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Lumbar disc disease PowerPoint Presentation

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Description : This medical presentation titled "Lumbar disc disease" tells us everything we need to know about lumber disc disease.

Tags : Lumbar disc disease, Degenerative Disc Disease, Lumbar Spine Motion Segment, Sagittal Section, Spinal Cord, Intervertebral disc, Vertebral body, Dura mater, Extradural or epidural space, Spinal cord, Subarachnoid space

Published on : Apr 27, 2021 | Views : 4162 | Downloads : 22

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Slide 1-

Lumbar disc disease
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Very Important Talk!! -- LBP A major public health problem The leading cause of disability for people < 45 2nd leading cause for physician visits 3rd most common cause for surgical procedures 5th most common reason for hospitalizations Lifetime prevalence: 49%–80% Pai et al. 2004, Orthop Clin N Am
Slide 3-

Epidemiology 60 – 90% of adults experience back pain at some point in their life. -  incidence age 35- 55 y.o. - 90% resolve in 6 weeks - 7% become chronic - M/ F equally affected Most patients with LBP improve on their own in time (even without treatment).
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Types of LBP Non-specific “idiopathic”: 85% Degenerative disc disease: discogenic pain, disk herniation, degenerative scoliosis Developmental: spondylolisthesis, idiopathic scoliosis Congenital: scoliosis Traumatic Infectious Inflammatory Neoplastic Metabolic Referred
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Low Back Pain Most episodes of LBP are self limited These episodes become more frequent with age LBP is usually due to repeated stress on the lumbar spine over many years (“degeneration”), although an acute injury may cause the initiation of pain
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Degenerative Disc Disease (DJD) Unfortunately, DJD seems to be sort of a “wastebasket term” that is often used to describe age-related changes on MRI, etc. While these changes are indeed “degenerative,” this happens as we age and is not necessarily indicative of any significant underlying pathology or condition. The majority of individuals > 60 will show some type of degenerative change(s) on lumbar imaging.
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DJD Degeneration of an individual disc space typically refers to loss of disc height, loss of water content, fibrosis, end plate sclerosis/defects, osteophyte complexes, etc.
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Lumbar Spine Motion Segment Three joint complex Intervertebral disc + 2 facet joint Ligamentous structure, vertebral body
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Sagittal Section through the Spinal Cord Intervertebral disc 2. Vertebral body 3. Dura mater 4. Extradural or epidural space 5. Spinal cord 6. Subarachnoid space
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Intervertebral Disc Hydrostatic, load bearing structure between the vertebral bodies Nucleus pulposus + annulus fibrosus No blood supply L4-5, largest avascular structure in the body
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Nucleus Pulposus Type II collagen strand + hydrophilic proteoglycan Water content 70 ~ 90% Confine fluid within the annulus Convert load into tensile strain on the annular fibers and vertebral end-plate
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Annulus Fibrosus Outer boundary of the disc Type I collagen
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Vertebral End-Plate Cartilaginous and osseous component Nutritional support for the nucleus Passive diffusion
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Facet Joint Synovial joint Rich innervation with sensory nerve fiber Load share 18% of the lumbar spine
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Facet Joint ** Primary disc degeneration  Secondary change in the posterior facet joint and soft tissue
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Important Questions 1. Is systemic disease the cause? 2. Is there social or psycological distress that prolongs or amplifies symptoms? 3. Is there neurologic compromise that requires surgical intervention?
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To Answer These Important Questions 1. Careful History and Physical Exam 2. Imaging and Labs WHEN indicated
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Differential Diagnosis of Low Back Pain
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Evaluation in older adults Cancer, compression fractures, spinal stenosis, aortic aneurysms more common Osteoporotic fractures without trauma Spinal Stenosis secondary to degenerative processes and spondylolisthesis more common Increased AAA associated with CAD Early radiography recommended
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Clues To Systemic Disease Age History of Cancer Fever Unexplained Weight Loss Injection Drug Use Chronic Infection Elsewhere Duration and Quality of Pain -Infection and Cancer not relieved supine Response to previous therapy h/o inflammatory arthritis elsewhere
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Things that should raise a “red flag” Previous hx of cancer, unexplained weight loss Immunosuppression, hx of steroid use, hx of IV drug abuse, hx of skin/other infection(s) Hx of recent falls or trauma (including surgery) Bladder dysfunction (usually urinary retention or overflow incontinence) or fecal incontinence, “saddle anesthesia”, leg weakness Pain that doesn’t improve with rest; failure to improve after 4 weeks conservative management
Slide 24-

