PLID – Causes, Symptoms, Diagnosis, Treatment

PLID (Prolapse lumbar intervertebral disc) is one of the most common vertebral column diseases of elderly people leading to back pain, radicular pain, and subsequently neurological deficit due to nerve root compression. It is a common condition that frequently affects the spine in young and middle-aged patients.[rx,, The lumbar intervertebral disc is a complex structure composed of collagen, proteoglycans, and sparse fibrochondrocytic cells that serve to dissipate forces exerted on the spine. As part of the normal aging process, the disc fibrochondrocytes can undergo senescence, and proteoglycan production diminishes. This leads to a loss of hydration and disc collapse, which increases strain on the fibers of the annulus fibrosus surrounding the disc. Tears and fissures in the annulus can result, facilitating a herniation of disc material, should sufficient forces be placed on the disc. Alternatively, a large biomechanical force placed on a healthy, normal disc may lead to extrusion of disc material in the setting of the catastrophic failure of the annular fibers.[

PLID (Prolapse lumbar intervertebral disc), also known as a slipped disc, is a medical condiververtibral dissection affecting the spine in which a tear in the outer, fibrous ring of an intervertebral disallows the soft, central portion to bulge out beyond the damaged outer rings. Rarely bowel or bladder control is lost, and if this occurs, seek medical attention at once. A common cause of lower back and leg pain is a lumbar ruptured disc or herniated disc. Symptoms of a herniated disc may include dull or sharp pain, muscle spasm or crampingsciatica, and leg weakness or loss of leg function. Sneezing, coughing, or bending usually intensify the pain.

Sciatica is a symptom frequently associated with a lumbar herniated disc. Pressure on one or several nerves that contribute to the sciatic nerve can cause pain, burning, tingling, and numbness that extends from the buttock into the leg and sometimes into the foot. Usually, one side (left or right) is affected.

Anatomy of PLID

plid

  • First, a brief overview of spinal anatomy so that you can better understand how a lumbar herniated disc can cause lower back pain and leg pain.
  • In between each of the 5 lumbar vertebrae (bones) is a disca tough fibrous shock-absorbing pad. Endplates line the ends of each vertebra and help hold individual discs in place. Every disc has a tire-like outer band (annulus fibrosus) that encases a gel-like substance (nucleus pulposus).
  • Disc herniation occurs when the annulus fibrous breaks open or cracks, allowing the nucleus pulposus to escape. This is called a herniated nucleus pulposus or herniated disc, although you may have also heard it called a ruptured disc or a bulging disc.
  • When a disc herniates, it can press on the spinal cord or spinal nerves.  All along your spine, nerves are branching off from the spinal cord and traveling to various parts of your body (to help you feel and move).  The nerves pass through small passageways between the vertebrae and discs, so if a herniated disc presses into that passageway, it can compress (or “pinch”) the nerve.  That can lead to the pain associated with herniated discs.

 

(In the illustration below, you can see a close-up look at a herniated disc pressing on a spinal nerve.)

This article on lumbar herniated discs will cover the symptoms, causes, and (most importantly) treatments.

Anatomy of Spine 

Complete intervertebral disc anatomy and biomechanics

Disc composition

Annulus fibrosis
  • Composed of type I collagen, water, and proteoglycans
  • Characterized by extensibility and tensile strength
  • High collagen / low proteoglycan ratio (low % dry weight of proteoglycans)
Nucleus pulposus
  • Composed of type II collagen, water, and proteoglycans
  • Characterized by compressibility
  • Low collagen / high proteoglycan ratio (high % dry weight of proteoglycans)
  • Proteoglycans interact with water and resist compression
  • A hydrated gel due to high polysaccharide content and high water content (88%)

