LOWER BACK PAIN AND HERNIA OF INTERVERTEBRAL DISC

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LOWER BACK PAIN AND HERNIA OF INTERVERTEBRAL DISC

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Functions of the Spine

• Structural support and balance for upright posture

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Functions of the Spine

• Protection
• Spinal cord and nerve roots

• Internal organs

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Functions of the Spine

• Flexibility of motion in six degrees of freedom

Left and Right Side Bending
Flexion and Extension
Left and Right Rotation
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Basic Terminology
Posterior

• Cranial - the head or towards the head
• Caudal - the tail or towards the tail
• Anterior - the front section or towards the front
• Posterior - the back section or towards the back
• Ventral - the front or anterior surface
• Dorsal - the back or posterior surface

Cranial
Dorsal
Ventral
Anterior
Caudal
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Vertebral Structures

• Pedicle notches

• Intervertebral foramen

Slight Notch

• Nerve roots exit

Deep Notch
Intervertebral Foramen
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Vertebral Structures
Body
Pedicle
Vertebral Foramen
Transverse Process
Lamina
Superior Articular Process
Spinous Process
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Vertebral Arches

• Anterior Arch
• Vertebral body
• Anterior 1/3 pedicles

• Posterior Arch
• Posterior 2/3 pedicles and posterior elements
• Arches form the vertebral foramen

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Vertebral Structures
Superior Articular Process

• Articular processes

Pars

• Pars interarticularis

Zygapophyseal Joint (Facet Joint)
Inferior Articular Process
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Lumbar Vertebrae

• Body - L1 to L5 progressive increase in mass

• Pedicles - longer and wider than thoracic oval
  shaped

• Spinous processes - horizontal, square shaped

• Transverse processes - smaller than in thoracic
  region

• Intervertebral foramen - large, but with
  increased incidence of nerve root compression

• Spinal foramen- large to allow for cauda equina
  and nerve roots

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Vertebral Structures

• Intervertebral Disc

• End Plate

• Cartilaginous

• Bony

• Apophyseal Ring

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The Motion Segment

• The FUNCTIONAL UNIT of the spine
• Comprised of
• Two adjacent vertebrae
• Intervertebral disc
• Connecting ligaments
• Two facet joints and capsules

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Intervertebral Disc

• Fibrocartilaginous joint of the motion segment
• Makes up ¼ the length of the spinal column
• Present at levels C2-C3 to L5-S1
• Allows compressive, tensile, and rotational
  motion
• Largest avascular structures in the body

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Intervertebral Disc
Annulus Fibrosus

• Annulus Fibrosus
• Outer portion of the disc

• Made up of lamellae

• Layers of collagen fibers
• Arranged obliquely 30
• Reversed contiguous layers

Lamellae

• Great tensile strength

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Intervertebral Disc

• Nucleus Pulposus

Nucleus Pulposus

• Inner structure
• Gelatinous
• High water content
• Resists axial forces

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Intervertebral Disc

• Largest avascular structure
• Blood supply by diffusion through end plates
• Damage to the blood supply leads to degradation
  of the disc

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Anatomy and Degenerative Change

• The Vertebral Body (VB)
• Key Roles
• Carry 80 of the axial loads through VB and disc
• Endplates enable nutrition to diffuse to disc

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Intervertebral Disc
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The Intervertebral Disc

• Has two roles
• Shock absorber of axial forces
• Pivot point in motion segment

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Intervertebral Disc
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Ligaments
Posterior longitudinal ligament
Anterior longitudinal ligament
Ligamentum flavum
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Spinal Ligaments

• Bands or sheets of tough, fibrous tissue that
  connect bones, cartilage, or other structures
• Become active when stressed to maximum range of
  motion
• Protect the joints from being hyperflexed

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The Intervertebral Disc and Degenerative Change

• Two major components of IVD
• Annulus fibrosis thick, fibrous radial tire
• Lamellae
• Nucleus pulposus ball-like gel

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The Intervertebral Disc (IVD) and Degenerative
Change

• By age 50, 95 of people show lumbar disc
  degeneration
• Not all have symptoms
• Significant changes to IVD are
• Water and proteoglycan content decreases
• Collagen fibers of AF become distorted
• Tears may occur in the lamellae
• Results in
• Disc loses height and volume
• Loses resistance to loading forces
• No longer acts as a shock absorber

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Overview - cont.

