1、Treating Bulging Discs& SciaticaAlexander Ching, MDDisclosures Depuy Spine Teaching and courses K2 Spine Complex Spine Study GroupDisclosures Take 2 I am a spine surgeon I like spine surgery I believe in spine surgery I make a living performing and researching spine surgeryOverview Introduction/The
2、Spine Bulging Discs Radiculopathy, AKA Sciatica Treatment Non-operative Operative Cauda Equina SyndromeINTRODUCTIONThe Spine Bone Muscle/Ligament Disk NerveThe Bones of the Spine 7 Cervical vertebrae 12 Thoracic vertebrae 5 Lumbar vertebrae The SacrumVertebral bodyCervicalThoracolumbarLumbarThoracol
3、umbarLumbarCervicalLumbar vs. Cervical10X Load Muscles and Ligaments “Tension Band” function Provide the support for the bones and discs Some of the strongest muscles in the body Help unload the discs and bonesThe Intervertebral Discs Shock Absorbers Stabilizers Hydraulic LiftsStructure Outer Layer
4、Annulus Tough sheath around core Provides Stability Central Core Nucleus Pulposus Water filled Rubbery Expands and contractsAging Discs Lose their water Lose their height Lose their resiliency Lose their strengthBULGING DISCSWhat Do Bulging Discs Mean? Discs lose protein Then lose water Then lose re
5、siliency Then lose height and bulge Sometimes herniate (spit material through the annulus)What Do Bulging Discs Cause? No symptoms (sometimes) Back Pain (sometimes) Radiculopathy (sciatica) Stenosis (sciatica sort of) Cauda Equina Syndrome (emergency)Back Pain and Bulging DiscsDegenerative Disc Dise
6、ase does not equal low back painNormal aging process includesDehydration of nucleusCollapse of the disc spaceSclerosis of the endplatesLUMBAR DISC HERNIATION/RADICULOPATHYAlso Known As SciaticaLumbar Radiculopathy Dysfunction in a specific nerve root distribution Pain Weakness Numbness Usual pattern
7、 is like a stripe down the leg Usually associated with disk herniation“Nerve Pain” Burning Shocking Muscle cramping Generally responds poorly to traditional pain medicine Hurts to do “everything”Other Causes of Leg Pain Cauda Equina Syndrome Giant disc herniation Lumbar spinal stenosis Spinal arthri
8、tis pinching multiple nerves Usually older patients, usually both legs, less specific areas Problems with blood flow to the leg Worse with exercise, better with rest Peripheral neuropathy Diabetes, other illnesses Stocking/glove pattern (starts at the toes, like a sock) Non-spinal nerve compression
9、No nerve compression on spine MRI Problems in the leg (knee or hip arthritis)Lumbar Spine Nerve RootsEpidemiology Estimated incidence of symptomatic lumbar disc herniation 1-2% Highest prevalence age 45-64 Suspected risk factors Sedentary lifestyle Frequent driving Chronic cough Pregnancy Smoking He
10、avy liftingPathophysiologyNerve Root CompressionInflammatory Response to Disc MaterialVs.Mechanical Compression Mixter and Barr describe discectomy for sciatica in 1934 Animal studies show decreased nerve root nutrition with mechanical compression Histology shows intraneural edemaBiologic Response R
11、adiculopathy in response to pieces of disc, without compression Animal model requires both displacement of nerve and exposure of disc material for radiculopathy Some inflammatory proteins have been identified in this processNON-OPERATIVE TREATMENTNatural History Multiple studies, multiple “interventions” 80% improve by six weeks 90% by twelve weeks 93% by 24 weeksNon-Operative Interventions Medications Anti-inflammatories Pain medicine Nerve pain medicinePhysical Therapy/Braces “Limited” evidence for braces in radiculopathy Physical therapy effective Type equivocalSTAY ACTIVE!
