Herniated Nucleus Pulposus

By:
Baron Ablang
Giselle Cruz
Denise Dela Cruz
Ronnel Mactal
Anatomy of Intervetebral Disc

1. Annulus fibrosus
2. Nucleus pulposus
3. End plate
Annulus Fibrosus

• Anulus fibrosus makes up peripheral portion

of disk structure
• Composed of fibrocartilage and type I
collagen

• Anulus is wider anteriorly than posteriorly

Nucleus Pulposus

• Nucleus has a high water content.

• mucopolysaccharide gel gives the
disc its high intrinsic pressure,
which allows it to resist
compressive forces.
• contains realtively more
proteoglycans giving it a looser
gelatinous texture.
End Plate

• attaches firmly to the osseous

endplate by means of numerous
collagenous fibers (Sharpey’s fibers)
• strengthens the osseous endplate,
which contains multiple perforations
• within the pores of the vertebral
endplate are numerous vascular
channels (major source of nutrients
Nerve Structure of the spine
Herniated nucleus
pulposus
• herniated nucleus pulposus is a slipped disk
along the spinal cord.
• The condition occurs when all or part of the
soft center of a spinal disk is forced through a
weakened part of the disk.
• Displacement of the central area of the disc
(nucleus) resulting in impingement on a nerve
root.
The four stages of disc herniation

• 1. Disc Degeneration: chemical changes

associated with aging causes discs to weaken, but
without a herniation.
• 2. Prolapse: the form or position of the disc
changes with some slight impingement into the spinal
canal. Also called a bulge or protrusion.
• 3. Extrusion: the gel-like nucleus pulposus breaks
through the tire-like wall (annulus fibrosus) but
remains within the disc.
• 4. Sequestration or Sequestered Disc: the nucleus
pulposus breaks through the annulus fibrosus and
lies outside the disc in the spinal canal (HNP).
Causes, incidence, and risk factors:

• The spinal vertebrae are separated by disks

filled with a soft, gelatinous substance, which
provide cushioning to the spinal column.
• These disks may herniate (move out of place)
or rupture from trauma or strain.
• Radiculopathy refers to any disease affecting
the spinal nerve roots. A herniated disk is one
cause of radiculopathy
• Most herniation takes place in the lumbar
area of the spine. Lumbar disk herniation
occurs 15 times more often than cervical disk
herniation, and it is one of the most common
causes of lower back pain.
• The cervical disks are affected 8% of the time
and the upper-to-mid-back (thoracic) disks
only 1 - 2% of the time.
• Nerve roots (large nerves that branch out
from the spinal cord) may become
compressed, resulting in neurological
symptoms, such as sensory or motor
changes.
• Disk herniation occurs more frequently in
middle-aged and older men, especially those
involved in strenuous physical activity. Other
risk factors include any congenital conditions
that affect the size of the lumbar spinal canal.
SYMPTOMS OF HERNIATED LUMBAR
DISK
• Muscle spasm
• · Muscle weakness or atrophy in later
• stages
• · Pain radiating to the buttocks, legs, and
• feet
• · Pain made worse with coughing,
• straining, or laughing
• · Severe low back pain
• · Tingling or numbness in legs or feet
SYMPTOMS OF HERNIATED
CERVICAL DISK
• Arm muscle weakness
• · Deep pain near or over the shoulder
• blades on the affected side
• · Neck pain , especially in the back and
• sides
• · Increased pain when bending the neck
• or turning head to the side
• · Pain radiating to the shoulder, upper
• arm, forearm, and rarely the hand,
• fingers, or chest
• · Pain made worse with coughing,
• straining, or laughing
• · Spasm of the neck muscles
Protrusion of the L4/5 disc

• Protrusion of the L4/5 disc may cause L5 root

pressure with pain radiating down the leg to the
dorsum of the foot.
• Numbness on the outer side of the calf and
medial two-thirds of the dorsum of the foot
• Weakness of dorsiflexion, particularly
of the foot and toes.
Protrusion of the L5/S1

• The S1 nerve root is compressed

• Pain and numbness on the outer side of the foot
and under side of the heel.
• Weakness of both eversion and antarflexion of the
foot
• The ankle jerk is diminished or absent
Protrusion of the L3/4

• Protrusion of the L3/4 disc may cause pressure on

the L4 nerve root
• Numbness over the front of the knee and leg
• The knee jerk is diminished.
• Weakness of the knee extensors.
Central protrusion

• Central protrusion of a lower lumbar disc

can press on the cauda equina and lead to
urinary retention.

• On examination there is usually perianal

numbness and a patulous anus.
• Emergency decompression is essential to avoid
permanent damage to sphincter innervation.
Cauda equina

• The spinal cord ends in the lumbar area

and continues through the vertebral
canal as spinal nerves. Because of its
resemblance to a horse's tail, the
collection of these nerves at the end of
the spinal cord is called the cauda
equina. These nerves send and receive
messages to and from the lower limbs
and pelvic organs.
• Limitation of lateral flexion of the lumbar spine to
the same side will be most marked with a
protrusion lateral to the nerve root
• while limitation of lateral flexion to the opposite
side will be most marked with a protrusion medial
to the nerve root.
Signs and tests

• A neurological examination will evaluate

muscle reflexes, sensation, and muscle
strength.
• Straight Leg raising:
• Well leg or cross leg sign: if there is a left
sided herniation, raising the right leg may
cause pain to shoot down the course of the
left sciatic nerve.
• Sciatic stretch test: this test is performed
after a straight leg raising test by lowering the
affecting leg a few degrees below the point .
• Spurling’s test (cervical) - you will bend your
head forward and to the sides while the PT
provides slight downward pressure to the top
of the head.
MEDICATIONS

• NSAID’s
• If the patient has back spasms, muscle
relaxants are usually given.
DIAGNOSTIC TESTS

• EMG may be done to determine the exact

nerve root that is involved.
• NCS is a test commonly used to evaluate the
function, especially the ability of electrical
conduction, of the motor and sensory nerves
of the human body. Nerve conduction studies
are used mainly for evaluation of
paresthesias (numbness,tingling, burning)
and/or weakness of the arms and legs.)
• Myelogram may be done to determine the
size and location of disk herniation.
• Spine MRI or spine CT will show spinal canal
compression by the herniated disk.
• Spine x-ray may be done to rule out other
causes of back or neck pain. However, it is
not possible to diagnosis herniated disk by
spinal x-ray alone.
Treatment

• Surgical : Diskectomy removes a protruding

disk.
microdiskectomy, a procedure
removing fragments of nucleated
disk through a very small opening.
Chemonucleolysis involves the
injection of an enzyme (called
chymopapain) into the herniated
disk to dissolve the protruding
gelatinous substance.
Physical Therapy

• TENS c HMP
• Traction
• Williams/McKenzie Exercise
• Strenghtening Exercise for back muscles
Prognosis

• Prognosis of disc herniation is generally good

regardless of treatment;

• Patients operated on for proven disc

herniations improved more rapidly than
patients treated non operatively;
• Within 4-5 years both operative and non
operative treatment groups will generally have
comprable neurologic recovery; hence long
term results are similar w/ or w/o surgery;
Complications

• · Long-term back pain

• · Loss of movement or sensation in the
• legs or feet
• · Loss of bowel and bladder function
• · Permanent spinal cord injury (very rare)