INTERVERTEBRAL DISC PROLAPSE(IVDP)

• A form of degenerative disc disease in which pressure on a vertebra causes the nucleus pulposus to press against the annulus fibrosus which results in spinal nerve compression and pain
• The intervertebral disc consists of three distinct components — the cartilage end-plates, nucleus pulposus and annulus fibrosus
• The term 'prolapsed disc' means the protrusion or extrusion of the nucleus pulposus through a defect in the annulus fibrosus
• The site of exit of the nucleus is usually postero-lateral on one or the other side. Occasionally, it can be central
• The commonest level of disc prolapse is between L4 -L5 in the lumbar spine and C5 -C6 in the cervical spine

Stages of disc prolapse

Nucleus degeneration- Degenerative changes occur in the disc before displacement of the nuclear material

Nucleus displacement

• Stage of disc protrusion: When the annulus becomes weak, the nucleus tends to bulge through the defect
• Stage of disc extrusion: When the nucleus comes out of the annulus and lies under the posterior longitudinal ligament; though it has not lost contact with the parent disc
• Stage of sequestration: The extruded disc may loose its contact with the parent disc

Stage of fibrosis- The residual nucleus pulposus becomes fibrosed. The extruded nucleus pulposus becomes flattened, fibrosed and finally undergoes calcification

• Repetitive mechanical activities- frequent bending, twisting, lifting, and other similar activities without break
• Living a sedentary lifestyle- individuals are more prone to herniated discs because muscles that support back and neck weakens
• Traumatic injury to lumbar discs- commonly occurs when lifting bent at the waist, rather than lifting with the legs while the back is straight
• Practicing poor posture- improper spinal alignment while sitting, standing, or lying downs strains the back and neck

Low backache: The onset of backache may be acute or chronic.

• An acute backache is severe with the spine held rigid by muscle spasm, and any movement at the spine painful. In extreme cases, patient is completely incapacitated, any attempted movement producing severe pain and spasm
• In chronic backache, the pain is dull and diffuse, usually made worse by exertion, forward bending, sitting or standing in one position for a long time. It is relieved by rest

Sciatic pain: This is usually associated with low back pain, but may be the sole presenting symptom. The pain radiates to the gluteal region, the back of the thigh and leg. The pattern of radiation depends upon the root compressed

• In S1 root compression, the pain radiates to the postero-lateral calf and heel
• In L5 root compression the pain radiates to the anterolateral aspect of the leg and ankle
• In a disc prolapse at a higher level (L2 -L3 etc.), the pain may radiate to the front of the thigh

Neurological symptoms:

• Sometimes, the patient complains of paraesthesias, most often described as ‘pins and needles’ corresponding to the dermatome of the affected nerve root
• There may be numbness in the leg or foot and weakness of the muscles
• If large disc material compress the theca and roots, a cauda equina syndrome results, where the patient has irregular LMN type paralysis in the lower limbs, bilateral absent ankle jerks, with hypoesthesia in the region of L5 to S4 dermatomes and urinary and bowel incontinence

Examination

• Posture: The patient stands with a rigid, flattened lumbar spine
• Movements: The patient is unable to bend forwards; because of severe muscle spasm in the paraspinal muscles.
• Tenderness: There is diffuse tenderness in the lumbo-sacral region. A localized tenderness in the midline or lateral to the spinous process is also seen in some cases

Tests

• Straight leg raising test (SLRT) - This test indicates nerve root compression. A positive SLRT at 40° or less is suggestive of root compression. More important is a positive contralateral SLRT
• Lasegue test- Hip is lifted to 90° with the knee bent. The knee is then gradually extended by the examiner. If nerve stretch is present, it is not possible to do so and the patient will experience pain in the back of the thigh or leg.

Neurological examination

L5-S1

• Nerve root affected- S1 root
• Motor weakness- weakness of plantar flexors of the root
• Sensory loss- over lateral side of the foot
• Reflexes- ankle jerk sluggish/ absent

L4-L5

• Nerve root affected- L5 root
• Motor weakness- Weakness of EHL & dorsi flexors of the foot
• Sensory loss- Over the dorsum of the foot and lateral side of the leg
• Reflexes- Ankle jerk normal

L3-L4

• Nerve root affected- L4 root
• Motor weakness- Weakness of extensors of knee
• Sensory loss- Over the great toe and medial side of the leg
• Reflexes- Knee jerk sluggish/ absent

Investigations

• Plain X-ray- chronic case -affected disc space may be narrowed and there may be lipping of the vertebral margins
• Myelograph
• CT scan
• MRI scan – confirm diagnosis
• Electromyography (EMG)

Conservative treatment

• Rest on a hard bed is necessary for not more than 2–4 days
• Drugs: Analgesics and muscle relaxants
• Physiotherapy: Hot fomentation, gentle arching exercises, etc.
• Others: Lumbar traction, transcutaneous electrical nerve stimulation (TENS) etc.

Operative treatment

• Fenestration
• Laminotomy
• Hemi-laminectomy
• Laminectomy

Ayurvedic Treatment

Internal medicines

• Amrutothara Kashaya
• Gandharvahasthadi Kashaya
• Sahacharadi Kashaya
• Ashtavarga Kashaya
• Dhanwantara Kashaya
• Rasnasapthaka Kashaya
• Dashamoolakatutraya Kashaya
• Maharasnadi Kashaya
• Hingutriguna taila
• Sahacharadi Avarthi
• Ksheera bala taila
• Yogaraja guggulu
• Dashamoolahareetaki Lehya

Later

• Lasuna Ksheera Paka with Sahacharadi avarthi
• Medicated Aja mamsa rasa

Procedure

Initially

• Murivenna bandage
• Lepa - Nagaradi
• Choorna Pinda Sweda-Jadamayadi Choorna, Kottamchukkadi Choorna
• Rusksha Vasthi – Amrutothara Kashaya + Vaiswanara choorna
• Virechana – Gandharva Eranda or Nirgundi Swarasa + Eranda thaila
• Vaitharana Vasthi

Later

• Patra Potala Sweda
• Jambeera Pinda Sweda
• Kati vasthi- Murivenna,Dhanwantharam taila
• Shashtika Pinda Sweda
• Yoga vasthi
• Anuvasana Vasthi – Sahacharadi taila/ Dhanwantara taila
• Niruhavasthi- Erandamooladi kashaya Vasthi
• Musthadi rajayapana Vasthi