1) There are 33 vertebrae in the spine, but due to fusion only 26 are functional. The vertebrae are divided into 7 cervical, 12 thoracic, and 5 lumbar vertebrae. 2) Degenerative disc disease is the most common cause of lower back pain. It involves the gradual drying out and loss of the intervertebral disc's ability to function as a shock absorber. This transfer of stress can lead to further degeneration of surrounding structures like facet joints. 3) Stages of disc degeneration include disc bulge, annular tears, and disc herniation which can be protruded, extruded, or sequestrated as it progresses. Identification of the specific

1. DR. NAVEEN RATHOR
RESIDENT DOCTOR
DEPARTMENT OF ORTHOPAEDICS
RNT MEDICAL COLLEGE

2. Cervical : C1-C7 =7
Sacrum: 5(fused)
Coccyx: 4(fused)
So there are total 33 vertebrae,
but due to fusion of sacral
and coccyx there are 26
functional vertebrae.
Thoracic: T1-T12 =12
Lumbar: L1- L5 =5
ANATOMY OF THE SPINE

3. Cervical Lordosis 20°- 40°
Sacral Kyphosis
Lumbar Lordosis 30°- 50°
Thoracic Kyphosis 20°- 40°
Sagittal Plane Curves
Adult Spinal Curvature Are Attained After The 10 Yr Converting Spine
From a “ C” Shaped To An Irregular “S”-shaped Structure.

4. Anatomy
Vertebra
– Body, anteriorly
 Functions to
Support weight
– Vertebral arch,
posteriorly
 Formed by two
pedicles and two
laminae
 Functions to
protect neural
structures

5. Vertebral Arch
Pedicles (Latin for Little Feet)
–Attached anteriorly to body
–Continuous posteriorly with laminae
–Intervertebral foramen
Superior vertebral notch
Inferior vertebral notch
Laminae (Latin for Thin Plates)
–Meet posteriorly to form spinous process.
–Both pedicle and laminae meet to forms vertebral
foramen which protect spinal cord.

6. Facet Joint
 Formed by articulation of
inferior and superior processes
of subsequent vertebrae.
 Orientation in lumbar spine is
toward sagittal plane, allowing
flexion and extension but
limiting rotation of the lumbar
vertebrae.
 Helps to prevent anterior
movement of superior vertebra
on inferior vertebra.
 Articular surfaces are made up
of non-innervated articular
cartilage.
 Capsule and synovial
membrane are innervated with
pain receptors.

7. Spinal Nerve Topography
31 pairs of spinal nerves
• 8 cervical
• 12 thoracic
• 5 lumbar
• 6 sacrococcygeal
• Each Spinal nerve root consist
sensory(supply particular
dermatome) and motor
division(supply muscles).
• All spinal nerves ,except
cervical, exit below their
corresponding vertebrae.

8. Disc and Nerve root relationship
every spinal nerve exits the canal by passing through the
vertebral foramen present on the side of adjacent
vertebrae.so in case of L4-L5 prolapse, there is L5 nerve root
compression.

9. 1)Protection of spinal cord &
internal organs.
2)Support & weight
transmission.
3)Axial disposition
4)Provides attachment to
muscles.
5)Movement
Functions of the Spine

10. Intervertebral disc
• Total 23(C6 T12 L5)-Present at levels C2-C3 to L5-S1.
• Hydrostatic, load bearing , shock absorbing structure between
the vertebral bodies.
• Fibrocartilagenous joint of the motion segment.
• Make up ¼ the length of the spinal column.
(The discs vary in size and shape with their position in the spine.
Discs also decrease in volume, resulting in a 16% to 21% loss in
disc height after 6 hours of standing or sitting.).
• Allows compressive, tensile, and rotational motion
• Largest avascular structures in the body
-Each disc unit has
– strong outer ring of fibers called the annulus fibrosus
– a soft , jelly like center called the nucleus pulposus
– 2 endplates

11. 1. INTERVERTEBRAL DISC

12. Intervertebral Disc
• Annulus Fibrosus
– Outer portion of the disc
Lamellae
 Great tensile, torsional &
radial strength
– Made up of lamellae fibrocartilage
Annulus
Fibrosus
– Layers of collagen fibers Type I
 Arranged obliquely 30°
 Some radial fibers
 Thicker anteriorly >posteriolry
 Attached to end plates

13. Intervertebral Disc
• Nucleus Pulposus Nucleus
Pulposus– Inner structure
– Notochord remnant
– Type II collagen
– Resists axial forces

14. Cartilage End Plate
• Approx 1 mm thick
• Considered part of disc rather than body
• Made up of hyaline cartilage mostly (young) and
fibrocartilage (old)
• The collagen fibers of the inner 2/3rds of the
annulus form the fibro cartilaginous component
of the VEP
• Provides nutritional support via passive diffusion.

