Disc lesions & Nerve Root Pain

Lesion is a non-specific term used in medicine to refer to a pathology of tissue. It indicates an area of tissue that has been injured, destroyed, altered (for the worse) or has a problem.

Disc lesion refers to disc degeneration Leads to reduced water content and

therefore reduced shock absorption Leads to nucleus pulposes collapsing

through annulus fibrosis to adjacent vertebra (known as Schmorl’s nodules)

Definition of Disc lesion

Trauma Flexion rotation injuries- heavy object is

lifted (gives rise to tear of the posterior longitudinal ligament and results in bulging of the disc)

Degeneration Disc loses elasticity due to collagen

changes and decrease in water content results in inability to handle compression forces

Increased pressure Nucleus absorbs moisture during physical

illness or emotional stress, swells and presses against annulus fibrosis

Causes

Age: Most common in middle age, especially between 35 and 45, due to aging-related degeneration of the discs.

Weight: excess body weight causes extra stress on the disks in your lower back.

Occupation: People with physically demanding jobs have a greater risk of back problems. Repetitive lifting, pulling, pushing, bending sideways and twisting also may increase your risk of a herniated disk. Working night shift has also been found to increase your risk.

Pregnancy

Risk factors

Changes start asymptomatically but causes weak link

Most injuries occur at L4,5 and L5, S1

Prolapse to anterior or lateral causes osteophytes which later attach to each other, resulting in loss of movement

Posterior prolapse causes more problems

Disc itself or osteophytes exert pressure on spinal cord or nerve roots

Pathology

Sudden pain when picking up heavy object- initially slight but worsens and can impair movement.

Repeated attacks occur suddenly e.g. sneezing or coughing

Pain after a prolonged sustained position Central or referred symptoms- not always clearly

defined Proximal worse than distal Pain diminishes when lying down with knees

supported or hanging in a specific position

Symptoms

Young, healthy patient Lateral tilt of the pelvis Increased lumbar lordosis Gluteal area sensitive to palpation Protective muscle spasm Sitting, coughing and sneezing painful Decreased intervertebral movements

Signs

AP- Sometimes shows tilt of vertebra Lateral- Narrowed disc space

X-Rays

OMT Rotation (grade 4-) Longitudinal Static traction Palpation techniques (except when ext.

comparable sign) Electrotherapy Exercises

Abdominal stabilisation Strengthening quadriceps and gluteal

mm. Neural mobilisation Posture correction and kinetic handling Surgery http://

www.youtube.com/watch?feature=player_embedded&v=i6r5ivym8Ug

Treatment

Avoid sitting positions (driving or bathing) Sit with knees lower than hips and use lumbar cushion Avoid sustained positions Avoid rotation movements when picking up objects Avoid sudden, jerky movements (sporting activities) Do not pick up heavy objects Swimming is good exercise- strengthens erector spinae Wear a brace during activities which aggravate

backache

Advice

Pressure on the nerve root causing pain

Pain not from nerve itself but as result from venous congestion

First sign is pins and needles in distal region of affected dermatome, pain intensifies and arterial blood circulation restricted

Nerve conduction suspended and nerve fall-out develops

Nerve Root Pain

Depends on: Strength of initial impulse Duration of abnormal pressure (longer, the

worse it becomes)

Degree of impairment

Disc prolapse Disc protrusion Osteophytes Traction injuries Swelling in intervertebral canal Stenosis Deep-seated muscle spasms Hypertrophic capsule

Causes

Nerve root irritation: Increased reflexes Abnormal sensation or paraesthesia

Nerve root pressure: Decreased reflexes Loss/ no sensation Muscle weakness- long term atrophy

Physical manifestations

Pressure on spinal cord: Gait disturbances Bilateral pins and needles Bladder dysfunction Increased reflexes below level of lesion Clonus and Babinski (+)

Pressure on cauda equina Saddle anaesthesia Urine retention

Manifestations cont.

Area: Well defined throughout

dermatome or dominates distal part of dermatome

Nature: Severe pain, sometimes total

loss of function, may be latent, often undulent and builds up.

Sharp, shooting pain which may paralyse patient

Root pain of C7 refers to medial border of scapula with cervical movements (Cloward areas)

S1 refers to medial buttock Acute phase, pain severe, sub-

acute and chronic, pain is intermittent

Characteristics of nerve root pain

Movement: Either distal or latent pain

in distal segment More distal pain is caused,

more careful the management

Deformities: Protective deformities

occur Patient stands on one leg

with other leg bent and toes resting on the floor

Severe nerve root pain: Hospital traction or traction as out

patient (Neurological examination is an

ABSOLUTE prerequisite, palpation techniques are CONTA-indicated)

Steroid injections As soon as symptoms improve,

mobilisation techniques (Gr. 4) may be added to traction

Treatment suspended after 85% improvement

If symptoms extremely severe, surgery is indicated

Treatment

Cervical root pain: Constant traction Collar for support to restrict movement Advice regarding sleeping positions

Lumbar root pain: Complete bed-rest Constant traction Takes longer to react to treatment

Specific treatment

Chronic: History of prolonged pain in back and leg Strong treatment techniques indicated (e.g traction and SLR)

Intermittent: Pain only occurring in one dermatome e.g the knee Local hypertrophy and palpation tenderness of interspinal

ligament Quick active tests and palpation techniques do not

reproduce symptoms Treatment:Trigger pointsNeural mobilisationUltrasound

Chronic and intermittent nerve root pain

OBJECTIVE: To evaluate the effect of therapeutic transforaminal lumbar epidural steroid injections in managing low back and lower extremity pain.

OUTCOME MEASURES: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake.

Effectiveness of therapeutic lumbar transforaminal epidural steroid injections

in managing lumbar spinal pain.

RESULTS: 27 studies met inclusion criteria, 15 randomized trials and 10 non-randomized studies. For lumbar disc herniation, the evidence is good for transforaminal epidural with local anesthetic and steroids, whereas it was fair for local anesthetics alone and the ability of transforaminal epidural injections to prevent surgery. For spinal stenosis, the available evidence is fair for local anesthetic and steroids. The evidence for axial low back pain and post lumbar surgery syndrome is poor, inadequate, limited, or unavailable.

CONCLUSION: In summary, the evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids and fair with local anesthetic only. Evidence is limited for axial pain and post surgery syndrome using local anesthetic with or without steroids.

Barnes,R.2011.NEUROMUSCULAR-SKELETAL REHABILITATION DICTATE.(Unpublished dictate.) University of the Free State , Free State.

Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, Christo PJ. 2012. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain.(http://www.ncbi.nlm.nih.gov/pubmed/22622912)

Retrieved 22 August 2012

South Wales Osteopathic Society. Disc lesions. (http://osteopathywales.com/index.php?option=com_content&view=article&id=204:disc-lesions&catid=22:medical-conditions)

Retrieved 19 August 2012.

References

Asher, A. 2006. Lesion (http://backandneck.about.com/od/l/g/lesion.htm).

Retrieved 19 August 2012.

Health on Care. 2012. Disc Herniation, Prolapse Disc : Definition, Causes, Symptoms, Diagnosis, Prevent and Treatment (http://www.healthoncare.com/disc-herniation-prolapse-disc.html).

Retrieved 19 August 2012.

References cont.