WEEK FIVE WORKBOOK QUESTIONS

Questions (from notes on Intervertebral disc syndrome parts 1 and 2)

1. What are the most frequent sites of disc lesions? Can you give reasons why these sites are
most frequent for IVD lesions?
L4/L5 (51%) due to being less stable followed by L5/S1 (42%) then L3/L4 (7%). The reason
is due to the areas holding the most disc loading compared to other areas of the spine
along with its lordosis curvature. C5/C6 are the most common areas of cervical IVD lesions,
although this is less common in comparison to the lumbar spine.

2. What is the difference between a sequestration, protrusion and extrusion for an

intervertebral disc lesion?
Annulus fibrosis outer 20-33% can cause pain.
Herniation: generic term for all forms below (or bulge – nucleus is still contained, but there
is annular tearing) UNLIKELY TO CAUSE NEURO PAIN
Disc Protrusion: Nucleus intact. The annular fibres are thinned but not ruptured (posterior
laterally most common area) CAN GIVE NERUO PAIN
Disc Extrusion: Rupture of annular fibres allowing some nucleus to extrude into the canal
NERUO PAIN
Sequestration: Nucleus herniated entirely beyond the annulus, sequestrated material may
move so that in some positions asymptomatic (Nucleus pulposus has detached from the
annulus, can stay in area/move up/move down) NEURO PAIN

3. List the typical clinical signs and symptoms of a patient suffering from an IVD lesion.
Annular tearing = simple referred dull pain or can be complicated neurological pain
Signs & Symptoms
(sensation usually goes before motor loss)
- Back pain, leg pain or both
- Aggravated by bending, coughing or sneezing
- Numbness over one dermatome
- Relieved by supine rest with knees and hips flexed to 90 degrees
- Muscle weakness/cramping
- Antalgic lean
- Between the age of 30 – 50
- Frequently had prior episodes of low back pain
- May be related to a precipitating event such as lifting, twisting or heaving a heavy object
but may follow a minimal provocation incident.
4. Do radiographs provide diagnostic significance? Why?
Limited value, although lateral view may show a reduction in disc height or AP lateral bending
views give an indication of the level of involvement but are not definitive by themselves.
Radiographs can show disc heights and can be used with conjunction with MRI/ CAT SCAN.

5. What diagnostic imaging is preferable for diagnosing an IVD lesion?

MRI scans
6. Generally, describe the chiropractic management of disc lesions.
Disc prolapse is not necessarily a contra-indication to manipulation, however care needs
to be taken with any approaches requiring lumbar torque or rotation. A conservative trial
approach with distraction manipulation or side posture manipulation can help to reduce
the symptoms, employed with the 90/90 traction in the absence of advancing neurological
WEEK FIVE WORKBOOK QUESTIONS

defects or cauda equina syndrome. Flexion distraction, traction, blocking, heat/cold,

trigger points.

7. List the clinical features of a thoracic disc herniation.

- Rare (due to less movement) and can produce serious consequences (including paraplegia
in the worst cases)
- Occurs predominantly in males (most common 40-50 years)
- Thoracic disc problems compress the cord or interrupt the vascular supply
- Predisposing factors: previous injury (often minor), degeneration, healed osteochondritis
(Sheuermann’s disease aka adolescent osteochondrosis)
- Vague back pain
- May be referred unilaterally or bilaterally to chest abdomen or legs
- Pain aggravated by C flexion, coughing or straining.
- Pain relieved by recumbency
- Sensory deficits may include paraesthesia and paresis of the lower extremities
- Often shows degenerative changes on radiographs with calcification of the disc.
8. List the clinical features of a cervical disc herniation.
- Incidence of cervical disc prolapse = 5.5/100,000
- Scapular region/arm involvement
- Occur at 20-55 years (males > females)
- Static posture & repetitive arm/hand activity
- Usually bulge is postero-lateral, causing unilateral nerve root impingement and sharp neck
and arm pain
- Most common level is C5/C6 affecting the C6 nerve root
- Acute is usually associated with trauma while chronic is more common in older patients
with repetitive micro-trauma
- Local neck pain with sharp dermatomal radiation
- Must shake arm to decrease symptoms
- Sleep often disturbed at night
- Decreased cervical ROM
- Antalgic with neck flexion and lateral flexion
- Muscle weakness may precede onset of pain
- Positive orthopaedic tests for IVF encroachment and space occupying lesion
- Often unable to lie prone due to pain

9. Do IVD lesions always involve the nerve root? Explain your answer.
Disc can protrude or bulge: Centrally, Posteromedially (in axilla of the nerve root), Posterolaterally
(outside the axilla of the nerve) which determines whether nerve root is involved or inflammation
irritates the nerve.

