Lumbar disc diseaseLumbar disc disease

Dr. Ajay BajajDr. Ajay BajajMCh Neurosurgery, PGI, ChandigarhMCh Neurosurgery, PGI, Chandigarh

Consultant NeurosurgeonConsultant NeurosurgeonDR BALWANTSINGH HOSPITALDR BALWANTSINGH HOSPITAL

GEORGETOWNGEORGETOWN

Very Important Talk!! -- LBPVery Important Talk!! -- LBP

• A major public health problem

• The leading cause of disability for people < 45

• 2nd leading cause for physician visits

• 3rd most common cause for surgical procedures

• 5th most common reason for hospitalizations

• Lifetime prevalence: 49%–80%

Pai et al. 2004, Pai et al. 2004, Orthop Clin N AmOrthop Clin N Am

FrequencyFrequency

• United States• Lifetime incidence of LBP is reported to

be 60-90% with annual incidence of 5%. Each year, 14.3% of new patient visits to primary care physicians are for LBP, and nearly 13 million physician visits are related to complaints of chronic LBP, according to the National Center for Health Statistics.

Types of LBPTypes of LBP

1. Non-specific “idiopathic”: 85%

2. Degenerative disc disease: discogenic pain, disk herniation, degenerative scoliosis

3. Developmental: spondylolisthesis, idiopathic scoliosis

4. Congenital: scoliosis

5. Traumatic6. Infectious7. Inflammatory8. Neoplastic9. Metabolic 10.Referred

Disc Disc

• Nucleus pulposus-water rich, gelatinous,axial load, pivotal point,binds vertebrae together

• Annulus fibrosus-fibrous and tougher, less water content,contained the nucleus pulposus

SAGGITAL VIEWSAGGITAL VIEW

DISC PHYSIOLOGYDISC PHYSIOLOGY

DISC NUTRITIONDISC NUTRITION

DIURNAL CHANGEDIURNAL CHANGE

• During day time- disc shrinks by 20%

• Body height reduced by 15 – 25 mm

• In night- body height is increased.

MRI appearance MRI appearance

• T-2 weighted image• Black disc –

dessication

Natural disc ageing Natural disc ageing

• 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.

FACTORS CONTRIBUTING FACTORS CONTRIBUTING TO DISC AGEINGTO DISC AGEING

IDIOPATHIC BLOOD VESSEL/NUTRIENT LOSS AND IDIOPATHIC BLOOD VESSEL/NUTRIENT LOSS AND DEHYDRATION/DECREASED PROTEOGLYCANS DEHYDRATION/DECREASED PROTEOGLYCANS

PRODUCTIONPRODUCTION

Other factorsOther factors

• Vertebral end plate calcification

• Arterial stenosis

• Smoking

• DM

• Exposure to vibration.

NON ENZYMATIC GLYCATION-GLUCOSE AND DISC NON ENZYMATIC GLYCATION-GLUCOSE AND DISC COLLAGEN-ADVANCED GLYCATION END PRODUCT-COLLAGEN-ADVANCED GLYCATION END PRODUCT-

AGEAGE

Disc degenerationDisc degeneration

Steps of disc herniationSteps of disc herniation

DISC HERNIATION OR DISC HERNIATION OR PROLAPSEPROLAPSE

• Protrusion ( contained or subligamentous herniation )

• Extrusion ( non-contained or transligamentous herniation )

• Sequestration ( freek fragment )

Internal disc disruption/grade -3 Internal disc disruption/grade -3 radial annual tearradial annual tear

Disc protrusion/PLL is still intactDisc protrusion/PLL is still intact

Disc extrusion/ PLL is rupturedDisc extrusion/ PLL is ruptured

MRI disc extrusionMRI disc extrusion

Disc sequestration/final end stage Disc sequestration/final end stage of disc diseaseof disc disease

NERVE ANATOMY NERVE ANATOMY INTRAOPERATIVE VIEWINTRAOPERATIVE VIEW

MRIMRI

• The gold standard for imaging of the herniated lumbar disc is magnetic resonance imaging

WHAT TO LOOK IN MRIWHAT TO LOOK IN MRI

T-1 AXIAL VIEWT-1 AXIAL VIEW

T-2 AXIALT-2 AXIAL

PROTON DENSITY IMAGEPROTON DENSITY IMAGE

ZONES OF ANTERIOR EPIDURAL ZONES OF ANTERIOR EPIDURAL SPACE / HERNIATION ZONESSPACE / HERNIATION ZONES

• Central region• Paracentral region or

lateral recess• Intraforaminal zone or

subarticular zone• Extraforaminal zone

Posture and intradiscal pressurePosture and intradiscal pressure

• The most common sites for a herniated lumbar disc are L4-5 and L5-S1, resulting in back pain and pain radiating down the posterior and lateral leg, to below the knee

• Back pain caused by a herniated lumbar disc is exacerbated by sitting and bending; conversely, the pain of lumbar muscular strain is aggravated by standing and twisting movements.

PATHOPHYSIOLOGIC MECHANISM PATHOPHYSIOLOGIC MECHANISM OF NERVE ROOT INVOLVEMENTOF NERVE ROOT INVOLVEMENT

• Mechanical deformation of the nerve root

• Biochemical activity if the disc tissue on the nerve root

Sciatic nerveSciatic nerve

TREATMENT OPTIONSTREATMENT OPTIONS

• Surgery Vs conservative treatment.( Weber,peul et al,)

• Same results with respect to over-all-long term improvement.

• Advantage of surgery: if indicated:-faster pain relief and back to work.

• Exception: severe pain with radiculopathy,progressive neurological deficit, development of cauda equina syndrome.

• Due to our findings, we recommend conservative treatment for up to 2 months. If there is no improvement in symptoms and signs, surgery should then be considered without further conservative treatment options."

• if patients are improving slowly, then they should continue conservative care.

Case Case

MRIMRI

Operative photograph of discOperative photograph of disc

Sciatica caused by referred pain from Sciatica caused by referred pain from a disc without neural compressiona disc without neural compression

53 year old patient. Left sided buttock pain radiating down left leg up to knee for 2 years.Recurring flare-ups.Pain aggravated on sitting.Not sleeping well

Tried Physio for 7 months. On Gabapentin, Amitrptilline, Oxyxontin .

Left L34 Nerve Root Block- no benefit

MRI- Degenerative changes at L34. No neural compression.

?? Cause of Pain, and what are the treatment options

F=53F=53L34 Analgesic Discogram. Local Anesthetic and Omnipaque dye injected into the disc space.

All her back and left thigh pain eased for 4 weeks . Was able to sleep comfortably for first time in 2 years

L34 Posterior Lumbar Interbody L34 Posterior Lumbar Interbody Fusion- complete relief of painFusion- complete relief of pain

Reports complete relief of pain 4 weeks after surgery.

MessagesMessages

• Inflamed discs can cause referred leg pain without neural compression by irritating the sinu-vertebral nerve

• Mild disc degeneration can result in quite severe pain- because of inflammatory chemicals in the disc space- not seen on MRI scans

• Analgesic Discography- a new technique – offers a simple way to confirm the relevant disc as the pain generator

• Interbody fusion can then be used to treat the problem definitively.

Take Home MessagesTake Home Messages

• Know the natural history of the disease

• Know your patient

• Correlate clinical findings, MRI and discograms if needed

• Until definitive evidence available, choose the most cost-effective available treatment option: cognitive therapy, exercise, fusion, arthroplasty, dynamic stabilization

THANK YOUTHANK YOU