Nerve Root Anatomy of PLID

The key difference between the cervical and lumbar spine is

Pedicle/nerve root mismatch
  • Cervical spine C6 nerve root travels under C5 pedicle (mismatch)
  • Lumbar spine L5 nerve root travels under L5 pedicle (match)
  • Extra C8 nerve root (no C8 pedicle) allows the transition
Horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
  • Because of the vertical anatomy of the lumbar nerve root, a paracentral and foraminal disc will affect different nerve roots
  • Because of horizontal anatomy of the cervical nerve root, a central and foraminal disc will affect the same nerve root

Location 

Central Prolapse
  • Often associated with back pain only
  • May present with cauda equina syndrome which is a surgical emergency
Posterolateral (paracentral)
  • Most common (90-95%)
  • PLL is weakest here
  • Affects the traversing/descending/lower nerve root
  • At L4/5 affects L5 nerve root
Foraminal (far lateral, extraforaminal)
  • Less common (5-10%)
  • Affects exiting/upper nerve root
  • At L4/5 affects L4 nerve root
Axillary
  • Can affect both exiting and descending nerve roots
Anatomic
  • Protrusion > eccentric bulging with an intact annulus
  • Extrusion > disc material herniates through annulus but remains continuous with disc space sequestered fragment (free)disc material herniates through the annulus and is no longer continuous with disc space. Axial back pain (low back pain)
  • This may be discogenic or mechanical in nature
Radicular pain (buttock and leg pain)
  • Often worse with sitting, improves with standing
  • Symptoms worsened by coughing, Valsalva, sneezing
Cauda equina syndrome (present in 1-10%)

Types of PLID

According to the position of spine disc herniation are 3 typeswww.rxharun.com/intervertibral-disc-prolaps

Herniation may develop suddenly or gradually over weeks or months. The 4 stages to a herniated disc are

  • 1) Disc Degeneration or Bulsing Disc – Chemical changes associated with aging causes discs to weaken, but without a herniation.
  • 2) Prolapse – The form or position of the disc changes with some slight impingement into the spinal canal and/or spinal nerves. This stage is also called a bulging disc or a protruding disc.
  • 3) Extrusion – The gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.
  • 4) Sequestration or Sequestered Disc – The nucleus pulposus breaks through the annulus fibrosus and can then go outside the intervertebral disc.

www.rxharun.com/herniated_disc/plid

Causes of PLID

  • Piriformis syndrome – This develops when the piriformis muscle, a small muscle that lies deep in the buttocks, becomes tight or spasms, which can put pressure on and irritate the sciatic nerve & causes PLID.
  • Spinal stenosis  – This condition results from the narrowing of the spinal canal with pressure on the nerves.
  • Spondylolisthesis – This is a slippage of one vertebra so that it is out of line with the one above it, narrowing the opening through which the nerve exits.
  • Cauda equina syndrome  A rare but serious condition that affects the nerves in the lower part of the spinal cord; it requires immediate medical attention. Cauda equina syndrome may permanently damage the nervous system and even lead to paralysis.
  • Bony growths (osteophytes) – Osteophytes are bony lumps (bone spurs) that grow on the bones of the spine or around the joints. They often form next to joints affected by osteoarthritis, a condition that causes joints to become painful and stiff.

www.rxharun.com/Ruptured-disc-in-lateral-view-Stock-Photo-disc-spine-spinal copy

  • Bone spurs – are bony outgrowths on the edges of joints. Bone spurs form where cartilage is worn away (for example in arthritis) and bone is rubbing on bone. In an effort to protect the body, new bone forms on the edge of joints. This is called a bone spur. Bone spurs are not painful in themselves, but unfortunately, the bone spurs can rub on nearby bone or nerves, causing problems. In the spine, bone spurs can intrude into space normally reserved for the nerves, thus causing sciatica.
  • Sudden injury or accident – Some unexpected traumatic events, such as a car accident, can lead to sciatica. Injuries sustained and new scar tissue can place stress on the sciatic nerve.
  • Pregnancy – During pregnancy, pain in the back of the thighs spurred by shifts in the pelvic region can be misdiagnosed as sciatica. However, there are situations in which the sciatic nerve is actually being pressed as a result of these changes. Speak to your doctor if you think you are suffering from sciatica or pelvic groin pain.
  • Tumors – within the spine may compress the root of the sciatic nerve.
  • Infection within the spine.
  • Injury within the spine.