15. MOLECULAR COMPOSITION OF DISC

16. FUCTION OF DISC
1)Seperation of veretebral bodies
2)strong and flexible structure for
movement between vertebrae
3)spinal colum height
4)shock absorber

17. • The FUNCTIONAL UNIT of
the spine movement.
• Comprises of:
– 1.Two adjacent vertebrae
– 2.Intervertebral disc
– 3. Two facet joints and capsules
– 4.Connecting ligaments:
– including the ligamentum flavum,
interspinous, supraspinous,
intertransverse ligament .
– IVD provides the most resistence
to compression, whereas the
facet allow for rotation, lateral
bending ,and extension.
Spine Motion Segment

18. Lower Back Pain
• Lower back pain is a symptom,not a disease.
• Low back pain is one of the most common reason for all
physician visits.
• Approximately 90% of adults experience back pain at some
time in life.
90% do not require active intervention.
Acute Low Backache-pain duration is less than
3 month.
usually self limiting.
-Chronic low backache-persistent or fluctuating
last longer then 3 months.

19. CausesMechanical
(affecting spine
only)
• Muscle strain
• Osteoarthritis
• Spinal stenosis
• Discogenic
• Spondylolisthe
sis
• Vertebral
fracture
• congenital
Non mechanical (systemic
diseases)
• Ankylosing spondylitis
• Neoplasms
• Infections( TB, Herpes,
osteomyelitis)
• Atherosclerosis
• Visceral pain
Biomechanical
causes
• Poor posture
• Sedentary lifestyle
Pyschological causes
• Depression
• stress
ENDLESS
PRACTICALLY

20. Causes of Back Pain
25-40% Back Pain
(Discogenic Back Pain)-m/c
cause

22. RED FLAG SIGN
-indication for evaluation-> 50 yr age
– History of Cancer
– Weight loss
– Unrelenting night
pain
– Steroid use
– Fever
– Significant
trauma
– Failure to
improve
conservative
therapy
– osteoporosis
 Cauda Equina
Syndrome
– Saddle anesthesia
– Bowel/bladder
dysfunction
– Loss of sphincter tone
– Rapid progression
– Unilat or bilat major
motor weakness

23. Yellow Flags
indication of poor outcome
• Affect-anxiety , depression , irritability
• Belief -that back pain is harmful or severely
disabling that it needs to be eliminated.
• behaviour-avoidance behavior and reduced
activity level
• Social -withdrawal and low mood
• Work-Expectation that pain increases with
activity.

24. CONCEPT OF PAIN GENERATOR
• Pain generator is pathoanatomic site or a
pathological structure from which the primary
cause of patients low back pain thought to be
originate.
• It is primary / sole cause of patient illness.
• So basic approach is identification of pain
generator and treat it.
• So now a days focus on identification of pain
generator first.

25. Pain generator in low backache
• Lumbar IVD –m/c
• Vertebral body-
fracture/osteoporosis/infection/neoplasm
• Nerve roots-lumber canal stenosis/radiculopathy
• Facet joint-degeneration/fracture
• Spinal muscle-myofascial pain/sprain
• Sacroilliac joint
• Spinal ligaments-ALL/PLL/interspinous ligaments

26. Discogenic back pain
• Pain syndrome that
originates from a lumber
disc.(pain generator)
• Broadly degenerative disc
disease (DDD)is a cause of
discogenic back pain.
• Most common cause of
lower backache.

27. DEGENERATIVE DISC DISEASE
• Degenerative disc disease (DDD) has been used
to describe a wide variety of clinical,morphologic
and radiographic changes in the DISC.
• Surgeons and radiologist describes it the
presence of osteophytes ,loss of disc height and
reduced signal intensity on MRI.
• Pathologist describes it by changes in
proteoglycans /water content,crack and fissures .

28. Factors Contributing To Disc Degeneration
1)Aging-most consistent physiological reason.
-Reduction of concentration of cells in the disk.
-Reduction of rate of synthesis of proteoglycans
-Type 2 collagen replaced by type1
2)MECHANICAL-degeneration is more common
and more severe at lower lumber levels.
3)Low grade infections-tuberculosis,gram positive
4) Metabolic disease - DM, Alkaptonuria
5) Toxic factors - low ph, smoking , alcohal
6)Genetic association-aggrecan gene polymorhism
7)Neurogrnic inflammation

29. Decrease in end plate
Permiability
Failure of nutrient supply
&
Accumulation of waste
Low p H
Injury
Pathophysiology-Disc Degeneration

30. Pathophysiology-Disc Degeneration
 Loss of Proteoglycan &
collagen and degradation
 Fall in osmotic pressure
of disc matrix
 No longer behaves
hydrostatically under load
 Loose height and fluid
more rapidly
 Stress concentration along
End plates and Annulus
www.ipscindia.com

