INTRODUCTION TO

INTERVERTEBRAL DISC ANATOMY,

PIVD (LUMBAR) AND ITS
MANAGEMENT
 ANATOMY OF INTERVERTEBRAL DISC
• fibro cartilaginous structure.

• contributes 25% of the height of spinal column.

• function of shock absorption, transmitting compressive loads between vertebral bodies.

• Composed of the central nucleus pulposus(NP), the peripheral annulus fibrosus(AF) and
the end plates(EP).

• The end plate is a bilayer of cartilage that separate the IVD from the
vertebral body(VB) and serves as growth plate for the VB.
 NUCLEUS PULPOSUS:
– Highly hydrated structure,
approx. 88% water

– Hydrophilic matrix: composed of

proteoglycans(PG) ,type-2
collagen and elastin fibers.

– Low collagen and high PG ratio.

– Characterised by compressibility.
 ANNULUS FIBROSUS

-composed of concentric rings/lamellae of

highly organised Type-1 collagen fibres which
are interwoven.

-high collagen and low PG ratio

-lamallae are thicker anteriorly and laterally

and thinner posteriorly

-AF functions to contain the NP and maintain

its
pressurization under compressive loads.

-characterized by extensibility and tensile

strength
 BLOOD SUPPLY

• Blood Supply
– the disk is avascular with capillaries terminating at
the end plates
– nutrition reaches nucleus pulposus
through diffusion through pores in the endplate
 NERVE SUPPLY
• Innervation
– the dorsal root ganglion gives rise to the
sinuvertebral nerve which innervates the
superficial fibers of annulus
• no nerve fibers extend beyond the superficial
fibers
– neuropeptides thought to participate in sensory
transmission include
• substance P
• calcitonin
• VIP
• CPON
 (A)In the normal, healthy disc, the
nucleus distributes the load
equally throughout the annulus.

(B)As the disc undergoes

degeneration, the nucleus loses some
of its cushioning ability and
transmits the load unequally to the
annulus.

(C)In the severely degenerated disc,

the nucleus has lost all of its ability
to cushion the load, which can lead
to disc herniation.
SPECTRUM OF DEGENERATIVE JOINT
DISEASES OF SPINE

• Internal disc disruption

• Disc herniation
• Degenerative spondylolisthesis
• Spinal stenosis
• Adult spinal deformities
 Spectrum of changes(Kirkaldy Willis Concept)
Internal disc disruption

Disc herniation

Intervertebral space decrease

Overloading of facet joints, ligamentous instability

Instability of motion segment

Degenerative spondylolisthesis

Attempt to stabilise by formation of osteophytes and ligaments

hypertrophy Spinal stenosis

Adult spinal deformity

Etiology of Intervertebral disc degeneration
Repetitive mechanical activities – Frequent bending, twisting, lifting, and other similar
activities without breaks and improper stretching

Living a sedentary lifestyle – more prone to herniated discs because the muscles that
support the back and neck weaken, which increases strain on the spine.

Traumatic injury to lumbar discs- commonly occurs when lifting while bent at the
waist, rather than lifting with the legs while the back is straight.

Obesity – overloading the motion segment.

Poor posture – Improper spinal alignment

Tobacco abuse – toxins reduces the disc’s

ability to absorb nutrients, which results in
the
weakening of the disc.

Mutation- in genes coding for proteins involved in the regulation of the extracellular
matrix, such as MMP2 and THBS2,
 Cellular and Biochemical Changes of the
Intervertebral Disc

 Decrease proteoglycan
content.
 Loss of negative charged
proteoglycan side chain.
 Water loss within the
nucleus pulposus.
 Decrease hydrostatic
property.
 Loss of disc height.
 Uneven stress
distribution on the
annulus.
Pfirmann Grading on MRI
 ANNULAR TEARS

Concentric tears :
circumferential lesions, involves
outer layers of the annular wall.

Radial tears:
characterized by an annular tear
which permeates from the deep central part
of the disc (nucleus pulposus) and extends
outward toward the annulus, in either a
transverse or cranial-caudal plane.

