- 1. PROLAPSED LUMBAR INTERVERTEBRAL DISC (PLID)
PROF. (DR.) MD. SHAH ALAM
MBBS, MS, FCPS, FRCS
Fellowship Training in Spine Surgery (USA)
Imperial Spine Course (UK)
Professor
Department of Ortho & Spine Surgery
National Institute of Traumatology & Orthopaedic Rehabilitation (NITOR)
Dhaka, Bangladesh
- 3. FUNCTIONS
- 4. FUNCTIONS
- 9. • Secondary curves
Secondary curves develops in response to
weight bearing. Purpose of these curves
are to keep the spine balanced in sagittal
plane. The lordotic cervical & lumbar
curves are the secondary curves.
- 10. LUMBAR SPINE
- 11. ANATOMY OF LUMBAR
SPINE
- 13. INTERVERTEBRAL DISC
- 14. Intervertebr
al foramen
- 15. Intervertebral Disc
Is a hydrostatic, load bearing structure between
the vertebral bodies from C2-3 to L5-S1.
1/6th of vertebral column
Nucleus pulposus + annulus fibrosus.
Is relatively avascular.
L4-5, largest avascular structure in the body.
- 16. Vital Functions of the IVD
Restricted intervertebral joint motion
Contribution to stability
Resistence to axial, rotational, and bending
load
Preservation of anatomic relationship.
- 17. Biochemical Composition
Water : 65 ~ 90% wet wt.
Collagen : 15 ~ 65% dry wt.
Proteoglycan : 10 ~ 60% dry wt.
Other matrix protein : 15 ~ 45% dry wt.
- 18. Annulus Fibrosus
Outer boundary of the disc.
Helicoid pattern, more than 60 distinct
concentric layer of overlapping lamellae of
type I collagen.
Resist tensile, torsional and radial stress
Attached to the cartilaginous and bony end-
plate at the periphery of the vertebra.
- 19. Nucleus Pulposus
Type II collagen strand + hydrophilic
proteoglycan.
Water content 70 ~ 90% Confined fluid within
the annulus.
Convert load into tensile strain on the annular
fibers and vertebral end-plate.
- 20. Intervertebral Disc
- 21. Disc Nutrition
Nutrition depends on
diffusion from
adjacent vertebral
body through porous
central concavity of
vertebral column
- 22. Diurnal Change
During day time- disc shrinks by 20%
Body height reduced by 15 – 25 mm
In night- body height is increased.
- 23. Natural disc ageing: Degeneration starts as
early as at 16 years of age
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.
- 24. Factors Contributing To
Disc Ageing
Idiopathic Blood Vessel/Nutrient Loss And
Dehydration/Decreased Proteoglycans
Production
Vertebral end plate calcification
Arterial stenosis
Smoking
DM
Exposure to vibration
- 25. Disc pressure
Normal intra-discal pressure: 10-15 kg/cm2
(Sitting)
In lying: Pressure decreases by 50% than
sitting
In standing: < 30% Of sitting.
- 26. Is a medical condition affecting lumbar spine,
in which a tear in the outer fibrous ring
(annulus fibrosus) of an intervertebral disc that
allows the soft, central portion (nucleus
pulposus) to bulge out beyond the damaged
outer rings
Prolapsed Lumbar Intervertebral Disc
(PLID)
- 27. This tear may result in the release of
inflammatory chemical mediators which cause
severe pain, even in the absence of nerve root
compression.
Disc herniations are a condition in which the
outermost layers of the annulus fibrosus are
still intact, but can bulge when the disc is
under pressure.
- 28. NORMAL DISC
HERNIATED
DISC
- 29. Types of herniation
Posterolateral disc herniation
Central (posterior) herniation
Lateral disc herniation
- 31. Disc prolapse (
lumbagosciatica)
- 33. Epidemiology
Disc herniation can occur in any disc
Two most common forms are lumbar and
cervical disc herniation.
The former is the most common, causing
lower back pain (lumbago) and often leg pain
as well (sciatica).
- 34. Epidemiology
Lumbar disc herniation occurs 15 times more
often than cervical disc herniation.
Most disc herniations occur in thirties or
forties when the nucleus pulposus is still a
gelatin-like substance.
With age the nucleus pulposus changes ("dries
out") and the risk of herniation is greatly
reduced
Mostly at L4/5 level.
- 35. Epidemiology
After age 50 or 60, osteoarthritic degeneration
(spondylosis) or spinal stenosis are more
likely causes of low back pain or leg pain.
