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BACK PAINBACK PAIN
Disc herniation
HistoryHistory
Primitive cultures attributed it to the work of demons
Ancient Greeks recognized the symptoms as a disease
Goldthwait in 1911 attributed back pain to posterior dislacement of the disc (disc tumor)
Barr in 1932 attributed sciatica to herniated lumbar disc –suggested surgical treatment
epidemiologyepidemiology
Hult estimates 80% of people are affected by this symptom at some time in their lives (Acta Orth Scand 1954)
Dillane,fry and Kalton reported 79% of men 89% of women the specific cause was unknown( BMJ 1966)
epidemiologyepidemiology
Saal and Saal noted: 80% of those reporting chronic back pain did not report limitation of activity
Females more frequently than malesNo racial differences
epidemiologyepidemiology
Carey et al 1992: incidence 3.9% chronic low back pain in 4437 North Carolinians
34% of those permanently disabled
CostCost
Lost work timeCompensation (~~2 billion $/year in USA)Treatment (1/3 total cost)
Factors affecting…..Factors affecting…..
Jobs requiring heavy and repetitive lifting,use of machine tools,operation of motor vehicles
Cigarette smokersAnxiety, depression, stressful occupationsNumber of pregnancies
Frymoyer et al JBJS 1983
……..
Scoliosis
Jackson,Simmons Spine 1983
Patients taller than 181cm
Gyntelberg F Dan Med Bull 1974
Obesity
Deyo,Bass Spine 1989
Disc anatomyDisc anatomy
Nucleus pulposusNucleus pulposus
Loose,nonoriented,collagen fibril framework supporting a network of cells resembling fibrocytes and chondrocytes
Gelatinous matrix of various glucosaminoglycans,water and salts
Annulus fibrosusAnnulus fibrosus
Concentric rings of fibrocartilaginous tissue
Rings attach to each other with additional diagonal fibers
Rings are thicker anteriorly
Neural elementsNeural elements
Neural fibers exist in the outer rings of the annulus
They are branches of sinu vertebral nerve lying dorsally (small filamentous nerve originates from ventral ramus)
Bogduk N : Spine 7:319 1982
Natural historyNatural history
Stage I : Dysfanction
15-45 y old,circumferential & radial tears in disc annulus, localised synovitis of facets
Stage II: Instability
35-70y old, internal disc disruption, progressive disc resorption, facet degenaration,sublaxation, joint erosion
Natural historyNatural history
Stage III : Stabilisation
Osteophytes, stenosis, spondylosis
Kirkaldy-Willis Spine 4:102-109, 1979
Disc disease :one of recurrent episodes of pain followed by periods of significant or complete relief
Simple compression of nerve Simple compression of nerve root creates sensory & motor root creates sensory & motor
symptoms but no painsymptoms but no pain
Smyth MJ, Wright V JBJS Smyth MJ, Wright V JBJS 40A:1401-1418 195840A:1401-1418 1958
Chronic irritation by Chronic irritation by compression tends to be compression tends to be
painfulpainfulSmyth,Wright JBJS 1958Smyth,Wright JBJS 1958
Howe,Laser,Calvin Pain 3:25-Howe,Laser,Calvin Pain 3:25-41,197741,1977
Consequences of pressureConsequences of pressure
Alteration in intraneural blood flowProblems with axoplasmic transportInflamation, edema, demyelination
Nobuhiro H,Hwan-Mo L,Weinstain JN textbook of spinal disorders 1996
Rydevik BL,Brown MD,Lundberg G : Spine 9:7-15 1984
Kawakami et alKawakami et alJournal of Orthopaedic Journal of Orthopaedic
Research vol 18-2, 2000Research vol 18-2, 2000Mechanical constriction leads to
demyelination,alters pain related behaviorNucleus pulpusus:mechanical hyperalgia4-0 silk loop: no hyperalgiaSilk loop +nucleus pulpusus: thermal
hypralgesia
Park JB,Chang H,Kim YS Park JB,Chang H,Kim YS Spine 1;28(1):100 2003Spine 1;28(1):100 2003
Immune reactionIncrease interleukin 12,T-helper Type I,
interferone-gamma(INF-gamma),Th2(IL-4)
Kawakami et al Spine Kawakami et al Spine 21(18):2101-2107 199621(18):2101-2107 1996
pHInterleukin IPhospholipase A2Nitric Oxide
THANK YOUTHANK YOU