Transverse tears:
also known as “peripheral tears” or
“rim
lesions,” are horizontal ruptures of
fibers, near the insertion in the bony ring
L4-L5 CT discogram
demonstrating a large left
posterolateral radial anular tear
associated with a left foraminal
and extraforaminal herniaton
 INTRAVERTEBRAL HERNIATIONS
Herniated discs in the cranio-caudal
(vertical) direction through a break in
one or both of the vertebral body
endplates are referred to as
intravertebral herniations-
Schmorl’s nodes.

They are often surrounded by reactive

bone marrow changes.

Nutrient vascular canals may leave

scars in the endplates, which are weak
spots representing a route for the
early formation of intrabody nuclear
herniations
 PROLAPSED INTERVERTEBRAL DISC

• Lumbar region > cervical region.

• Affects young adults 30-40 years

• M ale:female ratio 3:1, L4-5(95%) and L5-S1

• Herniates through the postero-lateral corner of

annulus fibrosus(thin region)

• Most commont causes:

– Sudden violent trauma (sports injuries)
– Less severe trauma in degenerated annulus(lifting,
 Anatomic classification

Disc protrusion: the herniated portion of the disc covered

with a thin layer of annulus

Disc extrusion: disc material herniated through annulus

but remains continuous with disc space

Disc sequestration: the disc fragment herniates through

the
annulus and loses contact with the originating disc space
Classification based on the location of
the disc herniation
• Posterolateral/paracentral prolapse:
– Commonest
– PLL weakest in this area
– Herniated disc impinges on the
traversing nerve roots(e.g the L5 nerve
root in L4-5 disc prolapse)

• Central prolapse:
– may present with back pain only or
Cauda-
equina(severe cases)

• Foraminal/extra foraminal/far lateral

herniation:
– Less common
– The herniated disc impinges on the
exiting nerve roots
(e.g. L4 nerve root in L4-5 level)
 Clinical features: History
• History of episode of trauma
• Radicular pain (buttock and thigh pain, extending below the
knee following the distribution of the involved nerve roots)
• aggravated by flexion, sitting, straining, sneezing, cough
• decreased by rest, especially in the semi-Fowler position
• Other symptoms:
– Weakness Corresponding to level of neurological
involvement
– Paraesthesia in dermatomal distribution
– Cauda equina

• Natural course of symptomatic PIVD is slow resolution of

symptoms over 6-8 weeks period in 80% of cases
 Cauda Equina syndrome
• Emergency
– Aggressive evaluation and management
– Large central herniation
• 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 perineumBowel
disturbances
 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
 Provocative tests
– straight leg raise
• a tension sign for L5 and S1 nerve root
• technique
– can be done sitting or supine
– reproduces pain and paresthesia in leg at 30-70 degrees hip flexion
• sensitivity/specificity
– most important and predictive physical finding for identifying who is a good
candidate for surgery
– contralateral SLR
• crossed straight leg raise is less sensitive but more specific
– Lesegue sign
• SLR aggravated by forced ankle dorsiflexion
– Bowstring sign
• SLR aggravated by compression on popliteal fossa
– Kernig test
• pain reproduced with neck flexion, hip flexion, and leg extension
– Naffziger test
• pain reproduced by coughing, which is instigated by lying patient supine
and applying pressure on the neck veins
– Milgram test
• pain reproduced with straight leg elevation for 30 seconds in the supine
position
SLUMP TEST
FLIP TEST
Clinical features -Neurology

L1 L2
Clinical Features- Neurology

L3
Clinical Features- Neurology

L4
 Clinical Features- Neurology

L5

Trendele
n berg
test
Clinical Features- Neurology

S1
 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
 Differential Diagnosis
SPINAL CAUSES:
-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)

EXTRASPINAL CAUSES:

• 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)
 KEY DIAGNOSTIC POINTS
LUMBAR DISC PROLAPSE SPINAL
STENOSIS
 Leg pain greater than back pain  Heaviness(no pain) develops after walks
 SLRT + a limited distance.
 Neurological deficit present  Flexion relieves symptoms
ANNULAR TEARS  No neurological deficit
 Back pain greater than leg pain  SLRT -ve
 Bilateral SLRT positive MYOGENIC OR MUSCLE RELATED
FACET JOINT  Pain localised to affected muscle
ARTHROPATHY
 Localized tenderness present unilaterally Pain increases on prolonged muscle use
over joint  Pain reproduced with sustained muscle
 Pain occurs immediately on spinal contraction against resistance
extension  Contralateral pain with side bending
 Pain exacerbated with ipsilateral
side bending
 Investigations- Plain Radiographs

