Intervertebral Disc Prolapse (Ivdp) : Roshan Thomas Abraham (MPT Neuro)

INTERVERTEBRAL
DISC
PROLAPSE(IVDP
)
ROSHANTHOMAS ABRAHAM

Is a hydrostatic, load bearing
structure between the
vertebral bodies from C2-3 to
L5-S1 .
 Nucleus pulposus + annulus
fibrosus
 Is relatively avascular.
 L4-5, largest avascular
structure in the body.
U
.
.
Vital Functions of the IVD
 Restricted intervertebral joint motion

 Contribution to stability
 Resistance to axial, rotational, and bending load
 Preservation of anatomic relationship
Is a medical condition affecting the spine in
which a tear in the outer, fibrous ring (annulus
fibrosus) of an intervertebral disc allows the
soft, central portion (nucleus pulposus) to bulge
out beyond the damaged outer rings.
TYPES OF HERNIATION
 posterolateral disc herniation –
 protrusion is usually posterolateral into vertebral canal, compress the
roots of a spinal nerve.
 protruded disc usually compresses next lower nerve as that nerve
crosses level of disc in its path to its foramen. (eg.protrusion of fifth
lumbar disc usually affects S1 instead.
 central (posterior) herniation:
 less frequently, a protruded disc above second lumbar vertebra may
compress spinal cord itself or or may result in cauda equina
syndrome.
 lateral disc herniation:
 may compress the nerve root above the level of the herniation
 L4 nerve root is most often involved & patient typically have
CLASSIFICATIONS OF HERNIATIONS
 Degeneration
 Loss of fluid in nucleus pulposus
 Protrusion
 Bulge in the disc but not a complete rupture
 Prolapse
 Nucleus forced into outermost layer of annulus fibrosus- not
a complete rupture
 Extrusion
 A small hole in annulus fibrosus and fluid moves into
epidural space
 Sequestration
 Disc fragments start to form outside of the disc area.
Schematic illustration
a) Normal
b) Bulging disk
c)Focal bulge or protrusion. The
nucleus material remains within
the outermost fibres of the
annulus fibrosus.
d) Prolapse or extrusion.
The nucleus material has penetrated
the annulus fibrosus but is contained
in front of the posterior
longitudinal ligament.
e) Sequester or free fragment.
CAUSE
S
 Repetitive mechanical activities – Frequent bending, twisting,
lifting, and other similar activities without breaks and proper
stretching can leave the discs damaged.
 Living a sedentary lifestyle – Individuals who rarely if ever engage
in physical activity are more prone to herniated discs because the
muscles that support the back and neck weaken, which increases
strain on the spine.
 Traumatic injury to lumbar discs-
commonly occurs when lifting while bent at the waist, rather
than lifting with the legs while the back is straight.
CAUSE
S
 Obesity – Spinal degeneration can be quickened as a result of the
burden of supporting excess body fat.
 Practicing poor posture – Improper spinal alignment while sitting,
standing, or lying down strains the back and neck.
 Tobacco abuse – The chemicals commonly found in cigarettes can
interfere with the disc’s ability to absorb nutrients, which results
in the weakening of the disc.
NORMAL DISC HERNIATED DISC
 symptoms of a herniated disc can
vary depending on the location

of the herniation and the
types of soft tissue that
become involved.
Herniated discs are not
diagnosed immediately, as the
patients come with undefined
pains in the thighs, knees, or
feet.
Location
 The majority of spinal disc herniation cases occur in lumbar
region (95% in L4-L5 or L5-S1).
 The second most common site is the cervical region (C5-C6, C6-
C7).
 The thoracic region accounts for only 0.15% to 4.0% of cases.
DIAGNOSI
S
 Diagnosis is based on the history, symptoms, and physical

examination.
X-Ray : lumbo-sacral spine;
 Narrowed disc spaces.
 Loss of lumber lordosis.
 Compensatory scoliosis.
CT scan lumber spine;

 It can show the shape and size of the spinal canal, its contents, and
the structures around it, including soft tissues.
 Bulging out disc.
MRI lumber spine;

 Intervertebral disc protrusion.
 Compression of nerve root.
NARROWED SPACE
BETWEEN L5 AND S1
VERTEBRAE,
INDICATING PROBABLE
PROLAPSED
INTERVERTEBRAL DISC -
A CLASSIC PICTURE
Complications
Cauda
equina
syndrome
Chronic pain
Permanant
nerve injury
Paralysis
TREATMENT OPTIONS
Pain medications.
Bed rest
Oral steroids .
Nerve root
block . Surgery
Indicated treatment.
Non-steroidal anti-inflammatory
drugs (NSAIDs).
Eg- Aspirin, Ibuprofen
Oral steroids
(e.g. prednisone or
methylprednisolone).
Benzodiazepines( lowerdose)
Epidural cortisone injection.
TREATMENT
Physical therapy include modalities to

temporarily relieve pain (i.e. traction, electrical
stimulation massage).
Patient education on proper body mechanics.
Weight control.
Tobacco cessation.
Lumbosacral back support.
surgery
Surgery is generally considered only as a last resort,
or if a patient has a significant neurological deficit.
The presence of cauda equina syndrome is
considered a medical emergency requiring
immediate attention and possibly surgical
decompression.
The indications for surgery
• persistent pain and signs of sciatic tension after 2–

