Prolapsed intervertebral
disc
Introduction
•The structure of spinal column consist of 33
vertebrae.
•Between the two vertebral bodies lies one disc.
•This disc consist three componants.
1) Cartilage endplate
2) Nucleus pulposus
3) Annulus fibrosus
• The nucleus pulposus is gelatinous material which
lies a little posterior to the central axis of the
vertebrae
• Nucleus pulposus is enclosed in annulus fibrosus.
• And the cartilage endplate lies between adjust
vertebral bodies.
WHAT IS PIVD?
• Prolapsed disc means protrusion or extrusion of
the nucleus pulposus through a rent in the
annulus fibrosus .
• It is not a one time phenomenon ; rather it is a
sequence of changes in the disc.
• This changes occure main three stages.
1) Nucleus degeneration
2) Nucleus displacement
3) Stage of fibrosis
1) Nucleus degeneration
In this stage nucleus become
soft and fragmented.
And weakning of annulus
fibrosus.
2) Nucleus displacement
The nucleus is under positive
pressure at all times.
When annulus become weak
because of injury. the
thickness has disintegrated.
•BULGE : In this early stage the disc is
stretched and does not completely return
to it’s normal shape ,when pressure is
relieved.
Nucleus pulposus is spiling outwards into
the disc fibres but not out of the disc.
PROTRUSION :
In this stage , bulge is very prominent and soft
jelly centre has spilled out to the edge of the
annulus fibrous. And held in by the remaining
disc fiber.
EXTRUSION :
In this stage, soft jelly has spilled out of the disc,
though it has not lost contact with parent disc
and lies contact with posterior ligament.
Once extrusion occure, the disc does not go
back.
Sequestration :
• The posterior longitudinal ligament is not
strong enough to prevent the nucleous from
protruding further.
• Now the extrudated disc may loose its contact
with the parent disc and become free
fragmant in canal.
Site of prolapsed of disc
1. Central (postero – medial )
If central prolapse occure it may compress
spinal cord and cause cauda eqena
syndrome. Dysfunction of bowel and blader.
2. Posterolateral
If posterolateral prolapse occure it may
compress spinal roots.
Causes of PIVD
1.
2.
3.
4.
Heavy manual labour
Repetitive lifting and twisting
Postural stress
Obesity
Symptoms :
1.
2.
3.
4.
5.
6.
Severe low back pain
Pain radiating to the buttocks, leg and feet
Pain made worse with coughing , straining and
sneezing
Muscle spasm
Tingling and numbness in leg and feet
Loss of bladder or bowel control in case of cauda
equina syndrom
DEMOGRAPHIC DATA
1)
2)
3)
4)
5)
NAME
: Divyaba J. Chavda
AGE
: 33 year old
GENDER : Female
OCCUPATION : Housewife
ADDRESS : 12,patel colony ,Tammna
bunglow , jamnagar.
6) WEIGH : 70 KG
7) HEIGHT : 167 Cm =1.67m
8) BMI
: 25 KG/m
under weight : < 18.5
normal : 18.5 – 24.5
over weight : >25
9) HAND DOMINANCE : Right
10) AFFECTED SITE : low back
B/L lower limb Rt>lt
11) SOCIOECONOMIC CONDITION : good
12) REFFERD BY : dr J.K. shani
chief complain
low back pain and radiating to the lower
limb (Rt > Lt).
Tingling and numbness to lower limb.
Difficulty in forword bending,
sitting,supine lying.
Pain in continuous one position.
History
1) present history
4 month ago pain over lower back area due
to constant travelling for 15 days ( from
20/5/18 to 6/6/18).
Then pain is aggravated due to household
work and over exertion.
then patient consulted orthopedic surgen
after one month and was given
injection.(every week 1 injection for 4 week).
1. Betnesol
2. B12 vitamin
3. x cain
4. dynapar aq
• The patient get temporary relief for one day but
the symptoms again appeared so she visited
another orthopedic surgeon.
• Then Patient was given 5 injections of NUROCURE
for vitamin B12 deficiency every alternate day,
and was advised for physiotherapy.
• Patient came to our OPD at 14 aug 2018and
started exercise for low back pain
2) past history
After caeseran section at 24 dece 2008,
according to the patient , she get pain due
to transfer from stetcher to bed .
The patient was at bed rest for 2 months
and again the symptoms appeared when
she started house hold work , so she
consulted orthopaedic surgeon and was
done CT scan and MRI at 5th june 2009 and
was diagnosed with PIVD. She was given
tablets and was advised physiotherapy. She
get relieved after this .
