Lumber and Lumber and Cervical Disc Cervical Disc

ProlapseProlapse

Ashraf Abd Elmoneim

Ezz ezz EldinProf. Of Neurosurgery

Term #of

Vertebrae

Body AreaAbbreviation

Cervical7Neck C1 – C7

Thoracic12Chest T1 – T12

Lumbar5 Low BackL1 – L5

Sacrum5( fused)Pelvis S1 – S5

Coccyx3Tailbone

Lumbar disc prolapse Nearly 75% of the lumbar flexion–extension occurs

at the lumbosacral junction, 20% at the L4/5 level and the remaining 5% is at the upper lumbar levels.

So it is not surprising that 90% of lumbar disc prolapses occur at the lower two lumbar levels; the most frequently affected disc is at the L5/S1 level.

The lumbar disc consists of an internal soft nucleus pulposus surrounded by an external laminar fibrous container, the annulus fibrosus.

Degrees of disc diseaseDegrees of disc disease

Disc bulgeDisc bulge symmetrical extension of disc beyond symmetrical extension of disc beyond the the endplates. endplates.

Disc protrusionDisc protrusion focal area of extension still attached to focal area of extension still attached to the the disc. disc.

Disc extrusionDisc extrusion fragment which lost its connection to the fragment which lost its connection to the disc.disc.

Disc sequestrationDisc sequestration fragment is contained within the PLL fragment is contained within the PLL

Disc migrationDisc migration fragment which travel caudal or rostral to fragment which travel caudal or rostral to endplate endplate

Clinical Picture

1- Low back pain: About 90% of the population suffer from

low back pain at some time.

30% of these will develop leg pain due to lumbar spine pathology.

The pain is worse on movement, coughing, sneezing or straining.

Pain is relieved with rest.

2- Sciatica: Pain in the leg due to lumbosacral nerve root

compression in the distribution of the sciatic nerveCauses Lumbar disc prolapse causing nerve root

compression.

Bony compression of the nerve root, usually by an osteophyte,

Narrowing of the ‘lateral recess’ of the spinal canal

Tumours of the cauda equina or by pelvic tumours.

3- Sensory & motor manifestations4- Sphencteric manifestations

Examination

Localized tenderness over the lower back. Scoliosis may be seen, usually concave to the side

of the affected leg. Straight leg raising (Lasegue’s test): will be

restricted on the affected side and, in severe cases, pain in the affected leg will be reproduced when the opposite leg is raised.

Wasting of certain muscle groups. Muscle weakness according to root compressed. Sensory affection according to root compressed. Deep tendon reflexes should be carefully tested.

L5/S1 disc prolapse

• Pain along the posterior thigh with radiation

to the heel

• Weakness of plantar flexion (on occasion)

• Sensory loss in the lateral foot

• Absent ankle jerk.

L4/5 disc prolapse• Pain along the posterior or posterolateral thigh

with radiation to the dorsum of the foot and great

toe

•Weakness of dorsiflexion of the toe or foot

• Paraesthesia and numbness of the dorsum of the foot and great toe

• Reflex changes unlikely.

L3/4 disc prolapse

• Pain in the anterior thigh

• Wasting of the quadriceps muscle

• Weakness of the quadriceps function and dorsiflexion of foot

• Diminished sensation over anterior thigh, knee and medial aspect

of lower leg

• Reduced knee jerk.

Investigations

X ray LSS: Which may reveal Straight lumbar curve Narrowing of disc spaces Osteoarthritic changes Associated spondylolisthesis &degenerative

changes.

Lumbar myelography was the time honored investigation for lumbar

disc prolapse. Its invasive technique & invention of CT & MRI

limited its use.

High-quality computerized tomography scanning and magnetic resonance imaging have largely superseded myelography for the diagnosis of lumbar disc prolapse.

The MRI is especially helpful in showing the size, configuration and position of the disc prolapse, as well as any associated nerve root or thecal compression.

In addition the MRI will also demonstrate pathology at other discs, such as degenerative changes as evidenced by decreased signal in the disc on the T2-weighted scans.

Treatment Most patients with sciatica achieve good pain relief

with simple conservative treatment and less than 20% will require surgery.

The likelihood of symptomatic relief without surgery is related to the pathology of the disc prolapse.

