This document discusses lumbar intervertebral disc prolapse, including its clinical features, investigations, and management. It notes that the condition most commonly affects people aged 30-40 and occurs at the L4-L5 level. Clinical features include back pain radiating into the leg. Investigations include physical exam, plain radiography, CT, MRI, myelography, and electrodiagnostic studies. Management involves non-operative options like medications and injections initially, with surgery considered if conservative measures fail.

1. Lumbar Intervertebral Disc
Prolapse-
Clinical Features, Investigations &
Management
Dr M Avinash
Ganga Medical Centre
Coimbatore

2.  Introduction
 Clinical features
◦ Back pain
◦ Other symptoms
◦ signs
 Differential diagnosis
 Investigations
 Management
◦ Non operative
◦ operative

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.  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. LUMBAR DISC DISEASE
Clinical Features

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. 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. 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. 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. Other Symptoms
 Weakness
◦ Corresponding to level
of neurological involvement
 Paresthesia
◦ Dermatomal distribution
 Cauda equina

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. 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. Clinical features- Tests
Straight Leg
Raising
Lasegue’s test
r/o hamstring
tightness

14. Clinical Features- Tests
CONTRALATERAL
LEG RAISING TEST
(FRAJERSZTAGN
TEST)
AFFECTED
SIDE
NORMAL
SIDE

15. Clinical Features -Tests
Femoral nerve stretch test
L2,3 and 4 nerve roots
Bowstring sign

16. Clinical features – Flip test
NEGATIVE
POSITIVE

17. Clinical features-Slump test

18. Clinical features
NAFFZIGER TEST VALSALVA MANEUVRE

19. Clinical features- ROM
 Flexion-
◦ Painful and restricted
 Lateral bending to the same side
◦ Painful and restricted

20. Clinical features -Neurology
L1 L2

21. Clinical Features- Neurology
L3

22. Clinical Features- Neurology
L4

23. Clinical Features- Neurology
L5
Trendelenbe
rg test

24. Clinical Features- Neurology
S1

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. 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. Clinical features-Never forget
 Sacroiliac and hip joint examination
 Examination of peripheral pulses

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. 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. 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

31. Investigations
 THE CORNERSTONE OF
DIAGNOSIS OF LUMBAR DISC
DISEASE IS THE HISTORY AND
PHYSICAL EXAMINATION NOT THE
INVESTIGTION

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. 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. 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. Investigations –Radiography
Features of Instability-Traction
spurs
Tensile stresses by
ALL or outer
annulus fibres on
body periosteum

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. Reduction in Height of Pedicle
REDUCTION IN
THE HEIGHT OF
THE PEDICLE

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. Technique of Measuring
Translation
•Cobb Method
•Superimposition
method

41. Investigations- CT
Assessment of
◦ fractures
◦ spondylolysis
◦ preoperative planning,
◦ Alternative for assessing a patient with
instrumentation

42. 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.

43.  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

44. AXIAL LOCATION

45. SAGITTAL SECTION

46. 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

47.  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

48.  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.

55. Stages of Disc Prolapse

56. 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.

57. 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

58. 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.

59. 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

60. Air contrast is used rarely
-Only in situations in which the patient is extremely
allergic to iodized materials

61. 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.

62. 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

63. Electromyography
 the identification of
◦ peripheral neuropathy
◦ diffuse neurological involvement

64. 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

65. 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

66. 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

67. 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

68. 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

69. Epidural Steroid-Techniques
 Interlaminar Approach
 Transforaminal Approach
 Caudal Approach

70. 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

71. 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

72. 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

73. Discography-Lumbar

74. 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

76. 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

77. Treatment
 Conservative
◦ Bed rest
◦ Medications
◦ Physical therapy
◦ Lifestyle modifications
◦ Chiropractic manipulation
◦ Lumbo-sacral orthosis
◦ Selective injections
◦ Intradiscal Electrothermal Therapy ( IDET )
 Operative

79. 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

80. Medications
 NSAIDs
◦ Selective COX-2 inhibitors
◦ Preferential COX-2 inhibitors
◦ Nonselective
 Acetamenophen
 Opiods
 Steroids
 Muscle relaxants
 Anti depressants
 Anti Seizure

81. Physical Therapy
 Excercises
 Back School
 Others : IFT, SWD, TENS, Traction

82. 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

83. 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.