Associate causes of PLID

corda equina syndrome/spinal nerve & pheripheral nerve anatomy

Degenerative

Trauma

  • Traumatic events leading to fracture or partial dislocation (subluxation) of the low back (lumbar spine) result in compression of the sciatic nerve.
  • Spinal fracture or dislocation
  • Epidural hematoma (may also be spontaneous, post-operative, post-procedural or post-manipulation)
  • A collection of blood surrounding the nerves following trauma (epidural hematoma) in the low back area can lead to compression of sciatica.
  • Penetrating trauma (gunshot or stab wounds) can cause damage or compression of the sciatic nerve.
  • A rare complication of spinal manipulation is a partial dislocation (subluxation) of the low back (lumbar spine) that can cause sciatica syndrome.

Herniated Disk

corda equina syndrome/spinal nerve & pheripheral nerve harniation

  • Most disk herniations will improve on their own (are self-limiting) and respond well to conservative treatment, including anti-inflammatory medications, physical therapy, and short periods of rest (one to two days).
  • Sciatica syndrome can result from a herniated lumbar disk.
  • Of lumbar disk herniations, most occur either at the vertebral levels L4-L5 or L5-S1.
  • Seventy percent of cases of herniated disks leading to sciatica syndrome occur in people with a history of chronic low back pain, and some develop sciatica syndrome as the first symptom of lumbar disk herniation.
  • Males in their 30s and 40s are most prone to cauda equina syndrome caused by disk herniation.
  • Most cases of sciatica syndrome caused by disk herniation involve large particles of disk material that have completely separated from the normal disk and compress the nerves (extruded disk herniations). In most cases, the disk material takes up at least one-third of the canal diameter.

Spinal Stenosis

  • Spinal stenosis is any narrowing of the normal front to back distance (diameter) of the spinal canal.
  • Narrowing of the spinal canal can be caused by a developmental abnormality or degenerative process.
  • The abnormal forward slip of one vertebral body on another is called spondylolisthesis. Severe cases can cause a narrowing of the spinal canal and lead to sciatica syndrome

Tumors (Neoplasms)

Inflammatory Conditions

  • Both acute and chronic form may be seen in long-standing ankylosing spondylitis (2nd-5th decades; average 35 years)
  • Long-lasting inflammatory conditions of the spine, including Paget disease and ankylosing spondylitis, can cause a narrowing of the spinal canal and lead to sciatica syndrome.

Infectious Conditions

corda equina syndrome/spinal nerve & pheripheral nerve harniation too

Accidental Medical Causes (Iatrogenic Causes)

  • Poorly positioned screws placed in the spine can compress and injure nerves and cause sciatica syndrome.
  • Continuous spinal anesthesia has been linked to cases of sciatica syndrome.
  • Lumbar puncture (spinal tap) can cause a collection of blood in the spinal canal (spontaneous spinal epidural hematoma) in patients receiving medication to thin the blood (anticoagulation therapy). This collection of blood can compress the nerves and cause sciatica syndrome.
  • Aortic dissection
  • Arteriovenous malformation

Symptoms of PLID

corda equina syndrome/spinal nerve & pheripheral nerve harniation too

  • Weakness in the Legs – The weakness is oftentimes asymmetric.
  • Loss of Sensation – Those affected may experience numbness or tingling in their perineum
  • Loss of Reflexes – A person’s knee and ankle reflexes might be diminished, along with anal and bulbocavernosus abilities.
  • Sensory Loss – Sensory loss may range from, ‘pins and needles,‘ to complete numbness. It might affect a person’s bowel, bladder and genitalia Bladder, Bowel and

Associate clinical feature is

Approximate area of “saddle anesthesia” seen from behind (yellow highlight)