31. Pathophysiology-Disc Degeneration
• Normal Disc – Pressure evenly distributed along
end plates and annulus
• Degenerated disc – Uneven stress across
End plates and annulus –Fissures and
Tear-disc prolapse-disc herniation
•Due to uneven stress on disc causes
secondary facet joint arthropathy

32. Degenerative Disc Disease
• Pathophysiology:
1. Disc gradually dries out, loses height and
volume.
2. NP changes from a turgid gelatinous
bulb to brownish dessicated structure.
3. AF develops fissures parrallel to the vertebral
end plates.
4. Compressive loads transfer away from nucleus
to margins
5. Sclerosis of endplate reduces disc nutrition.
6. Facet joints wear away cartilage, begin to
override
7. Motion segment becomes hypermobile
8. Osteophytes develop to attempt to stabilize
motion segment
9. Osteophytes may encroach on neural structures.

33. Aging of Disc Degeneration of Disc
• Affects Nucleous
• Increased proteoglycan
fragmentation and water
content is decreased
• Nucleus is gradually
replaced by collagen fibers.
• Disc height is maintained.
• Annulus & End plates
• Concentric or radial tear in the
annulus, Inwards buckling of
annulus & radial bulging of outer
annulus
• Endplate defects & vertical bulging
of endplates into the adjacent
vertebral bodies.
• Reduced disc height

34. DEGENERATIVE INTERVERTEBRAL
DISC DISEASE
(STAGES OF DISC DEGENERATION)
A. ) - DISC BULGE
B. ) - ANNULAR TEAR
C. ) - HERNIATION
PROTUSION
EXTRUSION
SEQUESTRATION
MIGRATION

35. A ) DISC BULGE
- Diffuse symmetrical outpouching of the annulus
fibrosus caused by early disc degeneration & collapse.
-Bulging can be symmetrical or asymmetrical.
-The term bulge refers to a morphologic
characteristic and is not correlated with etiology or
symptomatology.
-Bulging can be physiologic , can reflect advanced
degenerative disc disease or can be associated with
bone remodeling.
(Fardon and Milette 2001).-

37. B ). ANNULAR TEAR
Disruption of concentric collagenous fibers comprising
the anulus fibrosus
1)Concentric tears are circumferential lesions which are found in
the outer layers of the annular wall . They represent splitting between
adjacent lamellae of the annulus, like onion rings. Concentric tears
are believed to be of traumatic origin especially from torsion overload
injuries.
2)Radial tears are characterized by an annular tear which
permeates from the deep central part of the disc (nucleus pulposus)
and extends outward toward the annulus, in either a transverse or
cranial-caudal plane.
*Responsible for disc degeneration.
3)Transverse tears, also known as “peripheral tears” or “rim
lesions,” are horizontal ruptures of fibers, near the insertion in the
bony ring apophyses.

38. CONCENTRIC TEARS
TRANSVERSE TEARS /
PERIPHERAL TEARS
RIM LESIONS
RADIAL TEARS

39. C). DISC HERNIATION
Herniation is defined as a localized displacement of
disc material (nucleus, cartilage, fragmented
apophyseal bone, fragmented annular tissue) beyond
the limits of the intervertebral disc space.
(Fardon and Milette 2001).
 Intravertebral Herniations
 Protruded Disc
 Extruded Disc
 Sequestration
 Migration

40. -Herniated discs in the cranio-caudal (vertical)
direction through a break in one or both of the
vertebral body endplates are referred to as
“intravertebral herniations” (also known as Schmorl’s
nodes).
-They are often surrounded by reactive bone marrow
changes.
- Nutrient vascular canals may leave scars in the
endplates, which are weak spots representing a route
for the early formation of intrabody nuclear
herniations
INTRAVERTEBRAL HERNIATIONS

41. The terminology “protruded disc” is used when the base
of the disc is broader than any other diameter of the
displaced material.
Based on a two-dimensional assessment of the disc
contour in the transverse plane, a protruded disc can be
focal (involving <25% of the disc circumference) or
broad-based (involving 25%–50% of the disc circumference).
“ PROTRUDED DISC

42. The terminology “extruded disc” is used for a focal disc
extension of which the base against the parent disc is
narrower than the diameter of the extruded disc material,
measured in the same plane.
EXTRUDED DISC HERNIATIONS
Extrusion: the base of the herniation is
narrower than the apex (toothpaste sign)

43. Extrusion is also used when there is no continuity between the
herniated disc material beyond the disc space and that within the disc
space
If the displaced disc material has no connection with the parent disc, it
is called a “sequestrated fragment” (Fig. 6.19). This is synonymous with
a “free fragment”.

