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Lumbar Intervertebral disc prolapse

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clinical features , investigations & management

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Lumbar Intervertebral disc prolapse

  1. 1. Lumbar Intervertebral Disc Prolapse- Clinical Features, Investigations & Management Dr M Avinash Ganga Medical Centre Coimbatore
  2. 2.  Introduction  Clinical features ◦ Back pain ◦ Other symptoms ◦ signs  Differential diagnosis  Investigations  Management ◦ Non operative ◦ operative
  3. 3. Introduction  Understanding of disc degeneration- evolved.  Treatment is far from satisfactory  limited by lack of specific diagnoses  Need to improve understanding at a basic science and clinical level.  79% men & 89% women-specific cause unknown.  Unless pathological process is better described, and reliable criteria for the diagnosis are determined, ◦ improvement in treatment outcomes cannot occur, regardless of the technology available
  4. 4.  Best Approach ◦ History > physical examination > diagnosis supported by diagnostic studies  Wrong approach ◦ Matching diagnosis and treatment to the results of diagnostic studies ◦ MRI shows disc herniations in 20% to 36% of normal volunteers ◦ 76% of asymptomatic controls
  5. 5. LUMBAR DISC DISEASE Clinical Features
  6. 6. Clinical Features  AGE: 30 – 40 years  SEX: Male affected more than female  MOST COMMON LEVEL: L4-L5 (next common level is L5-S1)  MOST COMMON TYPE: Posterolateral type
  7. 7. Clinical Features-Back Pain 1. Mechanical ◦ midline, worse with activity 2. Instability ◦ midline, gluteal, worse in morning, sinuvertebral nerve 3. Radiculopathy 4. Claudication ◦ heaviness of one or both legs 5. Inflammatory ◦ worse in morning better with activity 6. Infection/Tumors ◦ rest pain and night pain
  8. 8. Clinical features- Radiculopathy  Radicle- root  Shooting pain distributed along the dermatome of the involved nerve root  biochemical mediators(TNF alpha, interleukins) or mechanical compression  Pain typically radiates below the knee  Leg pain = or > than back pain  Worse on activity or bending forwards  May have red flags
  9. 9. Clinical features- History  May attribute to episode of trauma  Prolonged history of repetitive lower back and buttock pain ◦ relieved by a short period of rest.  suddenly exacerbated, often by a flexion episode, with the appearance of leg pain.  increasing with activity, especially sitting, straining sneezing  decreased by rest, especially in the semi- Fowler position
  10. 10. Other Symptoms  Weakness ◦ Corresponding to level of neurological involvement  Paresthesia ◦ Dermatomal distribution  Cauda equina
  11. 11. Cauda Equina  Emergency ◦ Aggressive evaluation and management  most consistent symptoms(Tay & Chacha) ◦ saddle anesthesia ◦ bilateral ankle areflexia ◦ bladder symptoms  Other symptoms- ◦ numbness and weakness in both legs, ◦ rectal pain, ◦ numbness in the perineum,
  12. 12. Clinical Features- Signs  Antalgic gait ◦ Affected hip more extended and knee more flexed than normal side  Trendelenberg gait (L5 nerve root)  List ◦ abrupt planar shift ◦ Axillary disc –same side ◦ Shoulder disc- opposite side  Thigh and calf muscle wasting  Loss of lumbar lordosis  Paraspinal spasm- central furrow sign Flat back deformity of chronic IVDP
  13. 13. Clinical features- Tests Straight Leg Raising Lasegue’s test r/o hamstring tightness
  15. 15. Clinical Features -Tests Femoral nerve stretch test L2,3 and 4 nerve roots Bowstring sign
  16. 16. Clinical features – Flip test NEGATIVE POSITIVE
  17. 17. Clinical features-Slump test
  18. 18. Clinical features NAFFZIGER TEST VALSALVA MANEUVRE
  19. 19. Clinical features- ROM  Flexion- ◦ Painful and restricted  Lateral bending to the same side ◦ Painful and restricted
  20. 20. Clinical features -Neurology L1 L2
  21. 21. Clinical Features- Neurology L3
  22. 22. Clinical Features- Neurology L4
  23. 23. Clinical Features- Neurology L5 Trendelenbe rg test
  24. 24. Clinical Features- Neurology S1
