Statistics for lumbal disc disease • 80% of the population will experience low back pain • 7% to 14% will have symtomps longer 2 weeks • 1% to 2 % will undergo surgery • This involves a change in the architecture of the disc with a typical loss in the gelatinous stucture (nucleus puposus) or a fibrotic disc with amyloid and lipofucin deposits. • The first manifestation of the degerative process involves tears in the center of the disc, which gradually increase and progress to the anulus fibrosus. • The most common manifestation of degerative nvolvment includes osteophytes on the adjacent vertebral bodies which are oriented primarily in horizontal direction. • Ostephytes grow first on the anterior and, later, posterior edge of the vertebral body. Bulging disc • Symmetrical disc bulge beyond the vertebral body Disc herniation (protution, prolaps) • Central subtance of the nulceus puposus escapes toward the defect in the anulus fibrosus and focal protution of the disc beyond the perimeter of the vertebra occurs Disc exterusion • Nucleus puposus penetrates trought the external layer of the annulus fibrosus, but remains connected to the rest of the nucleus substance Extrution with sequestration of the disc • The posterior longitudinal ligament is perforated and one more free fragments of the nulceus pulposus migrate within epidural space, but not into the spinal canal Predictive value of clinical and surgical findings in patients with lumbago-sciatica (Kosteljanetz,1984)
• In a prospective, consecutive study of patients
with lumbar back pain and sciatica, various clinical features and surgical findings were evaluated in order to analyse the predictive value regarding (1) level of diseased interspace (2) presence and type of lesion responsible for root compression (3) outcome after surgery. • One hundred patients underwent surgery solely on clinical grounds. Fifty-eight had disc herniation. The level of disc herniation was correctly predicted in three quarters of patients with aprolapsed disc. The outcome after surgery was good in 77 patients. • Only few clinical features, namely male sex and scoliosis were predictors of a good outcome. Lasegue's sign was indicative of root compression in 90%, but only two-thirds had disc herniation. Conversely one-third had disc herniation in spite of a “negative” test. Lasegue's sign was not superior to other clinical tests in predicting outcome • The most important indicator of a good outcome was the presence of disc herniation at surgery. Patients with disc pathology other than true disc herniation fared equally with patients, who had normal discs disclosed at surgery. • Myelography was undertaken in all patients prior to surgery, the results of which are analysed in the following paper • It is known fact that the clinical significance of a disc hernitiation can be confirmed in approximatly 20%-30% of examinations (CT or MRI) in healthy inividuals. • These hernitiations are neurogycally asymtomatic and are not accompanied by any problems. • However, they are never asymtomatic funtionally, meanning they are always lingked to functional reactive changes inthe muscle and soft tissue. • According to Allat (1994), disc herniation is found in 39% of individuals who report no problems. • During radiculopaty, allat showed a disc protusion in 50% of cases and a disc herniation in 24% of the cases. • As result of compensatory mechanisms, a disc herniation may not be source of neurological signs or even subsjecyive findings. • A demonstrated disc herniation always needs to be observed in aclinical picture and in functional context. • In a number of cases, low back pain preceds pain radiating into the lower extremities. • This is also why disc herniation needs to be considered as acause of not only spinal root syndromes, but also of low back pain. • At the same time, back pain develops and progresses to the lower extremities similiarly to nerve root irritation but without the presence of neurogical findings.