INTERVERTEBRAL DISC PROLAPSE

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The

vertebral column is the central bony pillar of the body. It supports the skull, pectoral girdle, upper limbs, and thoracic cage and, by way of the pelvic girdle, transmits body weight to the lower limbs. Within its cavity lie the spinal cord, the roots of the spinal nerves, and the covering meninges, to which the vertebral column gives great protection.
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The

vertebral column is composed of 33 vertebrae 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused to form the sacrum), and 4 coccygeal (the lower 3 are commonly fused). Because it is segmented and made up of vertebrae, joints, and pads of fibrocartilage called intervertebral discs, it is a flexible structure. The intervertebral discs form about one fourth the length of the column.
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They may be regarded as semi-elastic discs, which lie between the rigid bodies of adjacent vertebrae .They are thickest in the cervical and lumbar regions, where the movements of the vertebral column are greatest. Unfortunately, their resilience is gradually lost with advancing age.
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Each disc consists of a peripheral part, the anulus fibrosus, and a central part, the nucleus pulposus. The anulus fibrosus is composed of fibrocartilage, in which the collagen fibers are arranged in concentric layers or sheets. The nucleus pulposus in children and adolescents is an ovoid mass of gelatinous material containing a large amount of water, a small number of collagen fibers, and a few cartilage cells. It is normally under pressure and situated slightly nearer to the posterior than to the anterior margin of the disc.
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The

upper and lower surfaces of the bodies of adjacent vertebrae that abut onto the disc are covered with thin plates of hyaline cartilage. No discs are found between the first two cervical vertebrae or in the sacrum or coccyx. Functions:- Their physical characteristics permit them to serve as shock absorbers when the load on the vertebral column is suddenly increased, as when one is jumping from a height. Their elasticity allows the rigid vertebrae to move one on the other.
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A sudden increase in the compression load on the vertebral column causes the semifluid nucleus pulposus to become flattened. Sometimes, the outward thrust is too great for the anulus fibrosus and it ruptures, allowing the nucleus pulposus to herniate and protrude into the vertebral canal, where it may press on the spinal nerve roots, the spinal nerve, or even the spinal cord and cause back ache,sciatica.

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There

is narrowing of joint space. The weakest part of annulus is posterolateral part and as a result the nerve root is often compressed in lateral part of spinal canal.Central protrusion can result in compression of cauda equina.

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1.Traumatic-80%

cases traumatic origin 2.Increased tension 3.Degeneration-15% .Disc loses elasticity and fluid content.cant resist body wt and liable to herniate.

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1.Lumbosacral

region-L4/5 and L5/S1.80% occures at this region. 2.Lower cervical region-C5/6 and C6/7.19% Occures at this region. 3.Dorsal region-constitute 1%of all disc prolapse

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A.CERVICAL DISC PROTRUSION Is relatively uncommon. Midline protrusion:-rare,anterior part of the cord is slightly compressed with compression of the ant.spinal artery and veins.artery compression lead to disturbence of spinothalamic and pyramidal tract and some damage of ant horn cells.vein-stasis and cong of ant horn cells below leison.->s/o disseminated sclerosis/primary lateral sclerosis appear.spastic paralysis,secondary atrophic changes(ant horn cell involvement)
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Lateral protrusion:-common will cause pain and stiffness of neck.pain often radiate to scapular region and to occiput.Do not involve multiple nerve root,but involve the root emerges above the corresponding vertebra. When C6 nerve root is involved pain will be complined of at shoulder tip,outer border of upper arm and dorsum of forearm.there is sensory weakness of lateral border of upper arm,forearm.weakness of jerks C7-pain at shoulder tip,back of upper arm and forearm,sensory loss,weakness of jerk.

