DISC LESIONS

1. DISC LESIONS

2. Outcomes Be familiar with the anatomy and function of the disc. Be familiar with the causes and pathology of a typical disc lesion. Be familiar with the clinical presentation of a typical patient with a disc lesion. Be familiar with the different types of disc lesions. Be familiar with the term protective list.

3. Outcomes Be familiar with the most widely used physiotherapy treatment protocol for a patient with a typical disc lesion, annular disc lesion and flat tyre syndrome. Be able to give appropriate exercises and advice to a patient with a typical disc lesion.

4. Definition Disc degeneration leads to: Decreased water content Reduced shock absorption

5. Anatomy Disc consist of fibrous cartilage Outer part – annulus fibrosis Inner part – nucleus pulposes Disc serve as shock absorber Disc increases in thickness lower down to enable it to resist greater forces At an early age the disc already undergo degeneration and lose some of their shock absorbing function Degeneration leads to prolapse of the nucleus through the weakened annulus to the adjacent vertebra This is known as Schmorl’s nodules

7. Anatomy Direction of the prolapse is determined by the attachment of the disc to the ligaments Disc is loosely attached to the ant longitudinal ligament which in turn is firmly attached to the vertebral bodies Disc is firmly attached to the post longitudinal ligament and less firmly to the post part of the vertebral bodies Post longitudinal ligament is narrower and weaker and therefore disc prolapse more readily takes place posterior-lateral.

8. Disc extrusion Nucleus pulposus has penetrated the outer annular fibers Slow onset – may have a history of rotation of flexion movement Flexion is the most painful movement Predisposing factors of tensions, fatigue and cold may give rise to increased disc pressure Pain is aggravated by long periods of sitting in flexion, sitting with stretched legs, sustained flexion , coughing and sneezing Relief is experienced in a lying position

9. Disc extrusion May experience referred pain – non nerve root structures e.g. longitudinal ligament may be affected May experience difficulty to reach an upright position from a sitting position due to the fact that flexion is required during the first part of the movement

10. Disc sequestration One or more fragments of the nucleus have broken free from the herniated mass and have escaped into the canal Nucleus pulposes escapes into the spinal canal and may press against the dura, spinal cord and/or peripheral nerve-roots May also sequestrate more anterior and affect the autonomic nervous system May happen slowly or fast, usually after a rotation movement or if a heavy object is being picked up in the flexed position

11. Disc sequastration Symptoms as for disc extrusion - only worse If the cord is involved: Gait is affected Bilateral pins and needles Spastic bladder (upper neuron) Babinski and clonus occur If the caudaequina is affected: Lower motor neuron bladder symptoms Saddle para/anaesthesia (S4 signs)

12. Disc sequestration If the dura is involved: Extra-segmental referral Bilateral central pain or Unilateral central pain Widespread distribution If the peripheral nerves are affected: experiences nerve root referred symptoms If the sympathetic nervous system is affected: Sensation of heat or cold Feeling as if water is running down the arm Nausea and fatigue

13. Disc sequestration Primary postero-lateral sequestration – only pain in the leg, no central pain. Difficult to treat Disc sequestration lessens the disc space and that may in turn affect the facet joints which may lead to synovial dysfunction

16. Causes Trauma: flexion rotation movements when something heavy is picked up. Gives rise to the tear of the post longitudinal and resultant bulging of the disc Fall on the behind can also be a cause Degeneration – disc loses its elasticity as a result of the changes in the collagen fibres and decreased water content, resulting in the disc unable to handle the body’s compression forces and causes bulging Increased pressure: nucleus pulposus absorbs moisture, swells and presses against the annulus

17. Pathology Changes in the disc start asymptomatically Gives rise to a weak link which collapses under abnormal compression or tension Most injuries occur at L4,5 and L5/S1 Prolapse of the disc to ant or lateral causes ant or lateral osteophytes which can later be attached to one another Degeneration causes the disc space to narrow and the facet joints must now carry weight instead of regulating movement Prolaps of the disc to post causes more problems

18. Patology Prolapse usually takes place to posterior-lateral and the disc itself or osteophytes may expert pressure on the spinal cord itself or on nerve-roots The collapsed disc material initially presses against the dura mater which causes backache and further against the nerve-root which causes backache and nerve-root symptoms