44. SEQUESTRATION & MIGRATION
If the displaced disc material has no connection with the parent disc, it
is called a “sequestrated fragment” (Fig. 6.19). This is synonymous with
a “free fragment”.
Sequestration -indicate that the displaced disc material has lost completely any
continuity with the parent disc
Migration -indicates displacement of disc material away from the site of extrusion.

46. STAGES OF DDD
Disc bulge:- diffuse symmetrical outpouching of the annulus fibrosus
caused by early disc degeneration& collapse
Protrusion:- base wider than any diameter of the material displaced
beyond disc space
Extrusion:- displaced portion has a greater diameter than its connection
with the parent disc at its base
Sequestration:- when disc extrusion has lost all connection with the
parent disc
Migration:- an extruded disc, whether sequestrated or not, that has been
displaced above or below the edge of the disc space

47. • Depending upon whether the
displaced portion is completely
enveloped by intact outer
annulus or combination of
annulus and PLL( s/t called
capsule):-
• Contained:-
• Un contained:-
– Subligamentous:- disc material
contained beneath the PLL
– Transligamentous
– Submembranous:- disc material
contained only by peridural
menbrane
CLASSIFICATION DD

48. • Depending upon the relationship of the herniated
material to the posterior annulus and PLL:
– Central( midline):- herniation along the posterior annulus
– Posterolateral:- along the weaker lateral expansion of PLL
m/c because it is weakest portion of annulus
– Foraminal( lateral )
– Extraforaminal ( far lateral)
• In relation to nerve root:
– Shoulder herniation
– Axillary herniation
• According to the level of LDH:-
– High LDH:- L1-L2, L2-L3, L3-L4
– Low LDH:- L4-L5, L5-S1
CLASSIFICATION

49. Shoulder v/s axillary disc
Shoulder disc
-Disc material compress the
nerve root laterally displacing
it medially.
-Patient will bend to opposite
side to relieve neural
irritation.
Axillary disc
-disc material compress the
nerve root medially displacing
it laterally.
-patient will bend to same
side to relieve neural
irritation.

51. APPROACH
• HISTORY
• PHYSICAL EXAMINATION
• NEUROLOGICAL EXAMINATION
• INVESTIGATION
• MANAGMENT

52. HISTORY
-PAIN- Commonest symptom
-Onset of pain-Acute, chronic, or insidious
-Consistency of the pain-Constant vs. Intermittent pain
-Site of pain -Axial /Radicular involving limbs
combination of both
-Bowel and Bladder signs

53. Nature and intensity of pain
 Discogenic- focal,aching in nature,increased with activity
causing axial loading(flexion),decreased with rest
 Facetal pain-pain on extension of spine
 (Can be of muscle strain)
 Degenerative-Pain and stiffness in morning
 Inflammatory-prolonged pain with stifness > 1hr
 Tumour/infection- Night Pain unrelieved by rest

54. Pain with…
• Prone positionn
– Facet, Lat HNP, systemic
• Sitting
– Paramedian HNP,
annular tear
• Standing
– Lateral HNP, central
stenosis, facet syndrome
• Walking
– central stenosis

55. Neurogenic
Claudication
Pain
Vague cramping,
aching,
Location
Back, buttocks, lower '
extremities
Radiation Proximal to distal
Exacerbation
With standing,
Particularly with
trunk extended; less
with walking; rare
with bicycling unless
trunk is extended
Time to relief Prolonged(20 min)
Walking uphill less pain
Back pain Common
Limitation of
spinal movt
Common
Vascular Claudication
Tightness, cramping
(usually in calf)
Calf
Distal to proximal
With walking and bicycling (activities involving lower
extremities)
Rapid(5 min)
Pain
Uncommon
Uncommon

56. NEUROLOGICAL EXAMINATION
SENSORY EXAMINATION
L1-Anterior proximal thigh near
inguinal ligament
L2-Mid anteromedial thigh
L3-Proximal and medial to patella
L4-Medial lower leg and ankle(
best tested just proximal to
medial malleolus)
L5-Lateral and anterolateral leg
and dorsum of foot(Proximal to
first web space)

57. S1-Posterior calf , planter foot
,lateral toes(posterolateral
aspect of heel)
S2-Posterior thigh and
proximal calf(centre of
popliteral fossa)
S3,S4,S5-Perianal area

58. MOTOR EXAMINATION
• Motor testing nerve Root Level
• L1 ,L2 Iliopsoas(Hip flexion)
• L3 Quadriceps(Knee extension)
• L4 tibialis anterior(Dorsiflexion ankle)-
heel walking
• L5 EHL,EDL (Great toe extension) -
• S1 Gastrosoleus(Plantarflexion & Eversion)
Toe walking

