بسم اهلل الرحمن الرحيم

The National Ribat University

Faculty of graduate studies & scientific research

Athesis Submitted In Partial Fulfillment requaird for MSc

in Clinical & human Anatomy

Prevalence of the Disc Prolapse among Sudanese People

in Khartoum State Hospitals 2014

by: Mohammed Ibrahim Ahmed Mohammed

Supervisor: Dr. Mohammed Ahmed Abuelnor

2014

بسم هللا الرحمن الرحيم

اآلية

چٹ ڻۀ ۀ ہ ہ ٹ ٹ چ

١٢الذاريات: صدق هللا العظيم

Dedication

To my family

To my wife

Acknowledgement

I am thankful to the all named below for their correlation with me during my work, I would

like to express my appreciation to Dr. Mohammed Ahmed Abuelnour, my supervisor PHD of

human anatomy teacher of anatomy in yarmouk and alrazi colledges of medicine, He provided me

by information and the needs to achieve my research. Thanks radiologist in Fedail,alzytona and

Antalia Hospitals for who facilitated conducted research.

Thanks my colleagues Ahmed Awad Alkareem Elyas MSc of human and clinical anatomy,

Khalid Mohammed Taha MSc of human and clinical anatomy who have encouraged me in this

activity and helping me to achieve my program.

Deep thanks to professor Tahir Osman professor of anatomy and dean faculty of graduate

studies in National Ribat University.

مستخلص الدراسة

هذه الدراسة انتشار االنزالق الغضروفي وصفت السودانيين حسب الموقع ونوع الجنس ، في وقامت الدراسة باخذ سجالت المرضى السودانيين من بعض المستشفيات السودانية في الخرطوم مثل فضيل والزيتونة وانطاليا. وقد تم تشخيص هؤالء المرضى باستخدام تقنية التصوير بالرنين

من االناث ، واجريت هذه الدراسة في 13من الرجال و 94حالة 08وتم اخذ المغناطيسي .م ، وبعد تحليل هذه العينات وجد أن االنزالق الغضروفي 4839الفترة مابين يوليو وديسمبر لعام

L5,S1كان أكثر حدوثا في القرص بين اخر فقرة بطنية واول فقرة عجزية %9.61بنسبة تين البطنيتين الرابعة والخامسة ويليها القرص بين الفقر L4,L5 ويليها القرص %9160بنسبة

L3,L4بين ، والقرص بين C4,C5 وأقل حدوثا في القرص بين C5,C6 والقرص بين T6,T7 . ووجدت الدراسة ان اتجاه االنزالق الغضروفي يكون اكثر في االتجاه الجانبي الخلفي

سر من االيمن( ومن ثم يليه االنزالق في االتجاه )ويكون اكثر في االتجاه االي %.646بنسبة اكثر من الطفيفة بنسبة %61... ووجد ان درجة االنزالق الكبرى بنسبة %9.66االوسط بنسبة

1160%.

Abstract

Background: prevalence of prolapse intervertebral (PID) in Sudan.

This study described the prevalence of the prolapse intervertebral disc PID by

location &gender among Sudanese patients at Fedail ,Alzytona and antalia hospitals

in Sudan. This study is done by using MRI technique in 80 cases 49males and 31

females of the prolapse intervertebral disc between July and December 2014 are

analyzed for location , number of prolapse discs &gender.

the PID are commonest in L5,S1 (46.3%) Followed by L4,L5 (43.8%), L3,L4

(3.8 % ) C4,C5 (3.8 %) , one at C5,C6 (1.3 %) and T6,T7 (1.3 %).

The PID more common in males than females & the commonest side of

herniation at the level of L5 , S1 (46.3%) & L4, L5 (43.8%) . The direction of

herniation is more common Posterolaterally (52.6%) (28.8% & 23.8%) on the left

& right sides respectively) than centrally (47.5%). the degree of herniation is

commonly major (66.3%) than minor (33.8%).

