vighneshwaran's presentation

1. J.J.M MEDICAL COLLEGE
DAVANGERE
SEMINAR ON
LUMBAR DISC PROLAPSE
09/01/2013
MODERATORS
Dr. NAGABHUSHANA.D.M MS ORTHO,
Dr. PRASANNA ANNABERU MS ORTHO, PRESENTED BY
Dr.VIGNESHWARAN.P
PG IN ORTHOPAEDICS
1

2. HISTORY
 Aurelianus(5th century) clearly described the symptoms of SCIATICA.
 Andreas Vesalius (1543) first described the intervertebral disc.
 Forst(1811) described the Lasegue sign. He attributed it to Lasegue, his teacher.
 Virchow (1857), Kocher (1896) described acute traumatic rupture of the intervertebral disc that
resulted in death.
 Contugino(18th century) attributed the leg pain to the sciatic nerve.
 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.
 Stookey(1928) described cartilaginous compression thought as chondromas responsible for clinical
prersentation.
 Schmorl (1928) described Schmorl nodes.
 Dandy (1929) reported removal of a disc tumour or chondroma from patients with sciatica.
 Arnell&Lidstorm (1931) first used water soluble contrast medium.
 Mixter and Barr (1934) described disc herniation as the cause of Sciatica.
 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.
ANATOMY OF LUMBAR SPINE
There are five lumbar vertebrae making up the lumbar spine. Each vertebra has three functional
components: the vertebral bodies, designed to bear weight; the neural arches, designed to protect the
neural elements; and the bony processes (spinous and transverse), designed as out-triggers to increase
the efficiency of muscle action.
The vertebral bodies are connected together by the intervertebral discs, and the neural arches are
joined by the facet (zygapophyseal) joints. The discal surface of an adult vertebral body demonstrates
on its periphery a ring of cortical bone. This ring, the epiphysial ring, acts as a growth zone in the
young and in the adult as an anchoring ring for the attachment of the fibers of the annulus.
The hyaline cartilage plate lies within the confines of this ring. The size of the vertebral body
increases from L1 to L5, which is indicative of the increasing loads that each lower lumbar vertebral
level has to absorb.
The neural arch is composed of two pedicles and two laminae. The pedicles are anchored to the
cephalad half of the vertebral body and form a protective cover for the caudaequina contents of the
lumbar spinal canal. The ligamentum flavum (yellow ligament) fills in the interlaminar space at each
level. The outriggers for muscle attachment are the transverse processes and spinous process.
2

3. THE INTERVERTEBRAL DISC
The intervertebral disc consists of
outer fibrous annulus, containing
inner gelatinous nucleus pulposus.
ANNULUS FIBROSUS
The fibers of the annulus can be
divided into three main groups: the
outermost fibers attaching between
the vertebral bodies and the
undersurface of the epiphyseal ring;
the middle fibers passing from the
epiphyseal ring on one vertebral
body to the epiphyseal ring of the
vertebral body below; and the
innermost fibers passing from one
cartilage end-plate to the other.The
anterior fibers are strengthened by
the powerful anterior longitudinal
ligament.
The posterior longitudinal ligament affords only weak reinforcement, especially at L4-5 and L5-S1,
where it is a midline, narrow, unimportant structure attached to the annulus. The anterior and middle
fibers of the annulus are most numerous anteriorly and laterally but are deficient posteriorly, where
most of the fibers are attached to the cartilage plate.
The fibers of the annulus are firmly attached
to the vertebral bodies and arranged in
lamellae, with the fibers of one layer running
at an angle to those of the deeper layer. This
anatomic arrangement permits the annulus to
limit vertebral movements. This important
function is reinforced by the investing
vertebral ligaments.
NUCLEUS PULPOSUS
The nucleus pulposus is gelatinous, the load of
axial compression is distributed not only vertically
but also radially throughout the nucleus. This
radial distribution of the vertical load (tangential
loading of the disc) is absorbed by the fibers of
the annulus.
Weight is transmitted to the nucleus through the hyaline cartilage plate. The hyaline cartilage is ideally suited
to this function because it is avascular. If weight were transmitted through a vascularized structure, such as
bone, the local pressure would shut off blood supply, and progressive areas of bone would die. This
phenomenon is seen when the cartilage plate presents congenital defects and the nucleus is in direct contact
3

4. with the spongiosa of bone. The pressure occludes the blood supply, a small zone of bone dies, and the nucleus
progressively intrudes into the vertebral body this is known as SCHMORL’S NODE.
COMPOSITION
The nucleus consists of approximately 85% water, 10 to 20% of collagen and abundant amount of
proteoglycans. The annulus fibrosus contains 78% of water, 60 to 70% of collagen. The collagen prevent the
proteoglycans imbibing water and swell up. Thus collagen gives tensile property to the tissue and proteoglycan
gives compressive stiffness.
FUNCTIONS
The nucleus pulposus acts like a ball bearing, and in flexion and extension the vertebral bodies roll over this
incompressible gel while the posterior joints guide and steady the movements. The annulus acts like a coiled
spring, pulling the vertebral bodies together against the elastic resistance of the nucleus pulposus.
NUTRITION TO THE DISC
The intervertebral discs of a person up to the age of 8 years have a blood supply, but thereafter they are
dependent for their nutrition on diffusion of tissue fluids. This fluid transfer is through two routes: (a) the
bidirectional flow from vertebral body to disc and from disc to vertebral body and (b) the diffusion through the
annulus from blood vessels on its surface. This ability to transfer fluid from the disc to the adjacent vertebral
bodies minimizes the rise in intradiscal pressure on sudden compression loading. This fluid transfer acts like a
safety valve and protects the disc.
THE FACET JOINTS
The facet (zygapophyseal) joints are synovial joints that permit simple gliding movements. These are
like miniature KNEE JOINT. The lax capsule of the zygapophyseal joints is reinforced to some extent
by the ligamentum flavum anteriorly and the supraspinous ligament posteriorly, the major structures
restraining movement in these joints are the outermost fibers of the annulus. When these annular fibers
exhibit degenerative changes, excessive joint play is permitted due to this degenerative changes within
the discs render the related posterior joints vulnerable to strain.
THE LIGAMENTS
The strongest ligaments in the spine are the anterior longitudinal ligament and the facet joint capsules.
The interspinous-supraspinous ligament complex is of intermediate strength, and weakest of all is the posterior
longitudinal ligament.
Anterior longitudinal ligament (ALL) runs the length of the anterior aspect of the spine. It is
intimately attached to the anterior annular fibers of each disc and is a fairly strong ligament
useful in fracture reduction.
Posterior longitudinal ligament (PLL). is the posterior mate to the anterior longitudinal
ligament. It is a significant ligament in all areas of the spine except the lower lumbar region
4