59. MOTOR EXAMINATION-L2

60. MOTOR EXAMINATION-L3

61. MOTOR EXAMINATION-L4

62. MOTOR EXAMINATION-L5

63. MOTOR EXAMINATION-S1

64. REFLEXES
• Two principal deep tendon reflexes are
normally tested-
• L4-Patellar tendon reflex
• S1-Achilis tendon reflex
• L5-Tibialis posterior reflex

65. Discogenic Pain-Special test
*Primary focus on the L5 and S1 never roots, since 98%
of clinically important disc herniations occur at L4-L5
and L5-S1.
A)SCIATIC NERVE STRETCH TEST:-(L4 L5 S1 S2 S3)
-straight leg raising test
-laseague test
-Well straight leg raise
-Kernig’s/Brudzinski test
-bowstring test
B)femoral nerve stretch test:-(L2 L3 L4)

66. SLR TESTING
• During SLR maneuver , the L5 and S1 nerve
root either moves or passively deforms
approx. 2 to 6 mm at the level of foramen.
• Maximum tension is realized in the sciatic
nerve at 30 to 70 degree of elevation from
the supine.
• Crossed SLR is more specific of a disc
herniation( pathognomonic of
micromotion in affected side nerve roots
while raising normal side leg)
• <40* suggest impingement of protruding disc
on a nerve root
• >40* indicates tension on nerve root

68. BOWSTRING TEST
• reliable sign of nerve root compression
- do SLR test At the point where the patient experiences
pain, relax the tension by flexing the knee slightly; the
pain should disappear.
•Then apply firm pressure behind the lateral hamstrings
to tighten the common peroneal nerve
- the pain recurs in +ve test

69. SUDDEN SCIATIC STRETCH TEST
SUDDEN SCIATIC STRETCH TEST
• Hold the great toe of the
suspected side and
suddenly lift the bent knee
to straight position.
• Patient will feel bursting
pain at the low back.
• Can ne used to differentiate
between a malingerer and a
genuine patient of sciatic
radicuitis.

71. • FEMORAL NERVE STRETCH TEST:
• positive if the L2 L3 L4 roots

73. RADIOLOGICAL DIAGNOSIS
• Radiographs
– Early if ominous
signs
• Fever
• night pain
• age extremes
• h/o Ca
• wt loss
• Trauma
osteoporosis
– Symptoms present >
1 month

74. RADIOLOLOGICAL DIAGNOSIS
No specific help in diagnosis , but they provide a
global overview of the lumber spine alignment.
AP VIEW
• Alignment of vertebral
column
• Lesion of pedicles/ TP
• Side to side collapse
• Paravertebral soft tissue
shadows
• scoliosis
LATERAL VIEW
• Shape n size of vertebral body
• Anterior n posterior walls
integrity
• Superior n inferior surfaces of
body
• Wedging
• Disc space
• Spinal canal-between post end
of body n lamina-space
occupied by cord

75. COMPUTED TOMOGRAPHY
• extremely useful diagnostic tool
• painless, outpatient procedure can supply more information
about spinal disease
• Unfortunately, CT does not demonstrate intraspinal tumors or
arachnoiditis and is unable to differentiate scar from recurrent
disc herniation.

76. MAGNETIC RESONANCE IMAGING
• newest technological advance
in spinal imaging
• Diagnostic imaging modelity
of choice for lumber disc
diseade.
• The advantages :-
– ability to demonstrate
intraspinal tumors, examine the
entire spine, and identify
degenerative discs based on
decreased H2O content
– costly and requires specially
constructed facilities,increased
time to scan, problem with
claustrophobic patients.

77. MRI
• Test of Choice
• Architecture of Disc
• Disruption of endplates
• Secondary changes
• Herniation
-T2 Weighted images are most commonly used to identify
and assess primary LDH.
-Contrast enhancement is required to the T1 weighted
images to differentiate between scar tissue and herniated
disc material in patients who had prior lumber spine
surgery.
-MRI is72% sensitive, 68% specific, and 70% accurate in
detecting containment status of lumbar herniated discs.

78. Modic changes secondary to Disc
degeneration
MRI
Type III  Low signal in T1 and low
signal in T2--sclerotic changes.
Type- I  Low signal in T1-weighed
sequences and high signal in T2)---
edema.
Type II  High signal in T1-weighed
sequences and either high or intermediate
signal in T2) ---fatty replacement

79. MYELOGRAPHY
• Indicated if MRI is not available or
for patient in whom MRI is
contraindicated( cardiac pacemaker
or brain aneurysm clip)
• valuable in a previously operated
spine and in patients with marked
bony degenerative change that may
be underestimated on MRI
• improved by the use of
postmyelography CT scanning.
• Poorly tolerated and have no place
currently in diagnosis of LDH

80. Provocative Discography
-Gold standered in confirming the diagnosis of
discogenic pain
• Should be follow up with ct discogram
• Two component to make a definitive diagnosis-
1)provoke the concordent pain by presseurizing the
disc with a contrast material.
2)painless discogram in adjacent disc.

