Inter Vertebral Disc Prolapse

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Inter Vertebral Disc Prolapse

• Presented
• By
• MD. MONSUR RAHMAN
• MPT (Musculoskeletal disorders)
  
  

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INTRODUCTION

• No population appears without the experience of
  LBP at some point of time in their life
• 80 of the industrial population and 60 of the
  general population experience it
• Onset is commonly between 35 55 yrs of age
• Although most of these LBP subsides in 2 3
  months, recurrence is common as high as 85
• The sports person experience LBP commonly
• One fourth of the total number of patients
  referred to physiotherapy are of LBP

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CAUSES OF LOW BACK PAIN

• Acute lumbosacral strain,
• Unstable lumbosacral ligaments and
• Weak muscles,
• Osteoarthritis of the spine,
• Spinal stenosis,
• Intervertebral disk problems
• Unequal leg length.
• Older patients
• Other causes include kidney disorders pelvic
• problems, retroperitoneal tumors, abdominal
• aneurysms, and psychosomatic problems.
• Obesity,
• Stress.

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ANATOMY OF DISC

• It occupies 20 33 of total length of
  vertebral column
• It is composed of water, collagen and
  proteoglycons
• The disc allows some compression, flexion, and
  rotatory torque and acts as a shock absorber
  protecting the neural elements
• Three components
• Nucleus pulposus
• Annulus fibrosis
• Vertebral end plates

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PATHOLOGY

• The prolapsed disc means the protrusion or
  extrusion of the nucleus pulposus through the
  annulus fibrosis
• The commonest level is L4-L5 and C5-C6
• The site of exit of the nucleus is usually
  posterolateral side
• Basically two types
• 1.Self contained disc lesion
• The disc and the nucleus pulposus remain intact
  within the confines of the disc
• 2.Disc lesion with nuclear extrusion
• Extrusion of the disc material into the central
  canal

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STAGES 1.Stage of degeneration No
bulge2.Stage of protrusion Just a
bulge3.Stage of extrusion Out, but in
contact4.Stage of sequestration Out, no
contact5.Stage of fibrosis Repair
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CLINICAL FEATURES

• Low back pain.
• Radiates down to thigh(posteriorly), or upto
  calf.
• Pain increases in night, either due to abnormal
  movement of spine or stretching of muscles.
• Pain aggravates during cough, sneeze or laugh.
• Valsalva maneuver increases symptoms
• Pain increased during flexion of spine.
• Reduced by extension of spine
• Prolonged sitting increases symptoms than long
  standing

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• Muscle spasm is in errector spinae
• Tenderness on the back muscles
• Tenderness on the individual spinous process.
• In chronic, Muscle weakness is seen.
• Reduced back muscle endurance.
• Reflex are absent or sluggish
• Sensory deficits are also seen.

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DIAGNOSIS

• XRay
• MRI
• CT
• Discography
• Special test

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SPECIAL TEST

• SLR
• SLUMP test
• Bowstring

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DIFFERENTIAL DIAGNOSIS

• SPONDYLOLYSIS
• Pain in hyper-extension on lumbar spine
• Hamstring tightness with SLR positive
• X-ray (oblique) scotty dog sign
• SPONDYLOLISTHESIS
• Palpable step-off
• Sensory deficit
• History of fall
• X-ray scotty dog sign
• LUMBAR SPONDYLOSIS
• Decrease ROM
• Pain in movement

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• SPINAL STENOSIS
• Loss of lordosis
• Alternate / abnormal SLR
• Passive extension reproduce symptoms
• Intermittent claudication
• POTTS DISEASE
• History of TB
• Intermittent claudication
• Cold abscess
• Stiff spine, Weight loss.