  25. 25. Clinical Features- Red Flags  Extremes of age (<15yr , >55yr)  Neurological deficits  Fever  Unexplained weight loss(10lb in 6months)  Malaise  Rest pain/ night pain  Significant trauma  Drug and alcohol abuse
  26. 26. Non Organic Signs Of Waddell Described by Waddel in post op patients 1. Non anatomic tenderness 2. Simulation sign 3. Distraction sign 4. Regional sensory or motor disturbance 5. Overreaction(most sensitive)
  27. 27. Clinical features-Never forget  Sacroiliac and hip joint examination  Examination of peripheral pulses
  28. 28. Differential Diagnosis- Lumbar Disc Disease INTRASPINAL CAUSES Proximal to disc: Conus and Cauda equine lesions (eg. Neurofibroma, ependymoma) Disc level • Herniated nucleus pulposus • Stenosis (Canal or recess) • Trauma • Infection: Osteomyelitis or discitis ( with nerve root pressure) • Inflammation: Arachnoiditis, ankylosing spondylitis • Neoplasm: Benign or malignant with nerve root pressure(multiple myeloma, extradural tumors) • Other degenerative causes
  29. 29. Differential Diagnosis- Lumbar Disc Disease EXTRASPINAL CAUSES Pelvis • Cardiovascular conditions (eg. Peripheral vascular disease) • Gynaecological conditions • Orthopaedic conditions ( osteoarthritis of hip, Muscle related disease, Facet joint arthropathy) • Sacroiliac joint disease • Neoplasm Peripheral nerve lesions • Neuropathy (Diabetic, tumour, alcohol) • Local sciatic nerve conditions (Trauma, tumour) • Inflammation (herpes zoster)
  30. 30. KEY DIAGNOSTIC POINTS LUMBAR DISC PROLAPSE  Leg pain greater than back pain  SLRT +  Neurological deficit present ANNULAR TEARS  Back pain greater than leg pain  Bilateral SLRT positive FACET JOINT ARTHROPATHY  Localized tenderness present unilaterally over joint  Pain occurs immediately on spinal extension  Pain exacerbated with ipsilateral side bending SPINAL STENOSIS  Heaviness(no pain) develops after walks a limited distance.  Flexion relieves symptoms  No neurological deficit  SLRT -ve MYOGENIC OR MUSCLE RELATED  Pain localised to affected muscle  Pain increases on prolonged muscle use  Pain reproduced with sustained muscle contraction against resistance  Contralateral pain with side bending
  32. 32. Investigations- Plain Radiographs  Simplest and most readily available  AP and Lateral views  Loss of lumbar lordosis  Indications ◦ Positive SLR ◦ Red Flags ◦ Unresponsive to conservative treatment
  33. 33. Other views  Oblique views ◦ Spondylolisthesis and lysis ◦ Hypertrophic changes around foramina in cervical spine  Lateral flexion/ extension views  Ferguson View ◦ 20 degrees caudocephalic AP ◦ “far out syndrome,” ◦ fifth root compression by a large transverse process of the L5 vertebra against the ala of the sacrum.  Angled caudal views ◦ facet or laminar pathological conditions.
  34. 34. X ray- Signs of Instability  Indirect Signs ◦ Disc space narrowing, ◦ Sclerosis of end plates ◦ Osteophytes ◦ Traction spur ◦ Vacuum Sign  Direct signs ◦ Translational abnormalities on dynamic films
  35. 35. Investigations –Radiography Features of Instability-Traction spurs Tensile stresses by ALL or outer annulus fibres on body periosteum
  36. 36. Vacuum sign  Knuttson’s sign  radiolucent defect  presence of nitrogen gas accumulations in annular and nuclear degenerative fissures  typical central vacuum phenomenon ◦ gas collection that fills large neo- cavity occupying both the nucleus and annulus ◦ indicative of advanced disc degeneration.  Other type ◦ Gas at outermost part of the annulus fibrosus close to the vertebral corner ◦ rupture of the insertion of
  37. 37. Reduction in Height of Pedicle REDUCTION IN THE HEIGHT OF THE PEDICLE
  38. 38. Flexion Extension Views 1. Forward translation of one vertebra over the other - anterior sliding instability. 2. Backward translation - posterior sliding instability. 3. Excessive angular movement of a motion segment / rotation - angular instability. 4. Abnormal axial rotation in which posterior margin of the vertebral body has a focal double contour during bending.
