6&(1$5,2UTHAIWAN LEKYINGYONG, M.D.

30 June - 2 July 2003

Learning objectives

Period 1:• �¦µ�clinical characteristic of HNP

• �¦µ�type of HNP

• differential diagnosis HNP

Period 2: for management HNP

• physical modality, activity, orthosis andexercise

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Physical examination

• A thai man with good consciouness, Rt. Lateralbending positon

• not pale• Back: normal alignmentTenderness on extension and Lt. Lateral bending , taut

band at Lt. Paravertebral muscle• SLRT 80/ 70• FAIR test, sign of 4 –ve• Motor: Lt EHL, TA gr.4, others gr.5 all.• Sensory impaired LT, PPS 1st, 2nd , 3rd finger and

dorsal surface of Lt. Foot• DTR 2+ all• Trigger point at Lt. Gluteus maximus

Differential diagnosis

- HNP -MPS gluteus medius

- SCS -Piriformis syndrome

- Nerve sheath tumor - Spondylosis

- Ureteric stone, Renal calculi

- AVN ( idiopathic)

- Spondylolytic spondylolithesis

- Abcess- irritate sciatic n.

Learning objectives

• HNP ¡�. ¤µ�ª• MPS gluteus max., gluteus minimus, quadratus

lumborum, gluteus medius ¡�. ¦�·�µ• piriformis syndrome ¡�. �¦¥µ£¦�r• spondylolytic spondylolithesis ¡. ­¥µ¤

Lumbar myelogram

• Herniated disc at L4-5 disc level withcompression of bilateral exiting L5 andtraversing S1 nerve roots

Definite diagnosis

• HNP L4-L5 (shoulder type)

• MPS Lt. Gluteus maximus

Learning objectives

• Classification of disc herniation

• Management of disc herniation

indications for surgery

rehabilitation management

- physical modality

- activity

- exercise

- lumbar corset/support

Contents

• Disc herniation definition: abnormal rupture or protrusion of disc- Particularly in young- middle age man- Cause usually flexion injury- often occurs to one side- Most common L5-S1, L4-5Macnab’s classification- Bulging disc: intact annulus fibrosus- Prolapsed disk: incomplete defect annulus fibrosus- Extruded disk: complete defect annulus fibrosus, intact

posterior longitudinal lig.- Sequestered disk: part of nucleus pulposus is extruded

History- Most pt. Have back pain varied lengths of time- varying combined with back, hip, leg painBack pain: localized to midline LS region, radiaton to SI, high iliac

crest, coccygeal is more indicative of dural irritationButtock: pain is usually one of deep-seated, cramping painThigh :higher lumbar root, sharp pain, anterior thighLeg: L5/S1 root-cramp & vise-like feeling in belly of gastroc/ peroneal

mus., paresthesia in lateral calf (L5) / back of calf (S1)Foot: most common symptom is parethesia than pain- Younger patient may has only leg pain- Aggravated symptom: bending, stooping, lifting, cough, straining

at stool

PE

Back: loss of lordosis, paravertebral muscle spasmsciatic scoliosis: moreobvious on bending forward, limit flexion, extend ( lesser degree than flex)

Lateral flex.increase pain (Shoulder type:when flex to same side, axillarytype:opposite side)

-scoliosis is a reflex mechanism by which the spine flexes away fromsciatic nerve entrapment side by paraspinous muscle contraction

standing with affected hip&knee slighted flexion- +ve SLRT, crossover pain (well-leg raising sign )= lift well-leg, pain crosses

over into symptomaic hip, early sign of HNP, crossed SLRT : lift symptomatic leg & pain in asymptomatic leg, indicative

of disc herniation lying median to nerve root; axillary/ midline- muscle wasting is rarely seen unless symptom> 3mo., very marked wasting

suggests extradural tumor than HNP

• Investigation

Minimal requirement for diagnosis of HNP:plain x-rays and one other diagnostic study (myelography, CT/myelography, CT, MRI

MRI: necessary to plan a surgical procedure

management

I surgery

Indication:

- failure of conservative treatment: at least 6wks- not more than 3 mo.