81. Post Discography CT Scan-
Modified Dallas Grades
• Grade 0 – Normal disc, cotton ball appearance
• Grade 1 – Radial tear upto inner 1/3 of AF
• Grade 2 – Radial tear upto middle 1/3 of AF
• Grade 3 – Radial tear upto outer 1/3 of AF, but
extends < 30 degrees of disc circumference
• Grade 4 – Radial tear upto outer 1/3 of AF &
extends > 30 degrees of disc circumference
• Grade 5 – Radial tear with extra-annular leakage
into epidural space.
Site and Extent of Tear
Disc stimulation + Discography = Provocative Discography
Step 1 and 2 Step 3

83. Management
• Goal:-
- pain relief
-Rehabilitation
-Improve quality of life
*large gap between physician role and
patient expectations.
*appropriate patient selection ,
accurate diagnosis & Proper
management plan is basis of success
of therapy.

84. Conservative treatment
1)medication-analgesics and anti- inflammatory
-membrane stabilizer(anticonvulsants)
-narcotics
-antidepressants
-muscle relexants
-topical medications
2)Lifestyle modifications- weight management
-limit smoking & alcohal intake
-psychosocial support
3)physiotherapy
4)interventional pain management

85. TRANSCUTANEOUS ELECTRIC
NERVE STIMULATION (TENS)
• TENS uses pulse electric current through the
skin to stimulate underlying muscles.
• Conventionally 10-30 ma of current is used at
50-100 Hz
• Provide pain control by-
1)gate control theory
2)Release of endorphins

86. Interventional Pain management
Interventional Pain management
-Interventions pain management are Minimally Invasive, Non
Surgical and Target Specific procedures to Diagnose and to treat
Various painful conditions.
-It fills the gap between pharmacologic management of pain & more
invasive operative procedure.

87. Common interventional pain management
in discogenic pain:-
• epidural steroid injection
• annuloplasty
• provocative discography
• chemonucleolysis
• ozone nucleolysis
• percutaneous disc decompresion
• percutaneous discectomy
• percutaneous vertebroplasty
• Percutaneous kyphoplasty
• epidural adhesiolysis
• grey ramus block

88. EPIDURAL STEROID INJECTION
– offer relatively prolonged pain relief.
– Methylprednisolone is the usual steroid injected.
– The dosage may vary from 80 to 120 mg.
– The anesthetics used may include lidocaine,
bupivacaine, or procaine.
– current protocol is to inject the patient three times.
These injections are made at 7- to 10-day intervals.
– Several proposed mechanism of action which include
anti-inflammatory ,neuromembrane stabilization ,
modulation of peripheral nociceptor.

89. TECHNIQUES FOR EPIDURAL STEROID
1)loss of resistance method-loss of resistance feel when
needle enter in epidural space
- blind method
- high failure rate
2)fluoroscopic guided- Proper localizationzation of epidural
space and assures placement of steroide.
-now considered standered for epidural
steroid injections.

90. INDICATIONS:-
• Lumbosacral radiculopathy
• Lower back pain syndrome(spinal
stenosis/postlaminectomy syndrome)
• Phantom limb pain
• Vertebral comopressions
• Diabetic polyneuropathy
Contraindiacations:-
• Pregnancy
• cauda equina syndrome
• coagulopathy
• Anaphylactic reactions

91. APPROACHES FOR EPIDURAL STEROID
Three approaches:-
1)Lumbar Interlaminal-
-Can be performed in sitting , lateral or prone position.
- A syringe filled with air / saline is used to locate epidural space by loss of
resistance or flouoroscopically(resistance is offered by ligamentum flavum)
2)caudal epidural-
- performed with the patient in the prone position and flouroscopy in lateral view.
- palpate the sacral cornua , a 22G needle is introduced in sacral hitus.a distinct
pop is felt when sacrococcygeal membrane piereced.needle position checked by
flouroscopy
3)Transforaminal epidural-
-Thereputically more effective than lumbar interlaminal or caudal block as drug is
deposited more anteriorly right closed to target.
- Amount of drug is also much less(10-20 mg)
-Choice of Approach in failed back surgery syndrome.
-Technically difficult,more chances of nerve / spinal cord trauma, intraneural
injection

92. INDICATIONS
• Radicular symptoms in a specific dermatomal
distribution that correlates with MRI findings.
• Positive straight leg raising test or positive
bowstring sign, or both.
• No improvement after 6 weeks of conservative
therapy.
• Imaging studies (CT, MRI, discography)
indicating a subligamentous contained disc
herniation.
• Well maintained disc height of 60%.
percutaneous disc decompression

93. Minimally invasive procedure using small needle and probe to remove disc
material of prolapsed disc ,releasing pressure on nerves and relieving pain in
most of the patients of prolapsed/ bulging / slipped disc
Management : Disc Herniation
Percutaneous disc decompression

94. Percutaneous Disc decompression
• Rotating probe is inserted through needle
into the disc under X-Ray/ Fluoroscopic
guidance.
• Guiding needle is inserted through
“triangular safe zone-kambin triangle”(just
anterior to supetrior articular process and
superior to transverse process)
• Rotating tip removes small portion of disc material.
• Because only enough of the disc is removed to
reduce pressure inside the disc, the spine remains
stable.