Diagnosis of PLId

Physical exam

  • See lower extremity neuro exam
  • Motor exam
  • Ankle dorsiflexion (L4 or L5)
  • Test by having the patient walk on heels
  • EHL weakness (L5)
  • Manual testing
  • Hip abduction weakness (L5)
  • Have the patient lie on the side on the exam table and abduct leg against resistance
  • Ankle plantarflexion (S1)
  • Have the patient do 10 single leg toes stand

Straight Leg Raise ( SLR)

  • A tension sign for L5 and S1 nerve root
  • Can be done sitting or supine
  • Reproduces pain and paresthesia in the leg at 30-70 degrees hip flexion
  • Sensitivity/specificity most important and predictive physical finding for identifying who is a good candidate for surgery.
Contralateral SLR
  • Crossed straight leg raise is less sensitive but more specific
League sign
  • SLR aggravated by forced ankle dorsiflexion
Bowstring sign
  • SLR aggravated by compression on the popliteal fossa
Kernig test
  • Pain reproduced with neck flexion, hip flexion, and leg extension
Naffziger test
  • Pain reproduced by coughing, which is instigated by lying patient supine and applying pressure on the neck veinsMilgram test
  • Pain reproduced with straight leg elevation for 30 seconds in the supine position
  • Gait analysis
  • Trendelenburg gait due to gluteus medius weakness which is innervated by L5.

Others Physical Examination 

Observation of posture and function
  • In standing her shoulders – were shunted to the left side, her back was extended and pelvis anteriorly tilted, and there was visible hyper-tonicity of the lumbar paraspinal muscles.
  • This shunted antalgic posture – is commonly referred to as a lumber list. Observation of a lumber list, unfortunately, is a test lacking in reliability (Clare, Adams, & Maher, 2003). Maitland (2005), however, teaches us that if a person presents with an observable postural deformity, they are going to be more challenging to get better. In Sally’s case, she had a contralateral list (shoulders listed to the opposite side of back/leg pain), which is thought to respond more favorably to treatment than an ipsilateral list.
  • In my experience antalgic postures – are very important to detect because they indicate a protective position; a mechanism which the body is adopting (often subconsciously) in the acute phase of injury to protect the injury, and if the antalgic posture is not carefully examined and carefully corrected, it can make the patient a lot worse.
  • Movement tests – Tests that assess the spine’s range of motion may include bending the neck or torso forward, backward, or to the side. Additionally, if raising one leg in front of the body worsens leg pain, it can indicate a lumbar herniated disc (straight leg raise test).
  • Muscle strength – A neurological exam may be conducted to assess muscle strength and determine if a nerve root is compressed by a herniated disc. A muscle strength test may include holding the arms or legs out to the side or front of the body to check for tremors, muscle atrophy, or other abnormal movements.
  • Reflex test – Nerve root irritation can dampen reflexes in the arms or legs. A reflex test involves tapping specific areas with a reflex hammer. If there is little or no reaction, it may indicate a compressed nerve root in the spine.
Active range of movement
  • Lumbar flexion P2 (right-sided low back pain) R`(upper thigh).
  • Extension P2 (right buttock and leg pain) R` (vertical).
  • Other movements were not assessed day 1 due to severity and irritability.
Neurological examination
  • Weak single leg calf raises (SLCR) and was only able to perform three assisted raises to 50% range. Gr 5 strength of right leg SLCR x5 repetitions.
  • No other myotomal weakness was detected.
  • The S1 reflex on the right side was absent, with other lower limb reflexes being preserved.
  • No sensory changes were noted.
Neurodynamic Examination
  • The straight leg raise test (SLR) was positive in reproducing Sally’s posterior thigh pain and limited at 20 degrees on the right side.
  • Her left SLR was limited by hamstring tightness at 50 degrees.
  • The research suggests the SLR reliable re-assessment asterisks for patient progress. It has been shown to be 91% sensitive and 26% specificity in detecting lumbar disc pathology.D Neville et al. (2012) found that more than an 11-degree discrepancy in hip flexion range between sides was a clinically significant result. Compared to MRI, the SLR test has poor diagnostic accuracy and therefore is often used in conjunction with such imaging.