Contents the

II Dedication

III Acknowledgment

IV Abstract ( Arabic )

V Abstract ( English )

VI List of the content

VII List of figures

VIII List of abbreviation

Chapter one

1. Introduction 1

1.1. Background 1-2

1.2. Justification 3

1.3 Objective 3

1.3.1. General objective 3

1.3.2. Specific objective 3

Chapter two

Literature review 4

Chapter three

Materials & methods 7

Chapter four

Result 8

Chapter five

Discussion 12

Chapter six

6. Conclusion & Recommendation 14

6.1. Conclusion 14

6.2. Recommendation 14

Chapter seven

7. References 15

Annex

List of figures

Fig ( 1.1.) medial view of the vertebral colum…………………………….………..page ( 1 )

Fig ( 4.1.) gender distribution ……………………………………………..………………….page ( 8 )

Fig ( 4.2.) level or sites of herniation …………………………………………………page ( 9 )

Fig ( 4.3.) direction of herniation ……………………………………………………..page ( 10 )

Fig ( 4.4.) degree of herniation ………………………………………………………..…….page (11)

Fig (1) MRI show central herniation ………………………………………………….page (17)

Fig (2) MRI show posteriolaterally herniation to the left …………………..……..page (18 )

Fig( 3) MRI show posteriolaterally herniation to the right………………..……..page ( 19 )

List of abbreviation

PID prolapse intervertebral disc

IV intervertebral disc

LBP low back pain

MRI magnetic resonance image

Chapter one (introduction&objectives)

Chapter two (literature review)

Chapter three (Material&Methods)

Chapter four (Results)

Chapter five (Discussion)

Chapter six (Conclusion&Recomondation)

Chapter seven (References)

1. Introduction:

1.1. Background:

The vertebral coloumn consists of 33 vertebrae, there are 7 cervical, 12 thoracic,

5 lumber, 5 sacral and 4 coccygeal vertebrae.(1) Between the bodies of the vertebrae

there are fibro cartilaginous discs, the intervertebral disc (IV) consists of

1. Annulus fibrous peripherally (compose of concentric lamellae of

fibrocartilage).(2)

2. Nucleus pulposus (compose of ovoid mass of gelatinous material containing

large amount of water).(3)

Figure(1.1.) medial view of vertebral column.(3)

The intervertebral disc are largest in the lumbar and lumbosacral regions,

where the movement are greatest, also the intervertebral discs are large in the

cervical region.(3)There is no disc found between C1 and C2 vertebrae and also

between the sacral and coccygeal vertebrae.(2)The IV discs are form about one-

fourth of the length of the vertebral column.(2)

The IV disc is supported by anterior and posterior ligaments; the anterior

longitudinal ligament is strong fibrous band covers and connects the anterio

lateral aspects of the vertebral bodies and intervertebral discs, it extends from the

sacrum to anterior tubercle of C, the value of this ligament are Maintains stability

of the joints and prevents hyperextension of vertebral column. The posterior

longitudinal ligament is weaker than the anterior longitudinal ligament

the posterior longitudinal ligament runs with in the vertebral canal along the

posterior aspect of the vertebral bodies, it is attached to the posterior aspect of

the intervertebral disc and vertebral bodies from C2 to sacrum.The value of the

posterior longitudinal ligament helps and prevents hyperflexion of the vertebral

column and posterior herniation of the intervertebral disc.The functions of IV

disc are acts as shock absorber and prevent friction between the vertebral bodies.

The disc prolapse is a herniation of the nucleus pulpous through the annuls

fibrous, there are many types of disc herniation’s cervical, lumbar, and

Lumbosacral.(3)The signs and symptoms of disc prolapse are: back pain, neck

pain in case of cervical, weakness, numbness, tingling, and myelopathy.(4)

In the upper disc herniation at L1- L2, L2- L3 and L3- L4 levels have been

reported to constitute no more than 5% of all disc Herniation.(5)The herniation

occurred at L4 – L5, L5- S1 about 76% of all disc herniation and its commonly

more prevalence in male than female.(6)

1.2.Justification

The disc prolapse is very important due to compression of spinal nerves and

leads to sever back pain and neurological disorders

1.3. Objectives:

1.3.1. General objectives

To identify the Prevalence of disc prolapse among Sudanese people.

