The document describes the anatomy of the lumbar spine and intervertebral discs, the causes and symptoms of herniated discs, methods for diagnosing and treating herniated discs both non-surgically through physical therapy and pain management as well as surgically through procedures like discectomy and fusion, and post-operative care following back surgery.
The document describes the anatomy of the lumbar spine and intervertebral discs, the causes and symptoms of herniated discs, methods for diagnosing and treating herniated discs both non-surgically through physical therapy and pain management as well as surgically through procedures like discectomy and fusion, and post-operative care following back surgery.
The document describes the anatomy of the lumbar spine and intervertebral discs, the causes and symptoms of herniated discs, methods for diagnosing and treating herniated discs both non-surgically through physical therapy and pain management as well as surgically through procedures like discectomy and fusion, and post-operative care following back surgery.
The document describes the anatomy of the lumbar spine and intervertebral discs, the causes and symptoms of herniated discs, methods for diagnosing and treating herniated discs both non-surgically through physical therapy and pain management as well as surgically through procedures like discectomy and fusion, and post-operative care following back surgery.
Disc Prolapse Anatomy • Vertebral column (spin) consists of 33 vertebrae • Spine is divided into thoracic, lumber, cervical • Each section of spine containing 5-12 vertebrae • We will be focusing on the lower back or lumbar region Lumbar Anatomy • The lumbar section of the spine is made up of the lower 5 vertebrae • Commonly referred to as L1 to L5 • L5 connects to the top of the sacrum Anatomy of Lumbar Vertebra • The vertebral body is a thin ring of dense bone • Consisting of the body, pedicles and liminae • Vertebral foramen is a whole in vertebral body that spinal cord runs through Intervertebral Discs • Gel like Tissue between each vertebra • fibro cartilaginous cushions • serve as the spine's shock absorbing system • protect the vertebrae, brain, and other structures • The discs allow some vertebral motion extension and flexion. Intervertebral Discs • The disc is made up of 3 structures the • (1) Nucleus pulposus, gelatinous center • (2) Annulus Fibrosus. Its job is to contain the nucleus • (3) Vertebral end plates that attach the disc to the vertebrae Herniated disk • Can Occur when there is enough pressure from the vertebrae above and below • This can force some or all of the nucleus pulposus through a weakened or torn part of the annulus fibrosus. • The ruptured nucleus will often come incontact with and press on nerves near the disc. • This can result in severe pain • About 90% of herniated discs occur in the lumbar region. The discs in the cervical region are affected about 8%, those of the thoracic region only about 1- 2% • Herniated disks are one of the most common causes of back pain Mechanism of injury • Protrusion or rupture of the nucleus pulposus usually is preceded by degenerative changes. Loss of protein polysaccharides in the disk decreases the water content of the nucleus pulposus. The development of radiating cracks in the annulus weakens resistance to nucleus herniation. • There are 3 main ways discs can become herniated of ruptured • The extremely overweight are very susceptible because they are carrying around excess weight which puts extra pressure on the intervertebral disks • Improper lifting form, usually associated with bending with back and not with knees. Which can cause a sudden strain. This can be everyday lifting of objects or actual weight training • Twisting violently can also cause a sudden strain that could possible herniate a disk Mechanism of injury • capsule pushes back into the spinal canal, or it may rupture and allow the nucleus pulposus to be pushed back against the dural sac or against a spinal nerve as it emerges from the spinal column. • This produces pain due to pressure in the area of distribution of the involved nerve endings (radiculopathy). • Continued pressure may produce degenerative changes in the involved nerve, such as changes in sensation and deep tendon reflexes Recognition/ manifestations • Sharp and shooting pain the runs down low back, buttocks and down the thigh • complains of numbness or tingling anywhere in lower back, buttocks or leg • complains pain gets worse after any kind of strain to the body • Sometimes, the disk can pinch the nerve controlling bladder functioning • sciatica (leg pain resulting from sciatic nerve involvement) Evaluation/ diagnosis • The history of the injury; if the patient felt the pain immediately after performing a heavy activity that would be a good indicator of a herniated disk • An MRI is the best choice because it can clearly show the bones nerves and disks that might be damaged • A neurologic examination is carried out to determine if there is reflex, sensory, or motor impairment from root compression and to provide a baseline for future assessment. Treatment • The first thing that should be done is to rest and stay away from activity the agitate the symptoms • Then the application of ice and heat • This acts to relax the muscles in the back which can calm pain and any muscle spasms Treatment • Physical Therapy – Although performing physical Therapy does not directly help the disks, it does strengthen the muscles around it, so as to increase stability, which can help prevent herniated disks in the future Treatment • Pain relievers are often given to patient to alleviate pain • Anti-inflammatory drugs are given to reduce swelling • Surgery : – Laminectomy – Discectomy – Sometimes fusion is also performed Physical Therapy Exercises • Herniated disks can vary in severity and the rehabilitation plan can vary depending on the severity of the symptoms; • Phase #1 Rest- This can last from 2 days up to 2 months depending on the nature of the injury, typically the older the patient the longer the rest period. As stated before, rest should include immobilization of spinal column as well as icing and heating of the lower back Physical Therapy Exercises • Phase #2 After symptoms have subsided, anywhere from 10days to a few months exercises should be done to strengthen muscles around spinal column to help prevent another hernia. Doctors clearance is preferred so as not to begin exercises to early, which could cause a re injury. These exercises may be done with some slight lower back pain Physical Therapy Exercises • Exercise #1 while lying on your back bend your left knee up. Clench abs and butt, keeping back in neutral position. • Raise your other leg about 12in off floor, while knee is straight • Hold the position for 3 seconds • Then lower leg, do for 10 reps • Repeat the same with your other leg Physical Therapy Exercises • Exercise #2 Start with both knees on floor, clench abs and butt, back is straight • Put your hands on your hips. • Pickup your right foot and place on floor in front of you, while your left knee is still on floor • Lunge forward,. • Hold your position for 3-5 seconds • Return your right knee to floor • Do for 10 reps • Then repeat with the other leg Physical Therapy Exercises • Hamstring stretch • Lay down face up with one leg in door way other leg on wall • This stretches out ligaments and tendons that connect from leg to lower back Physical Therapy Exercises • Arm/Leg Raise • On your hands and knees • Tighten abs so spinal column is stiff • Raise right arm and left leg as shown to the right • Do 10 reps and switch arm/leg Physical Therapy Exercises • After all pain has gone the following exercise may be performed • Partial curl-lying on your back with knees bent and feet on floor • Tuck the chin into the chest • Curl upper body forward intill your shoulder blades are off the floor • Hold the position for 3 seconds and repeat for 10 reps Prevention • The stretches and exercises listed previously can strengthen the muscles around the discs, which can increase the stability of the discs • Teaching and practicing proper lifting form is essential in preventing these injuries Surgical management • surgical excision of a herniated disk is performed when there is evidence of a progressing neurologic deficit and continuing pain and sciatica that are unresponsive to conservative management. • The goal of surgical treatment is to reduce the pressure on the nerve root to relieve pain and reverse neurologic deficits Lumbar laminectomy Laminectomy Laminectomy: removal of the bone between the spinal process and facet pedicle junction to expose the neural elements in the spinal: allows the surgeon to inspect the spinal canal, identify and remove pathology, and relieve compression of the cord and roots Hemilaminectomy: removal of part of the lamina and part of the posterior arch of the vertebra Partial laminectomy or laminotomy: creation of a hole in the lamina of a vertebra Lumbar Discectomy • Discectomy: removal of herniated or extruded fragments of intervertebral disk Right L5-S1 Discectomy Surgery Fusion • Discectomy with fusion: a bone graft (from iliac crest or bone bank) is used to fuse the vertebral spinous process; the object of spinal fusion is to bridge over the defective disk to stabilize the spine and reduce the rate of recurrence Pre-operatively
– Routine pre-operative care
– Remind the patient that he should lie his BACK after the operation – Monitor for worsening of symptoms – Use anti-embolic stocking – Encourage ROME – Coordinate with the PT POST-operatively – Maintain BED rest – LOG ROLLING to turn – Never lie on PRONE – HEMOVAC -check tubing for kinks, record amount, report colorless moisture in dressing – Provide straight BACKED chair for LIMITED sitting ONLY POST-operatively Care for the surgical incision site. • Keep staples or sutures clean and dry and cover with dry dressing. • Notify physician if any signs or symptoms of infection occur, such as fever, redness or irritation, drainage, increased pain. Follow physician’s instructions regarding lifting, climbing stairs, driving a car, sexual activity, sports, exercise, and return to work. Practice stress reduction and relaxation techniques. POST-operatively Demonstrate proper body mechanics and prescribed exercise techniques. – Modify activity: • Avoid sitting or standing for more than 30 minutes. • Avoid twisting, flexing, extending, or rotating the neck. • Avoid long automobile rides. • Avoid sleeping in a prone position or use of pillows, to minimize neck flexion in bed; keep head in a neutral position. • Use adequate mattress and chair support. • Wear low-heeled shoes. Care of the cervical collar: • Wear the collar at all times until directed otherwise by the physician. • Keep the neck still while the collar is open. Wash the neck twice a day with mild soap. • With the assistance of a helper, wash the neck: – Lie flat and supine. – Open on each side of the collar and remove its front portion. – Gently wash and dry the neck. – Replace the front part of the collar. – Turn to one side with a thin pillow under the head. – Open one side. – Gently wash and dry the back of the neck. Refasten the collor. – Turn to the other side and wash and dry this side. Refasten the tab. – For men: Shave without twisting or moving the neck. This may be done with help while lying flat or sitting. Remove only the front part of the collar for shaving.
