PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc   AGRASEN HOSPITAL Gondia Vidarbha DR SANDEEP C AGRAWAL www.drsandeepagrawal.com www.agrasenortho.com

www.drsandeepagrawal.com AGRASEN HOSPITAL DR SANDEEP AGRAWAL GONDIA www.agrasenortho.com
PROLAPSE DISC (Slip Disc )
Herniation Intervertebral Disc 
 
Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
drsandeep123@gmail.com
Visit us at:
www.drsandeepagrawal.com
www,agrasenortho.com

DEFINITION
Outpouching of disc
Nucleus pulposus along with few
annular fibres and end plate
cartilage through tears in
annulus fibrosus into the
extradural space.

InterVertebral Disc

NUTRITION TO DISC

FUNCTION OF DISC

EFFECT OF AXIAL LOADING

Biochemical Change After Stress
• Matrix protein loss
• Loss of hydrostatic pressure
• Bulking of annular lamellae
• Annulus wall shear stress ↑, Tear
• Axial back pain & dysfunction

IN RELATION TO POSTURE

WHY DISC PROLAPSE IS MOST COMMON
POSTEROLATERALLY?

ETIOLOGY

PATHOPHYSIOLOGY OF LUMBAR INTERVERTEBRAL DISC
PROLAPSE 
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
!
Nucleus is less able to bear & disburse load,
transferring load to the posterior annulus

!
Extruded disc &
degraded nuclear
material impinge on
the nerve roots
Nucleus pulposus is an
immunogenic which
induce an
inflammatory response
Produces radicular
pain syndrome &
RADICULOPATHY

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

ANNULUS
IN TACT
!
Facet joints share
even more of the
axial load
!
Facet joints
undergo
degenerative
changes & develop
osteophytes
!
FACET JOINT
SYNDROME

STAGES OF DISC PROLAPSE

Herniation v.s Bulge
Contained disc :
Herniation disc
displacement of inner
disc material => annulus
fibrosus with focal
asymmetric outer
circumference
• Bulge : generalized
outpouch peripheral
margin of annulus without
focal displacement of
inner disc material
Herniation Bulge, Protrusion

Types of Disc Herniation (Contained)
Bulging Protrusion

Degree and location of disc
fragment displacement
• Noncontained
• Extrusion : remains in
continuity with inner
disc through annular
defect
• Sequestration : no
direct continuity with
inner disc

Types of Disc Herniation 
(Non-contained)
Extrusion Sequestered

AXIAL LOCATION

SAGITTAL SECTION

LIST (SCIATIC SCOLIOSIS)

RELATION OF INTRADISCAL PRESSURE
AND POSTURE

MOTION SEGMENT
ANTERIOR
ELEMENT
POSTERIOR
ELEMENT

DISC & NERVE ROOT RELATION
L5 is
TRAVERSING
NERVE ROOT
!
L5 is EXITING
NERVE ROOT

Aging Disc
• Loss of cells
• Dehydration
• Annular fissures
• Mechanical
incompetence
• Osteophyte

HIVD
• Paracentral herniation is the most common pattern and
compress the lower existing nerve nerve root
• Extraforaminal herniation is more likely compress the upper
nerve root
• The tumor necrosis factor-α may be a key factor of the pain
process
• The effects of mechanical deformation are compounded by
chemical sensitization of nerve root
• The inflammatory factors around the nerve root and dorsal root
ganglion includes IL-1, IL-6, PGE-2 and phospholipase A2
• These factors incites vascular changes around nerve root and
direct effect on the blood-nerve barrier, promoting intraneural
edema and reducing neuronal perfusion

• 95% involves L3-4 or L4-5
• Most patients are between the ages of 20 and 50 years
• In lumbar disc herniation, SLRT is sensitive and
specific
• The crossed straight leg raising test has a lower
sensitivity, but much higher specificity
• Nonsurgical treatments result in good resolution of
symptoms in up to 80-90% patients
• The surgical results are better in smaller disc
herniation
• Large extrusive disc herniation has greater likelihood
of total resorption