95. LASER DISCECTOMY
• Holmium-yttrium-aluminium garnet(HO:YAG)
Laser is most commonlu used.
• Can ne paired with the endoscope for disc
ablation.
• Smaller fragment can be removed through
endoscope and larger fragment are laser
ablated.
• Difficult technique , required steep learning
curve.

96. Ozone Discectomy/ ozonucleolysis
• It’s action is due to the
active oxygen atom .
• It attaches with the
proteo-glycan bridges
in the nucleus
pulposus.
• They are broken down
and they no longer
capable of holding
water.
• As a result disc shrinks
and mummified and
there is decompression
of nerve roots.

97. .
Under fluoroscopic Guidance
Correct level of the prolapsed
disc is identified
Needle is inserted into the centre
of the Disc and ozone is Injected.
Pain relief starts usually within
one week and ozone takes 3-4
weeks for its complete effect
Percutaneous Ozonucleolysis
Indicated for both contained and noncontained disc herniation
Ozone 30-40 % is used with oxygen mixture(oxygen-ozone ratio-70:30
ratio)
2-3ml injected intradiscally and 10-20 ml injected in paravertebral
space of affected disc snbsequently.
Repeated 8-10 times

98. Nucleotomy
• The herniation
suctioned toward the
probe where an
integrated knife then
cuts it away from the
disk. The material is
then suctioned away

99. INTRADISCAL ELECTROTHERMAL
ANNULOPLASTY(IDET)
• Indication
• Mild to moderate Degeneration
• Absent radicular symptom
• Positive discogram
• Contraindication
• Large disc herniation
• Canal stenosis
• Disc height loss > 50%
• Mechanism of Action
– strengthen the collagen fibers,
– Seal fissures,
– denature inflammatory exudates, or coagulate nociceptors

100. RADIOFREQUENCY
ANNULOPLASTY/INTRADISCAL
ELECTROTHERMAL ANNULOPLASTY(IDET)
D
i
s
c
o
g
e
n
i
c
P
a
i
n

101. Nucleoplasty or RF Coblation
Based on concept that if volume of disc is
reduced, it will shrink And back pain
reduced.
-nucleoplasty utilizes coblation technology in
which ablation and coagulation of nucleus
pulposes reduces the size of contained disc
herniation.
Indication
• Discogenic pain
with contained disc
herniation
(No prospective randomized controlled studies for purely Discogenic pain)
Contraindication
• Extruded disc
• Disc herniation >33 %
of sagittal diameter of spinal canal

102. Methylene Blue
• Weak Neurolytic effect
• Inhibition of Guanylate Cyclase
and NO synthesis
Intradiscal Methylene blue Injections

103. Hydrodiscectomy
• Cutting with water fluid Jet technology
– uses the Venturi Effect created by high
velocity saline jets to cut and aspirate
targeted tissue

104. GRAY RAMUS BLOCK
• GRB can be used as diagnostic tool as well as
therepeutic intervention to provide temporary
pain relief.
• Under fluoroscopy ,2-3 ml of local anaesthetic
with or without steroid is injected after
contrast confirmation of safe needle
placement at three levels.
• One level which is affected and lower each
upper and lower side.

105. VERTEBROPLASTY
Indications:-
-Pathological compression fractures
-Osteolytic bony lesion
-Meelomas,haemangiomas
-osteoporosis
*Contraindicated in coagulation disorders and infectious
disease of spine.
*Low viscosity bine cement is introduced in fractured
bone.
*Immewdiate pain relief possibly due to thermal effect
on small nerve ending responsible for pain.

106. KYPHOPLASTY
modification of vertebroplasty by
introduction of the percutaneous ballon
,where space for cement is created by
ballon insertion prior to cement injection.

