licina lumbar disc herniation
TRANSCRIPT
DISCHERNIATIONtearinouterdisc(brittle)
migrationofinnergel(lumpy)notusuallytraumatic
doesnotoccurinanormaldisc
What causesit?
nervepressurelegpain(sciatica)
What doesitcause?
What happenstoit?
• twophasesofpain•inflammation•compression
• inflammationcanbereversed• fragmentcanberesorbed• roughguide
•50%better in4wks•90%resolveeventually
DISCHERNIATION
radicular painparasthesiae
back pain
Whatarethesymptoms?
reduced straight leg raiseweaknessreflex loss
sensory loss
Whatarethesigns ?
DISCHERNIATION
Whatisthebestimaging?
Whenshoulditbedone?
• MRImodalityofchoice•moresensitive&specificthanCT•2xcostand4xinformation•sagittalandaxialimages•wholespinevisualised
• 20%ofasymptomaticpatientsage<60havedischerniation
• notnecessarywithin1st6wks•majorityresolve
• exceptions•caudaequina•progressiveneurology•severeintractablepain•suspiciontumour/infection
DISCHERNIATION
observe(physiotherapy)nerverootblock
Nerverootblock• injectionoflocalanaesthetic (Marcain)andcortisone(Celestone)
• intonerverootforamen• underCTguidance• usuallytemporary• goodifsurgerynotindicated• goodfordiagnosisifindoubt
How dowetreatit?
surgery
DISCHERNIATION
caudaequinasyndrome
unremittingpain
Prerequisites•symptoms>6weeks•legpain>backpain•legpaininradiculardistribution•nervetensionsigns(reducedSLR)•nervecompressionsigns•confirmedonimaging
When doweoperate?
SURGERYINTHEFORMOFDISCECTOMY
reliefoflegpainWhy doweoperate?
Outcomesatisfactoryresultin90%
DISCHERNIATION
functionalweakness
decompressionofnerve
Outcome• DaySurgeryprocedure• Backtosedentarydutiesby3weeks• Backtosportby6weeks• Goodorexcellentresultin90%• Recurrencerate6%• Disablinglowbackpain<5%
DISCHERNIATION
• mainlybackpain• referredratherthanradicularpain• psychosocialissues• chronicsymptoms• annulartearratherthanprolapse• lateral/foraminal prolapse
Whendoesn’tsurgerywork?
DISCHERNIATION
• 35y.o.male• 6weekhistoryofseveresciatica• numbness inS1distribution
• unabletosingleheelraiseonright• rightcalfwasting• rightSLRlimitedto15°
• 42y.o.female• 4 weekhistoryofsciatica• initially incapacitating,nowimproving
• absentanklejerk• mildcalfweakness• rightSLRlimitedto45°
• 28y.o.labourer• workinjurywithbackandlegpain
2/12ago
• mildnumbnessandweaknesswholefoot
• leftSLR30° - backandlegpain
Forsurgery• severesciatica• discherniationonMRI
Againstsurgery• young,manualworker• WorkCover claim• moderatebackpain• noclearneurologicaldeficit• diagnosisunclear
Epiduralinjectionsasmethodoftreatment
• 38y.o.female processworker• typicalsciatica• respondedwelltodiscectomy
• recurrenceofsymptomsuponreturntowork
Epiduralinjectionsasmethodoftreatment
• completeresolutionofpre-opsciatica• backpainwithnon-specificlegdiscomfort• anxiousaboutreturningtoworkduties
• 48y.o.maleaccountant• gradualonsetofsevererightthigh
andkneepain
• rightquadricepswastingandweakness
• absentrightkneejerk