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B.LUMBAR DISC PROLAPSE 1.Pain-lowback ache followed by referred sciatic pain.in almost all cases there is initial back ache later followed by sciatica.in some cases both occures simultaneously. Onset of pain may be a/c following trauma. Or sub a/c following hrs/days/weeks after trauma Or c/c-habitual back strain and pt complaines of increasing pain Pain is usually dull ache/stabing/shooting pain
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Site

of pain is usually lower lumbar region usually in midline.pain radiate to one or both sacroiliac jt,to buttock, or distally to lowerlimb.Pain accentuated by coughing. Other symptoms-paraesthesia,pins and needle sensation etc Small protrusion cause severe pain,as there is max friction of nerve root without much loss of conduction.large-less pain,conduction diminished,neurological symptoms more marked
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Commonly

seen in middle age. Usually last for 2-6 wks or continue longer. Serious neurological symptoms may be an indication for surgery. Motor weakness more likely to recover than sensory

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aetiology:-compressive leisons below the level of L1 may affect cauda equina or conus medullaris or both-IVDP,neoplasms,spinal arachnoditis,lumbar canal stenosis. Symptoms of root involvment-motor weakness in the form of LMN paralysis affecting glutei ms and ms of lower limb. Sensory root pain in the distribution of sciatic nerve often bilateral.

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Sensory

loss in the region of perineum,gluteal region and back of thighs.(saddle back anesthesia). Vesical and rectal incontinence. Impotency in males Anal and bulbo cavernous reflex are lost Compression of conus medullaris result in early loss of sphincteric fn and UMN signs of lower limb.

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O/E-SPINE Attitude-lumbar

scoliosis with convexity to affected side,kyphosis with slight flexion hip and knee o/p-local deep tenderness is elicited on /slightly lateral to the affected spine Mvmts-flexion,extension-restricted Lateral flexion painful,rotation free and painless
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Knee TEST

jerk diminished in lesion b/w L3-4

-Straight

leg rising test-pain <40 degree indicate IVDP PSLR-imp to differentiate sciatica from ds of sacroiliac joint. Femoral nerve stretch test-IVDP at L2-3 Naffzigiers test-lhermittes sign-cervical disc prolapse.

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Elderly Gradual

in onset Back pain on standing and walking with neurological finding. Walking distance is limited.Legs go rubbery and tend to give away >rest for 5-10 mts,going uphill

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.X RAY-AP &LATERAL VIEW Pathological narrowing of disc space in 1/3rd cases 2.Myelography 3.epidurography 3discography MRI

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1.REST-Strict

recumbency for 3 wks

essential. Corset-less severe cases Avoid stooping and lifting heavy wt 2.TRACTION-enforce rest.min of 1 hr daily for 3wks

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Epidural

injection of .5% procain to reduce IVDP Laminectomy followed by discectomy followed by arthrodesis

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1.Lumbar

spondylosis 2.Spondylolisthesis 3.Ankylosing spondylitis

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LOW BACK ACHE

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MECANICALprolapsed disc,spondylosis,spon dylolysis/spondylolist hesis,spnal stenosis,congenital abnormalities,nonspec ific

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INFLAMATOR Yinfection,sacro iliitis,AS,arach noiditis

METABOLICosteoporosis, osteomalacia ,hyperparath yroidism,pag ets ds

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NEOPLASTICmetastasis,myelo ma,reticulosis,oste oid osteoma,intrathec al tumors

REFERRED PAINPeptic ulcer,pancreas,b owel,kidney ds,aortic aneurism,endom etriosis,ovary,ret roperitoneal fibrosis,herpis zoster,hip ds,polymyalgia rheumatica
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OTHERSscheuermanns osteochondritis,fibro myalgia,diffuse idiopathic skeletal hyperostosis(DISH)

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Weakness

in small of back. - Pain and burning in back. [Oxal. ac.] - Trembling, twitching, spasms, weakness, heaviness, uneasiness - Sciatica. - Burning pains. - Paralysis of lower limbs with atrophy.

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Severe dull backache in lumbo-sacral articulation; more or less constant; affecting sacrum and hips. - Sensation of heaviness and lameness in back. - Paralytic feeling in arms, legs and spine. Back gives out-during pregnancy,leucorrhoea,prolapse<walking(sep),sto oping;must sit or lie down For persons with haemorrhoidal tendencies, and who suffer with gastric, bilious or catarrhal troubles.
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- Spine sensitive to touch (Ther.); worse mornings. - Pain : sore, aching, in lumbar and sacral regions; during exertion in the day time; while sitting (Zinc,Rhust,Sep,Cobalt,Cann.i,Berb,Valer). - Spinal irritation due to sexual excesses (Kali P) Every motion, every turn of body, causes pain in spine. Single vertebra sensitive to touch. Uncertainty in walking, stumbles over everything in the way; feels pain as if beaten, www.similima.com

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Severe

backache; must walk bent, with oppression of chest.