• The motion segment is the functional unit of the
  spine and consists of
• Muscle (activators)
• Ligaments (passive restraints)
• Adjacent vertebral bodies
• A 3-joint complex of two facet joints and a disc
  (pivots)
• Degeneration can begin in one or more of these
  joints, but ultimately all three will be affected

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Degenerative Conditions

• Provide an overview of degenerative conditions
• Degenerative Disease
• Spinal Stenosis
• Herniated Disc

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Degenerative Disease - Overview

• Loss of normal tissue structure and function due
  to aging process
• Changes are usually gradual, trauma sometimes
  accelerates
• Degenerative changes do not always lead to
  clinical symptoms
• When changes cause symptoms (often pain), the
  process is referred to as osteoarthritis
• Spondylosis is degenerative changes in the spine

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Anatomy and Degenerative Change

• The Vertebral Body (VB)
• Degenerative Changes
• Sclerosis Increased bone formation adjacent to
  endplates
• Reduces nutrition diffusing to disc
• Stiffens endplate, and reduces ability to absorb
  loads
• Osteophytes Formation of small bony spurs
• Can project into neuro structures

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Facet Joints and Degenerative Change

• Key Roles
• Carry 20 of compressive loads
• Help stabilize spine
• Degenerative Changes
• Cartilage lining loses water content
• Cartilage wears away
• Facets override each other
• Leads to abnormal function of motion segment

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Anatomy and Degenerative Change

• Ligaments and Muscles
• Ligaments attach bone to bone
• Provide stability, enable normal motion
• Degenerative Changes
• Partial ruptures, necrosis and calcifications
• Negatively impact function of motion segment

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Degenerative Disc Disease

• Changes include
• Disc loses height and volume
• Compressive loads transfer away from nucleus to
  margins
• Sclerosis of endplate reduces disc nutrition
• Facet joints wear away cartilage, begin to
  override
• Motion segment becomes hypermobile
• Osteophytes develop to attempt to stabilize
  motion segment
• Osteophytes may encroach on neuro structures

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Spinal Stenosis

• Narrowing of the spinal canal and/or lateral
  foramen through which the nerves travel
• Three types
• Central stenosis in central spinal canal where
  cord or cauda equina are located
• Lateral recess stenosis in the tract where nerve
  roots exit canal
• Acquired in lateral foramen where nerve roots
  exit to body
• Most frequent in lower cervical and lower lumbar
  spine

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Herniated Disc

• Often called ruptured disc
• Very common pathology
• L3-4, L4-5, L5-S1 common locations
• Thought to be a culmination of acute traumatic
  events to the disc

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Herniated Disc 4 degrees

• Nuclear herniation nucleus ruptures. No
  disruption of outer annular fibers
• Disc protrusion ruptured nucleus causes outer
  fibers to bulge
• Nuclear extrusion Complete split in annulus.
  Material leaks but remains attached to nucleus
• Sequestered nucleus Leaked substance no longer
  attached to nucleus

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INTRODUCTION

• The back and leg pain since - Greeks recognized
  it.
• In the fifth century AD Aurelianus clearly
  described the symptoms of sciatica.
• The sciatica arose from either hidden causes or
  observable causes- a fall, a violent blow,
  pulling, or straining.

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• The most notable of these is the Lasègue sign, or
  straight-leg raising test, described by Forst in
  1881 but attributed to Lasègue, his teacher.

This test was devised to distinguish hip disease
from sciatica.
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Biomechanics of the lumbar spine
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Biomechanics of the lumbar spine
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Biomechanics of the lumbar spine
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Biomechanics of the lumbar spine
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Biomechanics of the lumbar spine
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Biomechanics of the lumbar spine
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INTRODUCTION

• Mixter and Barr in their classic paper published
  in 1934 again attributed sciatica to lumbar disc
  herniation.

