TEXT BOOK READING

Presented by : dr. Maria Christien Agustie

Moderator:
Prof. dr. MI Widiastuti, PAK, Sp.S(K), MSc
Anatomy
 Vertebral column (spine) consists
of 33 vertebrae
 Spine is divided into cervical,
thoracic, lumbar, sacral,
coccygeus
 Each section of spine containing :
7 cerv vert, 12 thoracic vert, 5
lumbar vert, 5 sacral vert, 4
coccygeus vert.
 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
L1 to L5
 L5 connects to the top
of the sacrum
Lumbolordosis
Spinal curvature plays an
important role in increasing
elasticity against axial
compression, and in keeping
balance of body weight axis

Optimal lumbosacral
angle : 300
 Ligaments of the Vertebral Column

Anterior longitudinal ligament

•Runs from the skull (occipital bone) to the sacrum on

the anterior surface of the vertebral bodies and
intervertebral disks.
•Is narrowest at the upper end but widens as it
descends , maintaining the stability of the joints.

Posterior longitudinal ligament

•Interconnects the vertebral bodies and intervertebral

disks posteriorly and narrows as it descends .
•Supports the posterior aspect of the vertebral bodies
and the annulus fibrosus , but it runs anterior to the Another ligaments :
spinal cord within the vertebral canal. -lig. flavum
•Limits flexion of the vertebral column and resists -Lig. nuchae
gravitational pull.
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
hole in vertebral body that
spinal cord runs through
Intervertebral Disc
The disc is made up of 3
structures :
(1) Nucleus pulposus : gelatinous center
Consists of water, proteoglycans and collagen.
At birth- 90% water
Desiccate and degenerate as we age.

(2) Annulus Fibrosus. Its job is to contain

the nucleus
Consists of concentric layers of fibers at
oblique angles to each other

(3) Vertebral end plates that attach the

disc to the vertebrae
 Herniated disc
• Abnormal rupture of the
soft gelatinous central
portion of the disc (nucleus
pulposus) through the
surrounding outer ring
(annulus fibrosus).

Can Occur when

there is enough
pressure from the
vertebrae above and
below
 Five patterns differentiated by the
location and direction of nucleus
pulposus herniation
Herniation of the nucleus pulposus
can happen in the anterior,
posterior, or lateral direction or
in all four directions. Also there is
a form of herniation called
herniation inside of the vertebral
body.

Posterior herniation is divided into

two patterns: posteriolateral
herniation and posteriocentral
herniation.
Four patterns differentiated by the condition of
nucleus pulposus herniation
 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
Epidemiology
 56% of adults have disc bulging
 MRI scans show that between 20% & 35% of working
age adults have asymptomatic disc herniation
 There is lifetime incidence of 2% for symptomatic disc
herniation
 80% of general population will experience back pain
but only 2-3% will have sciatica
 peak onset : 4th to 5th decade.
 unusual < 20 years & > 60 years
 males > females (females present decade later than
males
 Diagnosis

 Symptoms :
 Low back pain: The pain is mainly located
in the lower back area; the back pain results
from pressure on the posterior longitudinal
ligaments and periphery of the annulus
fibrosus. The painful area is deep, and it is
usually dull pain or severe, acute pain.
Symptoms...
2)Shooting pain in the legs:
 Lumbar disc herniation often occurs at the L4-5 or L5-S1
level, causing lower back and and hip pain radiating down
the thigh on the lateral and posterior sides, down the
lateral side of the lower leg, and to the medial and or
lateral side of the foot, and toes. Coughing or sneezing
can aggravate the pain, causing shooting pain down the
lower limbs.
Symptoms...
3) Numbness and tingling:
 Protrusion of lumbar discs causes compression of the
spinal nerve roots, and local inflammation and swelling.
 Resulting nerve compression and lack of blood circulation
causes malnutrition to the nerves.
 Clinical symptoms are tingling, numbness and muscle
atrophy.
Dermatomes ...
 Red flags
 Night pain : may suggest tumor
 Fever, along with history of bacterial infections and drug
use : epidural abcess
 Leg pain : nerve root compressions
 Bilateral lower extremity numbness/weakness with bladder
and bowel dysfunction : cauda equina or conus lesions
 History of Carcinoma : metastasis
 Back pain in child : tumor or tethered cord
 Minor trauma in osteoporotic patients : compression fr.
Diagnosis
Signs :
1) Mobility of Lumbar Vertebral Column:
Normal range of motion
Flexion 90°
Extension 30°
Side bend 20°-30°
Twist 30°
Diagnosis.... Signs...
2) Points painful to pressure
 If the lumbar disc is herniated, its corresponding vertebra
has an obvious tender area. When that area is pressed,
pain occurs along the sciatic nerve distribution, shooting
down along the lower limb.
Signs...
3) Abnormal tendon reflexes
• If the lumbar disk is herniated, the knee tendon reflex or
Achilles tendon reflex can be weak, absent, or excessive.
• If the herniation is at L3-L4, the knee tendon reflex can be
weak or absent, and foot extension is weak;
• If herniation is at L4-L5, the knee tendon reflex and
Achilles tendon reflex is normal but toe extension is weak;
• If herniation is at L5-S1, the Achilles tendon reflex
becomes weak or absent, and foot flexion becomes weak.
4) Lasegue’s test/Straight Leg Raising Test :
(Supine) If there is pain in the lumbar area and lateral leg
on performing a straight leg raise up to 700
(modifications : Bragard’s sign, Sicard’s sign)