1.3.2. Specifics objectives:

To identify the prevalence of the disc prolapse among gender.

To describe different sites of PID in cervical, thoracic, lumbar and

Lumbosacral region..

To detect the degree of disk prolapse.

To detect the Site and direction of herniation (centrally or posterior laterally).

2.Literature review

Low back pain (LBP) is common already among children and the prevalence

increases with age.(7) lifetime prevalence being up to 50% of 20-year-old men.(8) The

etiology of LBP in adolescence remains largely unknown. Some authors claim that

adolescent LBP is primarily related to psychosocial factors. (9), (10)

In study conducted in Finland, on study population was a subcohort of the

Northern Finland Birth Cohort 1986. Subjects living within 100 km of Oulu (n _

874) were invited to participate in lumbar MRI at 20 to 22 years of age (mean: 21.2

years). Degree of DD, type of Modic changes, and presence of disc bulges,

herniations, high intensity zone (HIZ) lesions, and radial tears at all lumbar levels

were assessed.This study revealed that was significantly more frequent in men (54%

vs. 42%, P _ 0.005), as was multiple DD (21% vs. 14%, P _ 0.036). The prevalences

of disc bulges and radial tears were 25% and 9.1%, without gender differences.(11)

Twenty three-year-old man presented in Department of

Orthopaedics,Changzheng Hospital, Shanghai, Chinawith a six-month history of

right lower extremity radicular pain which had progressivelybecome more severe in

the previous 2 months. Careful physical examination showed diminished muscle

strength in the right lower extremity. Ptosis of the right foot was present and hallux

dorsiflexion strength was weaker in his right foot than in his left. He had a positive

Lasègue sign and straight leg raising test in the right leg; these were negative on his

left. X-ray films revealed disappearance of the physiological curvature of the lumbar

spine. Magnetic resonance imaging revealed disc herniation on the right side at the

L4–5 level. The preoperative diagnosis was therefore disc herniation at L4–5.(12)

Another study conducted in Germany on 1630 patients operated on between 2002

and 2007 due to central large disc herniations, this study reveajed that 59 patients

who had the diagnosis of central large disc herniations were 41 men and 18 women;

mean age was 34.7 years (range 21-72 years). 36 patients had central mass prolapse

that occupied more than 50% of the spinal canal. Intraoperative observations

confirmed that 29 out of 36 central mass prolapse patients (80.5%) had intact

posterior longitudinal ligaments. Interestingly, these 29 patients were found out to

have direct relation with age and occupation or other body training sports activities.

In the remaining 23 out of 59 patients, contained central disc herniations were

diagnosed. Their mean age was 44 years (range, 31-72). Most of them were

physically inactive compared to the central mass psolapse group.(13)

Another study conducted in Kenya on Six hundred and three cases (267 males,

336 females) of prolapsed intervertebral disc over 11 years between January 1997

and December 2007 were analyzed for location, number of prolapsed disks, gender,

age and predisposing conditions. The result of this was the determined locations

L4/5 was the commonest (42.3%), followed by L5/S1 (25.5%). Seventy seven

(20.9%) of the patients had multiple prolapsed disks. 1.4% were in the cervical

region, and only one in the thoracic. Prolapse intervertebral disk (PID) was

commonest in the 31 – 50 year age group females (M: F is 1:1.26, p=0.00), with

mean age 40.90+13.80 years, (range between 11- 85 years).(14)

Concern the cervical displacement in USA (new york) another study was

conducted the most common site of disk displacement are between the fifth and sixth

or C6- C7, cervical vertebrae, cervical displacement.(15)