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Definition

• Ruptured discs are among the most common and
  painful of all back ailments.
• The condition occurs when the outer cover of a
  disc is torn and the soft inner tissue extrudes.
  The extrusion often puts pressure on the spinal
  nerves, causing back and leg pain which can be
  severe.
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Prolapsed intervertebral disc

• It usually occurs in the L4/5 or L5/S1
  intervertebral disc regions and is most often
  seen on only one side but may be bilateral.
• It may occur in other regions, especially at the
  L3/4 level, and occasionally disc protrusion may
  occur at more than one level simultaneously.
• It is often due to degeneration of the disc and
  therefore occurs most commonly in middle or old
  age.
• Degeneration of the annulus fibrosus allows the
  nucleus pulposus to herniate through

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Leakage of nucleus pulposus material to nerve
roots, is a pathophysiologic mechanism in LBP and
sciatica

• Incision of the anulus fibrosus induces nerve
  root morphologic, vascular, and functional
  changes. An experimental study.
• Kayama --Japan Spine 1996
• The nerve conduction velocity was significantly
  lower in the incision group (13 14 m/sec)
  compared with the nonincision group (73 5 m/sec).
  
• The obvious signs of capillary stasis with an
  increased number and diameter of the intraneural
  capillaries in the incision group.

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Cultured, autologous nucleus pulposus cells
induce functional changes in spinal nerve roots

• Kayama --Sweden Spine 1998
• Nucleus pulposus cells and fibroblasts were
  cultured for 3 weeks, and various preparations
  were applied to the cauda equina in 29 pigs.
  After 1 week, nerve conduction velocity was
  determined by local electrical stimulation.
• Application of nucleus pulposus cells reproduced
  the previously seen reduction in nerve conduction
  velocity induced.

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Phospholipase A2 sensitivity of the dorsal root
and dorsal root ganglion

• Ozaktay USA Spine 1998 Jun
• Phospholipase A2 appeared to be neurotoxic when
  doses ranging from 100 to 400 U were applied on
  the mechanically sensitive segments of the dorsal
  root ganglia.
• PLA2 doses comparable to serum concentrations in
  human rheumatoid arthritis when applied to dorsal
  root ganglia.
• These results suggest that dorsal roots and
  dorsal root ganglion may be impaired by
  phospholipase A2, leading to sciatica and low
  back pain.

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Chronic Compression of Dorsal Root Ganglion
Produced by Intervertebral Foramen Stenosis

• Hu SJ- Xi'an, PR China Pain 1998 Jul
• An experimental model in the rat.
• A small stainless steel rod (0.5-0.8 mm in
  diameter) was inserted into the L5 intervertebral
  foramen
• These neurons had a greatly enhanced sensitivity
  to mechanical stimulation of the injured DRG and
  a prolonged after discharge.
• a persistent heat hyperalgesia 5-35 days
• The excitatory responses were evoked in the
  injured, but not the uninjured, DRG neurons.

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EPIDEMIOLOGY-risk factors

• Multiple factors affect the development of back
  pain.
• smoking, pro-longed daily driving of motor
  vehicles, jobs requiring frequent repetitive
  lifting of heavy objects and twisting, the use of
  jackhammers and machine tools, and the operation
  of motor vehicles episodes of anxiety and
  depression.
• It is more common in males than females and has a
  maximal incidence in the third and fourth decades
  of life.

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LUMBAR DlSC HERNlATION

• Back pain may be caused by stimulation of the
  pain fibers in the outer layers of the annulus
  fibrosus.
• Alternatively, distortion of the posterior
  longitudinal ligament, which is richly innervated
  by pain fibers, may result in back pain.
• Leg pain can result from compression of a nerve
  root by an HNP

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CIinicaI Presentation

• The following are risk factors for herniated disc
  disease in the lumbar spine
• smoking, pro-longed daily driving of motor
  vehicles, and frequent repetitive lifting of
  heavy objects and twisting.
• It is more common in males than females and has a
  maximal incidence in the third and fourth decades
  of life.