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For the bad effects resulting from mechanical injuries; even if received years ago. - Sore, lame, bruised feeling all through the body, as if beaten; traumatic affections of muscles. - After injuries with blunt instruments (Symph.). Everything on which he lies seems too hard; complains constantly of it and keeps moving from place to place in search of a soft spot (the parts rested upon feel sore and bruised, Bap., Pyr.; must move continually to obtain relief from the pain, Rhus.). Cannot walk erect on account of a bruised sort of feeling in pelvic region. Ascending rheumatism(led_descending cact,kalm) www.similima.com

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Wandering, radiating pains. All Berberis pains radiate, are not worse by pressure, but worse in various attitudes, especially standing and active exercise. Stitches in neck and back; worse, respiration. - Numb, bruised sensation. - Tearing, sticking with stiffness, making rising difficult, involving hips, nates, limbs, with numbness. - Lumbago. [Rhus; Tart. em.] - Post-operative pain in lumbar region
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Painful

stiffness in nape of neck. - Stitches and stiffness in small of back. - From hard water and sudden changes of weather Pain stitching,tearing <night,motion,warmth >rest,lying on painful side(puls,ptel),cold

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stiff

neck. - Swelling of glands of neck. - Pain in nape, as if it would break. - Pressure on dorsal region most painful. - Lumbago, with pain in hips and thighs. <least jar,motion,touch >rest

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Pain

as if sprained; can scarcely rise; from overlifting. - Rheumatism in lumbar region; weakness in small of back. - Rheumatism of muscles of back and shoulder after failiure of rhustox <cold air,wet weather,cold water,morning >Lying on painful side
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Chronic

lumbago; aggravated on beginning to move, and ameliorated on continued motion. - Pain lower part of back, with burning. When rhustox fails

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Rheumatic

pain from draught of air, with stiffness and dullness of head. - Soreness in sacro-iliac symphysis, as if broken. [Aesc] Stffness<menstrual period,morning

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- Sciatica. Flying pains, returning regularly for a long time. - Pain in lower limbs, with cramps and formication - pain<morning on waking - Lightning-like pains, with cramps. - Gait unsteady, tottering; worse in dark. - weakness in back in lumbar region Chronic rheumatism, sensitive and cold.

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- Left-sided sciatica, with numbness - Rheumatic tearing in limbs; better by warmth, especially heat of bed. - Unsteady walking and easily falling. - Cracking and tension in knees; stiffness in hollow of knee. stiffness on rising from seat

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Insupportable pain in loins and hips. - Lumbago. - Violent rheumatic pains drive him out of bed at night; compelled to walk about. - Burning of soles at night. [Sulph.] - Nightly paralytic loss of power in the feet, unable to step on them.

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Spine very sensitive, especially upper part. - Stiffness and contraction in neck and back. - Rheumatic pains in muscles of back and neck. - Pain in lumbar and sacral region, down thighs, and through hips. - Crick in back. - Uneasy, restless feeling in limbs. - Aching in limbs and muscular soreness. - Rheumatism affecting the belly of muscles, especially large muscles.
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Pain in back and sacrum; worse while sitting; better, walking or lying. - Weakness in legs and backache after emission - Weak knees. - Trembling in limbs. - Tingling in feet. - Foot-sweat, mostly between toes.

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- Paralytic pain in small of the back. - Lameness; worse by bending. - Trembling and pain in limbs - Numb and unsteady. - Knees crack on motion. - Lower limbs very weak. - Inflammatory swelling of knee. - Intensely painful, paralytic drawing. - Limbs straightened out, painful when flexed.
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<cold

in general-cold air,cold wet weather >moving about - Pain in small of back, as after long stooping. - Stiffness and lameness across neck and shoulders, after getting cold and wet. - Pain in shin-bones.
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Dull, heavy

pain. - Complete relaxation of the whole muscular system. - Every little exertion causes fatigue. - Dull aching in lumbar and sacral region, passing upward. - Pain in muscles of back, hips, and lower extremities, mostly deep-seated.