  39. 39. Technique of Measuring Translation •Cobb Method •Superimposition method
  40. 40. Investigations- CT Assessment of ◦ fractures ◦ spondylolysis ◦ preoperative planning, ◦ Alternative for assessing a patient with instrumentation
  41. 41. Investigations- CT ADVANTAGES • Extremely useful, highly accurate & noninvasive tool in the evaluation of spinal disease. • provides superior imaging of cortical and trabecular bone compared with MRI. • It provides contrast resolution and identify root compressive lesions such as disc herniation. • It also helps to differentiate between bony osteophyte from soft disc. • It helps to diagnose foraminal encroachment of disc material due to its ability to visualize beyond the limits of the dural sac and root sleeves.
  42. 42.  Limitations  It cannot differentiate between scar tissue and new disc herniation  It does not have sufficient soft tissue resolution to allow differentiation between annulus and nucleus  Literature  End plate avulsions in CT scan by Rajasekaran et al
  45. 45. Investigations- MRI  Most accurate and sensitive modality for the diagnosis of subtle spinal pathology,  test of chice  It allows direct visualization of herniated disc material and its relationship to neural tissue including intrathecal contents.  Advantages over myelography ◦ No radiation ◦ Op procedure ◦ No intrathecal contrast ◦ More accurate in far lateral disc ◦ Disc disease of LS junction ◦ Early disc disease
  46. 46.  Advantages over CT  imaging the disc  directly images neural structures.  shows the entire region of study (i.e., cervical, thoracic, or lumbar).  ability to image the nerve root in the foramen  Limitations  Showing abnormal anatomy in asymptomatic patient  Clinical exam is paramount
  47. 47.  Rajasekaran et al. found consistent differences dependent on the end plate in the pattern of gadodiamide diffusion into the nucleus pulposus. These pattern differences correlated more with degenerative changes and not with age.
  48. 48. Stages of Disc Prolapse
  49. 49. CONTRAST ENCHANCED MRI  Here GADOLINIUM labeled diethylenetriaminepentaacetate (Gd- DTPA) administered intravenously and MRI scan done. ADVANTAGES  Display the inflammatory reaction critical to the pathophysiology of radicular pain or radiculopathy  Allows discrimination of scar from recurrent disc.
  50. 50. Myelography  Unnecessary if clinical and CT or MRI findings are in complete agreement.  Indications ◦ suspicion of an intraspinal lesion, ◦ patients with spinal instrumentation, ◦ questionable diagnosis resulting from conflicting clinical findings and other studies . ◦ previously operated spine ◦ marked bony degenerative change that may be underestimated on MRI ◦ arachnoiditis
  51. 51. Myelography  Dyes Air, oil contrast, water-soluble (absorbable) ◦ metrizamide (Amipaque)-higher complication rates ◦ iohexol (Omnipaque)- approved for thoracic and lumbar myelography ◦ iopamidol (Isovue-M).  Water-soluble contrast media -standard agents for myelography  Advantages: absorption by the body, enhanced definition of structures, tolerance, and the ability to vary the dosage for different contrasts  Disadvantages : capable of showing the level at which the pathology lies but fails to show the nature of the lesion or its precise location in the anatomic segment  Complications: nausea, vomiting, confusion, and seizures. Rare complications include stroke, paralysis, and death. ◦ Arachnoiditis- iophendylate(oil contrast). Not noted in water contrast.
