licina lumbar disc herniation

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DISC HERNIATION tear in outer disc (brittle) migration of inner gel (lumpy) not usually traumatic does not occur in a normal disc What causes it ? nerve pressure leg pain (sciatica) What does it cause ?

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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

Patientinformationdiscectomyvideo

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