5. where it is flimsy and inconsequential thus lumbar disc problems are most common in this
region.
Interspinous/supraspinous ligament complex helps in flexion of lumbar spine.
Ligamentum flavum (the yellow ligament). This ligament is so named because of the
yellowish color that is given to it by the high content of the elastin fibers. The ligamentum
flavum bridges the interlaminar interval, attaching to the interspinous ligament medially and the
facet capsule laterally. It has a broad attachment to the undersurface of the superior lamina and
inserts onto the leading edge of the inferior lamina at each segment. Normally, the ligamentum
maintains a taut configuration, stretching for flexion and contracting its elastin fibers in neutral
or extension. In this way, it always covers but never infringes on the epidural space. With aging,
the ligamentum flavum loses its elastin fibers and the collagen hypertrophies, which results in
buckling of the ligamentum flavum and encroachment on the thecal sac, potentially contributing
to spinal stenosis.
MOTION SEGMENT
Basic functional unit of spine is MOTION SEGMENT. It includes two adjacent vertebral bodies and
intervening soft tissues. It is controlled actively by muscles and passively by ligaments. Disc is protected
from both torsional and compressive loads when motion segment in extension.
MOTION SEGMENT
ANTERIOR ELEMENTS POSTERIOR ELEMENTS
It includes vertebral body, It includes pedicles, facet
disc, anterior & posterior joints, posterior ligamentous
longitudinal ligaments. & muscular attachment.
Provides stability & Shock Control the spinal
absorption movements
HOW TO KNOW WHICH NERVE ROOT INVOLVED IN CASE OF DISC PROLAPSE?
For example the fifth lumbar nerve root passes
beneath the fifth lumbar pedicle and is also described
as the exiting nerve root at the L5-S1 segment.
Proximal to this, the L5 root passes across the L4-5 disc
L5 is TRAVERSING
space. The L5 nerve root is the traversing root at the
NERVE ROOT
L4-5 disc space, where it can be encroached on by an
L4-5 disc herniation in the common posterolateral
position. Distal to the L5 pedicle, the fifth lumbar nerve
L5 is EXITING root lies just lateral to the L5-S1 disc space, and a
NERVE ROOT lateral disc herniation at L5-S1 can encroach on the
fifth lumbar nerve root at this level.
5

6. BIOMECHANICS OF LUMBAR SPINE
LOAD BEARING
In axial compression load, there will be increase in intradiscal pressure which will be counteracted by
annular fibre tension and disc bulge.
In axial rotation of lumbar spine,
Torsion of disc Annular fibres in one direction are stretched significantly and opposite side
shortened stress concentration at region of postero-lateral annulus Fissures in postero-lateral
annulus
Torsion of vertebral body segment cause only peripheral circumferential tear in annular fibres after damage
to the posterior joints. But only lateral bending and flexion will cause acute rupture of lumbar intervertebral
disc.
THREE JOINT COMPLEX
It includes intervertebral disc & Facet joints. It has load bearing function. Facet joints and disc normally
resist 80% of torsion. 25% of axial compression load transmitted through the facet joints when the person is
standing and the facet joints share 0% axial load on the spine in sitting. The primary function of the facet joints
is to protect the disc from shear and rotational forces.
BIOMECHANICS OF LIGAMENTS
The ligaments of the lumbar spine act like rubber bands. They have an elastic physical property that allows
the ligament to stretch and resist tensile forces. Under compression, the ligaments buckle and serve little
function. In resisting tensile forces, ligaments allow just enough movement without injury to vital structures.
Passively, they maintain tension in a segment so that muscles do not have to work as hard.
ROLE OF ABDOMINAL CAVITY
Abdominal cavity and its surrounding muscles stabilize the spine for activities such as lifting.
INTRADISCAL PRESSURE
The final determining factor in biomechanical injury to spine is the INTRADISCAL PRESSURE.
IN RELATION TO POSTURE
Disc pressure is higher in sitting without support than standing
With use of backrest with inclination of about 1200, arm rest and lumbar support of about 5cm reduces
deformation of lumbar spine and decreases disc pressure.
6

7. In recumbent position on firm bedding surface with flexion at hip and knee,
Decrease stress on spine due to relaxation of spinal musculature
Decrease the stress on facet joints by decreasing lumbar lordosis.
IN RELATION TO MANUAL MATERIALS HANDLING
Lifting heavy weight with back stooped and legs straight more stressful than back straight lifting with legs
because
Shear forces are greater when lifting with back flexed
Articular facet capsules and posterior ligament are overstrained in flexed posture.
Heavy load held close to the body is much less hazardous to back than one lifted further away from the body.
DO & DONTS
7

8. LUMBAR DISC PROLAPSE
SYNONYMS: Herniated disc, Prolapsed disc, Sequestrated disc, Soft disc, Slipped disc, Protruding disc, Bulging
disc, Ruptured disc, Extruded disc, Disc.
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.
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
WHY DISC PROLAPSE IS MOST COMMON POSTEROLATERALLY?
 Incomplete annular lamellae in this quadrant (i.e) each lamellae end with fusion to an adjacent
lamellae not completely circular.
 Fibres of annulus were deficient posteriorly.
 Posterior fibres are only weakly reinforced by posterior longitudinal ligament especially L4-5 and L5-S1
where it is midline, narrow, unimportant structure attached to annulus.
ETIOLOGY
Congenital/ Developmental – Biochemical and structural abnormality in one or more disc
Repetitive microtrauma
Accumulated macrotrauma – Sports / Automobile injury
Poor nutrition
Poor Health habits – Lack of exercise, smoking
Biomechanical factors – Rotational torsional stress, flexion and compression injury
Poor posture habits – sitting and bending forwards, lifting heavy weight bending back
Autoimmune inflammatory reaction
Biochemical changes – In inner annulus and nucleus initiate/ potentiate the degradation of DISC
MATERIAL and predispose to herniation because of thinning or weakening of annulus.
PhospholipaseA2 and arachidonic acid are suspected
8

