Disc herniation

Protrusion
Rationale for Treatment

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Disc lesion – Rationale for treatment

1. Minimal movements - Inflammation phase

2. Controlled movements - Reparative phase

3. Increased movements - Remodeling phase

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Translucent Nucleus
Vascular supply Aggrecan = IDP 20kg
Collagen II
No regeneration

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White inner ⅔ annulus - no capillary Pink capillaries Sharpey’s fibres

Anaerobic metabolism Collagen I
Collagen III Capillaries 3-4mm
No regeneration Poor 2nd grade regeneration

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Inflammation phase – Minimal movements

Time: 5-8 days according to severity
Physiology: Sharpey's fibers - blood-borne cells activity, phagocytosis
Treatment: Minimal movements
1. Aims
➢ Avoid repeat injury
• Operator; forceful, EROM, position, prioritization of technique
• Patient; activity, work, guidelines
➢ Promote rest & reduced activity
3. Reduce loading: support
4. Nutrition & hydration
● 'fluid flow'. rest and activity, semi-fetal position
● diffusion path length, figure of 4
2. TTT Plan
1. Posture, above and below c/o
2. Pain-free ROM, short lever: soft tissue, articulation, HVT
3. Decompression: traction & release

3. Advice & Exercises

1. No flexion
2. How to get in/out bed/car/armchair, up/down stairs
3. Rest & reduced activity 4

Reparation phase - Controlled movements

Time: 4-6 weeks
Patho-physiology: Fibroblasts repair - new collagen matrix
Treatment: Passive controlled mobilization mid ROM.

1. Side lying position

• minimizes spinal compressive loading & reduces risk of herniation cyclic mid ROM
2. Cyclic stretching flexion (post. disc)
•

3.
and PLL. Loading...
stimulates collagen I synthesis, improves alignment & prevents adhesions of the outer annulus

Rotational movements (minimal)

• facilitates inter-lamellar movements and prevents adhesion
4. Soft tissue technique
• reduces pain, normalizes tone and reduces stress in the disc
5. Exercises
• off-weight bearing and eccentric

Expectation:
● Symptomatic relief, gradually pain free periods > pain periods
● Prognosis linked to No. spasms and activity level since last TTT
● Functional, increase in range and quality of ROM
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Remodelling - Increased movements

Time: 6-10 weeks
Patho-physiology: regression of cellularity, decreased synthesis, from granulation to scar tissue

Treatment:
1. Concentric
– techniques – history related
2. Cyclic loading
– anabolic effects
3. Static loading
– catabolic effects
4. Quantitative?
– optimum levels movement and weight are unknown? Loading criteria?
5. Exercises
– concentric to reach the EROM compression/stretch

Expectation:
– Functional & asymptomatic
– Return to normal activities
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Relief: recovery position

LSP Postural effect on the disc Sharpey’s fibres and soft tissues

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Treatment – ‘Figure of Four’

Diagnostic hypothesis: posterior lumbar disc lesion

Postural effects on the disc:

• reduces the diffusion path length, off weight bearing, legs parallel to spine
thighs at 45º to the trunk
• increases fluid flow movement, intermittent flex-extension foot & thighs 5º
 promotes nutrition and hydration
Adams A & Hutton ‘ The effect of posture on diffusion into lumbar intervertebral discs’ J. Anat. (1986), 147, pp. 121-134

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Patient selection
A. Outer posterior annulus lesions
1. pain worse:
– In early morning
– Flexion with spinal loading
– Preferential directional active movements
2. “high intensity zone” on MRI
3. Diagnosed contained herniation; protrusion, intrusion
B. Endplate lesions
A. symptoms are exacerbated by compressive loading
B. Schmorl’s node
C. Modic changes MRI
D. low bone mineral density
E. history - pain acute onset (D.D pain from a radial fissure gradual in onset)

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‘The success or failure of any therapy for back

pain depends on correct identification of the
pain source’

Professor Michael A. Adams

Clinical Anatomy, University of Bristol 2010
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The End
Monday Day clinic tutorial Evening clinic tutorial
3pm – 4th Year 6.00pm – Anyone BSO

14/01/13 Disc herniation - Clinic Repeat: Disc herniation - Clinic

21/01//13 Day off Disc herniation - Treatment
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28/01/13 Spondylosis Repeat:
Pathology - Clinic Spondylosis
Pathology - Clinic

04/02/13 Differential diagnosis Repeat: Differential diagnosis

Disc/ Facet Disc/ Facet
Clinic Clinic

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