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LumbarHerniatedDiscsWhycalledherniateddiscWhyspecialfocusforlumbarIncidenceandsocialfactorMorphalogyMostcommonMostdisturbingIntroductionObjectives•Identifytheanatomyofthelowerback•Understandthetypesoftraumathatcancauseaherniateddisc•Identifythesignsofaherniateddisc•Beabletoevaluatepatientswithpotentialherniateddiscs•AlsoabletofollowatypicaltreatmentprogramforlumbarherniateddiscsLumbarAnatomy•Thelumbarsectionofthespineismadeupofthelower5vertebrae•CommonlyreferredtoasL1toL5•L5connectstothetopofthesacrumAnatomyofLumbarVerebra•Thevertebralbodyisathinringofdensebone•Consistingofthebody,pediclesandliminae•VertebralforamenisawholeinvertebralbodythatspinalcordrunsthroughGellikeTissuebetweeneachvertebrafibrocartilaginouscushionsserveasthespine'sshockabsorbingsystemprotectthevertebrae,brain,andotherstructuresThediscsallowsomevertebralmotionextensionandflexion.DiscsfunctionThediscismadeupof3structuresthe•Nucleuspulposus,gelatinouscenter•AnnulusFibrosus.Itsjobistocontainthenucleus•VertebralendplatesthatattachthedisctothevertebraeDiscsstructureHerniateddisk•Occurwhenthereisenoughpressurefromthevertebraeaboveandbelow•Thiscanforcenucleuspulposusthroughaweakenedortornpartoftheannulusfibrosus.•Therupturednucleuswilloftencomeincontactwithandpressonnervesnearthedisc.•HerniateddisksareoneofthemostcommoncausesofbackpainMechanismofinjuryAged----------diskshaveworndownovertimeoverweight------------extrapressureontheintervertebraldisksImproperliftingform,Twistingviolently------suddenstrainthatcouldpossibleherniateadiskSymptomsLowerbackpain,sharpandshootingpaintherunsdownlowback,buttocksanddownthethighPain,weakness,numbnessortinglinginthelegs,buttocksandfeetProblemswithbowel,bladderorerectilefunction,inseverecasesHowcanwerecognizeaherniateddisk?Signs•Lumbarcurvatureisflattenedorevenkyphotic•Sidebendingtowardtheoppositesideofthepainusuallyrelievesthepain•Thestraightleg-raising(SLR)testwithradiatingpainbelowkneelevelseemsreasonablyassociatedtodischerniationObviouslyneurologicsignsalteredsensibility,reflexes,musclestrength,andmuscleatrophyshouldbetested.NeurologicsignsLocatednerverootandinvolvedsegmentNeurologicsignsQuads/TibialisAnteriorPatellarreflexSensoryGreattoeandmediallegL4NeurologicsignsL5StrengthofAnkleandgreattoedorsiflexionExtensorHallucisLongusSensorytodorsumoffootNeurologicsignsS1AnklereflexesandsensationofposteriorcalfandlateralfootPeroneals/GastrocAchillesreflexSensorytolateralandplantarfootDiagnosisGenerallyisbasedonthesymptomsoflowerbackpain.examineyoursensation,reflexes,gaitandstrength•X-ray--High-energyradiationisusedtotakepicturesofthespine.•MagneticResonanceImaging(MRI)--AnMRIprovidesdetailedpicturesofthespinethatareproducedwithapowerfulmagnetlinkedtoacomputer.•ComputedTomography(CT)Scan--ACTscanusesathinX-raybeamthatrotatesaroundthespinearea.Acomputerprocessesdatatoconstructathree-dimensional,cross-sectionalimage.•Electromyography(EMG)--Thistestmeasuresmuscleresponsetonervousstimulation.MRIMAGEDiagnosisHerniatedDisc(“slippeddisc”)TypesofherniationDegeneration:chemicalchangesassociatedwithagingcausedehydrated,collapsedandweak,butwithoutafrankherniation.Prolapse:thediscbulgesandmaycauseslightnarrowingofthespinalcanal,alsoknownasbulgeorprotrusion.Extrusion:nucleuspulposusrupturesthroughtheannulusfibrosusbutremainswithinthedisc.Sequestration:nucleuspulposussqueezedout,liesoutsidethediscandwithinthespinalcanal.L4vertebraL5vertebraL4exitsaboveherniationL5&lowerarecompressedL4/L5discherniationTypesofherniationCentralPosterlateralLateralDifferenciationCategoriesofLowBackPain（CAMPBELL’S）Extrinsiclesions•Urogenitalsystem,gastrointestinalsystem,vascularsystem,endocrinesystem,nervoussystemnotlocalizedtothespine,extrinsicmusculoskeletalsystem•Infections,tumors,metabolicdisturbances,congenitalabnormalities,associateddiseasesofagingIntrinsiclesions•Spinalmusculoskeletalsystem,localhematopoieticsystem,localneurologicsystem•Trauma,tumors,infections,diseasesofaging,immunediseasesDifferentialDiagnosisofLowBackPainDiseaseorconditionPatientage(years)Backstrain20to40discherniation30to50Osteoarthritisorspinalstenosis50SpondylolisthesisAnyageAnkylosingspondylitis15to40InfectionAnyageMalignancy50ATULT.PATEL,ABNAA.OGLE.DiagnosisandManagementofAcuteLowBackPain[J].AAFP,Vol.61/No.6(March15,2000).DifferentialDiagnosisofLowBackPainDiseaseorconditionLocationofpainBackstrainLowback,buttock,posteriorthighdischerniationLowbacktolowerlegOsteoarthritisorspinalstenosisLowbacktolowerleg;oftenbilateralSpondylolisthesisBack,posteriorthighAnkylosingspondylitisSacroiliacjoints,lumbarspineInfectionLumbarspine,sacrumMalignancyAffectedbone(s)DifferentialDiagnosisofLowBackPainDiseaseorconditionAggravatingorrelievingfactorsBackstrainIncreasedwithactivityorbendingdischerniationDecreasedwithstanding;increasedwithbendingorsittingOsteoarthritisorspinalstenosisIncreasedwithwalking,especiallyupanincline;decreasedwithsittingSpondylolisthesisIncreasedwithactivityorbendingAnkylosingspondylitisMorningstiffnessInfectionVariesMalignancyIncre