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• The clinician must rule out a compressive lesion
  of the sciatic nerve peripherally before
  ascribing the pain to a herniated disc.
• There may be a history of a previous injury.

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CIinicaI Presentation

• A symptom- HNP. Sciatica is pain along the course
  of the sciatic nerve.
• The classic symptom is low back pain with
  radiation of severe pain down the back of the leg
  to the ankle and foot.
• It may be associated with neurological signs such
  as motor and sensory loss and occasionally
  bladder involvement.

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The levels of lumbar HNP

• The most common levels - L4--L5 and L5--Sl.
• For this reason, radicular symptoms almost always
  refer to symptoms below the level of the knee, in
  the L5 or S1 dermatome.
• Leg symptoms can vary from numbness to
  dysesthesia to true pain.
• The herniation of the L4--L5 disc can compress
  the S5 and
• The lumbosacral disc causes compression of the S1
  nerve root.

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Symptoms and signs of the lumbar spine

• There is often associated spasm of the spinal
  muscles with tenderness over the lower lumbar
  spine on the side of the lesion.
• The muscular spasm may produce a scoliosis.
  Limitation of lateral flexion of the lumbar spine
  to the same side will be most marked with a
  protrusion lateral to the nerve root,
• while limitation of lateral flexion to the
  opposite side will be most marked with a
  protrusion medial to the nerve root.

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Focal signs

• Focal signs are dependent on the distribution of
  the affected nerve root.
• With L4 compression there is weakness of
  quadriceps and tibialis anterior, with sensory
  change over the medial aspect of the shin and
  depression of the knee jerk.
• L5 root compression may solely declare itself by
  weakness of extensor hallucis longus. Any sensory
  change is found over the medial aspect of the
  dorsum of the foot and the lateral shin.
• In an Sl root syndrome weakness can occur in the
  buttock muscles, the hamstrings or the calf
  muscles. The ankle jerk is likely to be depressed
  or absent. Sensory change particularly occurs
  over the lateral aspect of the foot and the calf.

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Protrusion of the L4/5 disc

• It may cause L5 root pressure with pain radiating
  down the leg to the dorsum of the foot.
• There may be numbness on the outer side of the
  calf and medial two-thirds of the dorsum of the
  foot
• with weakness of dorsiflexion, particularly of
  the foot and toes.

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Protrusion of the L4/5 disc
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• Protrusions at the L4/5 level will thus compress
  the L5 root, while protrusions at the L5/S1 level
  will compress the first sacral root.

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Protrusion of the L5/S1 disc

• It will press on the S1 nerve root and may lead
  to pain and numbness on the outer side of the
  foot and under side of the heel.

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Protrusion of the L5/S1 disc

• There may be weakness of both eversion and
  plantarflexion of the
• foot with a diminished or
• absent ankle jerk.

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Protrusion of the L3/4 disc

• It may cause pressure on the L4 nerve root
• may lead to numbness over the front of the knee
  and leg
• with diminution of the knee jerk
• and weakness of the knee extensors.

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Protrusion of the L3/4 disc

• Femoral nerve traction test

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Central protrusion of a lower lumbar disc

• It can press on the cauda equina
• lead to urinary retention.
• On examination there is usually perianal numbness
  and a patulous anus.
• Emergency decompression is essential to avoid
  permanent damage to sphincter innervation.

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Central disc protrusion

• Following a central disc protrusion, which can
  occur without an antecedent history of back pain,
  cauda equina compression occurs, often in an
  abrupt fashion.
• Severe pain results, with paravertebral
  localization or with radiation into both lower
  limbs.
• Typically, there is severe distal lower limb
  weakness with foot drop, depression of the ankle
  reflexes and impaired sphincter function. Saddle
  anaesthesia is common.