9. NATURAL HISTORY OF DISC DEGENERATION
The three stages of disc degeneration are:
 Stage of dysfunction
 Stage of instability
 Stage of stabilization
STAGE OF DYSFUNCTION
Episode of rotational or compressive Posterior facet joint Small capsular &
trauma (uncoordinated muscle & annular strain annular tear occurs
contraction)
Small subluxation of
posterior joint
Muscle splint the Posterior segment Posterior joint
Muscle become ischaemic
posterior joint muscle protect joint by synovium injured &
& metabolites get
subluxation sustained hypertonic result in SYNOVITIS
accumulated cause pain
maintained contraction
STAGE OF INSTABILITY
FACET Degeneration Attenuation Laxity of capsule
JOINT of cartilage of capsule
Increased
INCREASED
dysfunction
ABNORMAL
MOVEMENT
Coalescence Loss of nucleus Bulging of
DISC internal disruption annulus
of tears
STAGE OF STABILIZATION
Destruction Fibrosis Enlargement Locking facets Fibrosis
FACET JOINT
of cartilage in joint of facets around joint
INCREASED
Loss of Approximation Destruction Fibrosis in disc STIFFNESS
DISC
nucleus of bodies of plates & osteophytes
STABILIZATION
9

10. 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
ANNULUS ANNULUS
INTACT FAILS
Facet joints share even Fissures develop across annular
more of the axial load lamellae may extend upto disc
periphery
Facet joints undergo
Internal disc disruption cause
degenerative changes &
AXIAL PAIN
develop osteophytes
Expression of this degraded
FACET JOINT SYNDROME nuclear material through these
radial fissures
DISC
10 HERNIATION

11. FATE OF DISC HERNIATION
Nucleus pulposus is an
Extrude disc & degraded
immunogenic which induce an Produces radicular pain
nuclear material impinge
inflammatory response mediated syndrome &
on the nerve roots
by TNF alpha, IL, Phospholipase RADICULOPATHY
A2, Ntric oxide.
Extruded disc, Large herniations, Sequestrations have a greater tendency to resolution than small herniations &
disc bulges.
WHAT IS RADICULOPATHY?
Radiculopathy means the presence of objective signs of NEURAL DYSFUNCTION including motor weakness,
sensory loss/ paresthesias or diminished deep tendon reflexes. It is typically accompanied by radiating limb
pain which is intermittent, lanciating, electric or burning.
TYPES OF DISC PROLAPSE
Based on the intactness of annulus fibrosus
CONTAINED (intact NON CONTAINED
annular fibres) (disruption of annular fibres)
PROTRUSION SUBANNULAR TRANSANNULAR SEQUESTERED
EXTRUSION EXTRUSION
AREA OF THE DISC SHAPE OF THE DISC AXIAL LOCATION SAGITTAL LOCATION
Extrusion
Central Discal
<25% Focal Protrusion
R/L Central Pedicular
25-50% Broad based protrusion R/L Subarticular Infrapedicular
R/L Foraminal Suprapedicular
R/L Extraforaminal
11

12. AXIAL LOCATION SAGITTAL LOCATION
CLINICAL FEATURES
STAGE OF
DEGENERATIVE STAGE OF DYSFUNCTION STAGE OF INSTABILITY STAGE OF
DISEASE OF DISC STABILIZATION
- Low back pain often - Catch in back on movement. - Low back pain
localized or referred to - Pain on coming to standing decrease in severity
groin/ greater trochanter/ position after flexion.
posterior thigh
SYMPTOMS - Aggravated on movement
- Relieved on rest
- Local tenderness on one -Abnormal movement of spine - Muscle tenderness
side & at one level - Observation of catch - Stiffness
-Hypomobility sway or shift when coming erect - Reduced
- Muscle activity abnormality after flexion movements
SIGNS - Extension painful -Reversal spinal rhythm - Scoliosis
- Neurological examination
normal
-Abnormal movement AP VIEW - Enlarged facets
- Spinous process not rotate -Lateral shift - Loss of disc height
to the side of bend - Rotation - Osteophytes
- On lateral bending disc - Abnormal tilt - Small foramina
height on concave side not - Malaligned spinous process - Reduced movement
RADIOLOGICAL reduced OBLIQUE VIEW - Scoliosis
- Irregularity of posterior -Opening of facets
CHANGES facets LATERAL VIEW
- Small osteophyte on -Spondylolisthesis on flexion
anterior surface vertebral -Retrospondylolisthesis on
body extension
- Slightly decreased disc -Narrowing of foramen on
height extension
-Abnormal opening of disc
-Abrupt change in pedicle height
12

13. CLINICAL FEATURES OF LUMBAR DISC PROLAPSE
NERVE ROOT L1 L2 L3 L4 L5 S1
COMPRESSED
LEVEL OF DISC T12 – L1 L1 – L2 L2 - L3 L3 – L4 L4 – L5 L5 – S1
PROLAPSE
PAIN Thoraco lumbar Thoraco Upper lumbar Lower back, Sacroiliac joint,
Sacroiliac joint,
junction, groin, lumbar spine, anterior hip, postero hip, lateral
hip, postero
proximal part of junction, groin, aspect of lateral thigh, thigh & laterallateral thigh &
thigh proximal part proximal thigh anterior leg leg postero lateral
of thigh leg to heel
PARESTHESIA Oblique band Oblique band Oblique band Medial to shin Lateral leg, Posterior aspect
proximal 3 of mid 3rd of thigh
rd
lower part of of tibia, dorsum of foot, of thigh, back of
thigh anteriorly anteriorly thigh anteriorly medial aspect 1st web space calf, lateral side
just below just above the of the foot and sole of foot
inguinal knee
ligament
MUSCLE Iliopsoas (Hip Iliopsoas (Hip Iliopsoas (Hip TIBIALIS EXTENSOR PERONEUS
AFFECTED flexion) flexion), flexion), ANTERIOR HALLUCIS LONGUS &
MAINLY Quadriceps Quadriceps (Foot LONGUS BREVIS (Foot
(Knee (Knee inversion), (Dorsiflexion of eversion),
extension), extension), Quadriceps great toe), Flexor hallucis
adductor adductor (Knee Extensor longus (Plantar
brevis, longus, brevis, longus, extension), digitorum flexion of great
magnus (Hip magnus (Hip adductor longus & brevis toe), Flexor
adduction) adduction) brevis, longus, (Dorsiflexion of digitorum
magnus (Hip foot), Gluteus longus & brevis
13