10. What are the complications of an IVD syndrome?

Cauda equina (PLL starts to taper in lumbar area so IVD can herniated directly posterior
and laterally) , Myelopathy (long tract signs in the lower limb, bowel/bladder symptoms),
persistent symptoms.

11. What does SMART stand for? Are SMART changes usually detected in an IVD lesion?
WEEK FIVE WORKBOOK QUESTIONS

Sensory, motor, reflex, tension signs. SMART changes can be used to detect an IVD lesion if there
has been irritation to the nerve root.

12. Why do cervical disc herniations present with a diagnostic challenge? Explain your
answer.
Cervical disc herniations present a diagnostic challenge since symptoms do not always
relate correctly to the anatomical level of involvement.

13. Thoracic disc herniations are less common compared with cervical and lumbar lesions.
Why is this the case?
Due to the kyphosis curvature and the thoracic cage aiding in taking the load in comparison to the
cervical and lumbar disc lesions. Disc height and ratio also limits motion.

14. Are neurological signs ALWAYS present with IVD lesions?

No
15. What is a benign disc? Are there always clinical signs and symptoms associated with this
condition/entity?
If the bulge is contained without nerve root involvement, it may produce local symptoms
only due to lesion of the outer fibres of annulus fibrosis and stretch of P.L.L (posterior
longitudinal ligament) The pain is mediated by recurrent meningeal nerve and there are
not always symptoms.

16. Why are cervical IVD lesions less common compared to lumbar IVD lesions?
Cervical disc lesions occur less commonly than lumbar due to the loading components
within the spine. PLL and vertebral joints, annulus is thicken for extra support in the
cervical region

17. True or false: patients with IVD lesions are generally over 70 years of age. Explain your
answer.
False, generally disc lesions occur between the ages of 30-50 years. More degeneration
rather than perfusions due to dehydration that occurs during aging.

18. Describe the aetiology of an IVD lesion.

Annulus breaks down over time from repetitive microtrauma or trauma, usually there is a
history.
Non- Mechanical: Physiological changes (example: osteomyelitis & discitis) can lead to
structural changes (e.g endplate damage and schmorl nodes). Theses physiological
changes can be
1. Biomechanical changes: decrease in proteoglycan and water content that leads to
changes in the collagen fiber matrix
2. Histologic changes: Decrease in collagen matrix synthesis
3. Functional changes: Decrease in hydrodynamic function of nucleus causing more
loading on the annulus (stiffer and weaker)
Mechanical: mechanical damage such disc torsion and/or shearing forces can lead to
damage such as annular tears (circumferential/peripheral tears and radial fissures) leading
to disc prolapse .

19. Generally, using signs and symptoms, how would you differentiate an IVD lesion and a
facet lesion?
WEEK FIVE WORKBOOK QUESTIONS

More likely radicular signs vs referred ( the annulus fibrosis can give deep dull diffuse and
uncomplicated pain, similar to that of a facet). Referred pain will go below the elbow or
knee. Testing: Flexion will generally cause pain, (lumbar kemps & compression), SLR,
slumps, Bowstrings.

20. Which type of IVD lesion is more likely to give neurological signs, a bulge or a
sequestration?
Bulge more likely but Sequestration can lodge onto a nerve.

Refer to the PDF on the ‘Code of Conduct’ from the Chiropractic Board of Australia and answer the
following questions. Refer to ‘working with patients’ section 4.
True or False
1. Subluxation based chiropractors do not need to use diagnostic and therapeutic tools when
treating a patient. FALSE
2. Chiropractors don’t need to understand the reliability and validity of tests….it’s what
works that’s more important. FALSE
3. Subluxation based chiropractors don’t need to be bothered with a diagnosis and clinical
impression in patient care. FALSE
4. It’s important that a chiropractor behaves professionally at all times on social media. TRUE
5. Chiropractors should be aware of any relevant local, date or territory laws that may affect
the practice of different modalities. TRUE