5) Crossed straight leg raising test/ test O’connel :

passively flex the patient’s uninvolved hip while
maintaining the knee in full extension. A positive test is
considered when the patient reports reproduction of pain
in the involved limb at 40 degrees of hip flexion or less in
the uninvolved limb.

6) Raising the intrathecal pressure : Valsava test, Naffziger

test.
Lasegue Test
Imaging Examination
1) X-ray:
 The joint space between vertebrae is uneven.
 The vertebral foramen is narrowed
 There is bone spurring.
 There is spondylolysis--a defect in the pars interarticularis of a
vertebra.

2) Myelography :
 Confirms level of pathology
 Usually combined with CT scan
 Water soluble non ionic contrast medium used; e.g. metrizamide
or iopamidol
 60% accurate in diagnosis of lumbar disc herniation
Imaging Examination
 CT Scans and MRI’s
provide clear images to
examine bone, water, fat,
muscle, blood, tendon,
ligament, etc.

 CT and MRI have three views:

axial (transverse), sagittal and
frontal planes
Ⅷ Differential Diagnosis
1 Acute lumbar injury
2 Lumbar spinal stenosis
3 Piriformis syndrome
4 Sciatic neuritis
5 Spinal tumors
6 Sacroiliac joint injury
7 Third lumbar transverse process syndrome
8 Pelvic inflammatory disease
9 Entrapment syndrome of superior cluneal nerve
10 Entrapment syndrome of lateral femoral cutaneous
nerve
11 Greater trochanter bursitis
12 Entrapment syndrome of common peroneal nerve
Medications

 Muscle relaxers. Muscle relaxants may be prescribed

if you have muscle spasms. Sedation and dizziness are
common side effects of these medications.

 Cortisone injections. Inflammation-suppressing

corticosteroids may be given by injection directly into
the area around the spinal nerves. Spinal imaging can
help guide the needle more safely. Occasionally a
course of oral steroids may be tried to reduce swelling
and inflammation.
Treatment
 Conservative treatment — mainly avoiding painful
positions and following a planned exercise and pain-
medication regimen — relieves symptoms in 9 out of
10 people with a herniated disk.
Therapy
 Physical therapists can show you positions and
exercises designed to minimize the pain of a herniated
disk. A physical therapist may also recommend:
 Heat or ice
 Traction
 Ultrasound
 Electrical stimulation
 Short-term bracing for the lower back
Surgery

 A very small number of people with herniated disks

eventually need surgery, if conservative treatments fail
to improve the symptoms after six weeks, especially if
patients continue to experience:
 Numbness or weakness
 Difficulty standing or walking
 Loss of bladder or bowel control
 The -gold standard" of surgical treatment for
herniated discs is called a limited lumbar
laminotomy and microdiscectomy.
Prognosis
 Spontaneous resolution of symptoms from nerve root
impingement due to a herniated disc occurs in 90% of
all cases, most within the first 6 to 12 weeks.
 A typical bout of sciatica will improve spontaneously:
symptoms improve in 50% of patients by one month,
90% by three months.
 Surgery has a very high success rate (>90 %) in
improving the symptoms of herniated disc and allowing
a return to work and normal activity.
 The relief of leg pain with surgical intervention is a
much more predictable result (>90 %) than the relief of
central back pain (>50 %).