Intervertebral disc prolapse- Symptoms, Causes, Function & Treatment

Intervertebral disc prolapse
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Intervertebral disc

IV disc conisit of 3 distinct component 
1. The cartilage end plate: Cover the disc both above  and below.
2. Annulus fibrosis: Water +proteoglycans + collagen type I
3. Nucleus pulposus: Water more + proteoglyans +type II collagen.
Function of IVD
Restricted IV joint motion
Construction to stability
Resistance to axail rotation and bending load
Preservation of anatomic relationships
Intervertebral disc prolapse
-Also know as spinal disc herniation
-IVDP is a condition affecting the spine in which a tear in outer fibrous ring ( Annulus fibrous) of the IVD cause the soft  central portion (Nucleus pulposus) to buldge out and causes pressure on the spinal cord and its accompanying nerve roots.
Types of herniation
Posterlateral disc herniation- Its occur in Lumbar 5
Costral (Posterior) disc herniation- it occur in lumbar 2 and cauda equina
Lateral disc herniation- its occur in lumabr 4 nerve root
Pathology
It occur in 3 stages
1.Nucleus degeneratiion
2.Nucleus displacement
3. Stage of fibrosis
1.Nucleus degeneration
Degeneration changes occur in disc before the displacement of nuclear materal.
Softening of nucleus and its fragmentation.
2. Nucleus displacement
Its includes
1.protrusion: Nucleus tends to buldge within annulus fibrosis.
2.Extrusion: Tear in the annulus fibrosis begin.
3. Extrusion: Tear has opened up and the nucleus pulposus come out of annulus fibrosis.
4.Sequestrum: Fragment come out compity with tear of annulus fibrosis.
3.stage of fibrosis
Here, calcification of buldged part occurs along with osteophyte formation.
Causes: 
Repetitive mechanical activity
Traumatic injury to lumbar disc
Living a sedentary life style
Obesity
Practising poor posture
Tobacco abuse
Location 
Lumbar: L4- L5 or L5-S1
Cervical: C5- C6 or C6-C7
Clinical  features
Severe low back pain
Pain radiating to the buttocks, legs and feets
Walking can be painful or difficult
Pain made worse with  straining, laughing or coughing
Muscle spasm
Muscle weakness
Tingling or numbness in leg or feet
Lose of bladder or bowel control
Examination 
Inspections: Look for postural abnormalities (Scolosis, lordosis, kyphosis)
Palpation

1.Tenderness

2.Movement

 

  1. Tenderness: At the level of posterior articulation of the involved segment and pain on percusion of affected IV space.
  2. Movement
  • To test flexion: Ask the patient to bend forwards
  • Lateral flexion: Ask the patient to bend to the left or right
  • Extension: Ask the patient to bend backwards
  • Rotation: Ask the patient to rotate from the waist to left and right.
  • SLR test: Ask the patient to raise the leg at 90° Without flexing the knee.
  • Femoral nerve test: Ask the patient to lift the leg in prone.
  • Position: Presence of pain in anterior aspect of thigh indicates high level disc lesion.
Special test: 
A.Lumbar
1.SLR
-Patient is ask to raise the leg in supine position.
-0-30° – Hamstring tightness
-30-45° – Sciatica, peripheral nerve injury
-45-70° – SI joint or hip involvement
2. Slump test
-In sitting position,  ask the patient to bend forward with neck flexion and instructed to raise the leg.
3.Passive lumbar extensions  test
-Ask the patient to extend the trunk
4. Lasegue’s test
5.Bowstring test
6. Prone knee bending test
B.cervical
Spurling test
Distraction test
Compression test ULTT
Shoulder abduction test
Investigation 
1.X-ray
-Narrowed disc space
-Loss of lumbar lordosis
2.CTscan
-Bulging of disc
3.MRI
 -Intervertebral disc protrusion, compression of nerve root
4. Myography
Differnetial diagnosis 
Ankylosing spondylitis
Vascular insufficiency
Extra dural tumour
Spinal  tuberculosis
Complications 
Cauda equina syndrome
Chronic pain
Permanent injury
Paralysis
Treatment 
Conservative Rx
Pain medication:
NSAID’S
Muscle relaxant
Bed rest
Oral steroids
Nerve root block
Surgical treatment
If conservative treatment fail we can go for surgery
Fenestartion
Laminectomy
Hemi- Laminectomy
Laminotomy
Nuceloplasty
Percutaneous disectomy
Physiotherapy treatment
Before surgery
1. Cryotherapy (For acute)
-It is indicated during acute low back pain as it reduces pain, swelling and muscle spasm.
-It delays the nerve conduction
2. Thermotherapy
-Heat causes vasodilation there by  reducing the muscle ischemia.
-It decrease the pain and relieves the muscle spasm.
A. Superficial heat
B. SWD
C. Ultrasound
3. Tens
Given in both chronic and acute condition
4. Traction: It stretches the spinal muscles and ligament and thereby reduce the intra disclar pressure. It distract  the vertebral body and facet joint.
5. Corset and braces
They increase intea abdominal pressure the force is diverted against the diaphragm  and thoracic spine.
Some load will be transmitted to the oblique & transverse abdominal muscles.
6. Spinal manipulation
Mannual force is use to bring about the passive movement either within or beyond the active range of motion.
7. Massage
Massage helps by stimulating the tissue and thus relaxes the contracted muscles.
8. Exercise
Flexion exercise
Sitting
Forward bending
Increased lumbar lordosis
Fixed lumbar lordosis witb bending
Bridging
Knee hugs
Pelvic tilt
Extension  exercise
Lying
Walking
Repeated back bend
Decreased lumbar lordosis prone on elbow
Extension control
Hamstring stretch
Reasons
Reduce pain
To strengthen the muscle
To stretch contracted muscles, ligaments and capsule
To improve mobility
To improve postures
Physiotherapy after surgery
Principle
-Mobilization should be done as early as possible
-Normal lumbo lordosis to be maintained
1.Immediate
-Chest Pt
-Upper limb movement
-Gluteal and quadriceps isometric
-Hip and knee flexion by level drug
2. In 2nd -3rs post operative drug
Turning the whole body as one pattern from supine & side lying position.
3. After week
-Isometric abdominal exercise
-Assisted spinal extension position
-Supported sitting
4. After 4 week
-Graded spinal extension exercise
-Graded spinal flexion, rotation and slide flexion exercise
-Ambulation with correct posture and gait.

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