DISC LESIONS

Be familiar with the anatomy and function of the disc. Be familiar with the causes and pathology of a typical disc lesion. Be familiar with the clinical presentation of a typical patient with a disc lesion. Be familiar with the different types of disc lesions. Be familiar with the term protective list.

Outcomes

Be familiar with the most widely used physiotherapy treatment protocol for a patient with a typical disc lesion, annular disc lesion and flat tyre syndrome.

Be able to give appropriate exercises and advice to a patient with a typical disc lesion.

Outcomes

Disc degeneration leads to: Decreased water content Reduced shock absorption

Definition

Disc consist of fibrous cartilage Outer part – annulus fibrosis Inner part – nucleus pulposes Disc serve as shock absorber Disc increases in thickness lower down to enable it to resist greater forces At an early age the disc already undergo degeneration and lose some of their shock absorbing function Degeneration leads to prolapse of the nucleus through the weakened annulus to the adjacent vertebra This is known as Schmorl’s nodules

Anatomy

Direction of the prolapse is determined by the attachment of the disc to the ligaments Disc is loosely attached to the ant longitudinal ligament which in turn is firmly attached to the vertebral bodies Disc is firmly attached to the post longitudinal ligament and less firmly to the post part of the vertebral bodies Post longitudinal ligament is narrower and weaker and therefore disc prolapse more readily takes place posterior-lateral.

Anatomy

Nucleus pulposus has penetrated the outer annular fibers Slow onset – may have a history of rotation of flexion movement Flexion is the most painful movement Predisposing factors of tensions, fatigue and cold may give rise to increased disc pressure Pain is aggravated by long periods of sitting in flexion, sitting with stretched legs, sustained flexion , coughing and sneezing Relief is experienced in a lying position

Disc extrusion

May experience referred pain – non nerve root structures e.g. longitudinal ligament may be affected May experience difficulty to reach an upright position from a sitting position due to the fact that flexion is required during the first part of the movement

Disc extrusion

One or more fragments of the nucleus have broken free from the herniated mass and have escaped into the canal Nucleus pulposes escapes into the spinal canal and may press against the dura, spinal cord and/or peripheral nerve-roots May also sequestrate more anterior and affect the autonomic nervous system May happen slowly or fast, usually after a rotation movement or if a heavy object is being picked up in the flexed position

Disc sequestration

Symptoms as for disc extrusion - only worse If the cord is involved: Gait is affected Bilateral pins and needles Spastic bladder (upper neuron) Babinski and clonus occur If the cauda equina is affected: Lower motor neuron bladder symptoms Saddle para/anaesthesia (S4 signs)

Disc sequastration

If the dura is involved: Extra-segmental referral Bilateral central pain or Unilateral central pain Widespread distribution If the peripheral nerves are affected: experiences nerve root referred symptoms If the sympathetic nervous system is affected: Sensation of heat or cold Feeling as if water is running down the arm Nausea and fatigue

Disc sequestration

Primary postero-lateral sequestration – only pain in the leg, no central pain. Difficult to treat Disc sequestration lessens the disc space and that may in turn affect the facet joints which may lead to synovial dysfunction

Disc sequestration

Trauma: flexion rotation movements when something heavy is picked up. Gives rise to the tear of the post longitudinal and resultant bulging of the disc Fall on the behind can also be a cause Degeneration – disc loses its elasticity as a result of the changes in the collagen fibres and decreased water content, resulting in the disc unable to handle the body’s compression forces and causes bulging Increased pressure: nucleus pulposus absorbs moisture, swells and presses against the annulus

Causes

Changes in the disc start asymptomatically Gives rise to a weak link which collapses under abnormal compression or tension Most injuries occur at L4,5 and L5/S1 Prolapse of the disc to ant or lateral causes ant or lateral osteophytes which can later be attached to one another Degeneration causes the disc space to narrow and the facet joints must now carry weight instead of regulating movement Prolaps of the disc to post causes more problems

Pathology

Prolapse usually takes place to posterior-lateral and the disc itself or osteophytes may expert pressure on the spinal cord itself or on nerve-roots The collapsed disc material initially presses against the dura mater which causes backache and further against the nerve-root which causes backache and nerve-root symptoms