14. adduction) medius (Hip (Plantar flexion
abduction) of foot),
Gastronemius,
Soleus
(Difficulty in
walking on
toes), Gluteus
maximus (Hip
extension)
WEAKNESS Hip flexion Hip flexion, Hip flexion, Foot Dorsiflexion of Foot eversion,
Knee Knee inversion, great toe & Plantar flexion
extension, Hip extension, Hip Knee foot, Difficulty of great toe &
adduction adduction extension, Hip in walking on foot, Difficulty
adduction, heels, Hip in walking on
Difficulty in abduction toes, Hip
walking on extension
heels
ATROPHY - Quadriceps Quadriceps Quadriceps Minor Gastrocnemius,
Soleus,
REFLEXES - Knee jerk Knee jerk Knee jerk Changes Ankle jerk
slightly slightly diminished or uncommon ( absent or
diminished diminished absent Posterior tibial diminished
reflex
diminished or
absent
14

15. NEUROLOGICAL CHANGES AT DIFFERENT LEVEL OF DISC HERNIATION
15

16. AGGRAVATING FACTORS
Pain will aggravate on bending, stooping, lifting heavy weight, coughing, sneezing and straining at stool.
RELIEVING FACTORS
Pain relieved on lying in hip-knee flexed position, pillow under the knees or on the asymptomatic side in
fetal position. No position of comfort in case of high lumbar root lesions.
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
GAIT – Slow and deliberate walk holding their loins with the hands. In gross
nerve root tension, TIP-TOE WALK due to not able to put the heel to the
floor.
INSPECTION Deviation of spine to one side to take the nerve away from the
prolapsed disc is called SCIATIC SCOLIOSIS which become more obvious
on bending forwards.
Deviation of spine depends on the type of disc prolapsed medial or
lateral to nerve root,
Trunk deviated to opposite side – SHOULDER TYPE (lateral)
Trunk deviated to same side – AXILLARY TYPE (medial)
The SCIATIC SCOLIOSIS disappears on recumbency. The loss of lateral curvature of the lumbar spine on
recumbency helps differentiates the sciatic scoliosis from fixed structural scoliosis in which there will be no
change in curvature of lumbar spine on recumbency.
Loss of lumbar lordosis and paravertebral muscle spasm are seen in acute phase of the disease.
PALPATION
On applying lateral thrust to the spinous process may produce pain in the back at the affected level.
16

17. Tenderness on the adjacent paraspinal region due to muscle spasm and tenderness at the point between the
ischial tuberosity and the greater trochanter, at the centre point of the posterior aspect of the thigh, just lateral
to middle of the popliteal space, the middle of the calf and just behind the medial malleolus. Tender points in
the myotome corresponding to the probable segmental level of nerve root involvement.
MOVEMENTS
Forward flexion and extension are restricted. But lateral flexion can be free and full to one side depends on the
position of the protrusion in relation to the nerve root .If the patient feel leg pain on extension it is indicative of
SEQUESTRATED OR EXTRUDED DISC.
The cardinal signs of lumbar root compromise are ROOT TENSION, ROOT IRRITATION & ROOT COMPRESSION
TEST FOR ROOT TENSION AND ROOT IRRITATION
These are the test which tighten the sciatic nerve and compress the inflamed nerve root against a herniated
lumbar disc.
STRAIGHT LEG RAISING TEST
PROCEDURE: Patient in supine position, there should be no
compensatory lumbar lordosis. One of the examiner hand is placed
over the knee firm pressure exerted to maintain knee in full
extension and other hand of the examiner under the heel, the
examiner slowly raises the leg until leg pain is produced.
FINDING: If reproduction of pain before reaching 60 to 70 degree,
aggravated by dorsiflexion of ankle (LASEGUE’S SIGN)and relieved by
flexion of the knee
IMPRESSION: Tension on the fifth lumbar or first sacral root.
In patient in whom paresthesia in foot is predominant on repetitive
SLR intensifies the sensation of numbness.
BRAGGARD’S SIGN: After a SLRT is done the limb is slightly lowered and the foot is dorsiflexed. Stretching of the
sciatic nerve will cause intense pain
SICCARD’S TEST: It involves SLR along with extension of the big toe.
TURYN’S TEST: It involves only the extension of great toe.
CONTRALATERAL STRAIGHT LEG RAISING TEST (FRAJERSZTAGN TEST)
PROCEDURE: It is performed same manner as SLRT except that THE NON PAINFUL LEG is raised.
17

18. FINDING: If patient develops reproduction of pain in opposite extremity then the test is positive.
IMPRESSION: Positive test is very suggestive of HERNIATED DISC & also an indication of the location of extrusion
usually disc lies medial to the nerve root in the axilla.
Why reproduction of pain in affected limb occurs on elevation of the normal limb?
On lifting the normal Nerve root on the Along with this right Produce
limb (e.g) Left limb left will move side root brought pain over
against herniated disc right buttock
BOWSTRING SIGN
It is most important indication of root tension or irritation.
PROCEDURE: SLR is carried out until pain is reproduced at this level knee is
slightly flexed until pain abates. Then examiner rests the limb on his or her
shoulder and places the thumb in the poipliteal fossa over the sciatic nerve and
sudden pressure applied on the nerve.
FINDING: If patient developed pain in the back or down the leg test is positive
IMPRESSION: Significant root tension and irritation of nerve root by ruptured
disc
FEMORAL NERVE STRETCH TEST (REVERSE SLR TEST)
PROCEDURE: Patient is placed in prone position and the knee is
flexed and the hip is extended.
FINDING: If the patient develops pain over unilateral thigh and
which gets aggravated on further knee flexion indicates test is
positive
IMPRESSION: Tension on the 2nd, 3rd or 4th lumbar roots.
LIMITATION: Difficult to assess in the presence of hip or knee
pathology
LASEGUE’S TEST: Here the patient in supine position, the hip and knee are gently flexed to 90degree, then the
leg is gradually extended which reproduces the symptoms of sciatica.
CROSS OVER TEST
It is an important determinant of compression of lumbosacral roots in the midline.
PROCEDURE: The examiner gently raise the affected leg
FINDING: If patient develop symptoms in asymptomatic contralateral extremity
18