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Location of Pain and Motor Deficits in Association with Nerve Root Involvement at Each Lumbar Disc Level

DISC LEVEL LOCATION OF PAIN MOTOR DEFICIT

T12-L1

Pain in the inguinal region and medial thigh

None

L1-2

Pain in the anterior and medial aspect of the upper thigh

Slight weakness in quadriceps; slightly diminished suprapatellar reflex

L2-3

Pain in the anterolateral thigh

Weakened quadriceps; diminished patellar or suprapatellar reflex

L3-4

Pain in the posterolateral thigh and anterior tibial area

Weakened quadriceps; diminished patellar reflex

L4-5

Pain in the dorsum of the foot

Extensor weakness of big toe and foot

L5-S1

Pain in the lateral aspect of the foot

Diminished or absent Achilles reflex

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Manual palpation
  • Palpation was conducted on the left side-lying position with pressure applied only to the onset of pain (P1).
  • The presence of generalized hyperalgesia made it difficult to establish a comparable finding day.

Straight Leg Raise Test (SLR Test) 

Straight leg raise
Medical diagnostics
www.rxharun.com/Straight-leg-test

Straight Leg test sometimes used to help diagnose a lumbar herniated disc

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SLR test and its Modifications

SLR (BASIC) SLR2 SLR3 SLR4 CROSS LEG

SLR 5

HIP Flexion and adduction Flexion Flexion Flexion and Medial Rotation Flexion
KNEE Extension Extension Extension Extension Extension
ANKLE Dorsiflexion Dorsiflexion Dorsiflexion Plantar flexion Dorsiflexion
FOOT —— Eversion Inversion Inversion ——-
TOES —— Extension —– —— ——
NERVE BIAS Sciatic Nerve and Tibial Nerve Tibial Nerve Sural Nerve Common Peroneal Nerve Nerve Root (Disc Prolapse)

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Evidence

  • A Cross-sectional study by Boyd and Villa (2012)  examined normal asymmetries between limbs in healthy, asymptomatic individuals during SLR testing and the relationship of various demographic characteristics. The authors concluded that the overall range of motion during SLR was related to sex, weight, BMI and activity level, which is likely reflected in the high variability documented.
  • We can be 95% confident that inter-limb differences during SLR neurodynamic testing fall below 11 degrees in 90% of the general population of healthy individuals. In addition, inter-limb differences were not affected by demographic factors and thus may be a more valuable comparison for test interpretation.
  • Rabin et al. have shown the sensitivity of the SLR test to be.
  • Deville et al. found the specificity to be.
  • A systematic review of the Clinical utility of SLR by Scaia V, Baxter D and Cook C (2012) investigated the diagnostic accuracy of a finding of pain during the straight leg raise test for lumbar disc herniation, lumbar radiculopathy, and/or sciatica.
  • The authors concluded that Variability in reference standard may partly explain the inconsistencies in the diagnostic accuracy findings.
  • Further, pain that is not specific to lumbar radiculopathies, such as that associated with hamstring tightness, may also lead to false positives for the SLR; and may inflate the sensitivity of the test.

Diagnostic Test Accuracy Review (Cochrane Meta-analysis)

Assessed the performance of tests performed during physical examination (alone or in combination) to identify radiculopathy due to lower lumbar disc herniation in patients with low-back pain and sciatica. The review included 16 cohort studies (median N = 126, range 71 to 2504) and three case-control studies (38 to100 cases). Only one study was carried out in a primary care population. Most studies assessed the Straight Leg Raising (SLR) test. In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40). Results of studies using imaging showed more heterogeneity and poorer sensitivity. The crossed SLR showed high specificity (pooled estimate 0.90, 95% CI: 0.85 to 0.94) with consistently low sensitivity (pooled estimate 0.28, 95% CI: 0.22 to 0.35). Combining positive test results increased the specificity of physical tests, but few studies presented data on test combinations. The authors of the meta-analysis conclude that When used in isolation, current evidence indicates the poor diagnostic performance of most physical tests used to identify lumbar disc herniation. However, most findings arise from surgical populations and may not apply to primary care or non-selected populations. Better performance may be obtained when tests are combined.

