CASE REPORT

RADICULAR PAIN ec HERNIATED NUCLEUS PULPOSUS at L4-L5

Presented by: Sitti Aisyah Rieskiu C11107081 Advisors: dr. Evan dr. Nia Irayati Supervisor: dr. M Ruksal Saleh,Ph.D, Sp.OT
Orthopedic and Traumatology Department Hasanuddin University 2014

PATIENT IDENTITY

Name Age Sex RM Date of admitted

: Mrs. SA : 41 years old : Female : 643071 : Jan 20th 2014

HISTORY TAKING
Chief complain: low back pain
Patient feel pain at the lower back suffered 6 months. Pain feel like extracted and gradually at the lower back and leg. Pain referred from the lower back to the leg. It worsen when she walking and standing for a while and decreased if she lie down. History of lifting weight loading (+). History of trauma (-), history of chronic cough(-), history of loose weight (-). Micturition and defecation are normal

General Status

Well nourished/ Composmentis

VITAL SIGN BP: 110/70 mmHg HR: 80x/mnt, regular RR: 20x/mnt, thoracoabdominal type T : 36,7 C (axillar) VAS : 5/10

Localized Status

Vertebra Region : I : deformity (-), hematome (-), swelling (-), gibbus (-) P : tenderness (+) at the level as Lumbal 3-5, step off (-)
Straigh Leg Raise test at right leg (+)

Clinical Picture

5 5 5 5 5

5 5 0 5 5 5

Motoric Examination
5 5 5 5 5 5 5 5 5 5
yes

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Any anal sensation

0 Absent 1 Impaired 2 Normal NT Not testable

Reflex

Physiologic reflex
R L Biceps (+) (+) Triceps (+) (+) Achilles (+) (+) Patellar (+) (+)

Pathologic Reflex
R L

Babinski Chadock Openheim

(-) (-) (-)

(-) (-) (-)

Laboratory
WBC RBC 6,4 3,88

HB
HCT PLT GDS UREUM KREATININ SGOT SGPT CT BT HBsAg

12,6
35,4 312 91 21 0,70 22 32 830 230 Not Reactive

RADIOLOGIC FINDINGS THORAX PA

RADIOLOGIC FINDINGS

LUMBOSACRAL AP & LATERAL

MRI FINDINGS

MRI FINDINGS

Summary
Woman 41 years old admitted to the hospital with chief complain : Patient feel pain at the lower back suffered

6 months. Pain feel like extracted and gradually at the lower back and leg. Pain referred from the lower back to the leg. It worsen when she walking and standing for a
while and decreased if she lie down. History of lifting weight loading (+). From physical examination, hipostesia at right lower extremities and tenderness at the level CV lumbar, SLR test (+) at right leg.

Summary
From radiologics examination:
Lumbosacral AP/Lateral show : muscle spasm, and MRI show bulging disc level at CV L3-L4 compress thecal sac and irritated both of nerve roots. Protrusion disc level CV L4-L5 compress thecal sac and both of nerve root.

Diagnoses

RADICULAR PAIN ec HERNIATED NUCLEUS PULPOSUS at L4-L5

Treatment Analgesic Plan for decompression

HERNIATED NUCLEUS PULPOSUS

Discussion

ANATOMY

DEFENITION
Degenerative disc disease leads to a loss of turgor of the nucleus pulposus and a diminished elasticity of the annulus fibrosus. As a result, the disc bulges outward. Herniation is defined as a localized displacement of disc material (nucleus, cartilage, fragmented apophyseal bone, fragmented annular tissue) beyond the limits of the intervertebral disc space.

RISK FACTOR

Male gender Age 30-50 Heavy lifting, especially in a twisting motion Poor job satisfaction Cigarette smoking Prolonged vibration exposure

PATHOPHYSIOLOGY

Compression across disc space

Increase pressure within the nucleus

Soft nucleus deforms and flattens

Pushing against the annular fiber

Tensile hoop stress

PATHOPHYSIOLOGY

Disc disruption

Tear of annulus fiber

Withstands tensile force

Compress nucleus pulposus

Nucleus-anulus-endplate complex act

soft nucleus can be pushed through

CLASSIFICATION OF DISC HERNIATION

Morphology
Location

Timing

MORPHOLOGY
Eccentric bulging through an intact anulus fibrosus

Disc material crosses the anulus but continuity with the remaining nucleus within the disc space

Not continuous with the disc space; this is the typical free fragment

LOCATION

Central zone

Lateral recess Foraminal zone

Extraforaminal zone

Timing

CLINICAL PRESENTATION

History Taking :

Lower back pain relatively fleeting and is relieved

by rest Other symptoms : weakness and paresthesias

Physical Examination Inspection : Gait observation Palpation and Percussion : Pressure on the spinosus processes can reproduce sciatic symptoms Spasm can be noted in addition to tenderness; may be present as a ball of contracted muscle in one region. Localized tenderness Dermatomal sensory Abnormal rectal examination

SPECIAL TEST

The straight-leg raise (SLR) test The Lasegue maneuver The femoral stretch test

THE STRAIGHT-LEG RAISE (SLR) TEST

DIAGNOSTIC STUDIES
Plain Radiographs : Cannot show a herniated disc Ruling out obvious underlying problems, such as lytic lesions, tumors, infections, inflammatory spinal disorders, or instabilities
MRI : Free fragments (sequestered) can be differentiated from extruded disc herniations, and a symmetrical bulge can be differentiated from a contained protrusion. Neural encroachment can be detected within the spinal canal, the foramina, or extraforaminally

TREATMENT
Nonoperative Management

Goals are to restore strength, flexibility, and function that were lost secondary to pain, splinting, and spasm

Physiotherapy prescription usually includes torso stabilization training; paraspinal muscle stretching and strengthening; and a focus on gluteal, hamstrings, and abdominal exercises. Pharmacologic Treatment :Nonsteroidal antiinflammatory drugs (NSAIDs), single dose of a morphine- derivative analgesic, muscle relaxants

Operative Management : Open Simple Discectomy

An absolute indication for lumbar discectomy is a progressive neurologic deficit.

The relative indications for discectomy vary among surgeons and patients. Discectomy, in its many shapes and forms, can produce symptomatic relief in appropriately selected patients.

Thank