19. IMPRESSION: A large central disc protrusion
FLIP TEST
PROCEDURE: Patient is made to sit with knees dangling over the
side of the bed, the hip and knee are both flexed at 90degrees.
Now extend the knee joint fully.
FINDING: If patient develops sudden, severe pain, and patient will
throw his or her trunk backwards to avoid tension the nerve
indicates that the test is positive.
IMPRESSION: Root compromise
NAFFZIGER’S TEST: Here pressure applied on the jugular vein until the patient face flush. Now patient asked to
cough which produce pain in back indicate test is positive.
VALSALVA MANEUVER: Ask the patient to bear down as if he were trying to pass stools. If bearing down causes
pain in the back or radiating down to the leg it indicates test is positive.
The diagnosis of disc rupture is dependent on demonstration of root impairment as reflected by signs of
motor weakness, changes in sensory appreciation or reflex activity.
CAUDA EQUINA SYNDROME
The syndrome is a true spine surgical emergency that is often missed due to its rare occurance. The
condition is usually caused by a massive midline disc sequestration into the spinal canal, usually at L4-
L5 but also at L5-S1 and L3-L4. Higher disc ruptures are a rare cause of this syndrome.
The presentation is fairly classic. The patient usually has a prodromal stage of back pain and some leg
symptoms.Without much in the way of intervening trauma, there is a dramatic increase in back pain and the
occurrence of bilateral leg pain and perineal numbness. The numbness usually extends to the penis in men. The
patient then notices an inability to void because of the paralysis of the S2, 3, and 4 roots in the cauda equina.
On examination, marked reduction in SLR; numbness to pinprick in the perineal region (S2, 3, 4 dermatomes)
SADDLE ANAESTHESISA; and weakness corresponding to the level of the disc rupture. Reflexes will usually be
depressed (e.g., bilateral ankle reflex depression with either an L4-L5 or L5-S1 sequestered disc). The bladder
will be full to palpation/percussion, and any passage of urine will be due to involuntary overflow
incontinence.On rectal examination, decreased tone in the external sphincter will be noted.If there is any
suspicion at all that bladder and bowel function are impaired, in a back pain patient, an immediate diagnostic
study like EMERGENCY MRI is indicated. It should operated as early as possible because delay in surgery
increases the risk of permanent impairment of bowel and bladder function.
19

20. CRITERIA FOR THE DIAGNOSIS OF THE ACUTE RADICULAR SYNDROME (
SCIATICA DUE TO A HERNIATED NUCLEUS PULPOSUS)
DIFFERENTIAL DIAGNOSIS OF SCIATICA
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
EXTRASPINAL CAUSES
Pelvis
Cardiovascular conditions (eg. Peripheral vascular disease)
Gynaecological conditions
Orthopaedic conditions ( osteoarthritis of hip, Muscle related disease, Facet joint arthropathy)
Sacroiliac joint disease
Neoplasm
20

21. Peripheral nerve lesions
Neuropathy (Diabetic, tumour, alcohol)
Local sciatic nerve conditions (Trauma, tumour)
Inflammation (herpes zoster)
KEY DIAGNOSTIC TIPS FOR DISTINGUISHING AMONG FIVE IMPORTANT CAUSES OF SCIATICA
HERNIATED NUCLEUS PULPOSUS
 H/o specific trauma
 Leg pain greater than back pain
 Neurologic deficit present; Nerve tension signs present
 Pain increases with sitting & leaning forwards, coughing, sneezing, and straining
 Pain reproduced with ipsilateral straight leg raising and sciatic stretch tests, contralateral legraising test
 Radiologic evidence of nerve root impingement
ANNULAR TEARS
 H/o significant trauma
 Back pain usually greater than leg pain; Leg pain bilateral or unilateral
 Nerve tension signs are present ( But no radiologic evidence of impingement)
 Pain increases with sitting & leaning forwards, coughing, sneezing, and straining
 Back pain is exacerbated with bilateral straight leg raising and sciatic stretch tests
 Discography is diagnostic ( neither CT nor Myelogram shows abnormality)
FACET JOINT ARTHROPATHY
 H/o injury
 Localized tenderness present unilaterally over joint
 Pain occurs immediately on spinal extension
 Pain exacerbated with ipsilateral side bending
 Pain blocked by intrajoint injection of local anaesthetic or corticosteroid
SPINAL STENOSIS
 Back and/or leg pain develops after patient walks a limited distance; symptoms worsen with continued
walking
 Leg weakness or numbness present, with or without sciatica
 Flexion relieves symptoms
 No neurological deficit present
 Pain not reproduced on straight leg raising; pain reproduced with prolonged extension of spine and
relieved afterwards when spine flexed
 Radiologic evidence: Hypertrophic changes, disc narrowing, interlaminar space narrowing, facet
hypertrophy, degenerative spondylolisthesis L4-L5
21

22. MYOGNIC OR MUSCLE - RELATED DISEASE
 H/o Injury to muscle, recurrent pain symptoms related to its use
 Lumbar paravertebral myositis produce back pain; gluteus maximus myositis causes buttock and thigh
pain
 Pain is unilateral or bilateral, rather midline; does not extend below knee
 Soreness or stiffness present on rising in the morning and after resting; is worse when muscles are
chilled or when the weather changes ( arthritis like symptoms)
 Pain increases with prolonged muscle use ; is most intense after cessation of muscle use( directly
afterward and on following day)
 Symptom intensity reflects daily cumulative muscle use
 Local tenderness palpable in the belly of the involved muscle
 Pain reproduced with sustained muscle contraction against resistance, and passive stretch of the muscle
 Contralateral pain present with side-bending
 No radiologic evidence
INVESTIGATION
THE CORNERSTONE OF DIAGNOSIS OF LUMBAR DISC DISEASE IS THE HISTORY AND PHYSICAL EXAMINATION
NOT THE INVESTIGTION.
CT and MRI are ordered for two reasons: (a) almost always to verify the clinical diagnosis as correct
and at the same time to plan a surgical approach to the problem and (b) infrequently to solve a
differential diagnosis problem.
PLAIN RADIOGRAPH
It is not of much value in the diagnosis of disc herniation
It is mainly used to rule out other causes like ankylosing spondylitis, neoplasms.
Most commonly the herniation occurs at the end of phase I or in early phase II. Thus features of phase II
disc degeneration maybe seen
Radiological features are
 Narrowing of disc space
 Osteophyte 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
22

23. MYELOGRAPHY
Technique: water-soluble contrast agent is injected into the epidural space.
Abnormalities in myelography indicative of an Herniated nucleus pulposus (HNP) are as follows:
Normal Double density Distortion of S1 root sleeve Root sleeve
myelogram sac absent shortening
FALSE NEGATIVE MYELOGRAM SEEN IN
Foraminal HNP
Unscanned area (high lumbar disc not scanned).
Insensitive space at L5-S1
Short or narrow dural sac at L5-S1
Conjoint nerve roots distorting the contrast column
DISADVANTAGE
Myelography is 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 .
CT MYELOGRAPHY
CT myelography is minimally invasive modality here CT scan taken after myelography is done.
INDICATIONS
Patient with contraindication for MRI
Postoperative spine in which metal artifacts present
23

