Prolapsed intervertebral disc
The term PIVD (prolapsed intervertebral disc) means the protrusion or extrusion of the nucleus pulposus through a rent in the annulus fibrosus.
Disc herniation is a common back disorder. It is one of the most common diseases that produces low back pain and/or leg pain in adults, A herniated disc is a displacement of nucleus pulposus due to rupture of annulus fibrosus. More common at lumbar spine (L4-L5 and L5-S1) . It can also affect the cervical spine.
It is also known as Slip disc or Disc herniation.
Depending on the extent of the bulging of disc the symptoms vary.
The bulging disc may compressed the spinal nerve root exiting through intervertebral foramen (IV Foramen) giving rise to radiation of pain to the lower limb called Radiculopathy.
CAUSE
✓ Lifting heavy weight
✓ Degeneration of disc
✓ Increase lumbar curvature (Lumbar lordosis)
✓ Alterations in normal posture (Head forward posture)
✓ sedentary lifestyle
OTHER PHYSIOLOGICAL CAUSE
✓ Posterior annulus is thinner and weaker than anterior that's why forward bending posture exert more pressure over posterior annulus fibrosus and there by rupture of it, the nucleus bulge through it.
✓ Posterior longitudinal ligament is narrow at lumbar region. so the lumbar region is more prone for injury.
✓ Disc degeneration starts from lower lumbar spine from second decade of life.
SYMPTOMS
(Lumbar Spine)
✓ Low back pain and Pain is often made worse with sitting or bending forward.
✓ There is localized tenderness in the low back.
✓ Pain may or may not radiating dawn the lower limb. (If the extent of compression is more)
✓ Tingling or numbness in legs or feet.
✓ Muscle spasm.
✓ Muscle weakness or atrophy in later stages.
✓ In case of mild disc herniation one complain of only LBP.
✓ Loss of bladder or bowel control in case of cauda equina syndrome.
(Cervical Spine)
✓ Dull or sharp pain in the neck or between the shoulder blades, which can intensify in certain positions or after certain movements.
✓ Pain that radiates down the arm to the hand or fingers (this is called radiculopathy).
✓ Numbness or tingling in the shoulder or arm.
STAGES OF DISC HERNIATION
1) Bulging-
At this early stage, the disc is stretched and doesn't completely return to its normal shape when pressure is relieved. It retains a slight bulge at one side of the disc. Some of the inner disc fibres could be torn and the soft jelly ( nucleus pulposus ) is spiling outwards into the disc fibres but not out of the disc.
2) Protrusion-
At this stage, the bulge is very prominent and the soft jelly centre has spilled out to the inner edge of the outer fibres, barely held in by the remaining disc fibres.
3) Extrusion-
In the case of a herniated spinal disc, the soft jelly has completely spilled out of the disc and now protruding out of the disc fibres.
4) Sequestration- Here some of the jelly material is breaking off away from the disc into the surrounding area.
INVESTIGATION/TESTS
1. Proper evaluation of the patient is required to diagnose the condition.
2. X-ray and MRI can be done to confirm the diagnosis.
3. Other special tests such as straight leg raise (SLR Test), femoral stretch test should be done to find out the cause.
TREATMENT
Conservative Management
A) Bed rest
Complete bed rest for 2-7 days with anti-inflammatory and analgesic drugs can given to reduce the pain, inflammation and disc herniation.
B) Reduction:
Continue bed rest and traction for 2 weeks may reduce the herniation in over 90% cases. If no improvement with rest and traction, epidural injection of corticosteroid and local anaesthetic are given.
Operative Management
The Disc is removed by following techniques:-
A) Hemilaminectomy/Partial laminectomy
B) Laminectomy-
C) Microdiscectomy-
D) Laminotomy-
Physiotherapy Management
A) Rest
If the symptoms are sever the patient is advised to take complete bed rest on a hard surface. Short periods of walking at regular intervals.
B) Provide support to the Lumbar Spine
Use of L-S belt or brace provide support to the lumbar spine and increase the intra abdominal pressure hence normal Lumbar lordosis is maintained.
C) Exercise to reduce the protrusion of disc such as flexion/ extension exercise.
D) Mobilization of Spine
Mobilization of thoracic or cervicothoracic Spine help in reduction of bulge nucleus and spasm of para spinal muscles.
E) Soft tissue release
This technique help in increase blood flow to the nearby area, hence reduce in spasm.
F) Theraputic modality
✓ TENS, Ultrasound, IFT
used in acute or chronic case to reduce pain, spasm and induce relaxation.
✓ Cryotherapy
reduces muscle spasm and inflammation in acute phase.
✓ SWD
pulsed SWD in acute condition and continuous SWD in chronic cases.
✓ Traction
* beneficial to relieve nerve root compression and radiculopathy or paraesthesias in the acute phase of PIVD.
* Reduces nuclear protrusion by decreasing the pressure on the disc or by placing tension on the posterior longitudinal ligament.
* Duration of traction should be short in acute phase else there could be an increase in disc pressure leading to increased pain due to fluid imbibition ( less than 15 minutes of intermittent traction and less than 10 minutes of sustained traction).