In 2012 During 2nd delivery, she lifted heavy
weight during 5th month of pregnancy and the
symptoms of low back pain appeared again but
due to pregnancy , she was not taken any tablets
or exercise . So she was in stooped posture from
5 th month till 9th month of caeseran section,she
visited orthopaedic surgeon due to symptom of
low back pain.
Then she visited (hadved) and taken
treatment for 8th month.after than severe pain
was relief. And mild pain was negleted by
patient. She took care for ADLs.
Family history : Not relevant
medical history : migraine
Drug history :
1)Inj. Nurocure
2) Tab etova mr
3) Tab. Neurodenz
4) Tab. Macrep 8mg
5) Cap rob dsr
6) Bone mr gel
Surgical history : Not Relevant
Provisional Diagnosis
• Low back pain
• Radiating pain to the lower limb due to prolapsed
intervertebral disc.
Investigation
X-ray: 22 april 2013 Ap/Lat view
PID , L5-S1 with mild osteoporotic,
spondylotic changes of L5 spine.
MRI 6th may 2009
• MRI suggest posterior herniation of L5-S1
disc with compression over ventral
aspect of lumbar dural theca and exiting
nerve root.
• Posterior bulging of L4-L5 intervertebral
disc causing indentation over ventral
aspect of lumbar dural theca. not definite
compressive element
CT SCAN
6th may 2009
At the level of L5-S1 posterior border
of disc is convex. It suggest
herniation.
At the level of L4-L5 posterior border
of disc flat . It suggest bulge.
On Observation
•
•
•
•
•
•
Local
Deformity: mild Lordosis
Swelling: Absent
Wasting: Absent
Redness:Absent
Scar : Present, but not relevant to our
condition
• Trophical changes:Absent
GENERAL
• POSTURE
standing
1. Anterior: normal
2. Posterior: normal
3. Lateral: mild lordosis
Sitting
1. Anterior:normal
2. Posterior: normal
3. Lateral:normal( lordosis disapper)
cephalocaudal view: normal
GAIT
NORMAL
EXTENSION BIAS : pain is relieve in lumbar
extension . And aggravate in lumbar
flexion.
ON PALPATION
• Temperature: B/L equal
• Tenderness: present b/L at the level of
L5-S1
Grade = 2
• Spasm: Present= lower paraspinal region
• Swelling: Absent
• Crepitus:Absent
ON EXAMINATION
PAIN ASSESMENT
• Onset : chronic
• Precipitating factors: forward bending, over exertion,supine lying,
coughing,sneezing,pain is severe during menstruation.
• Quality: throbbing at lower back, sharp shooting radiating to lower
limb.
• Relieving factor: prone position,side lying,after exercise .
• Site of pain: buttock ,Posterior thigh , mid calf and posterolateral
to great toe b/L.
• Temporal variation: pain is severe in night and difficulty in morning
to standing directly due to pain.
• Visual analog scale
Rest: modrate
Activity: severe
Numerical rating scale
Rest:4/10
Activity: 6/10
Joint
Right
Active
passive
Left
Active
passive
Hip (flexion 0-125)
0-45
0-60
0-45
0-60
Extension (0-15)
0-8
0-13
0-8
0-12
Abduction (o-45)
0-30
0-40
0-20
0-30
Addction (0-2o/30)
0-15
0-25
0-18
0-30
Internal rotation (0-45)
0-15
0-20
0-30
0-35
External rotation (0-45)
0-25
0-30
0-15
0-20
Knee (flexion 0-135)
0-115
0-128
0-115
0-128
Extension (135-0)
115-0
128-0
Ankle (dorsiflexion 0-25)
0-20
0-20
0-15
0-15
Planter flexion (0-45)
0-40
0-42
0-45
0-45
Inversion (0-30)
0-20
0-25
0-22
0-25
Eversion (0-20)
0-10
0-15
0-15
0-20
115-0
128-0
• RANGE OF MOTION
LUMBAR
1) flexion = 3cm =18cm
2) extension = 2cm=13cm
3) side flexion = right side 15
left side 10
END FEEL
joint
right
left
Hip flexion
Abnormal firm
Abnormal firm
extension
Abnormal firm
Abnormal firm
abduction