A same case report in USA 35-year-old Caucasian man presented to our facility

with neck pain and left-sided upper and lower extremity pain. A magnetic resonance

imaging scan revealed a right paramedian herniated disc at the C5 to C6 level. All

other cervical levels were normal without central canal stenosis or neural foraminal

stenosis. Results from magnetic reasonance imaging scans of the brain and lumbar

spine were negative. An anterior cervical discectomy was performed at the C5 to C6

level, and an inter-body graft and plate were placed. Our patient had complete

resolution of his neck and left arm pain.(16)

Various studies have shown that the lifetime prevalence of a major episode of

low back pain ranges from 60% to 80%, but only 10% of these episodes are

accompanied by sciatica. Sciatica lasting longer than two weeks is even less

common, with a lifetime prevalence of 1.6%.(17)

The highest prevalence (23.7 per 100 persons) is in individuals between the ages of

forty-five and sixty-four years old.(18)

A sedentary lifestyle, frequent driving, chronic cough, pregnancy, smoking, and

frequent lifting of heavy objects are considered risk factors.(19), (20)

It is commonly agreed that lumbar disc herniation has a favorable natural history

(i.e., the clinical course of the disease without therapeutic intervention). Hakelius

examined essentially a natural history cohort, in that the patients were treated with

only bed rest and a corset for two months, and he observed a marked reduction in

pain and improvement in function over time: 80% of the patients had major

improvements after six weeks; 90%, after twelve weeks; and 93%, after twenty-four

weeks.(21)

3.Material and methods:

3.1 Study design:

Cross sectional study

3.2 Study area

Khartoum state hospitals, most patients came to these hospitals for treatment

due to high sophisticated equipment’s for diagnosis

3.3 Study population

Patients presented at these hospitals in radiological department prepared to

MRI imaging for vertebral coloumn, a patient record were considered

3.4 Inclusion criteria:

Patient underwent vertebral column MRI, and demographic and geographic

data were also considered

3.5 Exclusion criteria:

Patients with vertebral column deformity should excluded from this study

3.6 Sample size

The size of the sample is 80 vertebral column MRI image.

3.7 Sample technique:

The data were collected randomly by using design data collecting sheet, and

then the data were a analysed (student t- test and ANOVA) by sophisticated

software program SPSS version 17.01 IMN.

4 . Results

4.1. The prevelance of intervertebral disc herniation among gender and sites

4.1.1 . The PID among Sudanese gender

Our study shows that the prolapse intervertebral disc among Sudanese patients

in 80 cases of vertebral column images (MRI) , 49males and 31females . the data

were collected from the records of the patients that found in some Sudanese

hospitals in khartoum , this study revealed that the prolapse itervertebral disc in

Sudanese people is more common in males (61.2%) than females (38.2%).

Figure (4.1.) gender distribution with STD deviation

4.1.2.The prolapse intervertebral disc among sites of herniation

The prevelance of the disc prolapse in Sudanese people among sites of

herniation is commonest in the Lumbosacral region L5,S1(46.3%) ,followed by

L4,L5(43.8%) , L3,L4(3.8%) , C4,C5(3.8%) ,and more rare in the lower cervical

region C5,C6 (1.3%) and thoracic region (1.3%).

4.2.prevelance of the disc prolapse among the direction and thedegree of

herniation.

4.2.1.The PID among the direction of herniation

Our study revealed that the direction of herniation of the disc prolapse among

Sudanese patients is more common posteriolaterally (52.6%) (which lead to

stenosis of vertebral canal and compression of spinal nerves) than centrally

(47.5%) also lead to stenosis of the vertebral canal and compression of the spinal

cord.

Figure (4.3.) direction of the herniation

4.2.2. The PID among the degree of herniation

The degree of herniation among Sudanese patients in this study is commonly

major(66.3%) (which lead stenosis of the vertebral canal and compression of spinal

nerves and spinal cord and causes severe back pain and neurological disorders) ,

the degree of herniation is sometimes minor(33.7%) and also lead to stenosis of the

vertebral canal and causes back pain .

