PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc AGRASEN HOSPITAL Gondia Vidarbha DR SANDEEP C AGRAWAL

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 [email protected]

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DEFINITION Outpouching of disc

Nucleus pulposus along with few annular fibres and end plate cartilage through tears in annulus f ibrosus 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 SMOKINGBlood 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 BulgeContained 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 HerniationPathophysiology

• 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




Lumbar Disc HerniationPathoanatomy

• 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

Lumbar Disc HerniationClinical 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 POINTSLUMBAR 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










Lumbar Disc HerniationManagement

• 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. FlavumLower 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)




Lumbar Disc HerniationPrognosis 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 [email protected] 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 [email protected] 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 looseand 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

valuable.JADA ‘08

Health & Medicine

PROLAPSE DISC (Slip Disc ) Herniation Intervertebral Disc AGRASEN HOSPITAL Gondia Vidarbha DR SANDEEP C AGRAWAL