Hernia Nucleus Pulposus

Krisna Murti Dept Bedah RST Soepraoen

Disc herniation
Definition: abnormal rupture or protrusion of disc - Particularly in young- middle age man - Cause usually flexion injury - often occurs to one side - Most common L5-S1, L4-5 Macnabs classification - Bulging disc: intact annulus fibrosus - Prolapsed disk: incomplete defect annulus fibrosus - Extruded disk: complete defect annulus fibrosus, intact posterior longitudinal lig. - Sequestered disk: part of nucleus pulposus is extruded
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History - Most pt. Have back pain varied lengths of time varying combined with back, hip, leg pain Back pain: localized to midline LS region, radiaton to SI, high iliac crest, coccygeal is more indicative of dural irritation Buttock: pain is usually one of deep-seated, cramping pain Thigh :higher lumbar root, sharp pain, anterior thigh Leg: L5/S1 root-cramp & vise-like feeling in belly of gastroc/ peroneal mus., paresthesia in lateral calf (L5) / back of calf (S1) Foot: most common symptom is parethesia than pain Younger patient may has only leg pain Aggravated symptom: bending, stooping, lifting, cough, straining at stool

PE Back: loss of lordosis, paravertebral muscle spasm sciatic scoliosis: more obvious on bending forward, limit flexion, extend ( lesser degree than flex) Lateral flex.increase pain (Shoulder type:when flex to same side, axillary type:opposite side) -scoliosis is a reflex mechanism by which the spine flexes away from sciatic nerve entrapment side by paraspinous muscle contraction standing with affected hip&knee slighted flexion - +ve SLRT, crossover pain (well-leg raising sign )= lift wellleg, pain crosses over into symptomaic hip, early sign of HNP , crossed SLRT : lift symptomatic leg & pain in asymptomatic leg, indicative of disc herniation lying median to nerve root; axillary/ midline muscle wasting is rarely seen unless symptom> 3mo., very marked wasting suggests extradural tumor than HNP

 Investigation Minimal requirement for diagnosis of HNP:

plain x-rays and one other diagnostic study (myelography, CT/myelography, CT, MRI)

MRI: necessary to plan a surgical procedure

management surgery

Indication:

- failure of conservative treatment: at least 6wks- not more than 3 mo. - Bladder & bowel involvement - Increasing neurological deficit

II conservative treatment 1. Unloading spine Rest until pain start to abate (approximately48 hrs) Corset/brace Indications: - patient who is recovering after bed rest and return to work quickly - An older patient - Postoperative support Modification of work and activities 2. Antiinflammatory drugs 3. Analgesics 4. Traction ( intermittent 25%BW 20-30 min) 5. Heat/cold 6. Exercise ( modified Willium exercise - back pain, Mc Kenzie exercise leg pain)
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Spondylolytic spondylolithesis

spondylolysis: anatomic defect , causes discontinuity in pars interarticularis - May be unilateral or bilateral - Often found in radiological studies, with no clinical significance Spondylolithesis: forward/ backward translation subluxation of body of superior vertebrae upon its adjacent inferior vertebrae -usually forward slipping of L5 vertebra on sacrum
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Symptoms - major symptom- LBP (intermittent dull aching pain) - Often radiate into sacroiliac region, also into thighs PE

- limited ROM back - Palpable ledge at upper aspect of listhesis - Limited hamstring extensibility

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Lumbar SCS

: narrowing of spinal canal, nerve root canals/tunnels of intervertebral foramina - A-P diameter < 10 mm-12 mm was considered pathological - Normal LS canal is narrowest in A-P diameter at 3rd and 4th vertebrae - Central canal is usually narrowing from yellow ligament - Lateral canal is usually narrowing from osteophyte/ facet
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Symptom - back pain, sciatica, claudication, thigh and leg pain, HNP SCS Age 40-50 >50 Duration short long Level usually 1 level several level - pain relief by supine, squatting

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Tabel 4 Indikasi Operasi Diskus Intervertebralis Lumbar ------------------------------------------------------A. Absolut 1. Sindroma kompresi kauda ekuina 2. Paresis akut otot-otot penting B. Relatif 1. Sindroma radik saraf yang berat dan terusmenerus serta intraktabel 2. Sindroma radik saraf khronik dengan distribusi nyeri dan tanda-tanda neurologik segmental 3. Serangan berulang nyeri pinggang bawah dan siatika dengan distribusi segmental tanda-tanda neurologik -------------------------------------------------------

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Tabel 7 Indikasi Fusi pada Sindroma Lumbar ------------------------------------------------------Nyeri sakral hebat menetap pasca diskotomi Segmen takstabil serta nyeri yang diakibatkannya Osteokhondrosis serta spondilosis dengan nyeri pinggang bawah berat
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Thank you

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