A‘bulging’ disc is likely to settle with simple conservative measures.

But sciatica due to a nucleus pulposus that has herniated out of the disc space and ‘sequestrated’ outside the annulus will probably need surgery for satisfactory relief of symptoms.

Conservative treatment

Bed rest for a period of about 1-3 days`

Although traction is sometimes recommended it probably has only limited benefit and may result in lower leg complications.

Simple analgesic agents and non-steroidal anti inflammatory medication.

High-dose corticosteroids.

Vitamin B complex.

Muscle relaxant.

Surgical treatmentIndicationsIndications a) Pain: especially Incapacitating pain not

responding to conservative measures and recurrent episodes of pain

b) Neurological deficits c) Motor or sphincteric.

Aim of surgery:Aim of surgery: Excision of the disc prolapse with

decompression of the affected nerve root.

In the past the operation usually entailed a complete or partial laminectomy, identification of the compressed nerve root, its mobilization off the disc prolapse and excision of the herniated disc.

Recently disc prolapses can be excised with minimal disturbance to the normal bony anatomy and with the removal of only a small amount of bone.

A full laminectomy may occasionally be necessary prior to the disc excision of a large central disc prolapse causing cauda equina compression.

A percutaneous endoscopic lumbar discectomy can be done.

Cervical disc

The cervical disc consists of an internal nucleus pulposus surrounded by the external fibrous lamina, the annulus fibrosus.

The CDP is usually in the postero-lateral direction, because the strong posterior longitudinal ligament prevents direct posterior herniation.

Unlike the lumbar region, the nerves pass directly laterally from the cervical cord to their neural foramen, so that the herniation compresses the nerve at that level.

So aC5/6 disc prolapse will cause compression of the C6 nerve root, a C6/7 prolapse causes compression of the C7 nerve root.

Clinical presentation: The characteristic presenting features of these patients

are neck and arm pain and the neurological manifestations of cervical nerve root compression.

Cord compression (myelopathy).

Examination: Restricted cervical spine movements. The head is often moderately flexed, and tilted towards

the side of the pain in some patients but occasionally away from it in others.

If the disc herniation is longstanding there may be weakness &wasting in the appropriate muscle group.

Sensation should be tested & the sensory loss will be characteristic for the nerve root involved although there may be some overlap.

The deep tendon reflexes provide objective evidence of nerve root compression in the following distribution:

•• Biceps reflex C5Biceps reflex C5

• • Brachioradialis (supinator) reflex C6Brachioradialis (supinator) reflex C6

• • Triceps reflex C7Triceps reflex C7

A full neurological examination must be performed and particular care taken to assess the lower limbs for hypertonia, hyperreflexia and +ve babinski.

C6/C7 prolapsed intervertebral disc (C7 nerve root):

• Weakness of elbow extension.• Absent triceps jerk.• Numbness or tingling in the middle or index

finger.

C5/6 prolapsed intervertebral disc (C6 nerve root):

• Depressed supinator reflex.• Numbness or tingling in the thumb or index

finger.• Occasionally mild weakness of elbow flexion.

C7/T1 prolapsed intervertebral disc (C8 nerve root):

• Weakness may involve long flexor muscles, triceps, finger extensors and intrinsic muscles.

• Diminished sensation in ring and little finger and on the medial border of the hand and forearm

• Triceps jerk may be depressed.

Investigations MRI cervical spine: is now the investigation of choice

and has almost completely replaced both myelography and CT.

The cervical myelogram using water-based non-ionic iodine contrast material was a most useful investigation for determining the presence and site of the disc herniation.

CT scanning by itself is frequently not helpful, but if performed following intrathecal iodine contrast it will demonstrate a disc herniation, and smaller volumes of intrathecal contrast are necessary than with myelography.

Treatment

Conservative treatment:

Most patients with cervical disc herniation achieve good pain relief with conservative treatment.

Bed rest, cervical collar, simple analgesic medication, non-steroidal anti-inflammatory medication and muscle relaxants.

Surgical treatment:Surgical treatment:

The most commonly performed operations for cervical disc prolapse are:

Cervical foraminotomy with excision of the disc prolapse.

Anterior cervical discectomy, with subsequent fusion.

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