PPT HNP

Nur Zahiera Bt Muhamad Najib

030.08.298

Lecturer :

Dr. Arsanto Triwidodo,SpOT,FICS, K Spine, MHKes

DEFINITION A herniated disc is a fragment of the disc

nucleus which is pushed out of the outer disc margin, into the spinal canal through a tear or “rupture”. It presses on spinal nerves, producing pain down the accompanying leg.

The compression and subsequent inflammation is directly responsible for the pain one feels down the leg, termed "sciatica.” A herniated disc is a definite displaced fragment of nucleus pushed out through a tear in the outer layer of the disc (annulus).

CASE REPORT Name : Mrs. Neah Age : 45 years old Sex : women Religion : islam Ethnic : sundanese Education : SMP Civil Status : married

Date of enter to hospital: 22.12.2012(from Surgery Policlinic)

Date of examination: 14.01.2013 History taken have been done on 14.01.2013, 14.30 pm

HISTORY OF PRESENT ILLNESS

15 YEARS AGO- involved into an accident -> hit from her back ->felt into seated position ->

didn’t seek any medical treatment

3 MONTHS LATER: suddenly both legs numb and

cant walk

Warded at Cipto Mangunkusomo Hospital for 3

weeks -> no improvement -> trying alternative

medicine + medicine from hospital -> slowly

can walk again

control her health at

Islam Hospital

NOVEMBER 2013

complain felt the pain on her back,

radiating from the waist to buttock and

both lower legs, numbness on both her

feet, worse when start walking and

coughing, weak legs for walking,

stiffness on her hip and knee joint

PHYSICAL EXAMINATION

Head normalcephaly, black hair with normal distribution, difficult unpulg, no lesion and bump

Eyes normal shape, symmetric , pupile isokor, conjunctiva anemis(-/-), sclera icterik(-/-), direct light reflex(+/+) undirectly light reflex(+/+)

Ear normotia, no hyperemis, no secret(-/-), serumen(+/+), membran tympani intact with light reflex at 5 oclock for right ear and 7 oclock for left ear, corpus alenium(-/-)

Nose normal in shape, no deformity, septum deviation(-), concha hyperthrophy(-/-). secret(-/-)

Mouth lips not dry trismus(-), tongue not dirty, teeth normal, good oral hygiene, Hyperemis pharynx (-)

Neck normal in shape, no palpable the enlargement of lymph node

LungInspection movement of brething left and right

symmetric , retraction intercostal space(-/-), lesion(-)

Palpation vocal fremitus left and right symmetric, no compresive pain(-/-)

Percussion sonor in both side of lung

Auscultation sound of breathing right and left vesikuler, ronchi (-/-), wheezing(-/-)

Heart

Inspection no pulsation of ictus cordis appearance

Palpation ictus cordis palpable on intercostal space v, 1cm media from left midclavicle

Percussion right border: intercosta space v right parasterna lineLeft border: intercosta space v, 1cm media from left midclaviculaUpper broder: intercosta space ii from lef parasternal line

Auscultation sound of heart I-II reguler, gallop(-), murmur(-)

Abdomen

Inspection flat, smilling umbilicus(-), operation scar(-), veins dilatation(-),

Auscultation sound of intestine (+) 4x/min

Palpation supel, no compresive pain(-), defens muscular(-), liver not palpable, spleen not palpable, kidney : ballotement(-/-), CVA(-/-)

Percussion tympani, shiffting dullness(-)

Upper extremity

Right Left

Muscle Eutrophy Eutrophy

Tonus Normothony Normothony

Mass No abnormality No abnormality

Joints No abnormality No abnormality

Movements Active Active

Strenght Normal Normal

Edema No edema No edema

Local status (thorax and lumbar vertebra)

The patient stand up

LOOK The colour of the skin was same like the other part of the bodyScar (-), lesion (-), edema (-)Deformity : Scoliosis appearance (+)

FEEL Temperature equal like the other part of the bodyTenderness (-)Deformity on spine contour (+)

MOVE Spine jointFlexion = 50 ° (normal : 80°)Extension = 15° (normal : 30°)Lateral flexion = 35° (normal : 35°)

Sacroiliac joint :Pain on movement

The patient lay down

FEEL Fossa iliac palpationTenderness (-)Mass (-)Edema (-)

MOVE Straight Leg Raising (SLR) TestPain on 45° (normal : 60°)

NEUROLOGY STATUS

SENSORY

RIGHT LEFT

Mid-anterior thigh(L2) 2 2

Medial femoral condyle (L3) 2 2

Medial malleolus (L4) 1 2

Dorsum of the foot at the third metatarsal phalangeal joint (L5)

