Lumbar Discogenic Syndromes PDF

**Discogenic syndromes** ***Anatomy and Biomechanics*** Refer to: Joint structure and function, Chapter 4, page 118 -- 121 Notes on Spinal biomechanics ***Discogenic syndromes*** (Disc irritation, bulge / prolapse) **[Causes]** - Accumulated micro trauma and possibly an auto-immune reaction...

**Discogenic syndromes** ***Anatomy and Biomechanics*** Refer to: Joint structure and function, Chapter 4, page 118 -- 121 Notes on Spinal biomechanics ***Discogenic syndromes*** (Disc irritation, bulge / prolapse) **[Causes]** - Accumulated micro trauma and possibly an auto-immune reaction is responsible for disc degeneration - Fissures and tears occur in the annulus fibrosis which do not heal well - Posture (flexion) and activities (flexion / extension with rotation, jarring activities, prolonged positions) that increase intradiscal pressure will cause the nuclear material to "ooze" in a direction - The disc become inflamed, may bulge, protrude and may cause nerve root irritation / compression - The degeneration itself may be asymptomatic but the degenerated disc is a "weak link" and may deteriorate in the above mentioned progression if under prolonged / repeated load **[History]** - Onset rapid / slow. May have previous episodes - Precipitating activities are -- flexion / flexion -- rotation / lifting objects / prolonged sitting / jarring activities / a fall / weak immune system - Disc very vulnerable in early mornings **[Signs & symptoms]** - **Area** - Depend on involvement of other structures - Dura: around affected area, central and paravertebral - Posterior longitudinal ligament (PLL): Central or referred. Not clearly defined. Proximal pain \> distal pain - Nerve root sleeve: Central pain more distinct to one side - Nerve root: DDD -- Distal, Define, Dermatomal - **Character** - Deep (non-nerve root) / superficial, clearly (nerve root) - Severe inflammation: pain difficult to bear, distressing and sickening - If nerve root is involved: neurological symptoms - **Behaviour** - Aggravated: - Postures & activities that increase intradiscal pressure - Sneezing, coughing & valsalva manoeuvre - Eased: - Lying down / decrease of pressure - **Protective deformities** - Protective muscle spasm -- scoliosis, kyphosis, list **[Perpetuating factors]** - **Structural:** - Weak abdominal stabilisers: intra abdominal pressure - Kyphosis, lordosis, scoliosis - Abnormal gait -- leg length - **Ergonomic:** - Chair / table design - Poor work space -- rotation flexion activities (packing shelves) - **Activities:** - Any that increase intra-abdominal pressure - **Stress:** - Fatigue, decrease in immunity - **Disease:** - Viral infections - Scheuermann's disease - Auto immune diseases - Endplate fractures **[Treatment]** - Spinal mobilisation techniques. PA mobilisation UNLESS extension is worst sign - Lumbar stabilisation exercises (local and global) - Treat associated trigger points (search wide) - Neural tissue mobilisation - Education - Pathology - Avoid posture / activities that increase intradiscal pressure - Kinetic handling - Ergonomics ***Special discogenic cases*** Patients are complaining of severe pain and may be confined to bed. Usually irritable condition. Evaluate and treat accordingly. **[Treatment]** - After acute stage complete evaluation. Treat as above mentioned. ***"Flat tyre syndrome"*** **[Cause]** - Disc space narrowing due to degeneration / disc prolapsed ligaments and capsule have not yet adapted the height of intervertebral segment **[History]** - Slow / rapid onset with a precipitating jerky accident - Previous episodes which have precipitated disc degeneration - Acceleration of wear and tear due to job / hobby **[Signs & symptoms]** - **Area** - Local / referred depending on structures involved and severity of instability - **Character** - Catching pain, twingy, stabbing unexpected pain, back feels weak - **Behaviour** - Aggravated: - Prolonged standing, walking, lying, extension exercises - Arc of pain especially with flexion - Extension out of flexion very difficult and painful. Use hands to assist with extension - Palpation will provoke pain (palpate step = lysthesis) - Eased: - Stable positions. Sitting will aggravate symptoms if there is a disc lesion - **Protective deformities** - Depending on structures involved **[Perpetuating factors]** - Structural: - If more than one level involved: trunk stability / general degeneration - Activities & posture: - Activities that require quick movements. Large ROM, jarring especially into extension - Stress: - Unconscious use of body **[Treatment]** - Spinal mobilisation techniques - Spinal stability exercises - Neural mobility - Education: - Pathology - Avoid jerky, twisting jarring activities - Avoid extension posture and activities (if antero displacement) - Central stability - NB!! Education about cord / coda equine signs and symptoms. ***Juvenile disc syndrome*** More young men than woman are affected. Symptoms are mild spinal stiffness; muscle spasm and joint signs are out of proportion. In the lumbar area there is commonly a flexion deformity, which is retained with prone lying. Palpation techniques don't reveal much until a strong grade IV / V is done -- they shoot through the roof. Marked limitation with flexion and SLR. **[Treatment]** - The aim is to lessen pain rather than to increase the ROM. Range tend to improve with time ***Annular disc lesion*** (easily confused with locked z joint / severe trigger points) **[Cause]** - Crack in annulus **[History]** - Sudden onset as result of lifting heavy objects and turning **[Signs & symptoms]** - **Area:** - Depends on structures involved - **Character:** - Very severe, can be crippling - **Behaviour:** - Patient get stuck cannot move, cannot sit. May cause anxiety. Neural signs -- if bilateral be very careful - **Protective deformities** - Patient stuck in least painful position even though this position is painful **[Perpetuating factors]** Activities that require quick twisting especially associated with flexion. Stress / flu may cause patient to be more prone to injury **[Treatment]** - Spinal mobilisation - Spinal stabilisation - Trigger points -- do a wide search - Central stabilisation - Neural mobility - Education: - Pathology - Central stabilisation - Good general health - increase immunity - Avoid activities / postures that increase intra-abdominal pressure