  52. 52. Precautions  Clear explanation of the procedure  Hydration of the patient  using the lowest possible dose  discontinuation of phenothiazines and tricyclic drugs before, during, and after the procedure  30-degree elevation of the patient's head until the contrast material is absorbed  Proper equipment  Smaller gauge needles (22-gauge or 25-gauge)  Whitacre-type needle with a blunter tip and side port opening
  53. 53. Air contrast is used rarely -Only in situations in which the patient is extremely allergic to iodized materials
  54. 54. Procedure  Don’t place the needle cephalad to L2-3 - conus medullaris at risk  Midline needle placement minimizes ◦ lateral nerve root irritation ◦ epidural injection.  Tilt patient up - increases intraspinal pressure and minimize the epidural space.  dose of iohexol- 10 to 15 mL ,concentration of 170 to 190 mg/mL.  Higher concentrations for higher areas  A full lumbar examination should include upto level of T7  Cervical myelogram -allow the contrast to proceed cranially.  Extend the neck and head maximally to prevent - intracranial migration of contrast  blood in initial tap- abort procedure  proper needle position confirmed but CSF flow minimal or absent, suspect a neoplastic process.
  55. 55. Electrodiagnostic studies  Applied when clinical examination and imaging fail to provide a clear diagnosis or perhaps conflicting diagnoses  May include needle electromyelography, somatosensory evoked potentials or cervical root stimulation  Operator depended  May help differentiate primary cervical disorders from peripheral nerve entrapments syndromes or pain eminating from the intrinsic shoulder pathology
  56. 56. Electromyography  the identification of ◦ peripheral neuropathy ◦ diffuse neurological involvement
  57. 57. Investigations-Injection studies  Epidural steroid  Facet joint injections  Discography  Focused and controlled anesthesia of particular anatomic structures to help define loci of pain (excl discography)  Used when ◦ diagnosis is in doubt ◦ pathological condition diffuse ◦ Identification of pain generator difficult
  58. 58. Injection studies- Agents  Contrast ◦ diatrizoate meglumine ◦ iothalamate meglumine (Conray), ◦ iohexol (Omnipaque) safest to use ◦ iopamidol, ◦ metrizamide (Amipaque)  Local Anaesthetics ◦ Lidocaine ◦ Tetracaine ◦ bupivacaine- low conc & volume( <0.75%)  Steroid ◦ methylprednisolone acetate (depo-medrol)  Arachnoiditis due to polyethylene glycol ◦ Celestone Soluspan-betamethasone sodium phosphate and acetate  Isotonic saline
  59. 59. Injection studies-Epidural Steroid  Helpful in confirming pain generators, responsible for a patient's discomfort  correlate abnormalities seen on imaging studies with associated pain complaints  pain relief during the recovery of disc or nerve root injuries  Increase level of physical activity  Reduce need for oral
  60. 60. Epidural Steroid- Precautions  resuscitative and monitoring equipment  Intravenous access  use fluoroscopy ◦ Avoid needle misplacement ◦ Intravascular injection- aspirating not reliable ◦ Anatomical anomalies, such as a midline epidural septum or multiple separate epidural compartments
  61. 61. Epidural Steroid  Contraindications ◦ infection at the injection site ◦ systemic infection ◦ bleeding diathesis ◦ uncontrolled diabetes mellitus ◦ congestive heart failure.  Complications  Minor ◦ nonpositional headaches ◦ facial flushing insomnia ◦ low-grade fever, ◦ transient increased back or lower extremity pain  Major ◦ vasovagal reaction ◦ Dural puncture ◦ Positional headache ◦ epidural abscess, ◦ epidural hematoma, ◦ durocutaneous fistula, ◦ Cushing syndrome
  62. 62. Epidural Steroid-Techniques  Interlaminar Approach  Transforaminal Approach  Caudal Approach
  63. 63. Facet Joint Injections  Causes of facet pain ◦ meniscoid entrapment extrapment ◦ synovial impingement, ◦ Chondromalacia facetae, ◦ capsular and synovial inflammation, ◦ mechanical injury ◦ Osteoarthritis  “gold standard” for excluding the facet joint as a source of spine or extremity pain.  Intra articular or Medial branch block  No evidence of effective