24. ADVANTAGE: Accurate detection of root impingement and central lateral recess and foraminal
stenosis
DISCOGRAPHY
Definition: The discogram is physiologic evaluation of the disc that consists of a manometric, volumetric,
radiographic and pain provocative challenge.
Technique: Done by injecting saline or water soluble contrast into the disc through extradural or transdural
approach under fluoroscopic guidance.
PARAMETERS NORMAL DISC ABNORMAL DISC
VOLUME 0.5 – 1.5ml >1.5ml
END POINT PRESSURE Firm Spongy
RADIOGRAPHIC Contrast confined to nucleus Contrast extend beyond the nucleus
PAIN RESPONSE None/Pressure Typical/ Atypical/ Painless
USES
 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
CT DISCOGRAPHY
Post discography CT should be performed within 4hours of discography both axially and sagitally
reformatted images are obtained.
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.
NORMAL ANNULAR TEAR PROTRUSION EXTRUSION SEQUESTRATION
SCHEMATIC
DIAGRAM
24

25. CT
DISCOGRAP
HY
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.
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.
In Lumbar disc prolapse, disc herniation usually focal, asymmetric and dorsolateral in position and is seen to lie
directly under the nerve root traversing that disc causing demonstrable nerve root compression or displacement
indicating nerve root compression.
MRI
MRI is a single best diagnostic test for imaging the cervical, thoracic and lumbar disc herniation. It allows direct
visualization of herniated disc material and its relationship to neural tissue including intrathecal contents.
IMAGE T1 weighted image T2 weighted image
SEQUENCE
FAT Bright Less bright
FLUID Dark Bright
USES Study the anatomy of cord and nerve Study the pathologic changes in spine
roots and spinal cord Differentiate the nucleus from annulus fibrosus
25

26. T1 weighted image T2 weighted image
INDICATIONS FOR SPINE IMAGING
 Presence of underlying systemic disease
 Progressive neurological deficits
 Cauda equina syndrome
 Candidate for therapeutic intervention
 Failed clinically directed conservative therapy
In Lumbar disc herniation, MRI shows disc herniation and their effect on the thecal sac and nerve roots,
particularly on T2 weighted images.
Disc extrusions and sequestrated disc fragments on T2 weighted images shows greater signal intensity than the
parent disc due to reflection of inflammation and matched T1 images reveals the lesion hypointense against the
bright intra-foraminal fat.
CONTRAST ENHANCED 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.
OTHER DIAGNOSTIC TESTS
These tests are done to rule out diseases other than primary disc herniation.
ELECTROMYOGRAPHY – to rule out peripheral neuropathy.
SOMATOSENSORY EVOKED POTENTIALS (SSEP) – to identify the level of root involvement
POSITRON EMISSION TOMOGRAPHY
26

27. TREATMENT
CONSERVATIVE TREATMENT
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.
BED REST
In very acute condition patient must be hospitalized and kept on bed rest. Adequate analgesic relive the
pain and this helps the muscle spasm to subside. Patient should not be kept in bed rest for not more than 3
to 4 days. The amount of straight leg raising obtained without pain is a useful indication of recovery. During
bed rest, pelvic or skin traction can applied.
DRUG THERAPY
Bed rest can be supplemented with Non steroidal anti-inflammatory drugs, analgesics, muscle relaxants
and night sedation.
PHYSIOTHERAPHY
In acute condition, traction should not be applied, only short wave diathermy and ultrasonic massage,
infrared therapy can be used. In chronic disc prolapsed, skin traction or pelvic traction with 5 to 10 pounds
can be applied.
EXERCISES
For the patients with loss of lumbar lordosis, extension exercise are important. For the patient with weak
abdominal muscle, flexion exercise must be adviced.
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.
27

28. FOR ACUTE STAGE
BRIDGING EXERCISE
Here lie on the floor, knees bent, feet flat on the floor, palms
down and raise lower back and buttocks.
KNEE HUGS
Lie flat on the floor, pull left knee towards chest firmly and at
the same time straighten right leg. It helps to passively stretch
erector spinae and the contracted fascia and ligaments over
the posterior aspect of the lumbosacral junction. Thus unload
posterior disc
PELVIC TILT
Lie on the floor, knees bent, feet flat on floor, palms down.
Push lower back flat against the floor. This decrease the
lumbar lordosis and increase the anterior aspect of pelvis.
FOR SUBACUTE OR RECOVERY STAGE
HAMSTRING STRETCH
Lie on your back, bring your knee towards your chest so
your hip is at 90º.
Place your hands around your thigh; straighten your leg
towards the ceiling until you feel a comfortable stretch in
the back of the thigh.
Hold up to 30 seconds, repeat x3 – 5 times on both legs
28

29. KNEE ROLLS
Lie on your back with your knees bent, place your arms
out to the side, level with your shoulders and palms turned
upwards. Slowly roll your knees to the right, trying to keep
your knees and ankles together.
Repeat x6 times each side, hold the stretch for as long as
is comfortable for you.
EXTENSION CONTROL
Position yourself on all fours.
Lift your opposite arm and leg into a horizontal position.
Hold for 5 -10 seconds. Try to keep your body still.
Repeat on the other side.
PARTIAL CURL (MODIFIED SIT UPS)
Lie on your back raise your upper back off the floor as you
reach with both hands for your knees. Touch the top of your
knees with your fingers. Lower your upper back slowly on
the floor. Relax your arms and take a deep breath before
repeating the exercise.
EXTENSION EXERCISE (PRESS UP)
Lying face down, leaning on your elbow/forearms. Arch
the small of your back. Keep your knees and shoulders
relaxed. Repeat x6 –10 hold for 4 -6 seconds. This
helps to increase the extension flexibility and relaxes
the muscles of back and abdomen.
YOGAASANAS FOR LUMBAR DISC PROLAPSE
These should performed only after the pain had relieved and should not be performed in acute state.
Recommend poses for Lumbar Disc Prolapse:
Tadasana (Mountain Pose) Utthita Trikonasana (Triangle Pose)
Marichyasana III (Marichi's Pose) Ardha Urdhva Mukha Svanasana (Half
Bharadvajasana (Bharadvaja's Twist) Upward-Facing Dog Pose)
Virabhadrasana II (Warrior II Pose) Balasana (Child's Pose)
Utthita Parsvakonasana (Side Angle Pose) Shavasana (Corpse Pose)
29

