hello this is doctor corenman and we're going to talk about the surgical
indications and treatment
of cervical and lumbar herniated discs
the anatomy of the disc is relatively simple some people call it a jelly filled donut
for the
interior the jelly the nucleus is under pressure
and the outer part of the disc the
annulus that you can see here
are about sixty rings of collagen
very similar to plies on a tire
the nucleus itself is hydrophilic it loves water
and acts as a giant sponge to remain under pressure
the outer annulus holds the nucleus in
you can see its relationship to the nerve roots and back here
where the two nerve roots
and the central canal are right in back of the disc
the disc itself has a very good blood supply but literally disappears by the
age of eight
there are more torsional forces
than any other structure in the body
and injury to the disc here is cumulative
the discs age
obviously without a blood supply the disc itself
will loses its ability
to have the cells
continue to work at their
normal rate
and they become senescent
these cells are important
to make this structure work this is a highly orotic acid backbone
with the link ptoteoglycan monomer
these are hydrophilic this is what holds water in
and over time since the cells inside the disc
become senescent
these areas break down and as they break down there's less ability to hold water
and the pressure drops in the disc
as the pressure drops there is more stress placed on the outer wall
and outer wall starts to develop tears
what happens is initially annular tears you can see that wonderful
picture of an MRI with an annular tear here
where the disc has lost its ability to hold water so its black inside
and you can see this inflammatory tera
with a very small herniation here
this tear
is the starting of the degenerative cascade
it can lead to a disc herniation
itcould lead to instability of the entire motor complex
it could lead to loss of shock absorption
and it could lead to bone spur formation
the degenerate cascade starts with a tear in the disc
and then the jelly itself loses its ability to hold water the nucleus
because less able to hold hydration
and on an MRI and you can see a normal disc here
where there's plenty of white water within the disc space
you start to lose it here
a little more degenerative here and you can see this disc here is essentially
given up the ghost
so longer acting as a shock absorber
and you can see the boney changes around the outside of the vertebra
that surround the disc
these are stress fractures of the bone
and this is what causes that
deep dull ache
within the back
in patients who do vibration or impact activities
patient wiring
is important as some patients with this condition have
no back pain
and others have significant disabling back pain
a lumbar herniation
is essentially a tear through the back wall where the nucleus squirts out the
back so to speak
and fills up a portion of the canal
this of course compresses the nerve root and this will create nerve root
signs
now the hallmark symptoms are leg and buttocks pain
some people will be diagnosed with a something called a piriformis
syndrome but this is a very rare event in almost does not occur
the typical signs in a patient
will be sensory changes reflex deficits
possibly motor deficits
and certainly tension signs when you pull on the nerve
the nerve will hurt
these patients tend to like to stand
and don't like to bend forward they don't like to sit down
as flexion or sitting
will cause increased tension on the nerve
there's a very small subset of patients with a herniation that do get worse
with the extension
surgical indications are straightforward
if the patient has a motor deficit
in a major motor group
that will impair their gate
they certainly need surgery
this would include something called foot drop
or a problem with their gastroc solus group where they can't push up
the stairs or they can't push off or if they're quid becomes weak
patients with massive herniation can develop a cauda equina syndrome
this is where the back of the canal
is fully compressed
and the entire cauda equina passing through
starts to malfunction
patients with this can have saddle anesthesia can have significant
bilateral buttocks and leg pain
and can develop problems with bowel and bladder
the third indication for microdiscetomy
is significant pain
if patients have gone through a conservative care program do not have
cauda equina syndrome or motor deficit
and do not get better
with injections
with physical therapy in with medications these patients are
candidates for microdiscetomys
the microdiscetomy is a simple procedure a small incision was made in
the midline
this muscle multifidus
is detached from the center and gently pulled to the side and then a little
laminotomy is made here
it already shows the curet into the disc space in the ronger but the nerve is
decompressed first by removing the fragment
and then any loose material within the disc space
is removed
microdiscectomy results are pretty good
it's about a ninety to ninety five percent success rate for relief of pain
that five percent of patients who
do not get leg pain relief
may have nerve injuries called chronic
and that may not be able to be treated
with the surgery there is a ten to fifteen percent chance of having a
recurrent herniation as we've discussed before there is no
good blood supply to the disc and therefore tears in the disc
don't heal
a herniated disc means that there's been a through and through tear to the disc
and there's another chance of a recurrent herniation
with or without surgery
microdiscextomy patients can return to low mid-level function
in ten days
into high-level function in six weeks
competition can be in eight to twelve weeks
and rehabilitation is essential for this
for the cervical herniation
this will obviously create neck arm and scapular pain
it's important to note that most patients that have a herniated disc
will have referral pain
that ends up between the shoulder blades
patients with a herniation will develop motor
sensory
reflex and possibly even cord signs
these patients are better
with neck
flexion they like to have their head down
also some patients with a large herniation you see in this image right here
these patients
will have pain unless they put their arm up over their head
in an external rotation abduction maneuver
which is called Bakody sign
surgical indications for cervical herniation are again motor deficit
cord signs such as myelopathy
and pain
an ACDF is the standard treatment to take care of a large disc herniation
that is in the lateral aspect
the ACDF is an anterior cervical decompression infusion
and the success rate is probably just about as high
as in the lumbar spine
an ACDF you note you remove
whatever's left of the disc
you reach behind remove any of the herniated fragments or spurs
and then put a small bone graft in between a vertebra
and this creates the fusion
postoperatively this is what an x-ray looks like where
you have a solid fusion between vertebra and a plate which was put there to allow
the patient to rehab faster and earlier
ACDF results are very similar in many respects to the microdiscectomy
there's a ninety to ninety five percent success rate for relief of arm pain
there is a rate of pseudoarthrosis of lack of fusion
which is not high
but it's higher with
a cadaver specimen than with autograft
the fusion in or with autograft normally consolidates by six weeks
patients can be back to low energy activities in ten days mid-level
activities in six weeks and competition in eight to twelve weeks and again
rehabilitation is essential
the future
at a glance discal regeneration
possible artificial discs i think there is a place for them in the neck probably
not in lumbar spine
and even percutaneous treatment
thank you for your attention