Lumbar Disc Disease Discogenic Back Pain Internal Disc Disruption (IDD) Degenerative Disc Disease (DDD) Segmental Instability Lumbar Disc Herniation and Radiculopathy
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Lumbar Disc Herniation How pain is generated? Inflammatory Biochemical Vascular Mechanical compression
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History symptom of disc herniation : acute or gradual after trauma or without and inciting event most common 3rd and 4th decade Chief Complain Pain, radiating from the back or buttock into the leg Numbness and weakness Sharp, lancinating, shooting/radiating down the leg posteriorly below the knee Coughing, Valsalva maneuver  increase intracecal pressure  increase pain Sitting position, driving  out of lordosis  increase intradiscal pressure  increase pain
Slide 27-

Natural History Recovery from nonspecific LBP generally rapid – 90% within 2 weeks – some studies less rapid (2/3 at 7 weeks) Herniated Discs – slower to improve – only about 10% considered for surgery after 6 weeks With surgery, no earlier return to work – symptomatic and functional outcome sometimes better
Slide 28-

Posture and intradiscal pressure
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Concept Intervertebral discs can be thought of, conceptually, kind of like a “jelly donut.” The outside is the annulus fibrosus, and the inside “jelly” is the more watery nucleus pulposus. Intervertebral discs act as shock absorbers between the vertebral bodies. Just like jelly donuts have a “weak spot” where the jelly squirts out if you squeeze them, the annulus of discs is weak posteriorly where the nucleus pulposus can herniate through, causing symptoms.
Slide 30-

The most common sites for a herniated lumbar disc are L4-5 and L5-S1, resulting in back pain and pain radiating down the posterior and lateral leg, to below the knee Back pain caused by a herniated lumbar disc is exacerbated by sitting and bending; conversely, the pain of lumbar muscular strain is aggravated by standing and twisting movements.
Slide 31-

Sciatic nerve
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Disc Degeneration – Physiology With age and repeated efforts, the lower lumbar discs lose their height and water content (“bone on bone”) Abnormal motion between the bones leads to pain
Slide 34-

Disc Nucleus pulposus-water rich, gelatinous,axial load, pivotal point,binds vertebrae together Annulus fibrosus-fibrous and tougher, less water content,contained the nucleus pulposus
Slide 35-

SAGGITAL VIEW
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DISC PHYSIOLOGY
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DISC NUTRITION
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DIURNAL CHANGE During day time- disc shrinks by 20% Body height reduced by 15 – 25 mm In night- body height is increased.
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MRI appearance T-2 weighted image Black disc – dessication
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Natural disc ageing Loss of the proteoglycan molecule from the nucleus of the disc. Progressive dehydration. Progressive thickening. Brown pigmentation formation. Increased brittleness of the tissue of the disc.
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FACTORS CONTRIBUTING TO DISC AGEING
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IDIOPATHIC BLOOD VESSEL/NUTRIENT LOSS AND DEHYDRATION/DECREASED PROTEOGLYCANS PRODUCTION
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Other factors Vertebral end plate calcification Arterial stenosis Smoking DM Exposure to vibration.
Slide 45-

Disc degeneration
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Steps of disc herniation
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DISC HERNIATION OR PROLAPSE Protrusion ( contained or subligamentous herniation ) Extrusion ( non-contained or transligamentous herniation ) Sequestration ( freek fragment )
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Internal disc disruption/grade -3 radial annual tear
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Disc protrusion/PLL is still intact
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Disc extrusion/ PLL is ruptured
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MRI disc extrusion
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Disc sequestration/final end stage of disc disease
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Physical Examination Fever – possible infection Vertebral tenderness - not specific and not reproducible between examiners Limited spinal mobility – not specific (may help in planning P.T. If sciatica or pseudoclaudication present – do straight leg raise Positive test reproduces the symptoms of sciatica – pain that radiates below the knee (not just back or hamstring) Ipsilateral test sensitive – not specific: crossed leg is insensitive but highly specific L-5 / S-1 nerve roots involved in 95% lumbar disc herniations
Slide 55-