Figure (4.4.) the degree of herniation

5. Discussion

The disc prolapse is a herniation of the nucleus pulpous through the annuls

fibrous, there are many types of disc herniation’s cervical, lumbar, and

Lumbosacral.(3)The signs and symptoms of disc prolapse are: back pain, neck

pain in case of cervical, weakness, numbness, tingling, and myelopathy. (4)

The intervertebral disc herniation was studied widely by anatomist, radiologist, and

surgeons. Some of these studies mention that intervertebral disc herniation is

commonest at L5, S1 followed by L4, L5, other studies show that the commonest

site of disc herniation at L5, S1 & L4, L5 with equal percentages.

In this study we investigate the prevalence of the intervertebral disc herniation

among Sudanese, Our study shows that, the prolapse interverrtebral disc is more

common in the lower lumbar &lumbosacral regions in the Sudanese people, and

the upper cervical disc herniation is more common than the lower cervical disc

herniation . as the prolapse interverrtebral disc is very rare in the thoracic region ,

our this study confirm that the prolapse intervertebral disc in thoracic region is

very rare about (1.3%). (14) The commonest site of herniation occur at the level of

L5 -S1(46.3%) followed by L4-L5 (43.8%), this in confirm with the past studies

of the intervertebral disc herniation , because of the large weight bearing , and

more movement of the lower part of the vertebral column.(3),(11)

As it revealed that the muscular building and the bone stresses perform by the

muscular activity affect the shape and growth of the bones, especially the vertebral

column we study the distribution of prevalence of intervertebral disc herniation

among Sudanese males and females, our result indicate that, the prolapse

intervertebral disc is more common in males (61.2 %) than females (38.8 %). this

is because of association of the high muscular building and activities compared

with females. ( 3), (6)& (14)

Then we study the direction and the degree of the intervertebral disc herniation to

correlate these factors with the symptoms of the intervertebral disc herniation. Our

result revealed that the direction of herniation is more common Posterolaterally

(52.6% ,) ( with more occur in left side 28.8% rather than the right 23.8%) than

centrally (47.5%) , because the annulus fibrosus is more thiner posteriolaterally

and due to lack support of the posterior longitudinal ligament. (3)

The degree and the direction of disc herniation affect on the symptoms of the disc

herniation, to investigate that we study the degree of disc herniation among

Sudanese patients, our result show that (66.3 %) is major herniation associated

with pain and motor defects, and (33.7 %) with minor degree associated with back

pain.

6. Conclusion & Recommendation

6.1. Conclusion:

The PID more common in males than females & the commonest side of herniation at the

level of L5 , S1 46.3% & L4, L5 43.8% . The direction of herniation is more common

Posterolaterally 52.6% (28.8% & 23.8% on the left & right sides respectively) than

centrally 47.5%. the degree of herniation is commonly major 66.3% than minor

33.8%.

6.2. Recommendation:

Regarding to generalize this finding, further studies are needed to do a research

about the major & minor causes of the disc prolapse in the Sudan. This study will

be admitted to the radiologist & neurologist.

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Livingstone edition 10 , 1999, 425- 432 .

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(3).Keith L. Moore, clinical oriented anatomy, Lippincott Williams & Wilkins,

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184, 2003.

(5).Yonsei , lumbar disc degeneration, MEDJ, 52(2) 314 – 321, 2011.

(6).Jainitakattalo, jarokarppinen, degree of disc displacement, spine volume 34 –

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Annex:

Figure (1): showing the central herniation

Figure (2): showing the posteriolatrally left herniation

Figure (3): showing the posteriolatrally right herniation

The National Ribat University

Prevalence of the disc prolapse among Sudanese people in khartoum

state Hospitals 2014

By: Mohammed Ibrahim Ahmed Mohammed

Check list:

Number of the item …..( )

Gender : male ( ) , female ( )

Site of herniation:

Cervical …( ) ……………………………………….

Thoracic ( ) …………………………………………………

Lumbar ( ) …………………………………………………

Lumbosacral ( )

Direction of herniation:

Posteriolaterally ( ) ……….to the right ( )

…………to the left ( )

Centrally ( )

Degree of the herniation:

Major ( )

Minor ( )