• FINDINGS:
– Loss of lumbar lordosis
– Loss of disc height
 X ray views

• AP and Lateral views

• Oblique views
– Spondylolisthesis and lysis
– Hypertrophic changes around foramina in cervical spine
• Lateral flexion/ extension views
• Ferguson View
– 20 degrees caudocephalic AP
– 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.
 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
 Vacuum 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 an
annulus.
• indicative of
advanced disc
 CT
scan
Advantages:
• provides superior imaging of cortical and trabecular bone
compared with MRI.
• It provides contrast resolution and identify root
compressive
lesions such as disc herniation.
• differentiate between bony osteophyte from soft disc.
• diagnose foraminal encroachment of disc material due to its
ability to visualize beyond the limits of the dural sac and root
sleeves.
Limitations
• cannot differentiate between scar tissue and new disc
herniation
• does not have sufficient soft tissue resolution to
allow differentiation between annulus and nucleus
 Investigations- MRI
• Most accurate and sensitive modality for the diagnosis
of subtle spinal pathology.
• It allows direct visualization of herniated disc
material and its relationship to neural tissue including
intrathecal contents.
• Advantages over myelography
– No radiation
– Non invasive
– No intrathecal contrast
– More accurate in far lateral disc
– Disc disease of LS junction
– Early disc disease
Advantages of MRI 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.
– MRI findings can’t correlate with severity of
symptoms.
 Indications for MRI
• pain lasting > one month and not
responding to non-operative management
or
• red flags are present
– infection (IV drug user, h/o of fever and chills)
– tumor (h/o or cancer)
– trauma (h/o car accident or fall)
– cauda equina syndrome (bowel/bladder
changes)
Massive lumbar disc extrusion at L5–S1 in a 44-year-old man. Sagittal (a)
and axial (b) T1-weighted images; sagittal (c) and axial (d) T2-weighted
images. The extruded disc compresses and displaces the right S1 nerve
root. On the sagittal T1-weighted image, the continuity between the
extruding portion and the parent disc can clearly be identified.
 GADOLINIUM ENHANCED
CONTRAST MRI

-Investigation of choice for recurrent disc prolapse

-it allows to distinguish between post surgical
fibrosis(enhances with gadolinium) and recurrent
herniated disc(doesn’t enhance with gadolinium)
 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
Air contrast is used rarely
-Only in situations in which the patient is extremely
allergic to iodized materials
 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
 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
• May help differentiate primary cervical disorders
from peripheral nerve entrapments syndromes or
pain eminating from the intrinsic shoulder pathology
 MANAGEMENT
• NON OPERATIVE MANAGEMENT
– 90% respond to conservative management
– Rest in semi-fowler position,ice packs,
analgesics, muscle relaxants, oral steroids,
physical therapy and exercises
– Selective nerve root blocks: transforaminal SNRB
with local anesthetic agent and long acting
corticosteroid combination
– Lumbar epidural steroid injection
 Epidural Steroid injection
• Complications • Contraindications
• Minor – infection at the injection site
– Non-positional headaches – systemic infection
– facial flushing insomnia – bleeding diathesis
– uncontrolled diabetes mellitus
– low-grade fever, – congestive heart failure.
– transient increased back or
lower extremity pain
• Major
– vasovagal reaction
– Dural puncture
– Positional headache
– epidural abscess,
– epidural hematoma,
– Dura-cutaneous fistula,
– Cushing syndrome
 Epidural Steroid
injection Techniques

• Interlaminar Approach

• Transforaminal Approach

• Caudal Approach
 Bed Rest
• no data to suggest that bed rest alters the
natural history of lumbar disc herniation or
improves outcomes.
• Consensus of 2 days (if used)

Semi Fowlers
Position
 Physical Therapy
• Excercises
• Others : IFT, SWD, TENS, Traction
 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
 FOR ACUTE
STAGE

