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1. INTERVERTEBRAL DISC
PROLAPSE
PRESENTER : DR. S.H. RANNA
PGT,ORTHOPAEDICS
MODERATOR : DR. P. TAHBILDAR
PROF.&HOD
ORTHOPAEDICS
28.10.2015

2. HISTORY
Aurelianus (5th century) 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.

3. CONT..
• Mixter and Barr (1934)
described disc herniation as
the cause of Sciatica.
 Lindblom(1948) first
described DISCOGRAPHY.
 Lyman Smith (1963)
described
CHEMONUCLEOLYSIS.
 Kambin & Gellman (1983)
reported percutaneous
approach for lumbar
discectomy.

4. ANATOMY OF LUMBAR SPINE

5. Cont..

6. INTERVERTEBRAL DISC

7. NUTRITION TO DISC

8. EFFECT OF AXIAL LOADING

9. FUNCTION OF DISC

10. DISC & NERVE ROOT RELATION
L5 is
TRAVERSING
NERVE ROOT
L5 is EXITING
NERVE ROOT

11. RELATION OF INTRADISCAL PRESSURE
AND POSTURE

12. CORRECT SLEEPING POSTURE

13. IN RELATION TO MANUAL MATERIALS
HANDLING

14. 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.

15. 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: Postero-lateral type.

16. ETIOLOGY

17. MICROTROUMA

18. 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

19. STAGES OF DISC DEGENERATION
Stage of dysfunction
Stage of instability
Stage of stabilization

20. STAGE OF DYSFUNCTION
Episode of
rotational or
compressive trauma
(uncoordinated
muscle contraction)
Posterior facet
joint & annular
strain
Small capsular &
annular tear
occurs
Small
subluxation of
posterior joint
Posterior joint
synovium injured
& result in
SYNOVITIS
Posterior segment
muscle protect joint by
sustained hypertonic
contraction
Muscle become
ischemic &
metabolites get
accumulated cause
pain
Muscle splints the
posterior joint
subluxation
&maintained

21. STAGE OF INSTABILITY
Increased
dysfunction
FACET
JOINT
Degenerati
on of
cartilage
Attenuation
of capsule
Laxity of
capsule
DISC Coalescenc
e of tears
Loss of nucleus
internal
disruption
Bulging of
annulus
INCREASED
ABNORMAL
MOVEMENT

22. STAGE OF STABILIZATION
FACET
JOINT
Destruction
of cartilage
Fibrosis in
joint
Enlargement
of facets
Locking
facets
Fibrosis
around joint
INCREASED
STIFFNESS
STABILIZ
ATION
Fibrosis in
disc &
osteophytes
Destructio
n of plates
Approximati
on of bodies
Loss of
nucleus
DISC

23. PATHOPHYSIOLOGY OF PIVD
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

24. CONT..
Nucleus is less able to bear & disburse load,
transferring load to the posterior annulus
ANNULU
S IN TACT
Facet joints
share even more
of the axial load
ANNULU
S FAIL
Facet joints undergo
degenerative changes &
develop osteophytes
FACET JOINT
SYNDROME

25. CONT…
ANNULUS FAIL
Fissures develop across
annular lamellae may
extend upto disc periphery
Internal disc
disruption cause
AXIAL PAIN
Expression of this degraded
nuclear material through
these radial fissures
DISC
HARNIATION

26. FATE OF DISC HARNIATION
Extrude disc & degraded nuclear material impinge
on the nerve roots
Nucleus pulposus is an immunogenic which induces
an inflammatory response mediated by TNF alpha, IL,
Phospholipase A2, Nitric oxide.
Produces radicular pain syndrome &
RADICULOPATHY

28. AXIAL LOCATION
• Central
(R/L)
• Subarticular
(R/L)
• Foraminal
(R/L)
• Extra
foraminal
(R/L)

29. SAGITAL LOCATION
• DISCAL.
• PEDICULA
—R.
• SUPRAPED
-ICULAR.
• INFRAPEDI
-CULAR.

30. CLINICAL FEATURE
Level of
prolapsed
T12-L1 L1—L2 L2—L3 L3—L4 L4—L5 L5—S1
Nerve
root
compres
sed
L1 L2 L3 L4 L5 S1
pain Thorac
o
lumbar
junctio
n,
groin,
proxim
al part
of thigh
Thorac
o
lumbar
junctio
n,
groin,
proxim
al part
of thigh
Upper
lumbar
spine,
anterio
r
aspect
of
proxim
al thigh
Lower
back,
hip,
postero
lateral
thigh,
anterio
r leg
Sacroili
ac joint,
hip,
lateral
thigh &
lateral
leg
Sacroiliac
joint, hip,
postero
lateral
thigh &
postero
lateral
leg to
heel

31. Cont..
Level of
prolapsed
T12-L1 L1-L2 L2-L3 L3-L4 L4-L5 L5-S1
Nerve
root
compress
ed
L1 L2 L3 L4 L5 S1
Paresthesi
a/Sensory
loss
Oblique
band
proximal
3rd of
thigh
anteriorly
just below
inguinal
lig.
Oblique
band mid
3rd of
thigh
anteriorly
Oblique
band
lower part
of thigh
anteriorly
just above
the knee
Medial to
shin of
tibia,
medial
aspect of
the foot
Lateral
leg,
dorsum of
foot, 1st
web space
Posterior
aspect of
thigh,
back of
calf,
lateral
side and
sole of
foot

