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Hernia Nucleus Pulposus

Krisna Murti
Dept Bedah
RST Soepraoen
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Disc herniation
Definition: abnormal rupture or protrusion of disc
- Particularly in young- middle age man
- Cause usually flexion injury
- often occurs to one side
- Most common L5-S1, L4-5
Macnabs classification
- Bulging disc: intact annulus fibrosus
- Prolapsed disk: incomplete defect annulus fibrosus
- Extruded disk: complete defect annulus fibrosus,
intact posterior longitudinal lig.
- Sequestered disk: part of nucleus pulposus is
extruded
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History
- Most pt. Have back pain varied lengths of time varying
combined with back, hip, leg pain
Back pain: localized to midline LS region, radiaton to SI,
high iliac crest, coccygeal is more indicative of dural
irritation
Buttock: pain is usually one of deep-seated, cramping pain
Thigh :higher lumbar root, sharp pain, anterior thigh
Leg: L5/S1 root-cramp & vise-like feeling in belly of gastroc/
peroneal mus., paresthesia in lateral calf (L5) / back of calf
(S1)
Foot: most common symptom is parethesia than pain
Younger patient may has only leg pain
Aggravated symptom: bending, stooping, lifting, cough,
straining at stool
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PE
Back: loss of lordosis, paravertebral muscle spasm sciatic
scoliosis: more obvious on bending forward, limit flexion,
extend ( lesser degree than flex)
Lateral flex.increase pain (Shoulder type:when flex to same
side, axillary type:opposite side)
-scoliosis is a reflex mechanism by which the spine flexes
away from sciatic nerve entrapment side by paraspinous
muscle contraction standing with affected hip&knee
slighted flexion
- +ve SLRT, crossover pain (well-leg raising sign )= lift well-
leg, pain crosses over into symptomaic hip, early sign of
HNP , crossed SLRT : lift symptomatic leg & pain in
asymptomatic leg, indicative of disc herniation lying median
to nerve root; axillary/ midline muscle wasting is rarely seen
unless symptom> 3mo., very marked wasting
suggests extradural tumor than HNP
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Investigation
Minimal requirement for diagnosis of HNP:
plain x-rays and one other diagnostic study
(myelography, CT/myelography, CT, MRI)
MRI: necessary to plan a surgical procedure
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management
surgery
Indication:
- failure of conservative treatment: at least 6wks- not
more than 3 mo.
- Bladder & bowel involvement
- Increasing neurological deficit
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II conservative treatment
1. Unloading spine
Rest until pain start to abate (approximately48 hrs)
Corset/brace
Indications:
- patient who is recovering after bed rest and return to work
quickly
- An older patient
- Postoperative support
Modification of work and activities
2. Antiinflammatory drugs
3. Analgesics
4. Traction ( intermittent 25%BW 20-30 min)
5. Heat/cold
6. Exercise ( modified Willium exercise - back pain, Mc Kenzie
exercise -
leg pain)
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Spondylolytic spondylolithesis


spondylolysis: anatomic defect , causes
discontinuity in pars interarticularis
- May be unilateral or bilateral
- Often found in radiological studies, with no clinical
significance
Spondylolithesis: forward/ backward translation
subluxation of body of superior vertebrae upon its
adjacent inferior vertebrae
-usually forward slipping of L5 vertebra on sacrum
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Symptoms
- major symptom- LBP (intermittent dull
aching pain)
- Often radiate into sacroiliac region, also into
thighs
PE
- limited ROM back
- Palpable ledge at upper aspect of listhesis
- Limited hamstring extensibility
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Lumbar SCS

: narrowing of spinal canal, nerve root
canals/tunnels of intervertebral foramina
- A-P diameter < 10 mm-12 mm was
considered pathological
- Normal LS canal is narrowest in A-P
diameter at 3rd and 4th vertebrae
- Central canal is usually narrowing from
yellow ligament
- Lateral canal is usually narrowing from
osteophyte/ facet
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Symptom
- back pain, sciatica, claudication, thigh and
leg pain,
HNP SCS
Age 40-50 >50
Duration short long
Level usually 1 level several level
- pain relief by supine, squatting
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Tabel 4
Indikasi Operasi Diskus Intervertebralis Lumbar
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A. Absolut
1. Sindroma kompresi kauda ekuina
2. Paresis akut otot-otot penting
B. Relatif
1. Sindroma radik saraf yang berat dan terus-
menerus serta intraktabel
2. Sindroma radik saraf khronik dengan
distribusi nyeri dan tanda-tanda neurologik
segmental
3. Serangan berulang nyeri pinggang bawah dan
siatika dengan distribusi segmental tanda-tanda
neurologik
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Tabel 7
Indikasi Fusi pada Sindroma Lumbar
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Nyeri sakral hebat menetap pasca diskotomi
Segmen takstabil serta nyeri yang diakibatkannya
Osteokhondrosis serta spondilosis dengan nyeri pinggang
bawah berat

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Thank you