Presentation The classic presentation of Herniated Nucleus Pulposus (HNP), both for cervical and lumbar spine, is radiculopathy. The disc herniation impinges upon a nerve root, causing characteristic pain. Thoracic disc hernations are much, much rarer.
Slide 56-

Lumbar HNP 90% of herniated discs are paracentral (slightly off to one side) and affect the nerve root that corresponds to the lower vertebral level. Example: a typical L4/5 disc herniation would cause symptoms referrable to the L5 nerve root.
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Assessment of Function 98% disc herniations: L4-5; L5-S1 Impairment: Motor and Sensory L5-S1 L5: Weakness of ankle and great toe dorsiflexion S1: Decrease ankle reflex L5 & S1: Sensory loss in the feet
Slide 58-

STRAIGHT LEG RAISE TEST The straight leg raise test is positive if pain in the sciatic distribution is reproduced between 30° and 70° passive flexion of the straight leg. Dorsiflexion of the foot exacerbates the pain STRAIGHT LEG RAISE TEST
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Straight-leg raising : L5, S1 root Contralateral SLR : sequestrated or extruded disc Femoral stretching, reverse SLR : L3, L4 root Root Tension Signs
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Sciatica - radiating pain down the leg Radiculopathy radiating pain down the leg as a result of nerve root irritation Back Pain change in disc loading and shape, biomechanics loss of viscoelasticity. 90% of radiating pain have long-standing prior episodic low back pain
Slide 61-

Differential Diagnosis Vascular claudication Vascular assessment and flow study Dorsalis pedis palpation Spinal stenosis leg pain, dysesthesia, paresthesia, often not dermatomal pain d/t mechanical compression of spinal canal and foramen lordosis and axial loading symptomatic on walking, relief by sitting Thrombophlebitis Metabolic and peripheral neuropathy
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Neurologic Examination
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Imaging Studies Progressive Neurologic Defecits Failure to Improve Hx of Trauma Risk for Malignancy or infection
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Imaging Plain Radiography limited to patients with: -findings suggestive of systemic disease -trauma Failure to improve after 4 to 6 weeks CT and MRI more sensitive for cancer and infections – also reveal herniation and stenosis Reserve for suspected malignancy,infection or persistent neurologic defecit
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MRI The gold standard for imaging of the herniated lumbar disc is magnetic resonance imaging
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WHAT TO LOOK IN MRI
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T-1 AXIAL VIEW
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PROTON DENSITY IMAGE
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ZONES OF ANTERIOR EPIDURAL SPACE / HERNIATION ZONES Central region Paracentral region or lateral recess Intraforaminal zone or subarticular zone Extraforaminal zone
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Lumbar Disc Herniation – Treatment Conservative Tx. Moderate bed rest Spinal manipulation Physical therapy Medication NSAIDs Muscle relaxants Rarely narcotics Surgical Tx. “Microdiscectomy” Less than half of an inch incision Go home the same or next day Good results in up to 90% of cases
Slide 73-

Indication of Surgery Absolute surgical indication cauda equina syndrome acute urinary retension/incontinence, saddle anesthesia, back/ buttock/ leg pain, weakness, difficulty walking Relative indication progressive weakness no response to conservative treatment
Slide 74-

Lumbar HNP – when to operate The natural history of herniated discs is to resolve over time. If conservative management can adequately treat a patient’s pain, this is the preferred course of action. If conservative management fails to adequately control pain, surgery can be performed (often times on an outpatient basis).
Slide 75-

Results of Surgical Treatment Good outcome in 80-90% of cases Residual pain may last up to 6 months postop Results are worse if pain was present for over 8 months before the operation (permanent nerve damage?)
Slide 76-

Disc prolapse commonly occurs at: L4-L5 L5-S1 C5-C6 C4-C5 C3-C4
Slide 77-

The most common site for Prolapse of intervertebral disc is Cervical region Lower thoracic region Upper thoracic region Lumber region
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After L4 – S1 the next commonest site of intervertebral disc prolapse is C6- C7 T12 – L1 L1 - L2 L2 -L3
Slide 79-