Of all individuals, 60% to 80% experience
back pain during their lifetime.
Generally, males have a slightly higher
incidence than females.
- 36. Causes of PLID
Unaccustomed work
Bad posture
Over weight
Heavy weight lifting
Prolong standing /sitting
Pregnancy
Strenuous activity ( sneezing , coughing,
chronic Constipation)
- 37. ETIOLO
GY
- 38. EFFECT OF SMOKING
Blood vessel get
constricted
Transport of nutrients
& disposal of waste
products decreased
Disc cells get
deficient nutrition or
die
Disc degenerates
& results in DISC
INSTABILITY
- 39. History
Age : 20-45 yrs
Pain starts while lifting/forward bending.
Radiation :towards buttock ,lower limbs.
It is worsen by coughing or straining.
Later paraesthesia/numbness in legs/feet .
Cauda equina : urinary retention & perineal
numbness.
Muscle Weakness
- 40. STAGES OF DISC
DEGENERATION
Stage of dysfunction
Stage of instability
Stage of stabilization
- 41. Clinical Features
Vary depending on the location of the
herniation and the types of soft tissue that
become involved.
Often herniated discs are not diagnosed
immediately, as the patients come with
undefined pains in the thighs, knees, or feet.
- 42. Clinical Features
Unlike a pulsating pain by muscle spasm, pain
from a herniated disc is usually continuous or
at least is continuous in a specific position of
the body.
If the disc protrudes to one side, it may irritate
the dural covering of the adjacent nerve root
causing pain in the buttock, posterior thigh
and calf (sciatica).
- 43. Clinical Features
Neurological changes such as numbness,
tingling, muscular weakness, paralysis,
paresthesia, and affection of reflexes.
A large central rupture may cause
compression of the cauda equina.
Sometimes a local inflammatory response with
oedema aggravates the symptoms
- 44. Clinical Features
A posterolateral rupture presses on the nerve
root proximal to its point of exit through the
intervertebral foramen; thus a herniation at
L4/5 will compress the fifth lumbar nerve
root, and a herniation at L5/S1, the first sacral
root.
- 45. DISC & NERVE ROOT
RELATION
L5 is
TRAVERSIN
G NERVE
ROOT
L5 is
EXITING
NERVE
ROOT
- 46. Features Of Cauda Equina Syndrome
Bladder and bowel incontinence.
Perineal numbness.
Bilateral sciatica .
Lower limb weakness.
Crossed straight-leg raising sign.
- 47. Physical Examinations
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
- 48. Physical Examinations
Root Tension Signs
Straight-leg raising : L5, S1 root.
Contralateral SLR : sequestrated or
extruded disc.
Femoral stretching, reverse SLR : L3, L4
root.
- 49. Physical Examinations
Fever – possible infection.
Vertebral tenderness - not specific and not
reproducible between examiners.
Limited spinal mobility – not specific.
If sciatica or pseudoclaudication present – do
straight leg raise.
- 50. Physical Examinations
Positive test reproduces the symptoms of
sciatica.
Ipsilateral test sensitive – not specific: crossed
leg is insensitive but highly specific.
- 51. Diagnosis
Examination in a patient with suspected
lumbar (intervertebral) disk disease may
feature the following:
Abnormal gait
Abnormal postures
Decreased lumbar range of motion
Positive straight leg raising test: Indicative of
nerve root involvement
- 52. Diagnosis
Usually negative nerve root stretch test results
Perform the usual motor, sensory, and reflex
examinations (including perianal sensation
and anal sphincter tone when appropriate). It
is also mandatory to perform a careful
abdominal and vascular examination.
- 53. Differential diagnosis
Of PLID
Mechanical Pain
Discogenic Pain
Myofascial Pain
Spondylosis/spondylolisthesis
Spinal stenosis
Abscess
Hematoma
Discitis/osteomyelitis
Mass lesion/malignancy
Myocardial infarction
Aortic dissection
- 54. Investigations
Laboratory tests are generally not helpful in
the diagnosis of lumbar disk disease.
Indications for screening laboratory tests such
as the following include pain of a non
mechanical nature, atypical pain pattern,
persistent symptoms, and age older than 50
years.
- 55. Investigations
Complete blood count with differential
Erythrocyte sedimentation rate
Alkaline and acid phosphatase levels
Serum calcium level
Serum protein electrophoresis
- 56. Imaging studies
Plain radiograph
MRI: Imaging modality of choice
CT scanning
Myelography:
Dynamic L/S spine X-ray . : to rule out the
instability .
