IVDP

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IntervertebralDisc Prolapse

• D. Kavitha
• CON,EIMs

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DEFINITION

• Spinal disc herniation, also known as a slipped
  disc, is a medical condition affecting the spine
  in which a tear in the outer, fibrous ring of an
  intervertebral disc allows the soft, central
  portion to bulge out beyond the damaged outer
  rings.

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• Is relatively avascular structure and the
  Essential minerals and fluids required for
  regeneration enter the disks passively during the
  night

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FUNCTIONS OF IVD

• Location
• The majority of spinal disc herniation cases
  occur in lumbar region (95 in L4-L5 or L5-S1).
• The second most common site is the cervical
  region (C5-C6, C6-C7).
• The thoracic region accounts for only 0.15 to
  4.0 of cases.

• 1 It supports the axial load on the column that
  is delivered by the body mass.
• 2 Assist a limited range of motion at the spine.
• 3 Shock absorbing system.
• 4 Serve ligamental functions between vertebral
  bodies.
• 5 Assist to keep the normal shape curvature of
  each spinal region (cervical, thoracic, ..etc)

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Cervical disc herniation

• Cervical disc herniations occur in the neck, most
  often between the fifth sixth (C5/6) and the
  sixth and seventh (C6/7) cervical vertebral
  bodies.
• Symptoms can affect the back of the skull, the
  neck, shoulder girdle,scapula, shoulder, arm, and
  hand.
• The nerves of the cervical plexus and brachial
  plexus can be affected.

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Cont..,

• Lumbar
• Lumbar disc herniations occur in the lower back,
  most often between the fourth and fifth lumbar
  vertebral bodies or between the fifth and the
  sacrum.
• Symptoms can affect the lower back,buttocks,
  thigh, anal/genital region (via the Perineal
  nerve), and may radiate into the foot and/or toe.

• Thoracic
• Thoracic discs are very stable and herniations in
  this region are quite rare.
• Herniation of the uppermost thoracic discs can
  mimic cervical disc herniations, while herniation
  of the other discs can mimic lumbar herniations.

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Causes

• Living a sedentary lifestyle
• Individuals who rarely if ever engage in
  physical activity are more prone to herniated
  discs because the muscles that support the back
  and neck weaken, which increases strain on the
  spine.

• Obesity
• Spinal degeneration can be quickened as a
  result of the burden of supporting excess body
  fat.
• Practicing poor posture
• Improper spinal alignment while sitting,
  standing, or lying down strains the back and neck.

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Causes

• Repetitive mechanical activities
• Frequent bending, twisting, lifting, and other
  similar activities without breaks and proper
  stretching can leave the discs damaged.

• Traumatic injury to lumbar discs commonly occurs
  when lifting while bent at the waist, rather than
  lifting with the legs while the back is straight

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Causes

• Mutation
• - In genes coding for proteins involved in the
  regulation of the extracellular matrix, such as
  MMP2 and THBS2, has been demonstrated to
  contribute to lumbar disc herniation.

• Tobacco abuse
• The chemicals commonly found in cigarettes
  can interfere with the discs ability to absorb
  nutrients, which results in the weakening of the
  disc.

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Other Causes

• Aging
• Repeated stress
• Multigravida
• Use of vibrating equipment
• Small spinal cord
• Internal disc dearrangement
• Stressful occupation

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Pathophysiology
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Stages of Disc Prolapse
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Symptoms

• Pain behind the shoulder blade(s) or in the
  buttock(s)
• Pain running down one or both arms or legs
• The location of these symptoms depends upon which
  nerve(s) has been affected. In other words, the
  precise location of the symptoms helps determine
  your diagnosis.
• Weakness involving one or both arms or legs

• The symptoms of a herniated or prolapsed disc may
  not include back or neck pain in some
  individuals, although such pain is common.
• In severe cases, loss of control of bladder
  and/or bowels, numbness in the genital area, and
  impotence (in men)
• Numbness, pins and needles, or tingling in one or
  both arms or legs

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Types of herniation

• 2. central (posterior) herniation
• less frequently, a protruded disc above second
  lumbar vertebra may compress spinal cord itself
  or it may result in cauda equina syndrome.
• in the lower lumbar segments, central herniation
  may result in S1 radiculopathy.
• 3. lateral disc herniation
• may compress the nerve root above the level of
  the herniation
• L4 nerve root is most often involved patient
  typically have intense radicular pain.

• Posterolateral disc herniation
• protrusion is usually posterolateral into
  vertebral canal, compress the roots of a spinal
  nerve.
• protruded disc usually compresses next lower
  nerve as that nerve crosses level of disc in its
  path to its foramen. (eg.protrusion of fifth
  lumbar disc usually affects S1 instead.

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DIAGNOSIS

• X-Ray lumbo-sacral spine
• Narrowed disc spaces.
• Loss of lumber lordosis.
• Compensatory scoliosis.
• CT scan lumber spine
• It can show the shape and size of the spinal
  canal, its contents, and the structures around
  it, including soft tissues.
• Bulging out disc.