• The likely of recovery of neurologic deficit is dependent of
surgical intervention
• Patients with painless neurologic deficit still require surgery
• Patients with painless neurologic deficit require surgery only
when functional weakness in a major muscle group and no
return of function after 6 weeks
• The sensory nerve fibers are affected first and recover last
• Recurrent HIVD at the same level: 5% at 5-years F/U
• HIVD in elder patient commonly combined with spinal stenosis
or spondylolisthesis and more frequent in the upper lumbar
levels. Spontaneous resorption and improvement is less likely
• Neurologic deficit in young patients with HIVD is common and
the herniation is frequently an avulsed ring apophysis
• Foraminal epidural steroid injections may help in combating the
chemical mediators of pain and inflammation associated with
disc herniation
• A positive nerve block response indicated by a reduction of leg
pain by more than 50%

Lumbar Disc Herniation 
Pathophysiology
• TNF-α: sensitizing the nerve root after
mechanical deforming force.
• Inflammatory cytokines in the nerve root
and dorsal root ganglion
• Promoting intraneural edema and reducing
neuronal perfusion

Pathophysiology of H.I.V.D.

Ventral ramus, sympathetic chain, dorsal root ganglion

Pathoanatomy
• Disc material: nucleus pulposus,
cartilage, annulus fibrosis,
apophyseal bone
• Herniated disc <-> disc bulge
• Herniated disc: protrusion, extrusion,
sequestration
• Containment
• Location: central, paracentral,
foraminal, extraforaminal
• Axillary vs Shoulder
• L4-L5 disc compressing L5 root
(paracentral), compressing L4 root

Lumbar Disc Herniation
• Disc Herniation in the Elderly
– Spinal stenosis, spondylolisthesis
– Upper lumbar spine
– SLRT commonly negative
– Chronic fibrosis of the roots
– Spontaneous improvement is less likely
• Disc Herniation in Young Patients
– 1% to 3% of all HIVD
– Herniation: an avulsed apophysis

Symptoms of H.I.V.D.
• 1% of general population annually
• L4-L5, L5-S1 disc
• 20 – 50 years old
• Aggravated by coughing, sneezing, sitting
• SLRT
– Sensitive, not specific
• Crossed SLRT
– Lower sensitivity, higher specificity
• Nerve root tension: develops at 35° - 70°
• 1% to 10% (underwent surgery) with
cauda equina syndrome
Clinical Features

CONTRALATERAL LEG RAISING TEST
(FRAJERSZTAGN TEST)

WHY PAIN OCCURS ON AFFECTED SIDE
ON RAISING NORMAL LEG?
AFFECTED
SIDE
NORMAL SIDE

Symptoms
• Sudden onset back pain
=> highly innervated
outer annular fibers tear
• Back pain abate shortly
=> depressurization and
relief annular tension
• Back pain persist =>
large central disc
irritation of PLL

Symptoms
• Radicular pain accompanied by
paresthesias and varying degree motor,
sensory and reflex loss
• Activity accentuate pain ( cough, sneeze )
=> intraspinal and intradiskal pressure ⇑
• Cauda equian syndrome : incontinence of
bowel and bladder, bilateral leg motor
weakness, saddle anesthesia ( triad )

CAUDA EQUINA SYNDROME
• Marked reduction in SLRT
• Saddle anaesthesia
• Bilateral ankle jerk
depression
• Involuntary overflow
incontinence
• Decreased tone in external
sphincter

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

SPINAL STENOSIS
➢ Back and/or leg pain develops after walks a limited
distance.
➢ Flexion relieves symptoms
➢ No neurological deficit
➢ Pain not reproduced on SLRT
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

Physical Examination
Motor, Sensory, Reflex

Sensory Dermatome

Diagnosis of H.I.V.D.
• History ,Symptom,sign, and
P.E. 90%
• SLRT(straight leg raising
test) +
• Image study
•Computer Tomogram
•Magnetic Resonance
Image

L4

L5

S1

DISCOGRAHY

Management
• Conservative treatment
– Alters the natural history ?
• Foraminal epidural steroid injection
– Positive response: more than 50% leg pain improvement
– 3 to 4 times in one year
• Absolute indication for surgery
– Bladder and bowel symptoms
– Progressive neurologic deficit
• Relative indication for surgery
– Intractable pain more than 6 weeks
• Three sciatica episodes -> 100% future episodes
• Gold standard: laminotomy + discectomy
• Extraforaminal disc: Wiltse paraspinal approach