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Chronic

backache in lumbar region; better resting on back. - Lumbago with numbness in lower part of back and weight in pelvis. - Intense pain along the sciatic nerve; numbness alternates with pain. - Better, drawing limbs up, flexing thigh on abdomen - Chronic muscular rheumatism of back and neck.
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Backache,sweating,weakness

- Stiffness and paralytic feeling in back. - Burning in spine. [Guaco.] - Severe backache during pregnancy, and after miscarriage. - Back ache so badly while she is walking that she feels as if she could lie down on the street - Lumbago with sudden sharp pains extending up and down back and to thighs. www.similima.com

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Neuralgia

of coccyx, worse rising from sitting posture; must sit perfectly still. - Sensation of threads stretched from back to arms, legs, eyes, etc. - Sciatica, right side, better lying down. - Pain in tibia (may follow sore throat).

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- Pain in small of backs - Numbness, also drawing and tearing in limbs, especially while at rest or at night. - Sciatica, worse right side. Cannot lie on painful side Sciatica that comes on periodically>warmth,motion

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Pain

in back, with desire for some firm support. [Rhus; Sep.] - Numbness and tingling in fingers and lower extremities. - Painful contraction of hamstrings. [Caust.] Greatsensitiveness to pressure Coughing <pain
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Backache in lumbar region. - Burning in spine; worse, 3 to 4 a.m. - Cervico-brachial neuralgia; worse, touch. - Must situp in order to turn in bed. - Bruised pain below scapulae. - Sitting is painful.

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Burning

in back; pain as if broken. -feeling of intense heat running up the back - Weak spine. Hot spine >heat

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Aching

pains in lumbar region; pains streaking up and down spine into sacrum. - stand midway b/w bry and rhustox Backache-sore lame bruised feeling with constant desire to move but motion< - Back stiff, especially in morning on rising and during damp weather,night - Pains fly like electric shocks, shooting, lancinating, shifting rapidly. [Puls.; Kali bich.] - sciatica-pain run down the outer side of limb.
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Shooting

pain in the nape and back, between shoulders; in sacrum after sitting - Drawing, tensive pain in thighs and legs, with restlessness, sleeplessness and chilliness. Pain in limbs, shifting rapidly; tensive pain, letting up with a snap.

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Aching

in back of neck. - Pain and lameness in cervical vertebrae, worse dropping head forward, better standing, or sitting erect. - lumbar and sacral backache, pain appears to be in bone, continued motion relieves. - Backache between shoulders and lumbarsacral region, better after walking.

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- Pain and stiffness in small of back; better, motion, or lying on something hard; worse, while sitting. - Rheumatic pains spread over a large surface at nape of neck, loins, and extremities; better motion. [Agaric.] - Tearing down thighs. - Sciatica; worse, cold, damp weather, at night. - Numbness and formication, after overwork and exposure.
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Pain in nape, back - Backache better

back. - Lumbago worse morning before rising. - Spine and limbs feel bruised. - Small of back and loins pain. - Legs give out on rising from a chair, hips and thighs so weak. [Phos.;Con.] - Sciatica; worse, lying down at night; pain from back down hips and thighs. - Hamstrings feel shortened. [Graph.]
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and loins. pressure and lying on

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Weakness

in small of back. Pains extend

into back. - Lower extremities lame and stiff, tension as if too short. - Heaviness and bruised feeling. - Restlessness in all limbs, twitching and jerkings night and day. - Coldness of legs and feet.
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Muscles, especially of calves, feel bruised. - Backache; worse in morning before rising. - Extremities feel beaten and painful. - Joints stiff. - Crural neuralgia. - Dull aching of nates extending to hip-joint and small of back.

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Drawing

pain between shoulders. - Stiffness of nape. - Sensation as if vertebrae glided over each other. - Burning in soles and hands at night. - Sweat in armpits, smelling like garlic. - Stiffness of knees and ankles. - Cannot walk erect; stoop-shouldered.

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Pain

in sacrum. - - Pain from last cervical to fifth dorsal vertebra, very sensitive; worse touch. [Chin.s. ; Phosph.] - worse right side, coughing, straining, and at night, with sensitive vertebral column. - Contraction of tendons in bends of knees.

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Pain

in small of back. - Cannot bear back touched. [Sul.; Therid.; Cinch.] Tension and stinging between shoulders. - Spinal irritation. - Dull aching about the last dorsal or first lumbar vertebrae; worse sitting. - Burning along spine. Nape of neck weary from writing or any exertion.

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THANK YOU
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