107. Interventional Pain Procedures
• Limitations
• Contraindications
• Complications
• Not Alternative to Surgery
• Steep learning curve

108.  Glucosamine and chondrointin sulphate-
Enhance the Repair response of chondrocytes and retard the
enzymatic degradation of cartilage.
Cell based Therapies
Stimulate the disc cell to produce matrix
Direct injection of Growth factor/ Cytokine inhibitor- Unsuccessful
Gene of interest is introduced into target cell
 Nucleous Pulposus augmentation
Injectable Nucleous –Solution of Protein polymer and
crosslinking agent
Regenerative Therapies

109. Indication of surgery
• Emergent/ absolute:-
– Presence of cauda equina syndrome
– Progressive neurologic deficit
• Relative:-
– Persistent radiculopathy despite an adequate trial of non surgical
treatment( min of 6 wks).
– Recurrent episodes of incapacitating sciatica
– Significant motor deficit with persistent tension signs and pain
– Pseudoclaudication( activity related leg pain) caused by canal stenosis
resulting from a disc herniation
• Goal of surgery:-
– Alleviate the neural compression without further injury to the affected
nerve root
– Minimal disruption of surrounding normal tissues and maintenance of
spinal stability

110. Waddell’s Non-organic sign
indicate poor outcome of surgery if 3 out of 5
positive.
Finding Description
1. Tenderness a. superficial - pain with light touch
to skin
b. deep - nonanatomic widespread
deep pain
2. Stimulation a. pain with light axial compression
on skull
b. pain with light twisting of pelvis
3. Distraction No pain with distracted SLR
4. Regional a.nonanatomic or inconsistent
motor findings during entire exam
b. nonanatomic or inconsistent
sensory findings during entire exam
5. Overreaction Overreaction noted at any time
during examination

111. Surgical procedure
-Surgery involve decompressing the canal by removing a
piece of its wall(i.e. lamina)apart from removal of the
herniated disc(discectomy).
-the key of good results in disc surgery is appropriate patient
selection.
-before this step is taken , the surgeon must be sure of the
diagnosis.
-surgeon and Patient should be aware that the procedure is
predominantly for symptomatic relief of leg pain. Patient with
predominantly back pain may not experience relief.

112. Discectomy procedure
-Standard open lumbar
disectomy
-Microlumbar disc
excision
- endoscopic /
percutaneous
discectomy
- -Artificial total disc
replacement
Decompression procedure
-fenestration
-laminotomy
-hemileminectomy
-laminectomy
-facetectomy

113. Decompression procedure
• Fenestration-creating a hole in ligamentum flavum that
connects the adjacent laminas , thereby opening the
spinal canal.
• Laminotomy-in addition to fenestration , a part of
lamina is excised to widen the hole and create wider
space for decompressing the canal.
• Hemilaminectomy –removing of whole of lamina but
only of one side.
-usually is required when identifying the root is a
problem. This may occur with a conjoined root.
• Total laminectomy –the lamina of both side is removed
along with the spinous process.
-usually is reserved for patients with spinal stenoses
that are central in nature, which occurs typically in
cauda equina syndrome.

115. MICRODISCECTOMY
• Micro lumber disc excision has replaced
standered open laminectomy as procedure of
choice.
• Limited dissection required, less postoperative
pain , shorter hospital stay .
• The herniated disc is excised after creating a
fenestration in ligamentum flavum to reach
the disc.

117. TOTAL DISC REPLACEMENT• In this procedure degenerated disc material is removed and
an artificial disc is implanted in the spine.
• Prerequisite:-
-demonstarble disc degeneration as the cause of pain.
-intact facet joint posteriorly and no other pain generator is
demonstrable.
Indication:-
-failure of aggressive conservative treatment with disabling
LBP attributed to the lumber spine affecting no more than
two disc.
*material used for TDR are similar to arthroplasties
(polyethylene ,titanium , chrome cobalt) and various
replacement designs are also available.

118. THE FAILED BACK SYNDROME(FBSS)
• Any condition where there is failure to improve
satisfactorily following back surgery.
– Classification of failure:-
1)Early-symptomes either present immedietly or
within 2-3 weeks.
wrong level surgery or wrong procedure is
most common cause.
2)Intermediate- within weeks to monts
mat be related to recuurent disc
herniation,
or haedware problems.
3)late-after several months.
recureent pathology at the same or adjacent
segment is the common cause.

119. ETIOLOGY
-Wrong patient selection-m/c cause
-Incomplete diagnosis
-Wrong procedure
-Revision surgery
-Poor technique
-Progressive disease
-Systemic disorder

120. MANAGMENT
• It is best to prevent FBSS.
• Accurate diagnosis and presurgical patient
assement increases the suucess of surgery.
• In case of FBSS conservative treatment should be
tried first:-
-Intrathecal analgesia
-Intradiscal electrotherapy
-Medial branch radiofrequency lesioning
-Spinal cord stimnulation
-percutaneous adhesionolysis/percutaneous
epidural neuroplasty(racz procedure)
Remember success of revision surgery in spine
reduce with revision procedure and hence FBSS
would rise with more and more revision.

121. Debate is on…….

122. Surgery for back pain;
MRI…
• Clinical correlation is must
• Discography is very helpful

124. Questions Please?