  64. 64. Injection studies- Discography  Invasive, provocative,painful procedure done under fluoroscopic guidance.  Contrast medium is injected to pressurize the disc  patient’s pain response is the most important.  Discography, should be thought of as a part of the whole diagnostic workup.  It should not be given excessive importance.  Evaluated by CT or Fluoroscopy
  65. 65. Discography- Uses  Evaluate equivocal abnormality seen on myelography, CT or MRI  Isolate a symptomatic disc among multiple level abnormality  diagnose a lateral disc herniation  establish discogenic pain  select fusion levels  evaluate the previously operated spine ◦ distinguish between mass effect from scar tissue or disc material
  66. 66. Discography-Lumbar
  67. 67. Other diagnostic tests • SOMATOSENSORY EVOKED POTENTIALS (SSEP) – to identify the level of root involvement • POSITRON EMISSION TOMOGRAPHY  Bone scan & SPECT ◦ useful for localizing a pain generator when multiple radiographic abnormalities present  Blood investigations  Rheumatoid screening
  68. 68. TREATMENT There are many treatment options for patients with low back pain and neck pain, but, although there is a plethora of literature,there is very little conclusive evidence for any of them. The treatment options are usually used in combination
  69. 69. Treatment  Conservative ◦ Bed rest ◦ Medications ◦ Physical therapy ◦ Lifestyle modifications ◦ Chiropractic manipulation ◦ Lumbo-sacral orthosis ◦ Selective injections ◦ Intradiscal Electrothermal Therapy ( IDET )  Operative
  70. 70. Bed Rest  no data to suggest that bed rest alters the natural history of lumbar disc herniations or improves outcomes.  Consensus of 2 days (if used) Semi Fowlers Position
  71. 71. Medications  NSAIDs ◦ Selective COX-2 inhibitors ◦ Preferential COX-2 inhibitors ◦ Nonselective  Acetamenophen  Opiods  Steroids  Muscle relaxants  Anti depressants  Anti Seizure
  72. 72. Physical Therapy  Excercises  Back School  Others : IFT, SWD, TENS, Traction
  73. 73. Excercises  Better than medical care alone  Flexion-based isometric exercises appear to have the most support in the literature  Offer benefit by decreasing local muscle spasm and stabilizing the spine.  Begin when acute pain diminishes
  74. 74. Exercises GENERAL RULES FOR EXERCISE  Do each exercise slowly. Hold the exercise position for a slow count of five.  Start with five repetitions and work up to ten. Relax completely between each repetition.  Do the exercises for 10 minutes twice a day.  Care should be taken when doing exercises that are painful. A little pain when exercising is not necessarily bad. If pain is more or referred to the legs the patient may have overdone it.  Do the exercises every day without fail.
  77. 77. YOGAASANAS TADASANA (Mountain pose) MARICHYASANA III (Marichi's Pose) BHARADVAJASA NA (Bharadvaja's Twist)
  78. 78. VIRABHADRASAN A II (Warrior II Pose) ARDHA URDHVA MUKHA SVANASANA (Half Upward-Facing Dog Pose) BALASANA (Child's Pose)
  80. 80. Physical therapy  TENS ◦ Transcutaneous electrical nerve stimulation ◦ release of endogenous analgesic endorphins ◦ Central nervous system process in which a control center is altered to block transmission of pain ◦ Deyo RA et al ‘TENS is no different from a placebo’  Intermittent Pelvic Traction ◦ Goal- distract the lumbarvertebrae. ◦ enlargement of the intervertebral foramen, ◦ creation of a vacuum to reduce herniated discs, ◦ placement of the PLL under tension to aid in reduction of herniated discs, ◦ relaxation of muscle spasm, ◦ freeing of adherent nerve roots ◦ Does not alter natural history of disease
  81. 81. Back School  Education in proper posture and body mechanics  Helpful in returning the patient to the usual level of activity  Individual or Group instruction.  Now referred to as “back school.”  Quality and quantity of information provided may vary widely.  Bergquist-Ullman et al ◦ beneficial in decreasing the amount of time lost from work initially, ◦ does little to decrease the incidence of recurrence of symptoms or length of time lost from work during recurrences.’  The combination of back education and combined physical