Bone scanning: To rule out tumors, trauma, or
infection
- 57. Imaging studies
X-Ray : lumbo-sacral spine
Loss of lumber lordosis
Narrowed disc spaces
CT scan : lumber spine
Shape and size of the spinal canal
Its contents and the structures around it
- 58. Imaging studies
Myelogram
pressure on the spinal cord or nerves,
such as herniated discs, tumors, or bone spurs
MRI : lumbar spine
Intervertebral disc protrusion
Bulging out disc
Compression of nerve root
- 59. X-ray findings
- 60. MRI findings
Normal central
Right Left
- 61. Treatment options
Conservative
&
Surgery
- 62. Conservative
Non-steroidal anti-inflammatory drugs
(NSAIDs)
Patient education on proper body mechanics
Oral steroids
Physical therapy (i.e. traction, electrical
stimulation massage
- 63. Conservative
Anti-depressants
Lumbosacral back support
Tobacco cessation
Weight control
Intravenous sedation, analgesia-assisted
traction therapy (IVSAAT)
Epidural cortisone injection.
- 64. Epidural Steroid Injection (ESI)
The ESI is usually reserved for more severe
pain due to a herniated disc.
It is not usually suggested if surgery is
indicated
The ESI is probably only successful in
reducing the pain in about half the cases that it
is used.
- 65. Indications Of Surgery
Cauda equina syndrome
Progressive neurologic deficit
Profound neurologic deficit and
Severe and disabling pain refractory to four to
six weeks of conservative treatment.
- 66. The objectives of surgery
Relief of nerve compression.
Allowing the nerve to recover.
Relief of associated back pain.
Restoration of normal function
- 67. Surgical Options
Discectomy/Microdiscectom:
This procedure is used to
remove part of an
intervertebral disc that is
compressing the spinal cord
or a nerve root.
- 68. Surgical Options
The Tessys method:
The Tessys method
(transforaminal endoscopic
surgical system) is a
minimally invasive surgical
procedure to remove
herniated discs .
- 69. Surgical Options
Laminectomy:
To relieve spinal stenosis
or nerve compression
- 70. Surgical Options
Hemilaminectomy :
Hemilaminectomy is
surgery to help alleviate the
symptoms of an impinged
or irritated nerve root in the
spine
- 71. Surgical Options
Chemonucleolysis:
Chemical destruction
of nucleus pulposus.
Intradiscal injection
ofchymopapain , causes
hydrolysis of protein of
the nucleus pulposus.
Indicated in disc
herniation not responding
to conservative therapy
- 72. Surgical Options
Intradiscal electrothermic
therapy (IDET) :
The procedure works by
cauterizing the nerve
endings within the disc wall
to help block the pain
signals. IDET is a
minimally invasive
outpatient surgical
procedure developed over
the last few years
- 73. Surgical Options
Lumbar fusion:
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
- 74. Surgical Options
Disc arthroplasty:
Artificial Disc Replacement
(ADR) or Total Disc
Replacement (TDR) is a
type of arthroplasty.
Degenerated intervertebral
discs in the spinal column
are replaced with artificial
devices in the lumbar
(lower) or cervical
- 75. Surgical Options
Dynamic stabilization:
Dynamic stabilization is a
surgical technique designed
to allow for some
movement of the spine
while maintaining enough
stability to prevent too
much movement.
- 76. Surgical Options
Nucleoplasty:
The most advanced form of
percutaneous discectomy
developed to date. Tissue
removal from the nucleus
acts to “decompress” the
disc and relieve the pressure
exerted by the disc on the
nearby nerve root . As
pressure is relieved the pain
is reduced
- 77. Future treatment
(stem cell therapy)
Substantial progress has been made in the
field of stem cell regeneration of the
intervertebral disc. Autogenic mesenchymal
stem cells in animal models can arrest
intervertebral disc degeneration or even
partially regenerate it and the effect is
suggested to be dependent on the severity of
the degeneration.
- 78. Persistent pain after disc surgery ?
Wrong disc surgery
Recurrent disc Prolapse
Double root in same space
Spare of root in a space
Segmental instabilty
Incomplete removal of disc
Injury to root ( Iatrogenic )
- 80. PLID ….?
Is a medical condition affecting lumbar spine
due to trauma, lifting injuries, or idiopathic, in
which a tear in the outer fibrous ring (annulus
fibrosus) of an intervertebral disc that allows
the soft, central portion (nucleus pulposus) to
bulge out beyond the damaged outer rings