechanism of injury
3. Associated symptoms : Bowel function, fever, sleep
disturbance, numbness
4. Social history
5. Pain specific : location, quality, duration, onset,
severity. Frequency (constant vs intermittent), time of
day (if nocturnal, consider malignancy)
Range of motion examination
• Laseque sign
• Cross laseque sign
• Kernig sign
 Additional Examination
1. Radiology
MRI is golden standard of diagnosis for HNP, radiology
indication : no improvements after 6 weeks, other
worrisome findings
 Management

Non operative
operative
Non Operative
 Passive medical theraphy
• Warm / cold compress
This warm / cold compress is an
easy-to-do modality. To reduce
muscle spasm and inflammation.
Some patients feel pain lost on
warm compression, while others
on cold compressing.

• TENS (Transcutaneous
Electrical Nerve Stimulator)
Uses electrical stimulation to
reduce the sensation of lower
back pain by disturbing the pain
impulses transmitted to the brain
• Ultrasound
Ultrasound is a form of
warming in the inner layer
by using sound waves on
the skin that penetrate
until soft tissue
underneath. Ultrasound is
especially useful in
relieving acute pain
attacks and can promote
tissue healing
 Operative

If we found these red flags, we must consider operation

• Significant trauma history or minor in older adults
• Nocturnal pain in supine position with history of
cancer
• Bladder or bowel incontinence or dysfunction
• Constitutional symptomp (fever, weight loss,lymph
node enlargment)
 Differential Diagnosis

• Spondylolisthesis
Spondylolisthesis is a condition of the
spine in which one of the vertebrae is
foreheaded from one vertebra to the other
referred to as an anterolisthesis and a
slip-off is referred to as a retrolisthesis

• Spondylosis
In spondylosis there is degeneration of the
intervertebral discs where bone and
ligament are repeated depletion due to
continuous use, resulting in narrowing of
the disc space and the occurrence of
osteophytes, generally degenerative or
arising from continuous microtrauma
Complications
Cauda equina syndrome

Chronic pain

Peminant nerve injury

Paralysis
 Prognosis

Operative
At 1 year : 90 % good outcome with surgery compared
to 60% with non surgery
At 4 years: surgery is slightly better
At 10 years : same for both group
 DAFTAR PUSTAKA

• Ginting, NB. 2010. Karakteristik Penderita Nyeri Punggung Bawah (NPB).Available from, URL
:http://respiratory.usu.ac.id/bitstream/123456789/30756/4/chapterII.pdf.Diakses pada tanggal
1 Juli 2018

• Mansjoer, Arif. 2014.Kapita Selekta Kedokteran Jilid 2 Edisi Ketiga. Jakarta :Media
Aesculapius.

• Sidharta, Priguna. Sakit Neuromuskuloskeletal Dalam Praktek Umum. Jakarta : PTDian

Rakyat. 182-212

• Martini, Frederic H; Nath, Judi L. 2009. Fundamentals of Anatomy and Physiology Eight
Edition. San Fransisco : Pearson International Education.