  82. 82. Lifestyle Modifications  Avoidance of ◦ Repetitive bending /twisting/ lifting ◦ Contact sports ◦ Heavy weights ◦ 2wheelers, Auto rickshaws ◦ Soft mattress( Spring, foam)  Posture training  Back support while sitting  Firm mattress (rubberised foam, coir )
  83. 83. Chiropractic Manipulations  15% of the United States population seeks chiropractic help each year  Skargren et al. found ◦ chiropractic treatment to be more effectivefor acute low back pain (less than oneweek in duration) ◦ physical therapy more effective for pain of longer duration
  84. 84. Lumbo-Sacral Orthosis  Purpose is to stabilize and immobilize  Indications ◦ vertebral body fracture ◦ spondylolysis with spondylolisthesis ◦ Postoperative support  Their use in low back pain is doubtful  Not prescribed ◦ lack of compliance on the part of the patient, ◦ creating psychological dependence, ◦ validating the disability. ◦ weakening of postural back and abdominal muscles (not proven)  Does not alter natural history of the disease
  85. 85. Intradiscal Electrothermal Therapy  Low back pain of discogenic origin  Not useful in radiculopathy  posterolateral placement of a probe around the inner circumference of the annulus followed by heating of the probe.  ? Collagen alteration  Pre Requisites ◦ Normal neurology ◦ Negative SLR. ◦ absence of compressive lesions on MRI ◦ positive concordant discogram  Conflicting outcomes requiring refinement of
  86. 86. Novel Therapy  Infliximab ◦ TNF alfa inhibitor  Injection of Ozone into disc and around nerve roots
  87. 87. Operative Management  Prerequisites ◦ surgeon sure of diagnosis ◦ Patient feels that pain is debilitating enough to warrant surgery ◦ Understand that surgery does not stop the pathological process ◦ Nor does it restore disc to normal state ◦ May only provide symptomatic relief ◦ Physiotherapy and activity restrictions may be needed post op
  88. 88. Operative treatment  Patient selection is the Key ◦ predominant (if not only) unilateral leg pain ◦ extending below the knee ◦ present for at least 6 weeks. ◦ decreased by rest, antiinflammatory medication, or even epidural steroids ◦ returned to the initial levels after a minimum of 6 to 8 weeks of conservative care ◦ Physical signs: Positive SLR, neurological deficits ◦ Imaging should confirm the level of
  89. 89. Broad Indications ABSOLUTE  Bladder and bowel involvement: The cauda equine syndrome  Increasing neurological deficit RELATIVE  Failure of conservative treatment  Recurrent sciatica  Significant neurological deficit with significant SLR reduction  Disc rupture into a stenotic canal  Recurrent neurological deficit
  90. 90. Contraindications  Predominantly back pain rather than leg pain  Clinical findings and imaging do not correlate  Lack of adequate instruments  Bulging or protruding discs not ruptured through the annulus  Disc excision is an Elective procedure  only cauda equina syndrome warrants
  91. 91. Surgical Options  Standard discectomy  Limited Discectomy  Microsurgical Lumbar discectomy  Endoscopic discectomy  Additional Exposure ◦ Hemilaminectomy ◦ Total Laminectomy ◦ Facetectomy  Percutaneous Discectomy  Chemonucleolysis  Arthrodesis  Disc replacement
  92. 92. Standard Precautions  Infiltrate the operative field with 30 mL of 0.25% bupivacaine with epinephrine  Radiographic confirmation of level .  protect neural structures.  Epidural bleeding should be controlled with bipolar electrocautery.  Any sponge, pack, or cottonoid patty placed in the wound should extend to the outside.  Pituitary rongeurs should be marked
  93. 93. Standard Discectomy  Established procedure of proved efficacy  Absolute Indications ◦ cauda equina syndrome ◦ progressive neurological deficit despite non-operative treatment.  Relative Indications ◦ intolerable pain, ◦ severe postural list, ◦ persistent pain that markedly compromises the  ability to work,  perform household tasks,  engage in recreational activities.  no long-term difference in the improvement of static deficits among those treated operatively or non-operatively.