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• Occasionally the protrusion is central, pressing
  on the cauda equina and affecting autonomic
  control of the bladder leading to urinary
  retention.
• Urgent surgical decompression of the cauda equina
  is required as an emergency.

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CIinicaI Presentation

• Any maneuver that increases intraspinal pressure,
  such as straining at stool, coughing, or
  sneezing, may exacerbate symptoms.
• In over half the patients with sciatica from an
  HNP, a specific nerve root can be identified,
  simply by history.
• Weakness the tibialis anterior---go downstairs,
• the gastrocnemius soleus muscle group --- going
  upstairs difficult.

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Treatment

• Not all patients suffer pain
• As outer disc distorts, may protrude into spinal
  canal
• May lead to sciatica (pain down back of leg)
• Often start with conservative, non-operative care
• Spontaneous resolution of sciatica often occurs
• Patients with cauda equina syndrome require
  surgical attention
• Common surgical procedures include
• Laminectomy, discectomy, microdiscectomy,
  endoscopic discectomy, ablation procedure

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Physical Examination

• The posture Often there is a functional
  scoliosis
• Range of motion of the lumbar spine may be
  limited due to paravertebral muscle spasm or
  guarding. Forward flexion may increase the
  symptoms of sciatica.
• Palpation may show tenderness in the sciatic
  notch due to irritation of the nerve.

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Physical Examination

• Straight-leg raising is performed by gently
  elevating the outstretched leg from the
  horizontal with the patient lying supine. The
  degree of movement is recorded.
• The most specific sign for lumbar disc herniation
  is a contralaterally positive straight leg
  raising examination, also called cross-leg test.
• A femoral stretch test usually indicates a disc
  herniation at the L3--L4 level or above.
• A meticulous neurologic examination is necessary
  to detect motor weakness, sensory changes, and
  deep tendon reflex asymmetry.

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Plain X-rays

• Plain X-rays are of very limited value in the
  investigation of a lumbar radiculopathy.
• Beside Marked focal disc space narrowing, plain
  X-rays are often normal.
• But its most important value is rule out the bony
  disorders of the lumbar spine, TB, Tumor.

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Special Radiographic Studies

• Myelography
• Purpose
• Show compression or displacement of neural
  elements
• Method
• Radiopaque material injected into the thecal sac
• Standard x-rays and/or fluoroscopy
• Reading
• Neural structures are dark
• Contrast material white

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Special Radiographic Studies

• Discography
• Purpose
• Evaluate patency of disc
• Establish whether disc is causing back/radicular
  pain
• Method
• Place needle into disc under fluoro
• Inject dye into the disc
• Reading
• Dye leaks out of nucleus incompetent disc
• Injection reproduces pain disc as source of
  pain (Provocative discogram)

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Special Radiographic Studies

• Computed Tomography (CT/CAT)
• Purpose
• Detect bony tissue pathologies
• Method
• Multiple slices of axial x-ray images (1-4mm)
• Computer constructs into permanent image
• High radiation exposure

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Special Radiographic Studies

• Magnetic Resonance Imaging (MRI)
• Purpose
• Detect soft tissue pathologies
• Method
• Uses magnetic and radio wave energy
• Shows a two-dimensional slice
• Coronal, sagittal or axial view
• No radiation

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Special Radiographic Studies

• Bone Scan
• Purpose
• Detect inflammation, infection, tumor
• Method
• Inject radioisotope into the bloodstream
• Isotope absorbed by bone tissue
• Gamma scan detects radiation
• Reading
• Dark areas increased activity
• (hot spot)

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Radiology Overview
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Plain CT

• CT is recommended as the initial investigation
  for the evaluation of lumbar disc disease,
• It can show many disorders of the level
• lumbar canal stenosis
• the lateral recess syndrome
• calcification of the disc.

