Transcript The Lumbar Disc and Sciatica

The different types of patients
with Sciatica from a lumbar disc
Manoj Krishna.
Spinal Surgeon
www.spinalsurgeon.com
Type 1: Sciatica without disc
protrusion
•
•
•
•
•
•
Predominant leg pain
Increased on sitting
Eased on walking
MRI shows disc degeneration but no neural compression
Rx- Interbody Fusion
Mechanism: ? Sinuvertebral Nerve Irritation.
– ? Leakage of chemicals into disc space
Type 2: Small central disc protrusion
• Causes more back pain than sciatica
• These symptoms more likely to become
chronic
• Contained disc – still within PLL
• 38% do poorly from discectomy
• Rx- Do well with a Interbody Fusion
Type 2
Contained Central Disc Protrusions
Spasms, Locking
Left thigh and leg pain
Sitting < 5 minutes
Type 3: Large Central Disc protrusionCauda Equina Syndrome
• History of back pain
• One day the back pain disappears and patient
gets sciatica with buttock numbness and
dribbling, or bilateral leg pain
• Surgical emergency
• Urgent discectomy needed
Type 3
Cauda Equina Syndrome.
•
•
•
•
Type 4: Sequestered postero-lateral
disc protrusion
Present with unilateral sciatica
Severe pain initially
Highest chance of settling spontaneously
Manage with an epidural injection or just pain
relief till the pain settles
Type 4
Pain settled on its own
at 6 weeks from onset
May develop back pain
later
Type 5: Contained postero-lateral disc
protrusion
• Not extruded into the disc space
• Often Broad based
• 38% persistent sciatica with discectomy(
Carragee)
• Less likely to settle spontaneously with
conservative measures
• Or- may settle and develop an instability pattern,
with recurring episodes of leg pain
• Needs an interbody fusion
Type 5
Intermittent LBP several years.
Then Rt sciatica – LBP settled.
Scoliotic tilt and stooped
forwards 40 degrees. Rt SLR=40
L5 decreased sensation
WWW.KSPINE.NET
Type 6: Far lateral disc protrusion
•
•
•
•
Often at L34
Not easy to see on an MRI scan
Causes thigh pain- and quads wasting
Rx: Nerve Root Block- usually all that is
needed
• Discectomy: Needs a far-lateral approach
• Or , consider doing an interbody fusion
• 7% of disc herniations
Type 6
RD Fraser et al- Adelaide. JBJS 1997
30 cases
Foraminal Nerve Root Blocks
Only 3 needed surgery
Type 7: Small disc protrusion in a tight
spinal canal causing Stenosis
• Patients have a narrow spinal canal with no
symptoms
• Even a small disc protrusion tips the balance
causing a combination of leg pain, heavy legs,
loss of co-ordination
• Neuro deficit is out of proportion to the size of
the disc protrusion
• Needs urgent decompression- risk of cauda
equina syndrome
Type 8
Features of both left
sciatica and spinal
stenosis
Need to worry that this
could progress to a
cauda equina
syndrome
Struggling to walk
Acute onset, rapid
progression
Type 9: Recurrent Herniation at same
level
•
•
•
•
10% at 2 years( McGirt et al, Spine, 2009)
Higher if larger annular defect
Higher if limited discectomy done
But...more back pain associated with larger
disc removals
Type 8
Discectomy Oct
2000 –
Recurrence of LBP
and Lt leg pain.
Pain very severe.
‘ My Life is Hell’
VAS - 9/10
Small Recurrent
disc protrusion
•
•
•
•
•
10 year outcomes of discectomy
Yorimitsu et al. Spine.
131 cases
12.5% had a recurrent disc herniation
75% had back pain
13% had severe pain
Back pain associated with a degenerate disc at
time of surgery, age less than 35 and reduced
disc height
‘the remaining disrupted discs must continuously bear the weight and support
the trunk for the rest of the patient’s life’
•
•
•
•
•
Epidural Steroids vs Discectomy
Buttermann . JBJS, 2004
RCT
At 6 weeks randomised into 2 groups( N=169)
92% discectomy group very happy.
56% of epidural group happy
Subsequent discectomy had a similar
outcome.
• Half of patients in epidural group avoided
surgery at 3 years
• How long is it reasonable for a patient to
suffer and wait for the pain to settle? (
knowing that they can wake up from surgery
with the leg pain gone and if they accept the
small risks of surgery?)
• Should the doctor decide?
• Or the patient who is experiencing the pain?
Complications of Discectomy
•
•
•
•
British Association of Spine Surgeons( 2005)
3.5% dural leaks in primary discectomy
13% in revision cases
Infections rates 3%( Rohde,Spine)