back pain disc herniation. history primitive cultures attributed it to the work of demons ancient...
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BACK PAINBACK PAIN
Disc herniation
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HistoryHistory
Primitive cultures attributed it to the work of demons
Ancient Greeks recognized the symptoms as a disease
Goldthwait in 1911 attributed back pain to posterior dislacement of the disc (disc tumor)
Barr in 1932 attributed sciatica to herniated lumbar disc –suggested surgical treatment
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epidemiologyepidemiology
Hult estimates 80% of people are affected by this symptom at some time in their lives (Acta Orth Scand 1954)
Dillane,fry and Kalton reported 79% of men 89% of women the specific cause was unknown( BMJ 1966)
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epidemiologyepidemiology
Saal and Saal noted: 80% of those reporting chronic back pain did not report limitation of activity
Females more frequently than malesNo racial differences
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epidemiologyepidemiology
Carey et al 1992: incidence 3.9% chronic low back pain in 4437 North Carolinians
34% of those permanently disabled
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CostCost
Lost work timeCompensation (~~2 billion $/year in USA)Treatment (1/3 total cost)
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Factors affecting…..Factors affecting…..
Jobs requiring heavy and repetitive lifting,use of machine tools,operation of motor vehicles
Cigarette smokersAnxiety, depression, stressful occupationsNumber of pregnancies
Frymoyer et al JBJS 1983
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……..
Scoliosis
Jackson,Simmons Spine 1983
Patients taller than 181cm
Gyntelberg F Dan Med Bull 1974
Obesity
Deyo,Bass Spine 1989
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Disc anatomyDisc anatomy
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Nucleus pulposusNucleus pulposus
Loose,nonoriented,collagen fibril framework supporting a network of cells resembling fibrocytes and chondrocytes
Gelatinous matrix of various glucosaminoglycans,water and salts
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Annulus fibrosusAnnulus fibrosus
Concentric rings of fibrocartilaginous tissue
Rings attach to each other with additional diagonal fibers
Rings are thicker anteriorly
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Neural elementsNeural elements
Neural fibers exist in the outer rings of the annulus
They are branches of sinu vertebral nerve lying dorsally (small filamentous nerve originates from ventral ramus)
Bogduk N : Spine 7:319 1982
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Natural historyNatural history
Stage I : Dysfanction
15-45 y old,circumferential & radial tears in disc annulus, localised synovitis of facets
Stage II: Instability
35-70y old, internal disc disruption, progressive disc resorption, facet degenaration,sublaxation, joint erosion
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Natural historyNatural history
Stage III : Stabilisation
Osteophytes, stenosis, spondylosis
Kirkaldy-Willis Spine 4:102-109, 1979
Disc disease :one of recurrent episodes of pain followed by periods of significant or complete relief
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Simple compression of nerve Simple compression of nerve root creates sensory & motor root creates sensory & motor
symptoms but no painsymptoms but no pain
Smyth MJ, Wright V JBJS Smyth MJ, Wright V JBJS 40A:1401-1418 195840A:1401-1418 1958
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Chronic irritation by Chronic irritation by compression tends to be compression tends to be
painfulpainfulSmyth,Wright JBJS 1958Smyth,Wright JBJS 1958
Howe,Laser,Calvin Pain 3:25-Howe,Laser,Calvin Pain 3:25-41,197741,1977
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Consequences of pressureConsequences of pressure
Alteration in intraneural blood flowProblems with axoplasmic transportInflamation, edema, demyelination
Nobuhiro H,Hwan-Mo L,Weinstain JN textbook of spinal disorders 1996
Rydevik BL,Brown MD,Lundberg G : Spine 9:7-15 1984
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Kawakami et alKawakami et alJournal of Orthopaedic Journal of Orthopaedic
Research vol 18-2, 2000Research vol 18-2, 2000Mechanical constriction leads to
demyelination,alters pain related behaviorNucleus pulpusus:mechanical hyperalgia4-0 silk loop: no hyperalgiaSilk loop +nucleus pulpusus: thermal
hypralgesia
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Park JB,Chang H,Kim YS Park JB,Chang H,Kim YS Spine 1;28(1):100 2003Spine 1;28(1):100 2003
Immune reactionIncrease interleukin 12,T-helper Type I,
interferone-gamma(INF-gamma),Th2(IL-4)
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Kawakami et al Spine Kawakami et al Spine 21(18):2101-2107 199621(18):2101-2107 1996
pHInterleukin IPhospholipase A2Nitric Oxide
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