Herniated Nucleus Pulposus

By: Baron Ablang Giselle Cruz Denise Dela Cruz Ronnel Mactal

Anatomy of Intervetebral Disc
1. Annulus fibrosus 2. Nucleus pulposus 3. End plate

Annulus Fibrosus ‡ Anulus fibrosus makes up peripheral portion of disk structure ‡ Composed of fibrocartilage and type I collagen ‡ Anulus is wider anteriorly than posteriorly .

which allows it to resist compressive forces. ‡ mucopolysaccharide gel gives the disc its high intrinsic pressure. ‡ contains realtively more proteoglycans giving it a looser gelatinous texture. .Nucleus Pulposus ‡ Nucleus has a high water content.

End Plate ‡ attaches firmly to the osseous endplate by means of numerous collagenous fibers (Sharpey·s fibers) ‡ strengthens the osseous endplate. which contains multiple perforations ‡ within the pores of the vertebral endplate are numerous vascular channels (major source of nutrients .


Nerve Structure of the spine .

‡ Displacement of the central area of the disc (nucleus) resulting in impingement on a nerve root. ‡ The condition occurs when all or part of the soft center of a spinal disk is forced through a weakened part of the disk.Herniated nucleus pulposus ‡ herniated nucleus pulposus is a slipped disk along the spinal cord. .

Disc Degeneration: chemical changes associated with aging causes discs to weaken. ‡ 2. Extrusion: the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc. Prolapse: the form or position of the disc changes with some slight impingement into the spinal canal. Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP). ‡ 4. .The four stages of disc herniation ‡ 1. but without a herniation. Also called a bulge or protrusion. ‡ 3.

A herniated disk is one cause of radiculopathy .Causes. ‡ These disks may herniate (move out of place) or rupture from trauma or strain. ‡ Radiculopathy refers to any disease affecting the spinal nerve roots. incidence. and risk factors: ‡ The spinal vertebrae are separated by disks filled with a soft. gelatinous substance. which provide cushioning to the spinal column.

‡ Most herniation takes place in the lumbar area of the spine.2% of the time. ‡ The cervical disks are affected 8% of the time and the upper-to-mid-back (thoracic) disks only 1 . Lumbar disk herniation occurs 15 times more often than cervical disk herniation. . and it is one of the most common causes of lower back pain.

. such as sensory or motor changes. resulting in neurological symptoms.‡ Nerve roots (large nerves that branch out from the spinal cord) may become compressed.

.‡ Disk herniation occurs more frequently in middle-aged and older men. especially those involved in strenuous physical activity. Other risk factors include any congenital conditions that affect the size of the lumbar spinal canal.

legs. and feet · Pain made worse with coughing.SYMPTOMS OF HERNIATED LUMBAR DISK ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Muscle spasm · Muscle weakness or atrophy in later stages · Pain radiating to the buttocks. or laughing · Severe low back pain · Tingling or numbness in legs or feet . straining.

straining. and rarely the hand. or chest · Pain made worse with coughing. forearm. fingers.SYMPTOMS OF HERNIATED CERVICAL DISK ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Arm muscle weakness · Deep pain near or over the shoulder blades on the affected side · Neck pain . especially in the back and sides · Increased pain when bending the neck or turning head to the side · Pain radiating to the shoulder. upper arm. or laughing · Spasm of the neck muscles .

.Protrusion of the L4/5 disc ‡ Protrusion of the L4/5 disc may cause L5 root pressure with pain radiating down the leg to the dorsum of the foot. ‡ Numbness on the outer side of the calf and medial two-thirds of the dorsum of the foot ‡ Weakness of dorsiflexion. particularly of the foot and toes.

Protrusion of the L5/S1 ‡ The S1 nerve root is compressed ‡ Pain and numbness on the outer side of the foot and under side of the heel. ‡ Weakness of both eversion and antarflexion of the foot ‡ The ankle jerk is diminished or absent .

Protrusion of the L3/4 ‡ Protrusion of the L3/4 disc may cause pressure on the L4 nerve root ‡ Numbness over the front of the knee and leg ‡ The knee jerk is diminished. . ‡ Weakness of the knee extensors.

‡ Emergency decompression is essential to avoid permanent damage to sphincter innervation.Central protrusion ‡ Central protrusion of a lower lumbar disc can press on the cauda equina and lead to urinary retention. . ‡ On examination there is usually perianal numbness and a patulous anus.

These nerves send and receive messages to and from the lower limbs and pelvic organs. .Cauda equina ‡ The spinal cord ends in the lumbar area and continues through the vertebral canal as spinal nerves. Because of its resemblance to a horse's tail. the collection of these nerves at the end of the spinal cord is called the cauda equina.


.‡ Limitation of lateral flexion of the lumbar spine to the same side will be most marked with a protrusion lateral to the nerve root ‡ while limitation of lateral flexion to the opposite side will be most marked with a protrusion medial to the nerve root.


and muscle strength. sensation. ‡ Straight Leg raising: .Signs and tests ‡ A neurological examination will evaluate muscle reflexes.

raising the right leg may cause pain to shoot down the course of the left sciatic nerve. . ‡ Sciatic stretch test: this test is performed after a straight leg raising test by lowering the affecting leg a few degrees below the point .‡ Well leg or cross leg sign: if there is a left sided herniation.

you will bend your head forward and to the sides while the PT provides slight downward pressure to the top of the head.‡ Spurling¶s test (cervical) . .

MEDICATIONS ‡ NSAID¶s ‡ If the patient has back spasms. . muscle relaxants are usually given.

Nerve conduction studies are used mainly for evaluation of paresthesias (numbness. of the motor and sensory nerves of the human body.) .DIAGNOSTIC TESTS ‡ EMG may be done to determine the exact nerve root that is involved. ‡ NCS is a test commonly used to evaluate the function. burning) and/or weakness of the arms and legs.tingling. especially the ability of electrical conduction.

‡ Spine x-ray may be done to rule out other causes of back or neck pain. . it is not possible to diagnosis herniated disk by spinal x-ray alone. However. ‡ Spine MRI or spine CT will show spinal canal compression by the herniated disk.‡ Myelogram may be done to determine the size and location of disk herniation.

. a procedure removing fragments of nucleated disk through a very small opening.Treatment ‡ Surgical : Diskectomy removes a protruding disk. microdiskectomy. Chemonucleolysis involves the injection of an enzyme (called chymopapain) into the herniated disk to dissolve the protruding gelatinous substance.

Physical Therapy ‡ ‡ ‡ ‡ TENS c HMP Traction Williams/McKenzie Exercise Strenghtening Exercise for back muscles .

Prognosis ‡ Prognosis of disc herniation is generally good regardless of treatment. hence long term results are similar w/ or w/o surgery. . ‡ Patients operated on for proven disc herniations improved more rapidly than patients treated non operatively. ‡ Within 4-5 years both operative and non operative treatment groups will generally have comprable neurologic recovery.

Complications ‡ ‡ ‡ ‡ ‡ · Long-term back pain · Loss of movement or sensation in the legs or feet · Loss of bowel and bladder function · Permanent spinal cord injury (very rare) .

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