Lab Diagnosis of PLID

A doctor can diagnose cauda low back pain. Here’s what you may need to confirm a diagnosis

Imaging

  • X-rays – can show the alignment of the bones and whether the patient has arthritis or broken bones. They are not ideal for detecting problems with muscles, the spinal cord, nerves or disks.
  • CT scans – these are good for revealing herniated disks or problems with tissue, tendons, nerves, ligaments, blood vessels, muscles, and bones.
  • Bone scan – a bone scan may be used for detecting bone tumors or compression fractures caused by brittle bones (osteoporosis). The patient receives an injection of a tracer (a radioactive substance) into a vein. The tracer collects in the bones and helps the doctor detect bone problems with the aid of a special camera.
  • Electromyography or EMG – the electrical impulses produced by nerves in response to muscles is measured. This study can confirm nerve compression which may occur with a herniated disk or spinal stenosis (narrowing of the spinal canal).
  • Magnetic Resonance Imaging (MRI) scan – is a noninvasive test that uses a magnetic field and radiofrequency waves to give a detailed view of the soft tissues of your spine with a bulging disc. Unlike an X-ray, nerves and discs are clearly visible. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. An MRI can detect which disc is damaged and if there is any nerve compression. It can also detect bony overgrowth, spinal cord tumors, or abscesses.
  • Nuclear Magnetic resonance imaging (MRI) scan – which uses magnetic fields and computers to produce three-dimensional images of your spine.
  • A myelogram – is a specialized X-ray where dye is injected into the spinal canal through a spinal tap. An X-ray fluoroscope then records the images formed by the dye. The dye used in a myelogram shows up white on the X-ray, allowing the doctor to view the spinal cord and canal, a bulging disc in detail. Myelograms can show a nerve being pinched and a bulging disc by a herniated disc, bony overgrowth, spinal cord tumors, and abscesses. A CT scan may follow this test.
  • Computed Tomography (CT) scan – is a noninvasive test that uses an X-ray beam and a computer to make 2-dimensional images of your spine. It may or may not be performed with a dye (contrast agent) injected into your bloodstream. This test is especially useful for confirming which bulging disc is damaged.
  • Electromyography (EMG) & Nerve Conduction Studies (NCS) – EMG tests measure the electrical activity of your muscles. Small needles are placed in your muscles, and the results are recorded on a special machine. NCS is similar, but it measures how well your nerves pass an electrical signal from one end of the nerve to another. These tests can detect nerve damage and muscle weakness and a bulging disc.
  • Discogram – A discogram may be recommended to confirm which bulging disc is painful if surgical treatment is considered. In this test, the radiographic dye is injected into the disc to recreate disc pain from the dye’s added pressure.

corda equina syndrome/mri-harniation disc-too

  • Urodynamic studies – may be required to monitor the recovery of bladder function following decompression surgery.

In most cases of low back pain, medical consensus advises not seeking an exact diagnosis but instead beginning to treat the pain. This assumes that there is no reason to expect that the person has an underlying problem. In most cases, the pain goes away naturally after a few weeks. Typically, people who do seek diagnosis through imaging are not likely to have a better outcome than those who wait for the condition to resolve.

Treatment of PLID

Non-surgical

Rest – It is important that the patient take proper rest and sleep and avoid any activities which will further aggravate the disc bulge and its symptoms. Many minor disc bulges can heal on their own with rest and other conservative treatment.

Cervical Pillow – It is important to use the right pillow to give your neck the right type of support for healing from a cervical disc bulge and also to improve the quality of sleep.