1 1

Lateral heel (S1) 1 1

Popliteal fossa in the mid-line (S2)

1 1

MOTORIC

RIGHT LEFT

Small finger abductors (abductor digiti minimi) – T1

5 5

Hip flexors (iliopsoas) -L2 4 4

Knee extensors (quadriceps) – L3 4 4

Ankle dorsiflexors (tibialis anterior) –L4 4 4

Long toe extensors (extensors hallucis longus) – L5

4 4

Ankle plantarflexors (gastrocnemius, soleus) – S1

4 4

MOTORIC

Passive movement

Active movement

Right Left Right Left

Small finger abductors (abductor digiti minimi) – T1

5 5 5 5

Hip flexors (iliopsoas) -L2 5 5 5 5

Knee extensors (quadriceps) – L3 4 5 4 4

Ankle dorsiflexors (tibialis anterior) –L4 4 4 4 4

Long toe extensors (extensors hallucis longus) – L5

4 4 4 4

Ankle plantarflexors (gastrocnemius, soleus) – S1

4 4 4 4

REFLEX

Physiology reflex Right Left

1.Knee reflex Positive normal Positive normal

2. Achilles reflex Positive normal Positive normal

Pathological reflex

1. Laseque Pain at 45° Pain at 45°

2. Kernig Negative Negative

3. Barbinsky negative Negative

LABORATORY FINDINGValue Normal Value

Hemoglobin 13.7 g/dl 11,2-15,7 g/dl

Leucocyte 12. 500 /uL 3900-10 000/ul

Haematocrite 41% 39-45%

Erythrocyte 4.91 4.0-5.2

MCV 83 80-100 fl

MCH 28 27-34 pg

MCHC 34

Different count :Basophile EosinophileRodSegmentLymphocyteMonocyte

150

56308

0-22-52-5

47-8013-402-11

Trombocyte 376.000 (140.000-440.000/ul)

Erythrocyte sedimentation rate 26 sec <10 sec

Blood Glucose Level 97 90-110

Kidney function :creatine UreumUric acid

0.5254.1

2.40-5.700,4-0,717-43

Liver function : SGOT/ASAT

SGPT/ALAT

1016

<37

<41

Immunoserologist -Rheumatoid factor

Negative Negative

Fat Total cholesterol Triglyceride HDL cholesterol LDL cholesterol

18110936

124

<200<150>45

<133

CHEST X-RAY IMAGEDescription COR : CTR>50% Lung :normal vascular

reaction, infiltrate (-) Normal diaphragm and

sinus Interpretation :

cardiomegaly suspect

Vertebra lumbal and sacral radiology photo

Spur (+) on corpus lumbal vertebra I-V Narrow intervertebra disc lumbal vertebra

III-IV,lumbal vertebra IV-V, lumbal vertebra V- sacral I

Corpus lumbal vertebra V looks more posterior than lumbal vertebra IV

Compression fracture (-) Good pedicle Interpretation : lumbal osteoarthritis

: suspect HNP LV IV-V,

LV V-SV I

: Spondilolisthesis LV IV-V

(Grade III)

MAGNETIC RESONANCE IMAGING

Corpus vertebra L4 shift to anterior relatively to L4 (listhesis) Osteophyte formation on all corpus vertebra lumbalis Decrease signal intensity at disc L3-4 and L4-5 Multiple protruding disc to posterior that push the thecal sac

on the medial side, right and left radix compression at L2-3, L3-4 and L4-5

Conus medullaris ended at L1 with normal intensity, no focal lesion. No higher pathologic signal intensity intramedullary

No thickening of flavum ligament, interspinosum ligament and longitudinal ligament.

No pathologic change on paravertebra soft tissue.

Conclusion : spondilolisthesis L4-5

: HNP L2-, L3-4 and L4-5 with right and left

radix compression

Corpus vertebra L2 shift to anterior relatively to L3 with the shift distance <25% than corpus diameter.

Spur seen on corpus vertebra lumbal. There were higher pathologic signal intensity on L2 and L5. Lumbal intervertebralis disc intensity was decreased. Narrowed intervertebralis disc L2-L5.

Conus medullaris at the same level of L1. No higher pathologic signal intensity on medulla spinalis.

No pathologic change on paravertebra soft tissue.

Conclusion : spondilolisthesis L2 stage 1 with L2 and L3 marrow edema : spondiloarthrosis lumbal with HNP L2-3 to L5-S1

ECHOCARDIOGRAM

Interpretation summary -normal cardiac

dimension - normal RV and LV

function - normal heart valve - diastolic dysfunction

grade 1

Additional examination

Electromyelography (EMG) Nerve conduction velocity test

RESUME Woman, 45 years old came to Surgery Policlinic in Koja Hospital with

complaint pain on back and waist that radiate to both her legs. She felt numbness and weak on both feet . 15 years ago she was hit by a motorcycle and fell into seated position. Then three months later she suddenly cant move her legs and but can get walk back a few months later.