There are other special techniques of treatment which will discuss in upcoming posts.
Disc herniation is a common back disorder. It is one of the most common diseases that produces low back pain and/or leg pain in adults, A herniated disc is a displacement of nucleus pulposus due to rupture of annulus fibrosus. More common at lumbar spine (L4-L5 and L5-S1) . It can also affect the cervical spine.
It is also known as Slip disc or Disc herniation.
Depending on the extent of the bulging of disc the symptoms vary.
The bulging disc may compressed the spinal nerve root exiting through intervertebral foramen (IV Foramen) giving rise to radiation of pain to the lower limb called Radiculopathy.
CAUSE
✓ Lifting heavy weight
✓ Degeneration of disc
✓ Increase lumbar curvature (Lumbar lordosis)
✓ Alterations in normal posture (Head forward posture)
✓ sedentary lifestyle
OTHER PHYSIOLOGICAL CAUSE
✓ Posterior annulus is thinner and weaker than anterior that's why forward bending posture exert more pressure over posterior annulus fibrosus and there by rupture of it, the nucleus bulge through it.
✓ Posterior longitudinal ligament is narrow at lumbar region. so the lumbar region is more prone for injury.
✓ Disc degeneration starts from lower lumbar spine from second decade of life.
SYMPTOMS
(Lumbar Spine)
✓ Low back pain and Pain is often made worse with sitting or bending forward.
✓ There is localized tenderness in the low back.
✓ Pain may or may not radiating dawn the lower limb. (If the extent of compression is more)
✓ Tingling or numbness in legs or feet.
✓ Muscle spasm.
✓ Muscle weakness or atrophy in later stages.
✓ In case of mild disc herniation one complain of only LBP.
✓ Loss of bladder or bowel control in case of cauda equina syndrome.
(Cervical Spine)
✓ Dull or sharp pain in the neck or between the shoulder blades, which can intensify in certain positions or after certain movements.
✓ Pain that radiates down the arm to the hand or fingers (this is called radiculopathy).
✓ Numbness or tingling in the shoulder or arm.
STAGES OF DISC HERNIATION
1) Bulging-
At this early stage, the disc is stretched and doesn't completely return to its normal shape when pressure is relieved. It retains a slight bulge at one side of the disc. Some of the inner disc fibres could be torn and the soft jelly ( nucleus pulposus ) is spiling outwards into the disc fibres but not out of the disc.
2) Protrusion-
At this stage, the bulge is very prominent and the soft jelly centre has spilled out to the inner edge of the outer fibres, barely held in by the remaining disc fibres.
3) Extrusion-
In the case of a herniated spinal disc, the soft jelly has completely spilled out of the disc and now protruding out of the disc fibres.
4) Sequestration- Here some of the jelly material is breaking off away from the disc into the surrounding area.
INVESTIGATION/TESTS
1. Proper evaluation of the patient is required to diagnose the condition.
2. X-ray and MRI can be done to confirm the diagnosis.
3. Other special tests such as straight leg raise (SLR Test), femoral stretch test should be done to find out the cause.
TREATMENT
Conservative Management
A) Bed rest
Complete bed rest for 2-7 days with anti-inflammatory and analgesic drugs can given to reduce the pain, inflammation and disc herniation.
B) Reduction:
Continue bed rest and traction for 2 weeks may reduce the herniation in over 90% cases. If no improvement with rest and traction, epidural injection of corticosteroid and local anaesthetic are given.
Operative Management
The Disc is removed by following techniques:-
A) Hemilaminectomy/Partial laminectomy
B) Laminectomy-
C) Microdiscectomy-
D) Laminotomy-
Physiotherapy Management
A) Rest
If the symptoms are sever the patient is advised to take complete bed rest on a hard surface. Short periods of walking at regular intervals.
B) Provide support to the Lumbar Spine
Use of L-S belt or brace provide support to the lumbar spine and increase the intra abdominal pressure hence normal Lumbar lordosis is maintained.
C) Exercise to reduce the protrusion of disc such as flexion/ extension exercise.
D) Mobilization of Spine
Mobilization of thoracic or cervicothoracic Spine help in reduction of bulge nucleus and spasm of para spinal muscles.
E) Soft tissue release
This technique help in increase blood flow to the nearby area, hence reduce in spasm.
F) Theraputic modality
✓ TENS, Ultrasound, IFT
used in acute or chronic case to reduce pain, spasm and induce relaxation.
✓ Cryotherapy
reduces muscle spasm and inflammation in acute phase.
✓ SWD
pulsed SWD in acute condition and continuous SWD in chronic cases.
✓ Traction
* beneficial to relieve nerve root compression and radiculopathy or paraesthesias in the acute phase of PIVD.
* Reduces nuclear protrusion by decreasing the pressure on the disc or by placing tension on the posterior longitudinal ligament.
* Duration of traction should be short in acute phase else there could be an increase in disc pressure leading to increased pain due to fluid imbibition ( less than 15 minutes of intermittent traction and less than 10 minutes of sustained traction).
There are other special techniques of treatment which will discuss in upcoming posts.
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