Nonsurgical Rx
• Bed Rest (80% resolution within 6 weeks),
herniated disc reduced in size over time
( water content loss, inflammatory
cytokines reduction)
• Medication
• Activity modification
• Steroid injection => improved symptoms
• Chymopapain –Possible anaphylatic shock Lyman
Smith, 1963

CORRECT SLEEPING POSTURE
BED REST

IN RELATION TO MANUAL MATERIALS
HANDLING

FOR ACUTE STAGE
!
BRIDGING EXERCISE
!
KNEE HUGS

FOR RECOVERY OR SUBACUTE STAGE
!
EXTENSION CONTROL !
HAMSTRING STRETCH
!
KNEE ROLLS

Lifestyle Changes That Help Eliminate Pain :!
Tip #1: 
Use Your Body Symmetrically!
Tip #2: 
Make Your Work Area Posture Friendly!
Tip #3: 
Use a Telephone Headset!
Tip #4: 
Make Your Car Seat Posture Friendly!
!
Tip #5: 
Use Posture Support Devices!
Tip #6: 
For Women: Limit the Use and Height of High Heels!
!

DO’S & DON’T’S

EPIDURAL STEROID INJECTION

What Is Muscle-Balance
Therapy?!
Muscle-Balance Therapy is an
innovative approach to
eliminating back pain (and just
about any other ailment) by
addressing the imbalances in
your muscles.!
The Muscle-Balance Therapy
approach begins by assessing the
strength and ﬂexibility of your
muscle pairs—in your hips, pelvis,
spine, and throughout the body.!

What Is Inversion Therapy?!
As the name states, inversion therapy actually
“inverts” the body to an upside-down position.!
Imagine a balloon, for instance, one of those long ones that can be twisted into
different shapes to make balloon animals. If you were to squish one side with your
ﬁst, all the air in the balloon would form a bulge at the other side. Keep pressing and
eventually you could force the other end of the balloon to burst.!
Discs operate much the same way. As muscle imbalances— and gravity—apply
uneven pressure on a disc, the disc bulges to one side. This is what happens in the case
of a herniated disc.!
How Does Inversion Therapy Help?!
Inversion therapy literally reverses the compression caused by gravity—
and in part, muscle imbalances. In essence, it reverses the pressure on the
spine that is a result of gravity and muscle imbalances. Instead of
compressing your discs and making you shorter, inversion therapy—by
allowing you to hang upside down—actually stretches the spine out, as
well as the muscles supporting the spine and torso, giving the discs room
to reabsorb ﬂuids and move back into their proper positions—eliminating
pressure on nearby nerves.!

Indication for Surgical Rx
•Progressive neurological deficit
•Cauda equina syndrome
•Persistent radiculopathy with 6 weeks
conservative treatment
•Recurrent sciatica
•Motor defect with tension sign and pain
•Pseudoclaudication ( activity related leg
pain )

 
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

• Persistent intractable pain> 6 weeks ! surgery
• Disc herniation into stenotic cannal, patients can not
comply with dictates of conservative regimen, numbers
of csiatica episodes are also surgical indications
• Absolute surgical indications are bladder and bowel
involvement and progressive neurologic deficit
• The laminotomy and diskectomy is the gold standard
for surgical treatmentof posterolateral HIVD
• Wiltse paraspinal approach is for extraforaminal
HIVD
• Endoscopic discectomy
– PED
– MED
Surgical Treatment

Surgical Rx of Lumbar HIVD
!
• Traditional Open Discectomy
• Microscopic Discectomy) (AMD)
• AMD(Arthroscopic MicroDiscectomy)
PED (Percutaneous Endoscopic Discectomy)
- Hijikata and Kambin, early 1970’s
• MED (MicroEndoscopic Discectomy

•Limited open lumbar
laminotomy and disectomy –
remove only the displaced
fragment and nearby loose
intradiscal fragment - 90 %
success
•Unilateral partial medial
facetectomy – lateral recess
preexisting stenosis
Open Discectomy