Specific treatment for lumbar disk disease will be determined by your health care provider based on

  • Your age, overall health, and medical history
  • The extent of the condition
  • Type of condition
  • Your tolerance for specific medications, procedures, or therapies
  • Expectations for the course of the condition
  • Your opinion or preference

Typically, conservative therapy is the first line of treatment to manage lumbar disk disease. Approach for Treating and Reversing a Disc Bulge about half of the disc bulges heal within six months and only about 10% of the disc bulges require surgery. So, the good news is that conservative treatment for a disc bulge helps in treating as well as reversing the disc bulges.

Ice & Moist Heat Application

www.rxharun.com/low back pain-rest/Warm-Compress1

Ice application where the ice is wrapped in a towel or an ice pack for about 20 minutes to the affected region, thrice a day, helps in relieving the symptoms of a disc bulge. Heat application in the later stages of treatment also provides the same benefit.

Hot Bath –  Taking a hot bath or shower also helps in dulling the pain from a disc bulge. Epsom salts or essential oils can be added to a hot bath. They will help in soothing the inflamed region.

Traction – traction is the best essential treatment for bulging discs, pinched nerve, radiating pain management. It can be done in a manual and dynamic way to relieves pain in bulging discs.

www.rxharun.com/low back pain-rest/Warm-Compress/spinal-decompression-chair

  • Massage therapy – may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower back pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
  • Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
  • Spinal manipulation – is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
  • Back school –  is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether the back school is effective or not.
  • Patient education – on proper body mechanics (to help decrease the chance of worsening pain or damage to the disk)
  • Physical therapy – which may include ultrasound, massage, conditioning, and exercise. The goal of physical therapy is to help you return to full activity as soon as possible and prevent re-injury. Physical therapists can instruct you on proper posture, lifting, and walking techniques, and they’ll work with you to strengthen your lower back, leg, and stomach muscles. They’ll also encourage you to stretch and increase the flexibility of your spine and legs. Exercise and strengthening exercises are key elements to your treatment and should become part of your life-long fitness.
  • Over the Door Traction – This is a very effective treatment for a disc bulge. It helps in relieving muscle spasms and pain. Typically a 5 to 10-pound weight is used and it is important that patients do this under medical guidance.
  • Weight control – By keto diet or maintaining or changing the food habit to reduce the weight not any movement during the time of acute pain.
  • Use of lumbosacral back support – It is helpful for back support during any travels or everyday natural movement. It also helps to straighten the lumbar spine.
  • Holistic therapies – Some patients find acupuncture, acupressure, nutrition/diet changes, meditation, and biofeedback helpful in managing pain as well as improving overall health.
  • Typically – conservative therapy is the first line of treatment to manage lumbar disk disease. Approach for Treating and Reversing a Disc Bulge about half of the disc bulges heal within six months and only about 10% of the disc bulges require surgery. So, the good news is that conservative treatment for a disc bulge helps in treating as well as reversing the disc bulges.
  • Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins are proven to help heal back pain of all types. Therefore focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly healing PLID. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
    • In bulging disc needs ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
    • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines and salmon.
    • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
    • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items and foods made with lots of refined sugars and preservatives.

 

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Medications

  • Analgesics – It is basically paracetamol with prescription-strength drugs that relieve pain but not inflammation.
  • Muscle Relaxants –  These medications provide relief from spinal muscle spasms.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
  • Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes paresthesia, radiating pain with numbness, diabetic neuropathy pain, myalgia, burning, numbness, and tingling sensation
  • Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
  • NSAIDs Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenacetoricoxib, ibuprofen, and naproxen.
  • Calcium & vitamin D3 To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
  • Glucosamine & DiacereinChondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
  • Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
  • Dietary supplement – to remove general weakness & improved health.
  • Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
  • Corticosteroid – to healing the nerve inflammation and clotted blood in the joints. Steroids may be prescribed to reduce the swelling and inflammation of the nerves. They are taken orally (as a Medrol dose pack) in a tapering dosage over a five-day period. It has the advantage of providing almost immediate pain relief within a 24-hour period.
  • Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
  • Steroid injections – The procedure is performed under x-ray fluoroscopy and involves an injection of corticosteroids and a numbing agent into the epidural space of the spine. The medicine is delivered next to the painful area to reduce the swelling and inflammation of the nerves. About 50% of patients will notice relief after an epidural injection, although the results tend to be temporary. Repeat injections may be given to achieve the full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with physical therapy and/or a home exercise program.