30. TADASANA MARICHYASANA III BHARADVAJASANA
VIRABHADRASANA II UTTHITA PARSVAKONASANA UTTHITA TRIKONASANA
BALASANA
ARDHA URDHVA MUKHA SVANASANA
SHAVASANNA
30

31. EPIDURAL STEROID
Epidural steropid injections are useful for breaking the cycle of pain in acute lumbar disc herniations. This
injection relieves pain by suppressing the inflammatory component of nerve root irritation.
INDICATIONS OF EPIDURAL STEROID
 Painful SLRT or femoral stress test
 Patient with appropriate neurological deficit
 Patient with acute on chronic symptoms, with a different level of disc pathology
CONTRAINDICATIONS
- Infection -Hemorrhagic & Bleeding diasthesis
- Evolving neurological disease - Cauda equina syndrome
- Uncontrolled diabetes mellitus - Hypertension
TECHNIQUE: Methylprednisolone (80-120mg) mixed with 2% xylocaine and normal saline made into 10ml
and injected into the epidural space through interlaminar approach and patient in lateral decubitus position
using a glass syringe.
COMPLICATIONS OF EPIDURAL STEROID INJECTION
Failure inject drug into epidural space
Bacterial meningitis, Transient hypotension, Severe paresthesia, Headache, Transient corticoidism
SURGICAL TREATMENT
GOAL: To relive neural compression and hence radiculopathy while minimizing complications.
SURGICAL OPTIONS
POSTERIOR APPROACH
Standard laminectomy and discectomy
Fenestration operation – Limited laminotomy
Microsurgical laminotomy with disc fragment excision
ANTERIOR APPROACH with or without interbody fusion
PERCUTANEOUS APPROACH – Suction, laser or arthroscopic discectomy
INDICATIONS FOR SURGERY
ABSOLUTE
 Bladder and bowel involvement: The cauda equina syndrome
31

32.  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
CONTRAINDICATIONS FOR SURGERY
o Wrong patient ( poor potency for recovery)
o Wrong diagnosis
o Wrong level
o Painless Disc Prolapse (do not operate for primary complaint of weakness/paresthesia)
o Inexperienced surgeon applying poor technical skills
o Lack of adequate instruments
CHEMONUCLEOLYSIS
It is technique in which enzymatic dissolution of the disc done using CHYMOPAPAIN. Other substances used
are collagenase, apoproteinin, chondrotininase and cathepsins.
INDICATION – Low back with radicular pain
CONTRAINDICATION OF CHEMONUCLEOLYSIS
- Sequestrated disc - Significant neurological deficit
- Disc herniation with lateral stenosis - Cauda equina syndrome
- Previous treatment with chymopapain - Spinal tumour
- Recurrence of disc herniation -Spondylolisthesis
- Pregnancy -Diabetic Neuropathy
MOA: Chymopapain injected into the intervertebral disc degrades the proteoglycan of the disc thus decrease
the water holding property of the disc and result in shrinkage of the disc.
LAMINECTOMY AND DISCECTOMY
Anaesthesia: Usually general
Position: Prone in knee chest position (Jack knife position)
Incision: Midline vertical incision over affected interspace
usually 6 -8cms.
Exposure: Subcutaneous and deep tissue deepened –
Lumbodorsal fascia divided – Supraspinous ligament incised –
32
Paravertebral muscles reflected – Spinous process of 2 or more

33. LumboDorsal fascia divided – Supraspinous ligament incised – Paravertebral muscles reflected – Spinous process
of 2 or more vertebra removed - Lamina and ligamentum flavum exposed – Cord exposed –Dura retracted –
Nerve root inspected and retracted to expose the disc – Nick is made for any loose fragments of annulus – rest
of disc material removed using disc forceps.
Closure: In layers
Post operatively: Patient allowed to turn in the bed and allowed out of the bed by 1st week
Discharged in 10 to 15 days
Advice on Discharge: Not to do stretching exercises for 6 months
HEMI OR PARTIAL LAMINECTOMY: Lamina and ligamentum flavum on one side is removed taking care not to
damage facet joint.
FENESTRATION: Removal of a part of the lamina by inter-laminar approach
TOTAL LAMINECTOMY: Removal of all of the lamina
FREE FAT GRAFTING: Before closure fat is excised from the subcutaneous tissue, soaked in dexamethasone and
placed over the exposed dura and the spinal nerves. This helps to prevent muscle from adhering to the exposed
dura and in patients who required re-operation later.
COMPLICATIONS OF LAMINECTOMY AND DISCECTOMY
The complications associated with standard laminectomy and discectomy are
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 equina lesions
Neurological damage or nerve root injury
Urinary retention and urinary tract infection
FAILED BACK SYNDROME
It is a condition characterized by persistent postoperative backache and sciatica.
VERY COMMON CAUSES COMMON CAUSES – Neuritis, Referred pain from
nonspinous site
-Recurrent/ Persistent disc material
at operated site UNCOMMON CAUSES
- Disc prolapse at other site - Discitis / Osteomyelitis/ Epidural abscess
- Arachnoiditis
- Epidural scar / Fibrosis
33 - Conustumour
- Facet arthrosis / Spinal stenosis - Thoracic, High lumbar HNP
- Epidural haematoma

34. 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.
MICRODISCECTOMY
It is technique in which microscope used in performing the disc excision.
TECHNIQUE
Pt in kneeling position – Level disc herniation palpated – A 2 to 3 cm incision directly over disc herniation about
1cm to the side of midline – A power burr used to remove few mm of cephalad lamina & 2 to 3mm of medial
aspect of inferior facet – release Ligamentum flavum – With Kerrison rongeur 2 to 3mm of medial aspect of
superior facet removed – Decompress the lateral recess stenosis to the level of pedicle – exposure of lateral disc
space – Nerve root, ligamentum flavum, epidural fat are retracted towards midline – cauterize the bleeding
epidural veins over the herniated disc –Herniated disc removed – Disc space irrigated with a catheter – The
pituitary forceps used to remove the remaining loose fragments – spinal canal palpated for any residual disc
fragments - Bleeding controlled – Wound closed in layers.
ADVANTAGES OF MICRODISCECTOMY
 Allows more magnification & illumination
 Surgery done through a small incision
 Decreased tissue trauma
 Less blood loss
 Shorter hospital stay
 Quick recovery
DISADVANTAGES OF MICRODISCECTOMY
Increased incidence of missed pathologic changes ( eg: Lateral recess stenosis, recurrent disc
herniations)
Increased rate of infection
Limited field of vision with a small incision
MICROENDOSCOPIC DISCECTOMY
 It blends percutaneous procedures and the best of microdiscectomy
 It allows for a minimum of tissue injury while optimizing the visualization.
 The 1.5cm incision disrupts minimal muscle.
 Direct observation of the nerve root maximizes the success of the procedure.
 The surgical outcomes in terms of pain relief similar to Microdiscectomy.
 Return to activites and work is accelerated due to less tissue trauma.
 Improvement in outcome is found by lessening scar tissue (epidural fibrosis) and by enhanced
visualization of the nerve root compression.
34