84. FOR ACUTE STAGE
BRIDGING
EXERCISE
KNEE HUGS

85. FOR RECOVERY OR SUBACUTE
STAGE
EXTENSION CONTROL
HAMSTRING STRETCH
KNEE ROLLS

86. YOGAASANAS
TADASANA
(Mountain pose)
MARICHYASANA
III
(Marichi's Pose)
BHARADVAJASA
NA
(Bharadvaja's
Twist)

87. VIRABHADRASAN
A II
(Warrior II Pose)
ARDHA URDHVA MUKHA
SVANASANA
(Half Upward-Facing Dog
Pose)
BALASANA
(Child's Pose)

88. UTTHITA
PARSVAKONASANA
(Side Angle Pose)
UTTHITA
TRIKONASANA
(Triangle Pose)
SHAVASANNA
(Corpse Pose)

89. 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

90. 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

91. 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 )

92. 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

93. 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

94. 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

95. Novel Therapy
 Infliximab
◦ TNF alfa inhibitor
 Injection of Ozone into disc and
around nerve roots

96. 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

97. 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

98. 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

99. 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

100. Surgical Options
 Standard discectomy
 Limited Discectomy
 Microsurgical Lumbar discectomy
 Endoscopic discectomy
 Additional Exposure
◦ Hemilaminectomy
◦ Total Laminectomy
◦ Facetectomy
 Percutaneous Discectomy
 Chemonucleolysis
 Arthrodesis
 Disc replacement

101. 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

102. 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.

103. 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

104. 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

105. 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

106. 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,

107. Lumbar Microsurgical
Discectomy
 Drawbacks
◦ inadequate exposure
◦ incomplete decompression
◦ Costly equipment
 Contraindications
◦ Previously operated
◦ Spinal Canal Stenosis

108. Microsurgical Lumbar
Discectomy
 Requirements
◦ operating microscope with a 400-mm
lens,
◦ small-angled Kerrison rongeurs of
appropriate length,
◦ microinstruments,
◦ combination suction–nerve root retractor

109. 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

110. Microsurgical Lumbar
Discectomy

111. 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

112. 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

113. Endoscopic Discectomy
 purported
advantage of
shortened hospital
stay and faster
return to activity
 Not proved
 Endoscope instead
of microscope

114. 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

115. Hemilaminectomy
 required when
identifying the root
is a problem.
 Eg. Conjoined root

116. Total Laminectomy
 Reserved for patients
with spinal stenoses
that are central in
nature,
 Occurs typically in
cauda equina
syndrome.

117. 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.

118. 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

119. 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

120. 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

121. 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.

122. 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

123. 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

124. CHEMONUCLEOLYSIS
Chymopapain
injected into the
disc
Degrades the
proteoglycans in
the nucleus
Water holding
capacity of the
disc is decreased
Shrinkage of the
disc

125. Chemo nucleolysis
 Complications
◦ Neurological
 cerebral hemorrhage,
 paraplegia,
 paresis, quadriplegia,
 Guillain-Barre syndrome,
 seizure disorder.
◦ Anaphylaxis
 Procedure is not in favour now

126. 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

127. 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”

128. Lumbar Artificial Disc
Replacement

129. Disc Replacement
Patient not suitable
for artificial disc
replacement are
 Osteoporosis
 Spondylolisthesis
 Infection or tumour
of spine
 Spine deformities
from trauma
 Facet arthrosis

130. 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

131. THANK YOU