LAMINOTOMY & DISCECTOMY

Percutaneous Endoscope Discectomy

Indication
• Radicular pain
• Positive root tension sign
• Positive imaging study
• Persisted symptom at least 6 weeks of
proper conservative treatment

PED Procedures (Marking)

PED Procedures (Discography)
PED Procedures (Wound)

PELD Indications for good result
• Soft disc content (CT)
• Contained or not sequestrated (MRI)
• Without spinal stenosis
• Without instability
• Young age (<40 Y/O)
• Shorter S/S duration (3-6Ms)

MED 
(MicroEndoscopic Discectomy)
• 1997 , Smith & Foley
• Minimal damage
• Direct visualization by 
a. Muscle-splitting dilators 
b. Endoscope and Video
monitor

Procedures

Endoscope-guide Discectomy

Scope Images
Disc
Lig. Flavum
Lower edge
of L4

Potential disadvantages
• Learning curve
• Limited visualization
• Inadequate exposure
• Incomplete decompression
• Vessel & nerve damage
• Limited ability to treat lateral recess
and foraminal stenosis

PED & MED
PED
MED (laminotomy)

Prognosis and Outcome Following Intervention
• 80% - 90% obtains satisfactory recovery
• Resorption is possible
• Favorable nonsurgical treatment
– Less than 6 months
– Younger patients
– No litigation
• Recovery of neurologic deficit is independent of
surgical intervention
• After recovery of motor deficit, 30% sensory
deficit despite resolution of pain

DISC REPLACEMENT

Lumbar Disc Herniaiton
• Lumbar radicular pain and concordant
myelogram
– 1-year follow-up : Surgery is superior
– 4-year follow-up : Surgery is slightly better
– 10-year follow-up: similar, 60% symptoms free
• Long-term success rate following open
discectomy 76% - 93%

Recurrent Herniation and Reoperation
• Recurrent: 5% in 5 years, 14% in 10 years
• Reoperation
– Discectomy
– Decompression (laminectomy)
– Fusion

Intervertebral Disc Surgery
• Three classical surgical steps
conservative!
treatment
percutaneous!
surgeries
open!
surgeries
fusion!
surgeries
I
II
III

Complications
• Incidental durotomy, pseudomeningocele
• Wrong-level and wrong-side surgery
• Abdominal organ injury ( Vessel, ureter…..)
• Disc space infection
• Postoperative instability
• Recurrent disc herniation, ( D.D. Post-op
scar and recurrent disc )

Recurrent disc herniation
•Focal mass lesion without central
enhance
•Reherniation – 5 % ( same level
and side )
•Reherniation – 20 % ( include
opposite side)

Recurrent disc herniation
•Less favorable nonsurgical
treatment
•Predominant leg pain – revision
discectomy
•Predominant back pain – fusion
for instability

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

Key point of lumbar HIVD
• HIVD can be categorized as prolapsed,
extruded, or sequestered. MRI is the best
image tool for Dx.
• About 80% symptomatic lumbar herniation
can be treated by nonoperatively.
• If a disc causes significant neurologic
deficit or remitting, profound pain, surgery
may be indicated (esp. in adolescent.)

This presentation is for doctors and students in
general.!
. Graphics,Images and jpeg files are taken from
Google and yahoo Image to heighten the
specific points in this presentation. !
• If there is any objection/or copyright violation,
please inform drsandeep123@gmail.com for
prompt deletion. !
• It is intended for use only by the doctors of
orthopaedic surgery.!
. Views expressed in this presentation are
personal. • .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. !
There is no financial involvement.!
• For any correction or suggestion please
contact drsandeep123@gmail.com or
www.agrasenortho.com!

Life laughs at
you when you
are unhappy...
Life smiles at you when you
are happy… 
Life salutes you when
you make others happy...

Every successful person has a
painful story. 
Every painful story has a
successful ending. 
Accept the pain and get
ready for success.

Be bold when you loose 
and be calm when you win.
Heated gold becomes ornament.
Beaten copper becomes wires.
Depleted  
stone becomes statue. So the more
pain you get in life you become more
JADA ‘08

PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc   AGRASEN HOSPITAL Gondia Vidarbha DR SANDEEP C AGRAWAL www.drsandeepagrawal.com www.agrasenortho.com

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