Abnormal firm
Abnormal firm
adduction
firm
firm
Internal rotation
Abnormal firm
Abnormal firm
External rotation
Abnormal firm
Abnormal firm
Knee flexion
Abnormal firm
Abnormal firm
extension
hard
hard
Ankle dorsiflexion
Abnormal firm
Abnormal firm
Planterflexion
firm
firm
Eversion \inversion
Hard /Abnormal firm
Hard/Abnormal firm
muscle
Rt mmt
Lt mmt
Rt isometric
Lt isometric
Hip flexors
4/5
5/5
Strong; painful
Strong;painful
Hip extensors
2/5
2/5
Weak;painful
weak;painful
Hip abductors
4/5
4/5
Strong;painful
Strong;painful
Hip adductors
2/5
2/5
Weak;painful
Weak;painful
Int. rotators
5/5
5/5
Strong;painful
Strong;painful
Ext. rotators
5/5
5/5
Strong;painful
Strong;painful
Knee flexors
4/5
4/5
Strong;painful
Strong;painful
Knee extensors
5/5
5/5
Strong;painfree
Strong;painfree
Ankle
dorsiflexors
5/5
5/5
Strong;painfree
Strong;painfree
Planter flexors
4/5
4/5
Strong;painfree
Strong;painfree
Envertors/invert 5/5
ors
5/5
Strong;painfree
Strong;painfree
LUMBAR MMT
• FLEXORS = 2/5
EXTENSORS = 2/5
ROTATORS = 3/5
WEAK AND PAINFULL
TIGHTNESS
•
•
•
•
1) HAMSTRING = present
2) CALF = present
4) RECTUS FEMORIS (ELY’S TEST) = present
5) ADDUCTORS = present.
LIMB LENTH
TRUE
ASIS TO MEDIAL MELLEOLUS
Left = 88cm
Right = 88cm
APPARENT
UMBILICUS TO MEDIAL MELLEOLUS
Left = 96cm
Right = 96cm
XIPHI-STERNUM TO MEDIAL MELLEOLUS
Left = 115cm
Right = 115 cm
SENSATION
SUPERFICIAL SENSATION
PAIN – intact
• TEMPERATURE – intact
• FINE TOUCH - intact
• TWO POINT DESCRIMINATION
right
left
L4 =5 mm
L4 =6mm
L5 = 4 mm
L5 =5mm
S1 =6 mm
S1 = 6mm
sole of foot
Right
left
S1S2 =5mm
S1S2=5mm
S1=2mm
S1=6mm
L5=4mm
L5=3mm
DEEP SENSATION
Vibration =intact
REFLEX
• DEEP REFLEX
1) KNEE JERK(L3)
right
left
2 grade
2 grade
2) ANKLE JERK(S1)
right
left
0 grade
0 grade
GAIT ASSESMENT
1.
2.
3.
4.
Stride length: 85cm =33.46 inch
Step length : 42.5cm =16.73inch
Width:21cm =8.26inch
cadence:85/min
SPECIAL TEST
1. Slump test : positive
2. SLR1 (basic) : positive
SLR2,SLR3,SLR4 : negative
FUNCTIONAL ASSESMENT
• OSWESTRY DISABILITY SCALE
• ICIDH2(INTERNATIONAL CLASSIFICATION OF
IMPAIRMENT DISABILITY HANDICAPPED)
• Anatomical impairment:prolapsed intervertebral
disc.
• Physiological impairment:spasm ,tenderness,pain
during over exertion.
• Activity limitation : forward bending ,cross
sitting,standing,.
• Participation restriction:
DIFFERENTIAL DIAGNOSIS
1. Spondylolysis
2. Spondyloleisthesis
3. Spinal stenosis
CLINICAL DIAGNOSIS
• PID with radicular pain lower limb b/L.
MANEGMENT
SHORT TERM GOAL
• Pain relief
• Reduce spasm
• To correct posture
• Ergonomic advice
LONG TERM GOAL
To improve and maintain muscle strengh
Posture and activity modification
TREATMENT
• To correct posture : visual biofeedback
verbal biofeedback
Stretching
1. Calf stretching
2. Hamstring stretching
3. Rectus femoris stretching
4. Adductor stretching
MODALITIES
• Short wave diathrmy
• Lumbar traction
• Interferential therapy
Exercise
Back extensor exercise
1. Prone on elbow
2. Prone on hand
3. Progression : extension in standing.
HOME ADVISE
• Avoid flexion posture
To lift any object from the floor make sure bend knee
instead of bending spine.
while lifting any object make sure is near to you.
• Modification in position
sitting : do not cross sit on the floor.
avoid high sitting for long time, alter-position
modified sitting with 120 degree pillow suport .
• Lying : side lying , prone
place pillow under your knee.
• hot formantation.
Prognosis
MODERATE
Symptoms may relief