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CT myelography

• CT myelography complements myelography in the
  investigation of suspected lumbar disc
  protrusion. Myelography achieves a 60-80 per cent
  accuracy in the diagnosis of herniated lumbar
  disc. It tends to fail in the situation of
  lateral disc rupture or where there is a large
  epidural space or a short dural sac. For many
  patients plain CT suffices as a primary
  procedure. If it fails, routine myelography can
  be considered augmented, in some cases, by CT
  myelography. Either technique can clearly
  demonstrate either a posterolateral (Fig 13.16)
  or central disc prolapse.

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MRI

• MRI is now the screening technique of choice for
  the accurate definition of lumbar disc
  herniation.
• Using T2-weighted images, the nucleus pulposus
  and annulus fibrosus can be distinguished.
• Sagittal imaging using both Tl and T2 sequences
  defines the degree of disc protrusion and the
  extent of any spinal stenosis.

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MRI
Axial views are more valuable in assessing nerve
root compression. Even in the absence of disc
protrusion, MRI can identify tears in the annulus
fibrosus which sometimes enhance with gadolinium.
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The differential diagnosis

• The differential diagnosis of lumbar neurological
  compression includes the various causes of low
  back pain
• The causes of localised nerve root pressure.
• These include secondary tumours and multiple
  myeloma of the lumbar spine which usually cause
  vertebral destruction with sparing of the discs.
• Fractures and infections of the spine may also
  cause nerve root and spinal cord compression.

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Back Pain-Summary of Causes in the lumbar spine
and pelvis
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TRACTION

• In the case of sciatic irritation due to a
  prolapsed disc, pelvic traction, will help to
  distract the lumbar vertebrae and increase the
  size of the intervertebral foramina, thus
  relieving the pressure on the nerve.
• It may be necessary to continue this for two or
  three weeks, and the patient should be gradually
  mobilised with a lumbosacral brace.

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• Occasionally an epidural injection of local
  anaesthetic and steroids will alleviate the
  symptoms.
• In over 90 of cases, conservative management is
  successful and operation can be avoided. It is
  essential, however, that patients build up weak
  extensor muscles of the spine and regularly
  exercise the spine.
• Swimming in a warm pool is probably the best form
  of exercise.

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Surgical intervention

• The key to good results in disc surgery is
  appropriate patient selection and elective. The
  unilateral leg pain extending below the knee has
  been present for at least 6 weeks.
• This should allow a thorough evaluation to
  confirm the diagnosis, level of involvement, and
  the physical and psychological status of patient.
  
• Frequently when there is a rush to the operating
  room to relieve pain without proper investigation
  both the patient and physician later regret the
  decision.

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Lumbar laminectomy
129
Indications for operation on prolapsed discs

• No improvement in the symptoms and signs after 6
  weeks rest.
• An increase in the neurological deficit.
• Bladder or bowel involvement suggesting a cauda
  equine syndrome. It is mandatory and urgent only
  in cauda equina syndrome with significant
  neurological deficit, especially bowel or bladder
  disturbance.
• Intractable pain. The pain should have been
  decreased by rest, antiinflammatory medication,
  recurring after the conservative care. The
  progressive or unresponsive lesions with
  appreciable neurological signs despite
  conservative management.

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Lumbar laminectomy or laminotomy

• For the past 60 years, patients suffering from
  disc herniation underwent two procedures.

This laminotomy procedure requires making a two-
to four-inch incision in the skin, cutting muscle
and removing the bone overlying the damaged disc.
Because laminotomy is so invasive, it is called
an "open" procedure.
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Spinal stenosis

• Though in many patients spinal stenosis is
  congenital, in others it is secondary to
  hypertrophy of the bony elements of the lumbar
  canal, ligamental hypertrophy or disc
  degeneration. The stenosis may principally affect
  the central canal, the lateral recess, or the
  intervertebral foramen and nerve root canal
• Canal stenosis usually affects middle-aged men.
  Typically, paroxysmal numbness or paraesthesiae,
  rather than pain, appear in the lower limbs
  during walking and sometimes in certain standing
  postures. The symptoms often spread, usually from
  the distal parts of the extremities to the
  proximal, then resolve after resting or lying
  flat for several minutes. Physical examination
  tends to be unrewarding.

