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UTHAIWAN LEKYINGYONG, M.D.

30 June - 2 July 2003
Learning objectives
Period 1:
n.uclinical characteristic of HNP
n.utype of HNP
differential diagnosis HNP
Period 2: for management HNP
physical modality, activity, orthosis and
exercise
case
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Physical examination
A thai man with good consciouness, Rt. Lateral
bending positon
not pale
Back: normal alignment
Tenderness on extension and Lt. Lateral bending , taut
band at Lt. Paravertebral muscle
SLRT 80/ 70
FAIR test, sign of 4 ve
Motor: Lt EHL, TA gr.4, others gr.5 all.
Sensory impaired LT, PPS 1
st
, 2
nd
, 3
rd
finger and
dorsal surface of Lt. Foot
DTR 2+ all
Trigger point at Lt. Gluteus maximus
Differential diagnosis
- HNP -MPS gluteus medius
- SCS -Piriformis syndrome
- Nerve sheath tumor - Spondylosis
- Ureteric stone, Renal calculi
- AVN ( idiopathic)
- Spondylolytic spondylolithesis
- Abcess- irritate sciatic n.
Learning objectives
HNP u. .r
MPS gluteus max., gluteus minimus, quadratus
lumborum, gluteus medius u. ...
piriformis syndrome u. +. a..a
spondylolytic spondylolithesis u. a.
Lumbar myelogram
Herniated disc at L4-5 disc level with
compression of bilateral exiting L5 and
traversing S1 nerve roots
Definite diagnosis
HNP L4-L5 (shoulder type)
MPS Lt. Gluteus maximus
Learning objectives
Classification of disc herniation
Management of disc herniation
indications for surgery
rehabilitation management
- physical modality
- activity
- exercise
- lumbar corset/support
Contents
Disc herniation
definition: abnormal rupture or protrusion of disc
- Particularly in young- middle age man
- Cause usually flexion injury
- often occurs to one side
- Most common L5-S1, L4-5
Macnabs classification
- Bulging disc: intact annulus fibrosus
- Prolapsed disk: incomplete defect annulus fibrosus
- Extruded disk: complete defect annulus fibrosus, intact
posterior longitudinal lig.
- Sequestered disk: part of nucleus pulposus is extruded
History
- Most pt. Have back pain varied lengths of time
- varying combined with back, hip, leg pain
Back pain: localized to midline LS region, radiaton to SI, high iliac
crest, coccygeal is more indicative of dural irritation
Buttock: pain is usually one of deep-seated, cramping pain
Thigh :higher lumbar root, sharp pain, anterior thigh
Leg: L5/S1 root-cramp & vise-like feeling in belly of gastroc/ peroneal
mus., paresthesia in lateral calf (L5) / back of calf (S1)
Foot: most common symptom is parethesia than pain
- Younger patient may has only leg pain
- Aggravated symptom: bending, stooping, lifting, cough, straining
at stool
PE
Back: loss of lordosis, paravertebral muscle spasmsciatic scoliosis: more
obvious on bending forward, limit flexion, extend ( lesser degree than flex)
Lateral flex.increase pain (Shoulder type:when flex to same side, axillary
type:opposite side)
-scoliosis is a reflex mechanism by which the spine flexes away from
sciatic nerve entrapment side by paraspinous muscle contraction
standing with affected hip&knee slighted flexion
- +ve SLRT, crossover pain (well-leg raising sign )= lift well-leg, pain crosses
over into symptomaic hip, early sign of HNP
, crossed SLRT : lift symptomatic leg & pain in asymptomatic leg, indicative
of disc herniation lying median to nerve root; axillary/ midline
- muscle wasting is rarely seen unless symptom> 3mo., very marked wasting
suggests extradural tumor than HNP
Investigation
Minimal requirement for diagnosis of HNP:
plain x-rays and one other diagnostic study (
myelography, CT/myelography, CT, MRI
MRI: necessary to plan a surgical procedure
management
I surgery
Indication:
- failure of conservative treatment: at least 6
wks- not more than 3 mo.