The most common cause of acute sciatica is due to Trauma Secondaries of spine Acute prolapsed Intervertebral disc Tuberculosis of spine
Slide 80-

A building contractor suddenly complains of lower backache which increase on bending down He has Renal colic Tuberculosis of spine Disc prolapse Fibrositis'
Slide 81-

The most important single special investigation in lumbar disc prolapse is Epidurography Myelography MRI Discography Spinal venography
Slide 82-

Management in case of rupture of disc at L5, S1 is Emergency removal of disc Joint fusion Immobilization for 2 weeks with spinal brace Traction
Slide 83-

A 44-year-old man presented with acute onset of low backache radiating to the right lower limb. Examination revealed SLRT <40 on the right side, weakness of extensor hallucis longus on the right side, sensory loss in the first web space of the right foot and brisk knee jerk. Which of the following is the most likely diagnosis: Prolapsed intervertebral disc L4-5 Spondylolysis L5-S1 Lumbar canal stenosis Spondylolisthesis L4-5
Slide 84-

A previously healthy 45 yrs old laborer suddenly develops acute lower back pain with right-leg pain & weakness of dorsiflexion of the right great toe. Which of the following is true: Immediate treatment should include analgesics muscle relaxants & back strengthening exercises The appearance of the foot drop indicate early surgical intervention If the neurological sign resolve within 2 to 3 weeks but low back pain persists, the proper treatment would include fusion of affected Lumbar vertebra. If the neurological signs fail to resolve within 1 week, Lumbar laminectomy and exscision of any herniated nucleus pulposus should be done.
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Feature of L2-L3 prolapsed disc is/are Low back pain Straight leg raising test +ve Reversed straight leg raising test +ve Quadriceps weakness Loss of sensation on anteromedial thigh
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A middle aged lady presents with complaints of lower back pain. ON examination there is weakness of extension of right great toe with no sensory impairment. An MRI of the lumbosacral spine would most probably reveal a prolapsed intervertebral disc at what level? L3 - L4 L4-L5 L5-S1 S1-S2
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Which of the following is not recommended in the treatment of Chronic Low Back Pain: NSAIDs Bed Rest for 3 months Exercises Epidural steroid Injection
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All of the following are included as yellow flag signs of low back pain, except: History of systemic steroids use Reliance on Passive Treatment Social Isolation Belief that back pain is severely disabling
Slide 89-

A-year-old previously healthy man has had backache with muscle spasms, weakness, and pain felt in the right hip radiating all the way to his toes for the past 8 months. He does not have headaches or other neurologic problems. Physical examination reveals that the circumference of his right leg is smaller than the left, and he has paresthesias in an L5 distribution in the right leg. Which of the following conditions is he most likely to have? A Spondylolisthesis B Spina bifida C Herniated nucleus pulposus D Osteoporosis E Paget disease of bone
Slide 90-

A 15-year-old girl is noted to have an odd, twisted appearance to her back while she is out swimming with her friends. She is tall and thin. A radiograph reveals an abnormal lateral bowing of the spine, with 20 degrees of lateral curvature in the mid-thoracic region. Which of the following is most likely to produce these findings? A Asymmetric cartilage growth of vertebral body end plates B Multiple osteochondromas of the vertebral bodies C Vitamin D deficiency with rickets D A disorder of procollagen synthesis with multiple compressed fractures E Trauma
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Messages Inflamed discs can cause referred leg pain without neural compression by irritating the sinu -vertebral nerve Mild disc degeneration can result in quite severe pain- because of inflammatory chemicals in the disc space- not seen on MRI scans Analgesic Discography- a new technique – offers a simple way to confirm the relevant disc as the pain generator Interbody fusion can then be used to treat the problem definitively.
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Take Home Messages Know the natural history of the disease Know your patient Correlate clinical findings, MRI and discograms if needed Until definitive evidence available, choose the most cost-effective available treatment option: cognitive therapy, exercise, fusion, arthroplasty, dynamic stabilization
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THANK YOU