  94. 94. Positioning  Prone position  With bolsters  Knee chest position  Allows abdomen to hang free, ◦ minimizing epidural venous dilation and bleeding  Lateral position with affected side up
  95. 95. Salient Points  Lamina exposed cephalad and caudad to the level of the herniated disc  1-2 sqcm area of lamina removed exposing dura and nerve root  Visualise lateral edge of nerve root  Remove sequestered disc  Incise Annulus and remove central and lateral part of nucleus  Nerve root must freely move 1cm inferomedially
  96. 96. Limited Discectomy  Only the extruded or sequestered portion of the disc is removed.  The central or lateral portion of nucleus is not removed from the disc space.  One study only with a short term follow up  Good results  No recurrence  Only 2% had persistent pain
  97. 97. Lumbar Microsurgical Discectomy  first reported by Williams in 1978  procedure of choice for herniated lumbar disc  Decompression of the involved nerve root with minimum trauma to the adjacent structures.  Advantages ◦ decreased operative time, ◦ Decreased morbidity, ◦ less loss of blood, ◦ shorter stay in the hospital,
  98. 98. Lumbar Microsurgical Discectomy  Drawbacks ◦ inadequate exposure ◦ incomplete decompression ◦ Costly equipment  Contraindications ◦ Previously operated ◦ Spinal Canal Stenosis
  99. 99. Microsurgical Lumbar Discectomy  Requirements ◦ operating microscope with a 400-mm lens, ◦ small-angled Kerrison rongeurs of appropriate length, ◦ microinstruments, ◦ combination suction–nerve root retractor
  100. 100. Microsurgical Lumbar Discectomy  Original Guidelines ◦ Avoidance of laminectomy and of trauma to the facets, ◦ Preservation of all extradural fat, ◦ Blunt perforation of the anulus fibrosus rather than incision with a scalpel, ◦ Preservation of healthy, non-herniated intervertebral disc material, ◦ Remove only as much disc as is necessary to relieve the neural elements from visible and palpable compression.  New Guidelines ◦ Subtotal discectomy through an incision, made with a scalpel,in the anulus fibrosus; ◦ using bipolar coagulation; ◦ Removing the medial portion of the facet for exposure when necessary
  101. 101. Microsurgical Lumbar Discectomy
  102. 102. Post op  Immediate post op ◦ Monitor neurology ◦ Turn in bed , semi fowler position ◦ Walk with assistance to toilet ◦ Oral analgesics and muscle relaxants for pain ◦ Bladder stimulants to assist in voiding ◦ Discharge- after walking and voiding(day of surgery in microscopic discectomy) ◦ minimize sitting and riding in a vehicle to comfort ◦ Increase walking on a daily basis ◦ Avoid stooping bending lifting
  103. 103. Post op  Delayed ◦ Core strengthening between week 1 & 3 ◦ Lifting bending stooping gradually after 3 weeks ◦ Long trips avoid for 4-6weeks ◦ Walking jobs with minimal lifting 2-3weeks ◦ Prolonged sitting jobs 4-6 weeks ◦ Heavy labor, long driving 6-8weeks ◦ Exceptionally heavy manual labour- AVOID
  104. 104. Endoscopic Discectomy  purported advantage of shortened hospital stay and faster return to activity  Not proved  Endoscope instead of microscope
  105. 105. Additional Exposure Techniques  Large disc herniation, lateral recess stenosis or foraminal stenosis, may require a greater exposure of the nerve root.  If the extent of the lesion is known before surgery, the proper approach can be planned
  106. 106. Hemilaminectomy  required when identifying the root is a problem.  Eg. Conjoined root
  107. 107. Total Laminectomy  Reserved for patients with spinal stenoses that are central in nature,  Occurs typically in cauda equina syndrome.
