3. 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.
Elseberg (1928) described Chondromas derived from
disc of cervical region.
4. Stookey (1928) described cartilaginous
compression thought as chondromas
responsible for clinical prersentation.
Dandy (1929) reported removal of a disc
tumour or chondroma from patients with
sciatica.
Mixter and Barr (1934) described disc
herniation as the cause of Sciatica.
5. Peet& Echols (1934) referred to as Chondroma or
Ecchondrosis was really protrusion of intervertebral
disc.
Lindblom(1948) first described DISCOGRAPHY.
Lyman Smith (1963) described CHEMONUCLEOLYSIS.
Kambin & Gellman (1983) reported percutaneous
approach for lumbar discectomy.
24. 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.
25. 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: Posterolateral type
29. 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
31. STAGES OF DISC DEGENERATION
Stage of dysfunction
Stage of instability
Stage of stabilization
32. STAGE OF DYSFUNCTION
Episode of rotational Posterior facet joint Small capsular &
or compressive trauma & annular strain annular tear occurs
Small subluxation
of posterior joint
Posterior joint
SYNOVITIS
Posterior segment muscle
protect joint by sustained
hypertonic contraction
33. STAGE OF INSTABILITY
FACET Degeneration Laxity of
JOINT of cartilage capsule
INCREASED
ABNORMAL
MOVEMENT
Loss of nucleus
DISC Coalescence Bulging of
internal
of tears annulus
disruption
34. STAGE OF STABILIZATION
Destruction Fibrosis in
FACET JOINT
of cartilage joint
INCREASED
STIFFNESS
DISC Loss of Fibrosis in disc
nucleus & osteophytes
STABILIZATION
36. 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
37. Facet joints undergo
ANNULUS Facet joints share degenerative
IN TACT even more of the changes & develop
axial load osteophytes
FACET JOINT
SYNDROME
40. 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
69. 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
70. 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
71. INVESTIGATION
THE CORNERSTONE OF DIAGNOSIS OF
LUMBAR DISC DISEASE IS THE HISTORY AND
PHYSICAL EXAMINATION NOT THE
INVESTIGTION.
78. DISADVANTAGE OF MYELOGRAPHY
• Myelographyis capable of showing the level
at which the pathology lies but fails to show
the nature of the lesion or its precise location
in the anatomic segment .
80. USES OF DISCOGRAPHY
• To evaluate equivocal abnormality seen on myelography, CT
or MRI
• To isolate a symptomatic disc among multiple level
abnormality
• To diagnose a lateral disc herniation
• To establish contained discogenic pain
• To select fusion levels
• To evaluate the previously operated spine
81. CT DISCOGRAPHY
USES
• To determine whether the disc herniation is
contained, protruded, extruded or
sequestrated.
• To evaluate previously operated lumbar spine
to distinguish between mass effect from scar
tissue or disc material.
82. COMPUTED TOMOGRAPHY
ADVANTAGES
• CT is an extremely useful, highly accurate & noninvasive tool in
the evaluation of spinal disease.
• CT provides superior imaging of cortical and trabecular bone
compared with MRI.
• It provides contrast resolution and identify root compressive
lesions such as disc herniation.
• It also helps to differentiate between bony osteophyte from
soft disc.
• It helps to diagnose foraminal encroachment of disc material
due to its ability to visualize beyond the limits of the dural sac
and root sleeves.
83. LIMITATIONS
• 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.
84. MAGNETIC RESONANCE IMAGING
• It allows direct visualization of herniated disc
material and its relationship to neural tissue
including intrathecal contents.
98. CONTRAST ENCHANCED MRI
• Here GADOLINIUM labeled
diethylenetriaminepentaacetate (Gd-DTPA)
administered intravenously and MRI scan
done.
ADVANTAGES
• Display the inflammatory reaction critical to
the pathophysiology of radicular pain or
radiculopathy
• Allows discrimination of scar from recurrent
disc.
99. OTHER DIAGNOSTIC TESTS
• ELECTROMYOGRAPHY – to rule out peripheral
neuropathy.
• SOMATOSENSORY EVOKED POTENTIALS
(SSEP) – to identify the level of root
involvement
• POSITRON EMISSION TOMOGRAPHY
101. CONSERVATIVE
Majority of disc prolapse respond well to
conservative therapy. Resolution of first disc
prolapse takes place approximately 75% of
patients over a period of 3 months.
104. EXERCISES
GENERAL RULES FOR EXERCISE
• Do each exercise slowly. Hold the exercise position for a slow
count of five.
• Start with five repetitions and work up to ten. Relax
completely between each repetition.
• Do the exercises for 10 minutes twice a day.
• Care should be taken when doing exercises that are painful. A
little pain when exercising is not necessarily bad. If pain is
more or referred to the legs the patient may have overdone
it.
• Do the exercises every day without fail.
113. CHEMONUCLEOLYSIS
Chymopapain Degrades the Water holding
injected into the proteoglycans in the capacity of the disc
disc nucleus is decreased
Shrinkage of the
disc
115. SURGERY
GOAL
To relive neural compression and
henceradiculopathy while minimizing
complications.
116. 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
117. 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
123. COMPLICATIONS OF
LAMINECTOMY AND DISCECTOMY
• Infection – Superficial wound infection , Deep disc space
infection
• Thrombophlebitis/ Deep vein thrombosis
• Pulmonary embolism
• Dural tears may result in Pseudomeningocoele, CSF leak,
Meningitis
• Postoperative cauda equine lesions
• Neurological damage or nerve root injury
• Urinary retention and urinary tract infection
124. 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
125. COMMON CAUSES – Neuritis, Referred pain from
nonspinous site
UNCOMMON CAUSES
• Discitis / Osteomyelitis/ Epidural abscess
• Arachnoiditis
• Conus tumour
• Thoracic, High lumbar Herniated Nucleus Pulposus
• Epidural haematoma
126. The recurrence of pain after disc surgery
should be treated with all available
conservative treatment modalities initially.
The surgery should be tailored to the
anatomic problem only.
134. Patient not suitable for artificial disc
replacement are
• Osteoporosis
• Spondylolisthesis
• Infection or tumour of spine
• Spine deformities from trauma
• Facet arthrosis
138. INTRADISCAL ELECTROTHERMAL
THERAPY
• It is a new minimally invasive technique done
as an outpatient procedure.
• Done in patients with low back pain caused by
tears in the outer wall of the intervertebral
disc.
139. PROGNOSIS
• Extruded disc, Large herniations,
Sequestrations have a greater tendency to
resolution than small herniations& disc
bulges.
• Recurrence of disc prolapse can be prevented
by a proper exercise programme and
avoidance of stress to the lower part of back.
140. REFERENCES
• MACNAB’S BACKACHE by DavidA.Wong 4th edition
• THE LUMBAR SPINE by Sam W Wiesel 2nd edition
• MANAGING LOW BACK PAIN by W.H.Kirkildy – Willis 3rd
edition
• ORTHOPAEDIC PHYSICAL ASSESSMENT by David Magee 5th
edition
• ORTHOPAEDIC PRINCIPLE AND THEIR APPLICATION by TUREK
4TH Edition
• CAMPBELL’S OPERATIVE ORTHOPAEDICS 11TH EDITION
• INTERNET
141. “LEARN TO BE
GOOD TO
YOUR BACK
AND YOUR
BACK WILL BE
GOOD TO
YOU….”