INTERVERTEBRAL DISC PROLAPSE

HARI CHANDAN

Disc anatomy

-Intervertebral disc lies between adjacent vertebrae in the the vertebral column forming a fibrocartillagenous joint allowing movement of the vertebra

■ -Development of disc starts from third week of intrauterine life until ■ third decade of life.■ -23 discs through out the spine, absent only atlanto-axial articulation.■ -Thinnest in thoracic region ; thickest in lumbar region■ -Avascular

Disc anatomy

■The cartilage end-plates■Nucleus puplopes■Annulus fibrosis

■Disc gives spine the mobility■Disc acts as shock absorber■Disc increases height of spine by 25%

PATHOLOGY■ Prolapsed disc means the protrusion or extrusion of nucleus pulposes through a rent in

the annulus fibrosis.it is not a one time phenomena rather it’s a sequence of following events

1)NUCLEAR DEGENERATION : - softening of nucleus and its fragments

- weakening and disintegration of the posterior

part of the annulus

2)NUCLEAR DISPLACEMENT : - disc protrusion, - disc extrusion , sequestrated disc

■ 3)STAGE OF FIBROSIS :The is the stage of repair. The residual nucleus pulposus

becomes fibrosed.The extruded nucleus nucleus

pulposus becomes flattened,fibrosed and undergoes calcification.■ The site of exit of nucleus is usually posteriolateral.

ETIOLOGY OF DISC PROLAPSE

■Heavy and repetitive weightlifting ■Cigarette smoking and tobacco consumers■Anxiety and depression■Women with greater number of pregnancies■Obesity■ Improper postural habits■Occupations as auto drivers .

Clinical features■Low backache – repetitive , radiating to the buttocks and decreased by rest .pain

aggrevated when coughing,sneezing,straining,sitting.

■Radiculopathy – pain in the distribution of sciatic nerve ,invariably due to disc herniation. Leg pain equal to or more than back pain evidence the racdiculopathy may be due to disc herniation.

■Nerve root compression.

SLIGHT LEG RAISE TEST (SLRT)

■ Inference : localized pain indicates a disc lesion.

radiating pain indicates sciatic radiculopathy.

SLRT at 40 degrees or less indicates root compression.

Investigations■ Ct scan – posterior border of disc appears flat or convex

which is normally concave.

■MRI – very usefull. Shows prolapsed disc, theca, nerve roots clearly.

■Myelography : Radiopaque die is injected into spinal canal and radiographs are taken. not in use now.

■Radiography : Not reliable . 7-46% cases are missed .

Differential diagnosis

■Spondylitis■Vascular insufficiency■Extra dural tumour■Spinal tuberculosis

Treatment

■ Conservative: Rest

Drugs – analgesics and muscle relaxants

Physiotherapy

Lumbar traction

Transcutaneous electrical nerve stimulation ( tens)

Operative treatment

■Indications : 1. Failure of conservative treatment

2. Severe sciatic pain

3. Severe sciatic tilt

■Fenestration : Ligamentum flavum is excised and the spinal canal at the affected region is exposed.no longer done as it makes spine unstable

■Hemi-laminectomy :The whole of the lamina on one side is removed.

■Fenistration : Requires mri and radiographic studies. Spine is approached unilaterally, only the margin of upper and lower lamina are removed.

CHEMONUCLEOLYSIS

■Chymopapain with the property of dissolving fibrous and cartilaginous tissue is injected into the disc,under X-ray control

Endoscopic lumbar discectomy

■ Using a operative endoscope,through a small incision with

minimal damage and blood loss■ Less invasive ,minimal damage,minimal blood loss,

excellent results■ Come today, go tomorrow surgery.

THANK YOU