  108. 108. Facetectomy  reserved for ◦ foraminal stenosis ◦ severe lateral recess stenosis  If more than one facet is removed, a fusion should be considered  Especially in a young, active individual with a normal disc height at that level.
  109. 109. COMPLICATIONS OF LAMINECTOMY AND DISCECTOMY  Infection – Superficial wound infection , Deep disc space infection  Thrombophlebitis/ Deep vein thrombosis  Pulmonary embolism  Dural tears may result in Pseudomeningocoele, CSF leak, Meningitis  Postoperative cauda equine lesions  Neurological damage or nerve root injury  Urinary retention and urinary tract infection
  110. 110. FAILED BACK SYNDROME It is a condition characterized by persistent postoperative backache and sciatica. VERY COMMON CAUSES  Recurrent/ Persistent disc material at operated site  Herniated Nucleus Pulposus at other site  Epidural scar / Fibrosis  Facet arthrosis / Spinal stenosis
  111. 111. COMMON CAUSES – Neuritis, Referred pain from nonspinous site UNCOMMON CAUSES  Discitis / Osteomyelitis/ Epidural abscess  Arachnoiditis  Conus tumour  Thoracic, High lumbar Herniated Nucleus Pulposus  Epidural haematoma
  112. 112. The recurrence of pain after disc surgery should be treated with all available conservative treatment modalities initially. The surgery should be tailored to the anatomic problem only.
  113. 113. Chemo nucleolysis  treatment of lesions of the intervertebral disc by intradiscal injection of a lysing agent.  satisfactory results in 77 per cent of patients  Indication: prolapsed herniated disc
  114. 114. Chemo nucleolysis  Contraindications ◦ Sequestered disc ◦ Spinal stenosis ◦ previous injection of chymopapain ◦ allergy to papaya or its derivatives; ◦ Previous surgical treatment of the lumbar spine; ◦ herniation of more than two discs; ◦ a rapidly progressive neurological deficit; ◦ neurogenic dysfunction of the bowel or the bladder, or both; ◦ spondylohisthesis. ◦ Spinal tumour ◦ Pregnancy ◦ Diabetic neuropathy
  115. 115. CHEMONUCLEOLYSIS Chymopapain injected into the disc Degrades the proteoglycans in the nucleus Water holding capacity of the disc is decreased Shrinkage of the disc
  116. 116. Chemo nucleolysis  Complications ◦ Neurological  cerebral hemorrhage,  paraplegia,  paresis, quadriplegia,  Guillain-Barre syndrome,  seizure disorder. ◦ Anaphylaxis  Procedure is not in favour now
  117. 117. Percutaneous Discectomy  Mechanically decompress a herniated lumbar disc via a posterolateral cannula  Reduced morbidity  Reduced hospital stay  No anaphylactic reactions and neurological complications associated with chemonucleolysis  Indication: prolapsed herniated disc  Contraindications ◦ Presence of sequestered fragments ◦ Lumbar canal stenosis ◦ Lumbosacral discs
  118. 118. Disc Excision & Arthrodesis  First suggested by Mixter and Barr  Indicated for ◦ Marked segmental instability ◦ Done when facets are destabilized bilaterally to prevent Iatrogenic Spondylolisthesis  Frymoyer J et al “no significant difference in the results of patients who had discectomy and arthrodesis compared with the results in those who had discectomy alone”
  119. 119. Lumbar Artificial Disc Replacement
  120. 120. Disc Replacement Patient not suitable for artificial disc replacement are  Osteoporosis  Spondylolisthesis  Infection or tumour of spine  Spine deformities from trauma  Facet arthrosis
  121. 121. References  Campbell’s operative orthopaedics  An Instructional Course Lecture, American Academy of Orthopaedic Surgeons ◦ Radiculopathy and the Herniated Lumbar Disc CONTROVERSIES REGARDING PATHOPHYSIOLOGY AND MANAGEMENT ◦ Nonoperative Management of Low Back Pain and Lumbar Disc Degeneration  Current Concepts Review -Surgical Management of Lumbar Intervertebral-Disc Disease  Clinical orthopaedic examination – Bruce
  122. 122. THANK YOU