35. PERCUTANEOUS DISCECTOMY
To avoid the problem due to open disc excision an new technique was developed,
PERCUTANEOUS DISCECTOMY.
It can be done manually or by suction or laser or under arthroscopic guidance
Candidate for percutaneous discectomy should meet the following criteria:
 Contained disc herniation
 Major complaint of unilateral leg pain more than back pain
 Positive SLRT
 Specific neurological deficit
 Failure of conservative measures
CONTRAINDICATIONS OF PERCUTANEOUS DISCECTOMY
 Sequestrated disc
 Previous lumbar spine surgery
POSITION: Prone / Lateral decubitus
TECHNIQUE
MANUAL
With image intensification under local anaesthesia, Cannula is introduced into affected disc space
through posterolateral approach after adequate visualization of cannular placement within the disc.
Through this cannula, elongated rongeurs were introduced and manually disc material were removed
thus decompress the affected nerve root.
SUCTION DISCECTOMY
It is also known as
AUTOMATED PERCUTANEOUS
DISCECTOMY. Here similar to manual
method, instead of elongated rongeurs,
a thin 2mm cutting aspiration probe
that connected to a negative pressure
of 600mmhg. The device morselizes the
nucleus and carries it away in saline
irrigant.
PERCUTANEOUS LASER DISCECTOMY
Here ablative laser energy delivered through an optical fiber to the interior of the disc space.The disc
material removed by vaporization. The volume of disc material removal depends on the wavelength of laser
energy and the amount of energy utilized. A variety of laser are utilized like carbondioxide, Holmium: Yttrium-
aluminium-garnet (YAG), neodymium:YAG, argon.
PERCUTANEOUS ARTHROSCOPIC DISCECTOMY
In this technique, the spinal nerve root and offending disc material can be visualized directly and free
fragments of extruded disc material can be removed. Thus subannular and sequestrated disc can be removed.
35

36. COMPLICATIONS OF PERCUTANEOUS DISCECTOMY
Discitis, Psoas hematoma, Vasovagal reaction. Neurological and vascular injury are uncommon.
ARTIFICIAL DISC
The implant is designed to bear the load through the spine at that level and prevent further collapse of the
affected vertebral segments thus protect the remaining disc.
Patient not suitable for artificial disc replacement are
Osteoporosis
Spondylolisthesis
Infection or tumour of spine
Spine deformities from trauma
Facet arthrosis
The estimated life span of an artificial disc prosthesis is over 80years.
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.
TECHNIQUE: Patient awake and under a local anaesthesia with mild sedation, a special wire known as
Electrothermal catheter is inserted into the disc – Electrical current passed through the wire – Heating of the
disc theoretically modify the collagen fibres of the disc - Destroy the pain receptors in the area of disc
SPECIAL SITUATION WITH LUMBAR DISC PROLAPSE
LUMBAR DISC PROLAPSE with Spondylolisthesis
Patients with a spondylolisthesis may suffer from a disc rupture, which causes an acute radicular
syndrome. Most of these will occur at the level above the spondylolisthesis. A disc herniation at the
same level of the slip usually occurs into the foramen. For the disc herniation above the slip level,
simple disc excision or chemonucleolysis. For the disc herniation at the slip level, discectomy should be
accompanied by a stabilization procedure.
LUMBAR DISC PROLAPSE in Spinal Stenosis
Spinal stenosis can occur in the central canal or lateral zones. It can be an asymptomatic or a mildly
symptomatic condition that can suddenly convert to a significant disability when a disc herniation
occurs. The presenting symptoms will be mainly leg. Simple microscopic removal of the disc herniation
along with a local decompression of the stenotic segment is the proposed method of treatment. If, on
36

37. history, the stenotic component was significantly symptomatic before the occurrence of the HNP, a
wider decompression is needed to treat both the stenosis and the HNP.
LUMBAR DISC PROLAPSE in Instability
Patients with a long history of back pain and significant DDD revealed on plain radiograph may suffer
from a disc herniation at the degenerative level. If the disc degeneration and HNP are confined to one
level, consider fusion. If the disc degeneration is present at multiple levels, either on plain radiograph,
discography, or MRI, simple disc excision is the best choice.
LUMBAR DISC PROLAPSE in the Adolescent Patient
The younger patient with a disc herniation is a special problem. Because of the high incidence of
protrusions rather than disc extrusions, it is proposed that in this age group the optimal treatment is
chemonucleolysis rather than surgical intervention.
Recurrent LUMBAR DISC PROLAPSE (After Discectomy)
Reherniation of discal material occurs in approximately 2% to 5% of patients. The recurrence may
occur at any interval after surgery (days to years) and is most often at the same level/same side. If the
recurrence is at the same level/opposite side or another level, it can be considered a virgin HNP. But,
most recurrences are same level/same side, and scar tissue from the previous surgery introduces a
whole new element to diagnosis and treatment.
REFERENCES
1. MACNAB’S BACKACHE by David A.Wong 4th edition
2. THE LUMBAR SPINE by Sam W Wiesel 2nd edition
3. MANAGING LOW BACK PAIN by W.H.Kirkildy – Willis 3rd edition
4. ORTHOPAEDIC PHYSICAL ASSESSMENT by David Magee 5th edition
5. ORTHOPAEDIC PRINCIPLE AND THEIR APPLICATION by TUREK 4TH Edition
6. CAMPBELL’S OPERATIVE ORTHOPAEDICS 11TH EDITION
7. INTERNET
“LEARN TO BE GOOD TO
YOUR BACK AND YOUR
BACK WILL BE GOOD TO
YOU….”
37