- Bladder & bowel involvement

- Increasing neurological deficit

II conservative treatment1. Unloading spine

• Rest until pain start to abate (approximately48 hrs)

• Corset/brace

Indications:

- patient who is recovering after bed rest and return to work quickly

- An older patient

- Postoperative support

• Modification of work and activities

2. Antiinflammatory drugs

3. Analgesics

4. Traction ( intermittent 25%BW 20-30 min)

5. Heat/cold

6. Exercise ( modified Willium exercise - back pain, Mc Kenzie exercise -leg pain)

Spondylolytic spondylolithesis

spondylolysis: anatomic defect , causes discontinuityin pars interarticularis

- May be unilateral or bilateral

- Often found in radiological studies, with noclinical significance

Spondylolithesis: forward/ backward translationsubluxation of body of superior vertebrae upon itsadjacent inferior vertebrae

- usually forward slipping of L5 vertebra on sacrum

-Wiltse et al. classified spondylolithesis• Dysplastic: congenital abnormal of upper

sacrum/arch of L5,• Isthmic: lesion of pars interarticularis• Degenerative: progressive intersegmental

instability, female>male, age >=40 yrs• Traumatic: fracture/ dislocation of facet joint,

allowing forward displacement• Pathological: loss of stability secondary to

pathological destruction

• Symptoms- major symptom- LBP (intermittent dull aching

pain)- Often radiate into sacroiliac region, also into

thighs• PE- limited ROM back- Palpable “ledge” at upper aspect of listhesis- Limited hamstring extensibility

Lumbar SCS

: narrowing of spinal canal, nerve root canals/tunnelsof intervertebral foramina

- A-P diameter < 10 mm-12 mm was consideredpathological

- Normal LS canal is narrowest in A-P diameter at3rd and 4th vertebrae

- Central canal is usually narrowing from yellowligament

- Lateral canal is usually narrowing fromosteophyte/ facet

• Symptom- back pain, sciatica, claudication, thigh and

leg pain,HNP SCS

Age 40-50 >50Duration short longLevel usually 1 level several level- pain relief by supine, squatting

Piriformis syndrome

: compression of extraspinal n., forming the sciatic n.by piriformis muscle

• Postulated etiologies of piriformis synd.• Sacroiliac disease that causes piriformis muscle

contraction• Inflammatory disease of muscle, tendon/ fascia

of piriformis• Degenerative deformities of bony component of

notch• Abnormal of neurovascular bundle as they cause

through tunnel• Direct trauma to gluteal region of sacroiliac joint

• Symtom and sign- pain/paresthesia may be present along the entire

distribution/ segment of sciatic nerve- Motor deficit may co-exist with subtle atrophy- Predominant symptom, pain at sacral and gluteal

area, increase with sitting and walking, decreasefrom supine position

- Test: FAIR position (hip flex, adduct, internalrotate)

- -treat& Dx: injection of anestheic& steroid intopiriformis bursa/ muscle (direction: via vaginallyat insertion into tender muscle/ via gluteal muscleat sacral notch (located tender spot by PR)

• Treatment

- stretching piriformis

- Pelvic tilting exercise

- NSAIDs

- Steroid injection

Myofascial pain syndrome

� *OXWHXV�PHGLXV��­µÁ®�»�µ¦�ª�®¨� �OXPEDJR���n°¥�ªnµ *OXWHXV�0D[��*OXWHXV�PLQLPXV��SDLQ�DW�ORZHU�OXPEDU�DQG�LVFKLXP��UHIHU��LOLDF�FUHVW��6,�MRLQW��LVFKLXP��SRVWHURODWHUDO�RI�WKLJK��VDFUXP• Gluteus maximus

- pain at lower lumbar , aggravate by walking with forward bending ,sitting and extend back from flexion position

- refer pain to sacrum, above ischeal tuberosity, coccyx, gluteal cleft

• Gluteus minimus

- may be antalgic gait

- refer pain like sciatic n. lesion (pseudosciatica)