32. C0NT…
Level of
prolapsed
T12-
L1
L1-L2 L2-L3 L3-L4 L4-L5 L5-S1
Nerve root
compresse
d
L1 L2 L3 L4 L5 S1
reflexes Knee jerk
slightly
diminishe
d
Knee jerk
slightly
diminishe
d
Knee jerk
diminishe
d or
absent
Changes
uncommo
n
(Posterior
tibial
reflex
diminishe
d or
absent.
Ankle jerk
absent or
diminishe
d

33. CONT..
STAGE OF
DEGENERATIVE
DISEASE OF DISC
STAGE OF
DYSFUNCTION
STAGE OF
INSTABILITY
STAGE OF
STABILIZATION
SYMPTOMS Low back pain often
localized or referred
to groin/ greater
trochanter/
posterior thigh
- Aggravated on
movement
- Relieved on rest
Catch in back on
movement.
- Pain on coming to
standing position
after flexion.
Low back pain
decrease in severity
SIGNS Local tenderness on
one side & at one
level
-Hypo mobility
- Extension painful
- Neurological
examination normal
Abnormal
movement of spine
- Observation of
catch
Sway or shift when
coming erect after
flexion.
Muscle tenderness
- Stiffness
- Reduced
movements
- Scoliosis

34. PHYSICAL EXAMINATION
• ATTITUDE: The lumbar
spine is flattened and
slightly flexed, hip
and knee slightly
flexed on the
affected side and hip
rotates forward to
relax Piriformis

35. GAIT
• Slow and
deliberate walk
holding their
loins with the
hands.
• TIP-TOE WALK
due to not able
to put the heel to
the floor.

36. SIATIC SCOLIOSIS
• Deviation of spine to one side
to take the nerve away from
the prolapsed disc is called
SCIATIC SCOLIOSIS which
becomes more obvious on
bending forwards.
• Trunk deviated to opposite
side – SHOULDER TYPE
(lateral)
• Trunk deviated to same side –
AXILLARY TYPE (medial)

37. CONT..

38. CLINICAL EXAMINATION
• SLRT– positive < 40 degree.
• Cross SLRT – May or may not +ve.

39. LASEGUE SIGN

40. BOWSTRING TEST

41. FEMORAL NERVE STRETCH TEST

42. FLIP TEST
NEGATIVE POSITIVE

43. DIFFERENTIAL DIAGNOSIS
INTRASPINAL CAUSES
Proximal to 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

44. CONT..
EXTRASPINAL CAUSES
Pelvis
• 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)

45. KEY DIAGNOSTIC POINTS
LUMBAR DISC 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

46. CONT..
SPINAL STENOSIS
Back and/or leg pain develops after walks a
limited distance.
Flexion relieves symptoms
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

47. INVESTIGATIONS
•THE CORNERSTONE OF
DIAGNOSIS OF LUMBAR
DISC DISEASE IS THE
HISTORY AND PHYSICAL
EXAMINATION NOT THE
INVESTIGTION.

48. PLAIN RADIOGRAPHY
• Narrowing of disc space
• Osteophytes formation
along the peripheries of
the adjacent vertebral
bodies
• Sclerosis or condensation
of subchondral bone of the
adjacent vertebral bodies
above and below the
affected disc
• Loss of lumbar lordosis
• Translation of vertebral
bodies.

49. MYELOGRAPHY

50. CT SCAN
• ADVANTAGES
• highly accurate & noninvasive tool.
• superior imaging of cortical and trabecular bone.
• identify root compressive lesions such as disc
herniation.
• differentiate between bony osteophyte from soft
disc.
• to diagnose foraminal encroachment of disc
material

51. LIMITATION OF CT SCAN
• It cannot differentiate
between scar tissue
and new disc
herniation
• It does not have
sufficient soft tissue
resolution to allow
differentiation
between annulus and
nucleus.

52. MRI OF SPINE
• It allows direct
visualization of
herniated disc
material and its
relationship to
neural tissue
including
intrathecal
contents.

53. CONT..

54. TREATMENT
•CONSERVATIVE
•SURGICAL

55. CONSERVATIVE
• Majority of disc prolapse
respond well to conservative
therapy. Resolution of first
disc prolapse takes place
approximately 95% of patients
over a period of 3 months.

56. BED REST

57. DRUGS
• NSAIDS
• SOME MUSCLE RELAXANTS
• MOOD ELEVATORS & ANTI ANXIETY
DRUGS
• ETC…

58. PHYSIOTHERAPY
• TENS &IFT THERAPY

59. CONT..
EXTENSION CONTROL
KNEE ROLLS

60. Surgical treatment
GOAL-
To relive neural compression .
and hence radiculopathy
while minimizing
complications.

61. INDICATIONS
ABSOLUTE
• Bladder and bowel 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

62. 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

63. SOME OPERATIONS..
• HEMI OR PARTIAL LAMINECTOMY
• FENESTRATION
• TOTAL LAMINECTOMY
• LAMINOTOMY & DISCECTOMY

64. 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

65. THANK YOU…