This document provides an overview of the clinical characteristics, diagnosis, and management of herniated nucleus pulposus (HNP). Key points include:
- HNP most commonly occurs at L5-S1 and L4-5 levels and presents with back and leg pain that is exacerbated by bending, lifting, and coughing.
- Diagnosis is based on physical exam findings like limited range of motion and tenderness, as well as imaging studies like MRI that can identify the level and type of disc herniation.
- Treatment involves both conservative options like physical therapy, bracing, and medications as well as surgery for cases of neurological deficit or failure of conservative care. Proper rehabilitation including
This document provides an overview of the clinical characteristics, diagnosis, and management of herniated nucleus pulposus (HNP). Key points include:
- HNP most commonly occurs at L5-S1 and L4-5 levels and presents with back and leg pain that is exacerbated by bending, lifting, and coughing.
- Diagnosis is based on physical exam findings like limited range of motion and tenderness, as well as imaging studies like MRI that can identify the level and type of disc herniation.
- Treatment involves both conservative options like physical therapy, bracing, and medications as well as surgery for cases of neurological deficit or failure of conservative care. Proper rehabilitation including
This document provides an overview of the clinical characteristics, diagnosis, and management of herniated nucleus pulposus (HNP). Key points include:
- HNP most commonly occurs at L5-S1 and L4-5 levels and presents with back and leg pain that is exacerbated by bending, lifting, and coughing.
- Diagnosis is based on physical exam findings like limited range of motion and tenderness, as well as imaging studies like MRI that can identify the level and type of disc herniation.
- Treatment involves both conservative options like physical therapy, bracing, and medications as well as surgery for cases of neurological deficit or failure of conservative care. Proper rehabilitation including
30 June - 2 July 2003 Learning objectives Period 1: n.uclinical characteristic of HNP n.utype of HNP differential diagnosis HNP Period 2: for management HNP physical modality, activity, orthosis and exercise case raa a 37 J CC: J.a. 3 av J.a. .a+avva.v++ auu+| Jvvva J.a.a a v, ava (10) . , v+a+|, vvu+a, .aJaa...J.auur| (, , u+J.a) vas=4 avv.aava+v. r v+v+a Jaa.., .ava Jaruaua, aJ. a. rv u arua J.va+a a . + . r a+a Physical examination A thai man with good consciouness, Rt. Lateral bending positon not pale Back: normal alignment Tenderness 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 1 st , 2 nd , 3 rd 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 u. .r MPS gluteus max., gluteus minimus, quadratus lumborum, gluteus medius u. ... piriformis syndrome u. +. a..a spondylolytic spondylolithesis u. a. Lumbar myelogram Herniated disc at L4-5 disc level with compression of bilateral exiting L5 and traversing 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, L4-5 Macnabs 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 pain Back pain: localized to midline LS region, radiaton to SI, high iliac crest, coccygeal is more indicative of dural irritation Buttock: pain is usually one of deep-seated, cramping pain Thigh :higher lumbar root, sharp pain, anterior thigh Leg: 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: more obvious on bending forward, limit flexion, extend ( lesser degree than flex) Lateral flex.increase pain (Shoulder type:when flex to same side, axillary type:opposite side) -scoliosis is a reflex mechanism by which the spine flexes away from sciatic 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 6 wks- not more than 3 mo. - Bladder & bowel involvement - Increasing neurological deficit II conservative treatment 1. 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 discontinuity in pars interarticularis - May be unilateral or bilateral - Often found in radiological studies, with no clinical significance Spondylolithesis: forward/ backward translation subluxation of body of superior vertebrae upon its adjacent 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/tunnels of intervertebral foramina - A-P diameter < 10 mm-12 mm was considered pathological - Normal LS canal is narrowest in A-P diameter at 3 rd and 4 th vertebrae - Central canal is usually narrowing from yellow ligament - Lateral canal is usually narrowing from osteophyte/ facet Symptom - back pain, sciatica, claudication, thigh and leg pain, HNP SCS Age 40-50 >50 Duration short long Level 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, decrease from supine position - Test: FAIR position (hip flex, adduct, internal rotate) - -treat& Dx: injection of anestheic& steroid into piriformis bursa/ muscle (direction: via vaginally at insertion into tender muscle/ via gluteal muscle at sacral notch (located tender spot by PR) Treatment - stretching piriformis - Pelvic tilting exercise - NSAIDs - Steroid injection Myofascial pain syndrome 0Iufeus medius - ....+a+. (Iumbogo) u a. 0Iufeus Mox. & 0Iufeus minimus - poin of Iower Iumbor ond ischium - refer- iIioc cresf & SI joinf - ischium posferoIoferoI of fhigh - socrum 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)