• Diagnosis is based on the history, symptoms, and
  physical examination.
• At some point in the evaluation, tests may be
  performed to confirm or rule out other causes of
  symptoms such as spondylolisthesis,degeneration,
  tumors, metastases and space-occupying lesions.

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Normal MRI

• MRI lumber spine
• Intervertebral disc protrusion.
• Compression of nerve root.
• Myelogram
• pressure on the spinal cord or nerves, such as
  herniated discs, tumors, or bone spurs.

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Medical treatments

• Oral steroids (e.g. prednisone or
  methylprednisolone).
• Epidural cortisone injection.
• Intravenous sedation, analgesia-assisted traction
  therapy (IVSAAT).
• Weight control.
• Tobacco cessation.
• Lumbosacral back support.
• anti-depressants.

• Bed rest.
• Non-steroidal anti-inflammatory drugs (NSAIDs).
• Patient education on proper body mechanics.
• Physical therapy, to address mechanical factors,
  and may include modalities to temporarily relieve
  pain (i.e. traction, electrical stimulation
  massage).

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Cont..,

• Conservative
• Bed rest
• Medications
• Physical therapy
• Lifestyle modifications
• Chiropractic manipulation
• Lumbo-sacral orthosis
• Selective injections
• Intradiscal Electrothermal Therapy ( IDET )

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Novel Therapy

• Infliximab
• TNF alfa inhibitor
• Injection of Ozone into disc and around nerve
  roots

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Surgical management

• Discectomy/Microdiscectomy
• This procedure is used to remove part of an
  intervertebral disc that is compressing the
  spinal cord or a nerve root.

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The Tessys method

• The Tessys method (transforaminal endoscopic
  surgical system) is a minimally invasive surgical
  procedure to remove herniated discs .

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Laminectomy

• To relieve spinal stenosis or nerve compression

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Hemilaminectomy

• Hemilaminectomy is surgery to help alleviate the
  symptoms of an impinged or irritated nerve root
  in the spine

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Lumbar fusion

• Anterior lumbar fusion is an operation done on
  the front (the anterior region) of the lower
  spine.
• Fusion surgery helps two or more bones grow
  together into one solid bone.

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Cont..,

• Total Disc Replacement
• Artificial Disc replacement (ADR), or Total Disc
  Replacement (TDR),
• is a type of arthroplasty.
• It is a surgical procedure in which degenerated
  intervertebral discs in the spinal column are
  replaced with artificial devices in the lumbar
  (lower) or cervical (upper) spine.

• Fusion cages are new devices, essentially hollow
  screws filled with bone graft, that help the
  bones of the spine heal together firmly.
• Surgeons use this procedure when patients have
  symptoms from disc degeneration, disc herniation,
  or spinal instability.
• lumbar fusion is only indicated for recurrent
  lumbar disc herniations, not primary herniations

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Post operative management

• Immediate post op
• Monitor neurology
• Turn in bed , semi fowler position
• Walk with assistance to toilet
• Oral analgesics and muscle relaxants for pain
• Bladder stimulants to assist in voiding
• Discharge- after walking and voiding(day of
  surgery in microscopic discectomy)
• minimize sitting and riding in a vehicle to
  comfort
• Increase walking on a daily basis
• Avoid stooping bending lifting

• Delayed
• Core strengthening between week 1 3
• Lifting bending stooping gradually after 3 weeks
• Long trips avoid for 4-6weeks
• Walking jobs with minimal lifting 2-3weeks
• Prolonged sitting jobs 4-6 weeks
• Heavy labor, long driving 6-8weeks
• Exceptionally heavy manual labour- avoid

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Complications

• Chronic pain
• Peeminant nerve injury
• Paralysis

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Nursing management

• Assess the general condition of the patient
• Check the vital signs
• Assess the level and characteristics of pain
• Provide proper back care and skin care to the
  patient
• Advice patient to do proper exercise
• Provide adequate nutrition

• Change the position frequently
• Advice to avoid heavy exercise like heavy weight
  lifting
• Put traction for the prescribed period of time.
• Continue the medications till the doctor adviced

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Nursing management

• Use proper body alignment
• Use soft cervical collar to reduce pain
• Encourage walking, lying down, shifting weight
  from one foot to other when standing
• Avoid jumping
• Do strengthening exercise
• Adjust height of chair,
• Avoid forward flextion
• Sitting limited to 20- 50 min

• Assess the pt passes flatus present of bowel
  sounds
• Promote adequate bladder bowel emptying
• Use braces for/during movement
• Explain about signs symptom of complication
• Avoid prolonged standing
• Push objects than pull
• Keep load close to your body when lifting
• Lift with large leg muscles not the back muscles

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Bed Rest
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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.

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Exercise Yogaasanas
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Yogaasanas
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Yogaasanas
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Life style modification
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• Thank you