1. DISC LESIONS

2.  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

3.  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

4.  Disc degeneration leads to: Decreased water content Reduced shock absorption Definition

5.  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

7.  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

8.  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

9.  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

10.  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

11.  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

12.  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

13.  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

16.  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

17.  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

18.  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

19.  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

20.  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

21.  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

22.  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

23.  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)

25.  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)

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

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

29.  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

30. ANNULAR DISC LESION

31.  A crack in the annulus  Usually as a result of a sudden rotation movement in flexion Cause

32.  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

33.  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

34. FLAT TYRE SYNDROME

35.  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

36.  Slow or sudden onset after a jerky movement History

37.  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

38.  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

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

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