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Disc Degeneration & Prolapse

The commonest site of disc prolapse is lumbar spine in more than 90% of cases lumbar disc herniation are localized at L4 -5 (more common) and L5 — S1 .The commonest site of intervertebral disc prolapse in cervical spine is lower cervical spine (C5-6)
  1. Predisposing Factors
    Male (three times)
    Lifting Weight (M/C)
    .Physical stress (a combination of flexion & compression)

Description: download (16)

  1. Pathology & Types
    By Location
    1. Central prolapse
      Often associated with back pain only without radicular pain
      May present with cauda equina syndrome
    2. Posterolateral (paracentral)
      Most common (90-95%)
      Posterior Longitudinal Ligament is weakest here
      Affects the traversing/descending/lower nerve root Description: Aques2 Description: Aques2
      e.g L4/5 affects L5 nerve root
    3. Foraminal (far-lateral, extraforaminal)
      Less common
    4. Axillary
      Can affect both exiting and descending nerve roots
Anatomic classification

 Eccentric bulging with an intact annulus
Disc material herniates through annulus but remains continuous with disc space
Sequestered fragment (free)
Disc material herniates through annulus and is no longer continuous with disc space

                                                     Description: STAGES-OF-DISC-HERNIATION

  1. Neurological Involvement
    1. Central or paracentral disc herniation usually involves lower nerve root (eg L3-4 compress L­4, L4-5 compress L5 and L5-S1 compress S1 nerve root).
  2. Clinical Presentation
    1. Axial back pain (low back pain)
      This may be discogenic or mechanical in nature
    2. Radicular pain (buttock and leg pain)
      Often worse with sitting, improves with standing
      Symptoms worsened by coughing, valsalva, sneezing
    3. Cauda equina syndrome :orthopedic emergency
      Bilateral leg pain
      Lower limb weakness/saddle anesthesia
      Bowel/bladder symptoms
  • Provocative tests
    • Straight leg raise
      • A tension sign for L5 and S1 nerve root
        Can be done sitting or supine
        Reproduces pain and paresthesia in leg at 30-70 degrees hip flexion
      • Sensitivity/specificity
        Most important and predictive physical finding for identifying who is a good candidate for surgery
    • Contralateral SLR
      • Crossed straight leg raise is less sensitive but more specific
    • Lasègue sign
      • SLR aggravated by forced ankle dorsiflexion
    • Bowstring sign
      • SLR aggravated by compression on popliteal fossa
    • Naffziger test
      • Pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veins
    • Milgram test
      • Pain reproduced with straight leg elevation for 30 seconds in the supine position
  1. Mobility of lumbar spine is diminished more in flexion than in extension. The patient usually stands with slight tilt (list) to one side (sciatic scolisis).
  2. If the disc protudes medial to the nerve root the tilt is towards the painful side (to relieve pressure on the root) with the far lateral prolapse the tilt is away from painful side
  1. Neurological FeaturesC5
Nerve Root involvement
  1. Sensory Deficit: Upper lateral arm and elbow
  2. Motor Weakness: Deltoid, Biceps
  3. Reflex Change: Biceps

C6 Nerve Root involvement

  1. Sensory Deficit: Lateral forearm, thumb, and index finger
  2. Motor Weakness: Biceps, Extensor carpi radialis longus and brevis
  3. Reflex Change:
    1. Biceps
    2. Brachioradialis​

C7 Nerve Root involvement
  1. Sensory Deficit: Middle finger
  2. Motor Weakness: Triceps, Wrist flexors (flexor carpi radialis), Finger extensors
  3. Reflex Change: Triceps

C8 Nerve Root involvement
  1. Sensory Deficit: Ring finger, little finger, and ulnar border of palm
  2. Motor Weakness:
    1. Interossei
    2. Finger flexors
    3. Flexor carpi ulnaris
  3. Reflex Change: None

T1 Nerve Root involvement
  1. Sensory Deficit: Medial aspect of elbow
  2. Motor Weakness: Interossei
  3. Reflex Change: None

L4 Root involvement
  1. Sensory Deficit: Posterolateral thigh, anterior knee, and medial leg
  2. Motor Weakness: Quadriceps, Hip adductors
  3. Anterior Tibial Weakness: Reflex change, Patellar tendon, Anterior tibial tendon

L5 Root involvement
  1. Sensory Deficit: Anterolateral leg, dorsum of the foot, and great toe
  2. Motor Weakness: Extensor hallucis longus, Gluteus medius, Extensor digitorum longus and brevis
  3. Reflex Change: Usually none, Posterior tibial (difficult to elicit)

S1 Root involvement
  1. Sensory Deficit: Lateral malleolus, lateral foot, heel, and web of fourth and fifth toes
  2. Motor Weakness: Peroneus longus and brevis, Gastrocnemius-soleus complex, Gluteus maximus
  3. Reflex Change: Achilles tendon

Fig: Key sensory levels cervical and lumber region

  • MRI is investigation of choice .In case of confusion regarding symptomatic multilevel disc prolapse or recurrence we can go for myelography or nerve conduction test.

Description: Lagehernia.png

  1. Treatment
    1. Three ways of treating prolapse - rest, reduction, or removal; followed by rehabilitation.
    2. Rest for 3-5 days, with hips and knees slightly flexed.
    3. If improvement is not complete epidural injection of corticosteroid & local anesthetic may help.
    4. Back strengthening should be started only after pain has subsided.
    5. Chemonucleolysis dissolution of nucleus pulposus by percutaneous injection of proteolytic enzyme (chymopapain) - of theorotical significance.
    6. Operative removal of disc
      Laminotomy and discectomy (microdiskectomy)
           Indications are
                Persistent disabling pain lasting more than 6 weeks that have failed nonoperative options (and epidural injections)
                Progressive and significant weakness
                Cauda equina syndrome
    7. In low back ache (lumbago) bed rest should not exceed 2 days, because bed rest for longer period may lead to debilitating muscle atrophy and increased stifflness.

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