133
Spinal stenosis

• Plain X-rays are of limited value in the
  investigation of the stenotic syndromes.
• High-resolution CT is the investigation of
  choice, allowing definition both of the central
  canal and of the lateral recess. Findings include
  a congenitally narrow canal, facet joint
  degeneration, hypertrophy of the ligamentum
  flavum and degenerative disc disease. CT
  myelography is seldom necessary.
• MRI, though failing to provide the same bony
  detail as CT, is at least its equal in evaluating
  the various forms of spinal stenosis. Rarely, a
  clinical syndrome suggesting neurogenic
  claudication is encountered in patients with
  severe stenosis of the terminal aorta .

134
Spinal stenosis

• Spinal or foraminal stenosis is managed
  surgically if the symptoms are disabling. Lumbar
  disc prolapse, if central, is managed by
  immediate surgery. Posterolateral disc prolapse
  is managed conservatively initially but by
  surgery if symptoms fail to resolve with rest or
  recur at frequent intervals. If a focal root
  syndrome is identified clinically and confirmed
  by investigation, relief of limb pain following
  surgery is excellent.

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MicroEndoscopic Discectomy(MED)

• "Midline Endoscopic Device for Spinal Surgery" by
  Dr. Kevin Foley in 4th INTERNATIONAL MEETING ON
  ADVANCED SPINE TECHNIQUES held at the Sonesta
  Beach Resort in Bermuda on July 10-13, 1997.

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LUMBAR DISCECTOMY

• In the case of lumbar discectomy, the primary
  objective is to decompress the affected nerve
  root. The compressed nerve must be left fully
  decompressed and freely mobile. This may require
  extensive bony decompression, nerve root
  manipulation, and/or removal of herniated nucleus
  pulposus.

139
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140

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141

• Education regarding lifting, sitting and the
  benefit of a regular exercise program is also
  essential.

142
Treatment

• analgesics and non-steroidal anti-inflammatory
  medication,
• the optimum treatment consists of bed rest on
  fracture boards to ease the initial pain. The
  mattress should be supported by fracture boards
  with the knees slightly flexed over one or two
  pillows. This is followed by an exercise program
  to strengthen the back muscles together with
  heat. Education regarding sitting, lying and
  lifting is essential and swimming is the most
  effective long term exercise.
• Occasionally a lumbosacral corset, worn while the
  patient is working or travelling, will help
  relieve the pain.
• Pain relief is best achieved by mobilising the
  spine and strengthening the back muscles.
• Manipulation under anaesthesia may also be
  indicated in chronic cases without sciatic
  compression.

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Herniated Nucleus Pulposus Case Study
144
Lateral x-ray
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Lateral MRI, HNP L4-5
146
Axial MRI, HNP L4-5
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Degenerative Spondylolisthesis

• Wiltse Classification Type III
• Marchetti-Bartolozzi acquired type
• Most commonly occurs at L4-5
• Results from degenerative changes in facets
• May have a rotatory subluxation or lateral
  listhesis
• L5 nerve root commonly affected

148
Lumbar Spinal Stenosis

• Back pain almost always present
• Buttock, leg pain common
• Neurogenic claudication increases with walking
  /standing
• Usually causes back and leg pain
• Relief with flexing forward

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Spinal Stenosis

• Treatment
• Conservative options include
• Stretching, swimming, etc
• Epidural steroid injections
• Severe stenosis / intractable pain candidates for
  surgery
• Central stenosis laminectomy with medial
  facetectomy may be enough
• Stenosis in lateral recess or lateral foramen may
  require laminectomy, facetectomy and foraminotomy

150
Lumbar Spinal StenosisCase Study
151
Preoperative AP x-ray
152
Preoperative lateral x-ray
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Axial CT myelogram L2-3
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Axial CT myelogram L3-4
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Postoperative AP x-ray following multiple level
laminectomy
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Postoperative lateral x-ray following multiple
level laminectomy
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Thank You!