- Bladder & bowel involvement
- Increasing neurological deficit
II conservative treatment
1. Unloading spine
Rest until pain start to abate (approximately48 hrs)
Corset/brace
Indications:
- patient who is recovering after bed rest and return to work quickly
- An older patient
- Postoperative support
Modification of work and activities
2. Antiinflammatory drugs
3. Analgesics
4. Traction ( intermittent 25%BW 20-30 min)
5. Heat/cold
6. Exercise ( modified Willium exercise - back pain, Mc Kenzie exercise -
leg pain)
Spondylolytic spondylolithesis
spondylolysis: anatomic defect , causes discontinuity
in pars interarticularis
- May be unilateral or bilateral
- Often found in radiological studies, with no
clinical significance
Spondylolithesis: forward/ backward translation
subluxation of body of superior vertebrae upon its
adjacent inferior vertebrae
- usually forward slipping of L5 vertebra on sacrum
-Wiltse et al. classified spondylolithesis
Dysplastic: congenital abnormal of upper
sacrum/arch of L5,
Isthmic: lesion of pars interarticularis
Degenerative: progressive intersegmental
instability, female>male, age >=40 yrs
Traumatic: fracture/ dislocation of facet joint,
allowing forward displacement
Pathological: loss of stability secondary to
pathological destruction
Symptoms
- major symptom- LBP (intermittent dull aching
pain)
- Often radiate into sacroiliac region, also into
thighs
PE
- limited ROM back
- Palpable ledge at upper aspect of listhesis
- Limited hamstring extensibility
Lumbar SCS
: narrowing of spinal canal, nerve root canals/tunnels
of intervertebral foramina
- A-P diameter < 10 mm-12 mm was considered
pathological
- Normal LS canal is narrowest in A-P diameter at
3
rd
and 4
th
vertebrae
- Central canal is usually narrowing from yellow
ligament
- Lateral canal is usually narrowing from
osteophyte/ facet
Symptom
- back pain, sciatica, claudication, thigh and
leg pain,
HNP SCS
Age 40-50 >50
Duration short long
Level usually 1 level several level
- pain relief by supine, squatting
Piriformis syndrome
: compression of extraspinal n., forming the sciatic n.
by piriformis muscle
Postulated etiologies of piriformis synd.
Sacroiliac disease that causes piriformis muscle
contraction
Inflammatory disease of muscle, tendon/ fascia
of piriformis
Degenerative deformities of bony component of
notch
Abnormal of neurovascular bundle as they cause
through tunnel
Direct trauma to gluteal region of sacroiliac joint
Symtom and sign
- pain/paresthesia may be present along the entire
distribution/ segment of sciatic nerve
- Motor deficit may co-exist with subtle atrophy
- Predominant symptom, pain at sacral and gluteal
area, increase with sitting and walking, decrease
from supine position
- Test: FAIR position (hip flex, adduct, internal
rotate)
- -treat& Dx: injection of anestheic& steroid into
piriformis bursa/ muscle (direction: via vaginally
at insertion into tender muscle/ via gluteal muscle
at sacral notch (located tender spot by PR)
Treatment
- stretching piriformis
- Pelvic tilting exercise
- NSAIDs
- Steroid injection
Myofascial pain syndrome
0Iufeus medius
- ....+a+. (Iumbogo) u a. 0Iufeus Mox.
& 0Iufeus minimus
- poin of Iower Iumbor ond ischium
- refer- iIioc cresf & SI joinf
- ischium posferoIoferoI of fhigh
- socrum
Gluteus maximus
- pain at lower lumbar , aggravate by walking with forward bending ,
sitting and extend back from flexion position
- refer pain to sacrum, above ischeal tuberosity, coccyx, gluteal cleft
Gluteus minimus
- may be antalgic gait
- refer pain like sciatic n. lesion (pseudosciatica)