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• SPINAL TUMOUR
• Nocturnal pain and sleep disturbance
• Continuous pain
• LUMBAR FRACTURE
• Local swelling and haematoma
• UMN or LMN symptoms
• X-ray fracture
• PIRIFORMIS SYNDROME
• Pain in gluteal region and back of thigh
• No lumbar pain
• Piriformis stretch test positive

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• SI JOINT LESIONS
• Compression and distraction test positive
• LOW BACK STRAIN
• Para spinous spasm and tenderness
• Symptom on flexion
• No neurological symptoms
• HIP PATHOLOGY
• FABER test (figure of 4)
• No lumbar spine pain
• SLR negative

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MANAGEMENT

• Three ways of Treatment
• Rest
• Reduction
• Removal

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REST

• Bed Rest
• Traction for 10 KG
• Drugs NSAIDS, Paracetamol
• Spinal corset
• Reduce activity

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Reduction

• Continuous bed rest
• Traction for 2 weeks
• Epidural injections of corticosteroids
• Local anesthesia

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REMOVAL

• INDICATION FOR DISC REMOVAL
• Cauda equina lesion that doesnt clear up within 6
  hrs after traction Bed rest
• Neurological detoriation while under conservative
  treatment
• Persistent pain signs of Sciatic nerve tension
  after 3 weeks of conservative treatment.
• Level of prolapse is find by CT scan MRI.

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DRUG TREATMENT

• Paracetamol 1st choice
• If it is unsuitable/ineffective
• -NSAID s if suitable
• -Combination e.g. paracetamol, an NSAID, or
  codeine
• Muscle relaxant (diazepam-1st choice)

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ROLE OF PHYSIOTHERAPY

• PHYSICAL MODALITIES
• IFT
• TENS
• Ultra-sound
• Cryotherapy
• Moist heat
• Short wave diathermy

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• Main is lumbar spinal traction
• SPINAL TRACTION
• Intermittent or Continuous.
• 1/3rd of Body weight is used in traction.
• Gravitional traction
• LS belt

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EXERCISES

• SPINAL EXERCISES
• Global stabilization
• Whole erector spinae
• Segmental stabilization
• Multifidus, Transverse abdominis
• EXERCISES TO BE AVOIDED
• Forward bending and trying to touch the toes in
  sitting and standing
• Bilateral straight leg raising in supine lying
• Backward bending in standing

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• SPINAL MANUAL THERAPY
• LUMBAR BACK CORSET advised during travel as
  well as in sitting for a long time.
• ERGONOMICS Proper sitting advices, Work station
  modification, Frequent break at work, Regular
  exercises.
• Good nutrition.

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Dos and dons

• Dont bend forward
• Dont bent with trunk to lift weight
• Bent with knee hip.
• Carry weights equally on hands
• Lie on flat bed, avoid saggy bed.
• Keep pillows between knees to relax lumbar
  curvatures.
• Avoid long travel.
• Change the shock absorber of two wheelers.
• Sit erect on chair, avoid saggy postures.
• Do regular exercises.
• Dont stand for long time

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Dos and dons

• Sleep with hard mattress
• Stand, Sit Straight
• Change work atmosphere
• Kitchen height increased
• Foot rest for office workers
• Step standing for long standing occupation.

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Surgery

• Three methods of Surgery
• Partial Laminectomy
• Micro discectomy
• Percutaneous discectomy

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• Partial Laminectomy
• The lamina Ligamentum Flavum on one side are
  removed.
• The dura nerve root are gently retracted
  towards midline.
• Complications
• Infection
• Micro Discectomy
• Done by Microscope
• Posterior operation.
• Removal of herniated nucleus

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• Percutaneous Discectomy
• Herniated Material is aspirated through a special
  suction probe
• Method is still on TRIAL.
• Spinal Fusion
• Disc is excised
• Spine is fused with screws
• Spine is Stabilized to prevent degeneration in
  the apophyseal joints.

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Physiotherapy

• Patient was on BED upto 3 weeks
• 14 days
• Breathing Exercises
• Coughing
• Conditioning exercises
• Bed Mobility Turning

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• 410 days
• Continue the exercises
• Gentle Raising, Turning.
• Prone lying Shoulder Bracing
• Knee flexion/ Extension
• SupineAbdominal contractions
• Back arching
• Bridging
• Trunk Rotations

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• After 10 days4 weeks
• Exercises are continued
• Patient allowed to walk
• 12th day sutures are removed
• Patient train to SITSTAND

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• After 4 weeks
• Spine flexion started
• Posture correction
• Rotations of spine are initiated
• Side flexion encouraged.

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Do s and Dons

• Dont flex the Spine for 4 weeks
• Sit upright
• Walk erect
• Dont pick up objects from floor
• Never lift weights
• Return to work light work for 45 weeks
• Hard work after 812 weeks

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Thank you