19. Symptoms Sudden start of pain when the patient picks up a heavy object Pain initially only slight but worsens within a few hours Pain sometimes extremely severe and the patient’s movement is impaired Repeated attacks may come on suddenly e.g. sneezing, coughing and valsalva manoeuvre (increased pressure on the intervertebral canal ‘s bloodvessels which are sensitive – causes pain) Between attacks the patient may experience no symptoms

20. Symptoms In the case of mere bulging of the disc – pain is not clearly definable With real herniation and pressure on the nerve-root , more distinctive pain will occur in specific dermatomes Sometimes without incident, but after a prolonged sustained position Extension may be the comparable sign in a massive disc lesion Pain diminishes if the patient lies down with the knees supported, hanging in a particular position, sometimes standing in extension except if extension is the comparable sign

21. Symptoms Dura: Extra-segmental referred pain, thus not in a dermatome Posterior longitudinal ligament: Central or referred symptoms, not always clearly defined. Proximal is worse than distal Nerve-root sheath: Central and unilateral Nerve-root: Unilateral, distal worse, refers into a dermatome

22. Signs Patients usually young and healthy Have a lateral tilt of the pelvis Increased lumbar lordosis Back very sensitive to palpation, also across the gluteal area Flexion and rotation is restricted with an acute attack Protective muscle spasm Symptoms in leg as a result of nerve-root pressure with reduced sensation, muscle weakness, reduced tendon reflexes and positive signs of neural dynamics Sitting, coughing and sneezing is painful to the patient Decreased intervertebral movements

23. List (Lateral tilt) Posterior medial protrusion gives an ipsilateral laterally towards the side Ipsilateral list – thorax transfers laterally towards the side of pain Ipsilateral – protrusion is medial towards the nerve root More difficult to treat

25. List (Lateral tilt) Posterior lateral protrusion gives a contra-lateral list Contra-lateral list – thorax transfers away from the painful side Contra-lateral – lateral disc protrusion towards the nerve root Easier to treat and reacts well to traction

26. List (Lateral tilt)

27. Treatment Mobilising techniques: Rotation Grade IV- Longitudinal Static traction Palpation techniques (Except if extension is the comparable sign) Electrotherapy Trigger points Abdominal stabilising exercises

28. Treatment Strengthening exercises for m quadriceps and m gluteus if necessary Neural mobilisation Advice and home exercises Posture correction Kinetic handling Surgery

29. Advice Avoid sitting positions as a result of the increased pressure on the disc Shower rather than bathing Standing and lying will reduce the pain Avoid flexion and rotation movements of the back Swimming is good exercise Wearing of a brace with activities which aggravates backache (clinical reasoning is essential) Do not pick up heavy objects Avoid any activities which would aggravate the pain

30. ANNULAR DISC LESION

31. Cause A crack in the annulus Usually as a result of a sudden rotation movement in flexion

32. Signs and symptoms Severe pain Patient is unable to move or sit, appears anxious, sweaty and pale (get’s stuck) Feels faint Signs of neural dynamic tension may be positive – take care if bilateral

33. Treatment Rotation Grade IV- Longitudinal Traction may be used in certain cases, but refrain if patient experiences a stabbing pain Trigger points Abdominal stabilising Neural mobilisation Home advice

34. FLAT TYRE SYNDROME

35. Cause Narrowing of the disc space as a result of degeneration or prolapse Ligament and capsule have not yet adapted to the new height of the mobile segment

36. History Slow or sudden onset after a jerky movement

37. Signs and symptoms Central of referred pain depending on the structures involved and the degree of instability Stabbing pain, unexpected pain and the back feels weak Pain is aggravated by standing, walking, running, prone and extension movements An arch of pain may be present especially during flexion movements

38. Signs and symptoms To come into an upright position from flexion may be difficult and the patient often support himself with hands on thighs Palpation techniques can reproduce the pain and aggravate muscle spasm Pain is relieved by stable positions e.g. sitting

39. Treatment Rotation and longitudinal Grade IV- Palpation techniques up to Grade IV can also be applied with care Trigger points Neural mobilisation

40. Treatment Electrotherapy Stretches of especially back extensors and m psoas Abdominal stabilisers Strengthening of m gluteus and m quadriceps Home advice