Patology

Sudden start of pain when the patient picks up a heavy object Pain initially only slight but worsens within a few hours Pain sometimes extremely severe and the patient’s movement is impaired Repeated attacks may come on suddenly e.g. sneezing, coughing and valsalva manoeuvre (increased pressure on the intervertebral canal ‘s bloodvessels which are sensitive – causes pain) Between attacks the patient may experience no symptoms

Symptoms

In the case of mere bulging of the disc – pain is not clearly definable With real herniation and pressure on the nerve-root , more distinctive pain will occur in specific dermatomes Sometimes without incident, but after a prolonged sustained position Extension may be the comparable sign in a massive disc lesion Pain diminishes if the patient lies down with the knees supported, hanging in a particular position, sometimes standing in extension except if extension is the comparable sign

Symptoms

Dura: Extra-segmental referred pain, thus not in a dermatome

Posterior longitudinal ligament: Central or referred symptoms, not always clearly defined. Proximal is worse than distal

Nerve-root sheath: Central and unilateral

Nerve-root: Unilateral, distal worse, refers into a dermatome

Symptoms

Patients usually young and healthy Have a lateral tilt of the pelvis Increased lumbar lordosis Back very sensitive to palpation, also across the gluteal area Flexion and rotation is restricted with an acute attack Protective muscle spasm Symptoms in leg as a result of nerve-root pressure with reduced sensation, muscle weakness, reduced tendon reflexes and positive signs of neural dynamics Sitting, coughing and sneezing is painful to the patient Decreased intervertebral movements

Signs

Posterior medial protrusion gives an ipsilateral laterally towards the side

Ipsilateral list – thorax transfers laterally towards the side of pain

Ipsilateral – protrusion is medial towards the nerve root

More difficult to treat

List (Lateral tilt)

Posterior lateral protrusion gives a contra-lateral list

Contra-lateral list – thorax transfers away from the painful side

Contra-lateral – lateral disc protrusion towards the nerve root

Easier to treat and reacts well to traction

List (Lateral tilt)

List (Lateral tilt)

Mobilising techniques: Rotation Grade IV- Longitudinal Static traction Palpation techniques (Except if extension is the comparable sign) Electrotherapy Trigger points Abdominal stabilising exercises

Treatment

Strengthening exercises for m quadriceps and m gluteus if necessary Neural mobilisation Advice and home exercises Posture correction Kinetic handling Surgery

Treatment

Avoid sitting positions as a result of the increased pressure on the disc Shower rather than bathing Standing and lying will reduce the pain Avoid flexion and rotation movements of the back Swimming is good exercise Wearing of a brace with activities which aggravates backache (clinical reasoning is essential) Do not pick up heavy objects Avoid any activities which would aggravate the pain

Advice

ANNULAR DISC LESION

A crack in the annulus

Usually as a result of a sudden rotation movement in flexion

Cause

Severe pain

Patient is unable to move or sit, appears anxious, sweaty and pale (get’s stuck)

Feels faint

Signs of neural dynamic tension may be positive – take care if bilateral

Signs and symptoms

Rotation Grade IV- Longitudinal Traction may be used in certain cases, but refrain if patient experiences a stabbing pain Trigger points Abdominal stabilising Neural mobilisation Home advice

Treatment

FLAT TYRE SYNDROME

Narrowing of the disc space as a result of degeneration or prolapse

Ligament and capsule have not yet adapted to the new height of the mobile segment

Cause

Slow or sudden onset after a jerky movementHistory

Central of referred pain depending on the structures involved and the degree of instability Stabbing pain, unexpected pain and the back feels weak Pain is aggravated by standing, walking, running, prone and extension movements An arch of pain may be present especially during flexion movements

Signs and symptoms

To come into an upright position from flexion may be difficult and the patient often support himself with hands on thighs Palpation techniques can reproduce the pain and aggravate muscle spasm Pain is relieved by stable positions e.g. sitting

Signs and symptoms

Rotation and longitudinal Grade IV- Palpation techniques up to Grade IV can also be applied with care Trigger points Neural mobilisation

Treatment

Electrotherapy Stretches of especially back extensors and m psoas Abdominal stabilisers Strengthening of m gluteus and m quadriceps Home advice

Treatment