BRIDGING EXERCISE KNEE HUGS

FOR RECOVERY OR SUBACUTE
STAGE

EXTENSION CONTROL
HAMSTRING STRETCH

KNEE ROLLS
 Physical therapy
• TENS
– Trans-cutaneous 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 lumbar vertebrae.
– enlargement of the inter-vertebral 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
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 )
 Operative management
• Standard discectomy
• Limited Discectomy
• Microsurgical Lumbar discectomy
• Endoscopic discectomy
• Additional Exposure
– Hemi laminectomy
– Total Laminectomy
– Facetectomy
• Percutaneous Discectomy
• Chemo-nucleolysis
• Arthrodesis
• Disc replacement
 SURGICAL
MANAGEMENT
• Indications
– persistent disabling pain lasting more than 6 weeks that have failed non-
operative options (and epidural injections)
– progressive and significant weakness
– Cauda-equina syndrome

• Positive predictors for good outcome of surgery

– leg pain is chief complaint
– positive straight leg raise
– weakness that correlates with nerve root impingement seen on MRI
STANDARD
DISECTOMY
• Prone position
• With bolsters
• Knee chest position
• Allows abdomen to
hang free,
– minimizing epidural
venous dilation and
bleeding
• Lateral position with
affected side up
 Salient Points
• Lamina exposed cephalad and caudad
to the level of the herniated disc
• 1-2 sq cm 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
– Foraminotomy

• Free fat graft to reduce post

op scarring
Far lateral microdiscectomy
• indications
– for far-lateral disc herniations
• technique
– utilizes a paraspinal approach of Wiltse
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
Hemilaminectomy
• required when
identifying the root is
a problem.

• Eg. Conjoined root

• Reserved for patients
with spinal stenosIs that
are central in nature,

• Occurs typically in cauda

equina syndrome.
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.
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,
– earlier return to work.
– Visibility for assistant
Lumbar Microsurgical
Discectomy
• Drawbacks
– inadequate exposure
– incomplete decompression
– Costly equipment
• Contraindications
– Previously operated
– Spinal Canal Stenosis
Microsurgical Lumbar
Discectomy
• Requirements
– operating microscope with a 400-mm lens,
– small-angled Kerrison rongeurs of appropriate
length,
– microinstruments,
– combination suction–nerve root retractor
 Percutaneous endoscopic 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

Contraindications
– Presence of sequestered fragments
– Lumbar canal stenosis
– Lumbosacral discs
COMPLICATIONS
• 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
 CHEMONUCLEOLY
SIS

Chymopapain Degrades the Water holding

injected into the proteoglycans in the capacity of the disc
disc nucleus is decreased

Shrinkage of the
disc
 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
 Chemo nucleolysis
• Complications
– Neurological
• cerebral hemorrhage,
• paraplegia,
• paresis, quadriplegia,
• Guillain-Barre syndrome,
• seizure disorder.
– Anaphylaxis
• Procedure is not in favour now
Disc Excision & Arthrodesis
• First suggested by Mixter and Barr

• Indicated for
– Marked segmental instability
– Done when facets are destabilized bilaterally to
prevent Iatrogenic Spondylolisthesis

• Disadvantages of fusion:
– Alters the biomechanics of spine
– Loss of motion and overall shift in the sagittal
alignment
– Causes degenerative changes in the adjacent spinal
Total Disc Replacement
• CHARITE artificial disc (Depuy spine) was the first
implant approved by FDA for total disc
replacement in october 2004.
• Presently, there are only three lumbar
disc prostheses with FDA approval:
– the INMOTION, which is a modification of the Charite
(Depuy Spine, Raynham, MA),
– the ProDisc-L (DePuy Synthes),
– the activL (Aesculap, Center Valley,PA).

• All are approved only for single-level disc replacement.

ADVANTAGES OF DISC
REPLACEMENT
• Removes the disc/presumed main source of
pain
• Restore disc height----relieves load across the
facet joints----improves the pattern of load
bearing between vertebrae.
• Segmental stability, preservation and
improvement of segmental motion
• Maintain lordosis curve
• Limit disability and early return to
work
 PRE REQUISITES FOR DISC
REPLACEMENT
• Normal facet joints
• Good bone quality(non
osteoporotic)
• No spondylolisthesis or
spinal deformity
• No infection
• Single disc level
PRO DISC L
PRO DISC L
THANK
YOU