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Lumbar Disk Disease, TREATMENT OF LOW BACKACHE DUE TO LUMBAR DISK DISEASE…

- - - - The most common cause of low backache seems to be the lumbar disk disease.
        
        Bad posture plays a very significant role in the genesis of this disease.
        
        80% of the population is affected by this symptom at sometime
        
        In 78 % men and 89 % women, specific cause was not known.in life
        
        There are 23 disks throughout the spine,
        
        absent only in atlantoaxial articulation
        
        It is thinnest in the thoracic region and
        
        thickest in the lumbar
        
        It is thick anteriorly and
        
        thin posteriorly more so in the posterolateral aspect.
        
        Hence, posterolateral disk prolapse is more
        common.
  - - - Seen between 15 and 45 years of age.
        
        Circumferential and radial tears are seen in the disk annulus.
        
        Localized synovitis of the facet joints is seen.
      - Stage of instability
        
        Seen between 35 and 70 years of age.
        
        There is an internal disruption of the disk.
        
        Progressive disk resorption takes place.
        
        Degeneration of facet joints with lax capsules, subluxation and joint erosions are seen
        
        Stage of stabilization
        
        Seen over 60 years of age.
        
        Progressive development of hypertrophic bone about the disk and facet joints
        
        leading to segmental stiffening or frank ankylosis is seen.
        
        Disk herniation
        
        is considered as a complication of disk degeneration in stages II and I.
        
        Spinal stenosis
        
        is a complication in late instability and early stabilization stages.
        
        disk can herniate either into
        
        the body as Schmorl’s node
        
        or posteriorly towards the canal compressing the nerve roots.
    - - Disk bulging or protrusion
        
        This refers to
        
        some eccentric accumulation of nucleus
        
        with slight deformity of the annulus.
        
        Prolapsed disk
        
        is the one in which
        
        eccentric nucleus produces a definite deformity as it works through the fibers of the annulus.
        
        Extruded disk
        
        Here,
        
        the disk comes out into the canal and
        
        impinges on the adjacent nerve root.
        
        Sequestrated disk
        
        Here
        
        the nuclear material has separated from
        the disk itself and
        
        potentially migrates.
        
        L4-5 > L5S1 > L3-4 > L2-3 > L1-2
      - ETIOLOGY OF DISK HERNIATION
        
        Risk factors
        
        Jobs requiring heavy and repetitive weightlifting.
        
        Use of machine tools.
        
        Operation of motor vehicles.
        
        Cigarette smokers and tobacco consumers.
        
        Anxiety and depression.
        
        Stressful occupation as in doctors, police, etc.
        
        Women with greater number of pregnancies.
        
        Obesity and other cardiovascular risk factors.
        
        Monotonous work, working overtime, etc.
        
        Improper postural habits.
        
        DEFINITIVE CAUSES
        
        Degenerative changes make the disk susceptible to trauma.
        
        Any trauma, which suddenly increases the pressure, will result in rupture of the posterior fibers of the annulus,
        e.g.
        
        weightlifting,
        
        fall on the buttocks,
        
        direct trauma to the back,
        
        twisting movements and occupation involving flexion and lifting motions.
        
        Disk may also rupture
        
        during pregnancy, labor and
        
        after prolonged bed rest due to disk softening
        
        Disk rupture without any cause is due to degenerative process.
        
        CLINICAL FEATURES
        
        Low backache
        
        the usual history of lumbar disk herniation is of
        repetitive low back pain, radiating to the buttocks and decreased by rest.
        
        Pain is increased by flexion episode, sitting, straining, sneezing, coughing, etc.
        
        Pain is decreased by rest and in semiFowler position.
        
        Radiculopathy
        
        Sciatica. Leg pain equal to or more than the back pain evidence the radicular pain from the nerve root compression due to herniated disk.
        
        Nerve root compression
        
        About 95 % of the disk prolapse takes place through the L4-5 region compressing the L5 nerve root
- - - - traction
        
        Bucks extension skin traction and
        
        pelvic traction
        helps to relieve pain.
        
        belts/braces
        
        Maximal load reduction on the disk with tight
        corsets is 20-30 %
        
        Role of exercise
        
        Back education
        
        Epidural Steroids
        
        injecting a long-acting steroid and a local
        anesthetic into the epidural space.
        
        Its effect lasts for 3 weeks
        
        and is useful for sub acute and chronic cases.
  - - - Failed conservative management.
        
        Marked progressive weakness of muscles.
        
        Progressive neurological deficit.
        
        Cauda equina paralysis
      - Relative indications
        
        Recurrent episodes of incapacitating sciatica.
        
        Pain unrelieved by complete rest from activity.
    - - Laminectomy and disk excision
        
        Hemilaminectomy
        
        Fenestration surgery
        
        here, the spine is approached unilaterally
        
        and the spine on the opposite side is not exposed.
        
        Here, only the contiguous margin of
        upper and lower laminae is removed and medial facetectomy is done.
        
        The disk is now excised.
        
        This procedure requires that MRI and
        radiographic studies correctly locate the affected disk.
        
        Microscopic and
        Endoscopic lumbar
        discectomy
        
        Using an operating microscope or an endoscope, the disk can be excised through a very small incision (< 3.5 cm) with minimum damage to the structures and minimal blood loss.
    - - Indications are the same as for surgery. It is limited to lumbar spine.
        
        Drug used is chymopapain.
- - - - Look for the following points:
        
        Diffuse tenderness over the lower back
        .
        
        Localized tender infiltrates of the skin and subcutaneous tissue.
        .
        
        Palpable tender indurations of small intervertebral muscles.
        .
        
        Tenderness at the level of posterior articulation of the involved segment and pain on percussion of affected intervertebral
        space
      - movements
        
        All the movements of the spine are tested
        
        and found to be restricted in all directions.
    - - The dermatomal and the
        
        myotomal
        distribution are carefully analyzed to
        
        detect the level of lesion.
      - Clinical tests
        
        These tests are based on the stretching of sciatic nerve over the prolapsed disk:
        
        a. Forward bending to touch the toes.
        
        b. Sitting and alternatively extending one leg and then the other
        
        c. Slump test
        
        sitting bent forward and extending one leg and then the other.
        
        d. Straight leg raising test (SLRT)
        
        2 more items...
- - - - It, however, fails to detect
        
        intraspinal lesion,
        
        arachnoiditis and
        
        scar from disk herniation.
        
        It helps to detect
        
        the foraminal stenosis and
        
        the lateral disk prolapse.
      - MRI
        
        Discography
        
        Other tests of diagnostic importance
        
        bone scans,
        
        EMG,
        
        routine laboratory studies,
        
        injection studies, etc
- - - - Unstable spondylolisthesis
        
        Osteoporosis and compression of the
        vertebrae
        
        Marked loss of disk height at multiple levels
        
        Severe scoliosis
    - - Lumbar spondylosis
        
        Mild discopathy
        
        Arthroses of the facet joints
        
        Disk calcification
        
        Spina bifida
        
        Schmorl’s nodes
        
        Mild-to-moderate scoliosis
    - - ankylosing spondylitis,
        
        multiple myeloma,
        
        vascular insufficiency,
        
        arthritis of the hip joint,
        
        osteoporosis with stress fractures,
        
        extradural tumors,
        
        peripheral neuropathy,
        
        herpes zoster, etc.