1 3
weeks of conservative treatment.
• a cauda equina compression syndrome – this is
an emergency;
2
• neurological deterioration while under
3 conservative
treatment;
INTRADISCAL ELECTROTHERMIC THERAPY (IDET)
It is a fairly advanced procedure in

which electrothermal catheter is
inserted to the intervertebral disc heat s
the posterior annulus of the
causing contraction
disk, of collagen fibers
IDET is a minimally invasive outpatient
surgical procedure developed over the
last few years to treat patients with
chronic low back pain that is caused by
tears or small herniations of their
lumbar discs.
NUCLEOPLASTY
Nucleoplasty is the most

advanced form of
percutaneous discectomy
developed to date.
Tissue removal from the
nucleus acts to
“decompress” the disc and
relieve the pressure exerted
by the disc on the nearby
nerve root
DISCECTOMY/MICRODISCECTOMY -
This procedure is
used to remove part
of an intervertebral
disc that is
compressing the
spinal cord or a nerve
root.
CHEMONUCLEOLYSIS-
 Chemonucleolysis is the term

used to denote chemical
destruction of nucleus pulposus
[Chemo+nucleo+lysis].
 This involves intradiscal
injection of
chymopapain which causes
hydrolysis of he cementing
protein of the nucleus
pulposus.
This causes decrease in water
binding capacity leading to
reduction in size and drying the
LAMINECTOMY-
Removes the
lamina part to
relieve spinal
stenosis or nerve
compression
LUMBAR FUSION
Fusion surgery helps two or
more bones grow together
into one solid bone. Fusion
cages are new devices,
essentially hollow screws
filled with bone graft, that
help the bones of the spine
heal together firmly.
lumbar fusion is only
indicated for recurrent
lumbar disc herniations, not
primary herniations
DISC ARTHROPLASTY
 Artificial Disc Replacement (ADR),

or Total Disc Replacement (TDR),
is a type of arthroplasty.
 It is a surgical procedure in which
degenerated intervertebral
discs in the spinal column are
replaced with artificial devices in
the lumbar (lower) or cervical
(upper) spine.
 Used for cases of cervical disc
herniation
NURSING MANAGEMENT
Assessment
determining the onset,
location, and radiation of pain,
paresthesias, limited
movement,
diminished function of the neck, shoulders, and
upper extremities
PROVIDING PREOPERATIVE CARE
explanations about the surgery and reassurance that surgery

will not weaken the back.
Preoperative assessment also includes an evaluation of
movement of the extremities as well as bladder and bowel
function
To facilitate the postoperative turning procedure, the patient
is taught to turn as a unit (called logrolling)
Encouraged to take deep breaths, cough
ASSESSING THE PATIENT AFTER SURGERY
Vital signs are checked frequently and the wound is

inspected for hemorrhage
IV morphine -24-48
Sensation and motor strength of the lower extremities
are evaluated at specified intervals, along with the
color and temperature of the legs and sensation
of the toes.
Assess for CSF leakage
Assess for paralytic ileus
Assess for urinary retention
NURSING DIAGNOSIS
Acute pain related to the surgical

procedure
Nursing Interventions
 The patient may be kept flat in bed for 12 to 24 hours in
cervical surgery
 Pillow is placed under the head and the knee rest is elevated slightly
to relax the back muscles( cervical surgery)
Extreme knee flexion must be avoided
 Administering the prescribed postoperative analgesic agent,
positioning for comfort, and reassuring the patient that the pain can
be relieved.
Impaired physical mobility related to the postoperative
surgical regimen
Nursing interventions
 provide cervical collar cervical collar
 provide L-S binders
The neck should be kept in a neutral(midline) position
Patients are assisted during position changes(log rolling )
Deficient knowledge about the postoperative course and home
care management
INTERVENTIONS
 A cervical collar is usually worn for about 6 weeks.
 Instructed about strategies for pain management and about signs
and symptoms of complications
 The nurse assesses the patient’s understanding of these management
strategies
 advised to avoid heavy work for 2 to 3 months after surgery.
 Exercises are prescribed to strengthen the abdominal and erector
spinal muscles
Avoid sitting/standing for prolonged periods
Avoid twisting movements
Regular follow up

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INTERVERTEBRAL

 Restricted intervertebral joint motion

vary depending on the location

 Diagnosis is based on the history, symptoms, and physical

CT scan lumber spine;

MRI lumber spine;

Physical therapy include modalities to

• persistent pain and signs of sciatic tension after 2–

It is a fairly advanced procedure in

Nucleoplasty is the most

 Chemonucleolysis is the term

 Artificial Disc Replacement (ADR),

explanations about the surgery and reassurance that surgery

Vital signs are checked frequently and the wound is

Acute pain related to the surgical

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