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Surgical Treatment 

When these conservative measures fail, surgery for removal of a herniated disk may be recommended. Surgery is done under general anesthesia. An incision is placed in the lower back over the area where the disk is herniated. Some bone from the back of the spine may be removed to gain access to the area where the disk is located. Typically, the herniated part of the disk and any extra loose pieces of a disk are removed from the disk space.

  • Microdiscectomy – for a herniated disc, a minimally-invasive procedure in which the herniated portion of the disc is removed.
  • Artificial disc replacement – for degenerative disc disease and herniated discs is a minimally invasive procedure that replaces a damaged disc with a specialized implant that mimics the normal function of the disc, maintaining mobility.
  • Spinal fusion – fusion for degenerative disc disease, in which the disc space is fused together to remove motion at the spinal segment. Spinal fusion involves setting up a bone graft, as well as possible implanted instruments, to facilitate bone growth across the facet joints. Fusion occurs after the surgery.
  • Open Back Surgery – Traditionally, bulging discs are treated with an open back procedure, meaning the surgeon makes a large incision into the skin and cuts muscle and surrounding tissue to gain access to the problematic disc. This traditional surgical option is invasive, requires overnight hospitalization, general anesthesia, and requires a lengthy recovery coupled with strong pain medication.
  • Endoscopic Surgery – Fortunately, you have a second option with endoscopic spine surgery. Thanks to the advancement of surgical technology at bulged disc surgery can be performed using endoscopic procedures, meaning the surgeon makes a small incision to insert special surgical tools. During an endoscopic bulging disc operation, the surgeon uses a tiny camera to visualize and gain access to your damaged disc. This minimally invasive new approach offers shorter recovery, easier rehabilitation, and a much higher success rate than open back or neck surgery. A local anesthetic is all that is usually required.

Percutaneous Endoscopic Discectomy

With the increasing use of endoscopic surgical techniques in spinal surgery, PED was introduced to the treatment of pediatric LDH []. Two relevant articles published by Mayer et al. [] (4 cases) and Lee et al  (46 cases) were obtained from the literature search. PED was associated with a short-term success rate of 91.3 and 100% respectively, without complications such as leakage of CSF, nerve root injury, interspace infection, etc. The long-term follow-up is yet to be reported. Their recommended indications of PED for pediatric LDH include

  • (1) failure of 6 weeks of conservative treatment;
  • (2) a comparatively intact disc;
  • (3) subligamentous protruded or extruded disc. The minimally invasive nature of PED means less surgical trauma and shorter hospital stay. Its success, however, requires a correct selection of patients and the surgeon being able to master the surgical procedure.

Open Discectomy

  • Discectomy remains the most used surgical procedure for LDH in children and adolescents as well as in adults. It is generally agreed in the literature that posterior discectomy with partial laminotomy is indicated for posterolateral disc herniation, whereas hemilaminectomy or laminectomy is required in cases of central disc herniation. There were also reports of successful use of extraperitoneal anterolateral discectomy on a centrally protruded disc [.
  • More recently, MD has also been used for the treatment of pediatric LDH [] and associated with a good result. The present review found five published series with clinical outcomes obtained from 143 MD cases. The short-term success rate ranged from 98 to 100% while the mid and long-term success rate dropped to 92 and 85%  respectively.
  • Surgical indications should be proposed if conservative treatment fails, or if the neurological symptoms progress.
  • In such cases, microdiscectomy (under a magnifying glass or through a microscope) with preservation of the ligament flavum has been shown to be effective for preventing complications, avoiding peridural fibrosis and reducing symptomatic relapses

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