From physical examination, her BMI was in overweight range. From the local status examination, there was scoliosis appearance, spine curvature deformity in palpation and there was decrease range of flexion(50°) and extension (15°) for the spine joint. For the sacroiliac joint, there was pain on movement. When doing the Straight Leg Raising test there was pain on movement at 45°. For neurological status, there was impairment when doing sensory test start from L4 for pain test and L5 for light touch. In motoric test, the score was 4 start from L3 for active and passive movement . On 45°, there was pain while doing the Laseque Test.

The abnormal in lab was the erythrocyte sedimentation rate was high (26).

There was cardiomegaly suspect when doing the chest –xray. From the Vertebra Lumbal and Sacral Photo, there were lumbal osteoarthritis, suspect HNP LV IV-V, LV V-SV I and Spondilolisthesis LV IV-V (Grade III). The MRI says that this patient was suffered from spondilolisthesis L4-5 and HNP L2-, L3-4 and L4-5 with right and left radix compression. While the echocardiogram interpretation was normal cardiac dimension, normal RV and LV function, normal heart valve and diastolic dysfunction grade 1.

Working diagnosis= Hernia Nucleated Pulposus VL 2- VL 3, VL 3-VL 4,

VL 5-S 1

Base of diagnosis1. Anamnese2. Physical examination3. Laboratory finding4. Imaging finding

Differential diagnosis Canal stenosis Spondylolithesis

MANAGEMENTNon operative IVFD Ringer Lactate 30 drip per minute Metilcobal 3x500mg Neurobion 1x1 amp Oste Forte 1x 1 Kolkatrion 2x1 g Normal diet

Operative Preparation for laminectomy Prognosis Ad vitam : bonam Ad sanationam : dubia ad bonam Ad fungsionam : dubia ad bonam

CASE REVIEW

Vertebra held by ligaments

33 vertebrae

- 7 cervical

- 12 thoracic

- 5 lumbar

- 5 sacral

- 4 coccygeal

Orientation of vertebral column on surface.

T3 : medial part of spine of scapula

T7 : inferior angle of scapula

L4 : iliac crest S2 : posterior

superior iliac spine

INCIDENCE

Approximately 80% of HNPs occur in the lumbar region. (fourth decades, higher in males)

Approximately 20% of HNPs occur in the cervical region and 20-33% of these have concurrent lumbar disc involvement. ( sixth decades, higher in males )   

Less than 1% of the HNPs occur in the thoracic region. (fifth through sixth decades of life and the incidence is equal for both sexes.)

Pathologic lesions (i.e. spondylosis and spinal stenosis) have been noted in 50% of the cases with lumbar HNP.

Causes or Risk Factors

Accident or injury. Obesity. Activities that strain the back Sex (males). Cigarette smoking. Aging Genetics

Impaired mobility

MEDICAL MANAGEMENT

Physical Examination and History of Pain Neurologic Examination Foraminal Compressing test of Spurling Radiography Myelograph Spine x –ray Electromyelography (EMG) Nerve conduction velocity test Computed Tomography Magnetic Resonance Imaging (MRI)

Pharmacologic Management

Analgesics  Nonsteroidal Anti-

Inflammatory medications (NSAIDs)

Narcotic pain killers. Hydrocodone

(Vicodin) Naproxen

(Naprosyn) Tramadol (Ultram) Celecoxib (Celebrex)

Muscle relaxants Carisoprodol

(Soma). Metaxalone

(Skelaxin). Cyclobenzaprine

hydrochloride (Flexeril).

Steroids

Surgical management

Diskectomy Chemonucleolysis Microdiskectomy Laminectomy Spinal fusion Foraminotomy

Supportive Management

Diet and exercise Physical therapy Back braces Traction Use of devices Prevention of

complication of immobility

Health Education

Prognosis

A approximate 5% rate of recurrent disc herniation at the same level. Factors involved may be weight related level of physical conditioning, work or behavioral habits.

majority of disc herniations (90%) do not require surgery

approximately 5% of patients with herniated, degenerated discs will go on to experience symptomatic or severe and incapacitating low back. When this occurs, the prognosis is poor for returning to normal life activities regardless of age.

After a successful laminotomy and discectomy, 80-85% of patients do extremely well and are able to return to their normal job in approximately six weeks time).

THANK YOU