prolapsed vertebral disc

8/17/2019 Prolapsed Vertebral Disc

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The disc can herniate at any level in the spine, but it must commonly occurs in the lumbar region,

specifically at L4/L5 and L5/S1.

Clinical Features

The patient is typically a young and fit adult presenting with sudden onset back pain whilst lifting or

stooping. They are unable to straighten up due to severe pain.

From the onset of the injury, the patient may present with:

• Backache

• Sciatica (characteristic pain in buttocks and lower limb)

• Paraesthesia or numbness in lower leg or foot

• Muscle weakness

• Urinary retention

Backache and sciatica persists after the injury and is typically made worse by coughing or straining.

Observation

Sciatic Scoliosis - the patient may stand with a slight list to one side, increased during forward flexion


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Range of back movements severely limited in all planes

Palpation

Tenderness in the midline of lower back

Paravertebral muscle spasm

Special Tests

Straight Leg Raise (SLR) - Tests for herination at L4/L5 or L5/S1 discs. This test is performed with the

patient lying flat on their backs on the examination couch or bed.

1. Raise one leg, keeping the knee joint completely straight, until pain is felt in the buttock, thigh

or calf.

2. Note the angle at which pain occurs. In normal circumstances pain is felt above 80-90

degrees. The test is positve when pain is felt between 30-70 degrees.

3. Flexing the knee at this point will relieve buttock pain. Pressing on the popliteal nerve will

reproduce the pain.

4. Straighten the leg again and then lower the leg to below the angle where pain is felt. Dorsiflex

the foot. If the pain is due tosciatica, this should reproduce the pain.


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Patients with lumar herniation will have a limited SLR and it will be painful on

theaffected side. 'Crossed Sciatic Tension' - Raising the unaffected leg may cause sciatic tension on

the painful side. This may be observed but is not a common finding.

Femoral Stretch Test - May be positive if nerve root of L3/4 is affected. This test is performed with the

patient lying prone on the examination couch.

1. Flex the knee to 90 degrees

2. Extend the hip

Pain is felt in the anterior thigh. This test is weakly positive in lumber disc herniation.

Neurological Examination

At the corresponding level of prolapse, you may find:

• Muscle weakness (later wasting)

• Diminished reflexes

• Sensory loss

L5 impairment causes; weakness of big toe extension, weakness of knee flexion, sensory loss on the

outer side of the foot and sensory loss on the dorsum of the foot.

S1 impairment causes; weak plantarflexion, weak eversion of the foot, a depressed ankle jerk reflex

and sensory loss along the lateral border of the foot.

Cauda equina syndrome is aRED FLAG SYMPTOM.Cauda equina syndrome causes saddle

anaesthesia about the anus, perineum or genitals and loss of anal sphincter tone or faecal

incontinence. Patients may present with difficulty micturating.

Examination

Observation

Sciatic Scoliosis - the patient may stand with a slight list to one side, increased during forward flexionRange of back movements severely limited in all planes

Palpation

Tenderness in the midline of lower back

Paravertebral muscle spasm

Special Tests

Straight Leg Raise - Limited and painful on the affected side.

'Crossed Sciatic Tension' - Raising the unaffected leg may cause sciatic tension on the painful side.

his may be observed but is not a common finding.

Femoral Stretch Test - May be positive if nerve root of L3/4 is affected.


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Neurological Examination

At the corresponding level of prolapse, you may find:

• Muscle weakness (later wasting)

• Diminished reflexes

• Sensory loss

L5 impairment causes; weakness of big toe extension, weakness of knee flexion, sensory loss on the

outer side of the foot and sensory loss on the dorsum of the foot.

S1 impairment causes; weak plantarflexion, weak eversion of the foot, a depressed ankle jerk reflex

and sensory loss along the lateral border of the foot.

Cauda equina causes urinary retention and sensory loss over the sacrum.

Imaging

MRI is the most valuable method of imaging as it confirms the presence, level, size and extension of

the disc herniation. Traditionally water soluble myelography and computed tomography (CT) were

used to image the disc but these methods have proved to be less accurate and involve irradiation of

the spine and pelvis. An X-ray must be performed to rule out any bone pathology.

Diferential Diagnosis

1. Inflammatory disorders- Ankylosing Spondylitis causes severe and more generalised

stiffness and typical x-ray changes. Tubercolosis of the spine will produce a raised ESR.

2. Vertebral tumours - Cause constant pain. X-rays show bone destruction or pathological

fracture

3. Nerve tumours - may cause sciatica but pain is continuous. CT or MRI may delineate the

lesions


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Treatment

The majority of herniated discs will heal themselves within 6-8 weeks and do not require surgery.

Management problems arise if pain lasts longer than 8 weeks.

Non-Surgical or conservative management methods are usually tried first. These include:

• Patient education on body mechanics

• Physiotherapy

• Heat therapy

• Analgesics

• Anti-inflammatory drugs

• Oral or locally injected steroids

• Weight loss

• Smoking cessation

• Reduction - continuous bed rest and traction for 2 weeks

Once non-surgicl methods have failed, discectomy or microdiscectomyis usually the treatment of

choice.

Surgical management

The indications for surgical management are:

1. Cauda equina syndrome which does not clear up within 6 hours of starting bed-rest and

traction(Medical emergency)


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2. Persistent pain and severely limited straight leg raising after 2 weeks of conservative

management

3. Neurological deterioration while under conservative management

4. Frequently recurring attacks

Rehabilitation

Rehablilitation is essential for patients once they have recovered from acute disc rupture or disc

removal. The patient is taught isometric exercises in order to reduce the strain on their back. Light

work in resumed after 1 month and heavy work after 3 months. If the patient fails to recover fully,

heavy lifting should be avoided all together.

Reerences

• Solomon L, Warwick DJ, Nayagam S. (2005) Injuries of the Hip and Femur. In: Solomon L,Warwick DJ, Nayagam S. (Ed.) Apley's Concise System of Orthopaedics and Fractures. 3rd ed.

(pp197-197) London: Hodder Arnold.

• FEIG, D.S.,MD MSC, ZINMAN, B., MD, WANG, X., MSC and HUX, J.E.,MD MSC, 2008. Risk

of development of diabetes mellitus after diagnosis of gestational diabetes.Canadian Medical

Association journal,179(3), pp. 229-234.

prolapsed vertebral disc

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