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Pathophysiology of Inter-vertebral Discs approximately 20-25% of the length of the vertebral column comes from the intervertebral discs

scs with age, this percentage decreases as a result of the disc degeneration and loss of water in the discs the outer layer of the disc is known as the annulus fibrosus, made up of layers of collaginour fibres aligned in a criss-cross like pattern, angles around 60-65 degrees to the axis of the spine allowing for a combination of great strength and torsional movement the inner layer is known as the nucleus pulposus and is most highly developed in the cervical and llumbar spine over time, the gelatinous material will come to resemble the annulus fibrosus as it is replaced by fibrocartilage the degenerative process begins to occur in the second decade of life teens! the discs receives nutrition via diffusion primarily from the cartilaginous end plates a "mm thick plate located on the surfaces of the vertebral bodies! only the peripheral regions of the discs receive a significant amount of nutrition from the blood vessels# the vascular supply of these discs decrease with age direct vertical pressure on the disc secondary to weight bearing in combination with postural dysfunction! can cause the disc to pus an excess of fluid into the vertebral body $chmorl%s &odes!

Disc Prolapse occurs when the inner and outer annular fibres completely tear allowing the nucleus to extrude into the neural canal protrusion posteriolaterally will compress an && root Disc Herniation occurs when the internal annulus fibers tear and allow the nucleus to bulge and press on the outer annular fibers the outer fibers may also press on the posterior longitudinal ligament the outer fibers remain in tact can occur suddenly or over time usually affects people between the ages of '0-(5 significant amount of nucleus pulposus combined with degeneration of the annulus fibrosus! repair of the disc takes time due to the relatively avascular nature of the disc# )epair usually leaves the disc weaker than normal Four Types of Disc Herniation protrusion the disc bulges usually posteriorly! without rupturing the annulus fibrosus of the disc prolapse the disc bulges* only the outermost layers of the annulus fibrosus contain the nucleus extrusion part of the nucleus pulposus enters the epidural space# +he annulus fibrosus is ruptured but the nucleus pulposus lies under the ,--# common in posterior herniations! sequestration formation of fragments of both the nucleus pulposus and annulus fibrosus

.most common site of disc herniation occurs at -(--5 or -5-$" because this segment bears the most weight and has a relatively high lumbosacral angle "(0 degrees!

Causes "# /a0or +rauma - /12 - falling - lift and twist 2#,ostural 3eviation - anything leading to excessive rotational or hori4ontal stressing of the disc '# 5ear 6 +ear - microtrauma causing tearing of the annular fibers over time Possible Mechanism of Injury lumbar! person bends over to pick up something usually happy! trunk flexion7 flatten the anterior nucleus, opens up a posterior space and stretches the posterior fibers of the annulus person will 0erk into an erect posture possibly twisting at the same time while carrying a heavy load sudden return to extension7 redistributes the nucleus and shoots it into the posterior space with great force force of motion causes nucleus to protrude through the annular fibers Manifestations lumbar! "# -ocal ,ain - d8t irritation and inflammation of ligaments all, ,--! 2# )eferred ,ain - d8t pressure on the && root '# ,aresthesia - pins 6 needles, numbness along affected dermatomes (# $pecific /uscle 5eakness - will occur 9uickly only in // supplied by affected &&# 5# ,ain 2ggravated by /ovement - relieved with rest but increases with sitting and coughing - dull or knife like pain on side of herniation8prolapse! :linical ,icture7 -umbar

sits in slumped posture or stands to reduce pain may be unable to weight bear on painful leg lateral shift away from side of pain may have loss of ;&% lordosis, flattening of t-spine, shoulder girdle retraction

:linical ,icture7 :ervical $pine occurs anteriorally usually with whiplash! all lig# and anterior neck // affected trouble swallowing, or sore throat sensation posterior in0ury has similar manifestations as lumbar /anifestations sudden, acute onset of pain in the morning sharp pain that turns to general // spasm as day progresses unable to rotate head to one side Degenerative Disc Disease Definition: degeneration of the annulus fibrosus fibers of the intervertebral discs characteri4ed by pain and scarring# :auses "# :hronic overloading of the disc - microtearing of the annular fibers and migration of the nucleus 2# 2ging Aging Process decreased fluid content of the disc decreased height of disc vertebrae come closer together posterior ligaments become slack allows for more movement and decreases stability of the spine! may lead to excessive tilting of vertebrae during flexion possibility of tearing the annular fibers Contributing Factors trauma muscle imbalances postural dysfunction chronic degenerative changes in the disc Stages of Disc Degeneration poor blood supply to the disc lack of flexibility improper back support hypermobile8hypomobile facet 0oints

$tage "7 3ysfunction weakness, bulging and minor tears of the annulus which heal slowly d8t biomechanical changes disc protrusions may be sumptomatic considered reversible Manifestations painful chronic facet 0oint irritation 0oint effusion muscle spasm reduced )</ $tep 27 =nstability posterior annular fibers and 0oint capsule become lax and the vertebral segment becomes hypermobile small circumfrential separations between the layers of the disc disc secured by peripheral osteophytes in an attempt to restabili4e the vertebral segment with bony reinforcement along the spinal ligaments tissue change is considered permanent Manifestations pain d8t increased mobility && entrapment spondylolisthsis or anterior displacement of -5 on $" lumbar! $tage '7 stabili4ation loss of disc material and decreased disc height narrowing of the intervertebral foramen fibrosis of 0oint capsule and posterior ligament degeneration may spread to other vertebral levels

Manifestations osteophyte formation decreased )</ stenosis narrowing of spinal canal! dull, aching pain aggravated by movement intense, sharp, stabbing or referred pain d8t pressure on && root Cervical Degenerative Disc Disease gradual onset of neck stiffness and pain into shoulders worse on one side! progression of disease may cause7 paresthesia, loss of reflexes, mm weakness fre9uent occipital headaches slow or rapid onset of symptoms umbar Degenerative Disc Disease pain across low back, hip occasional in leg pain is worse with prolonged activity history of back in0ury Degenerative Disc Disease!Herniation

+rue neurological signs7 motor weakness specific to level of && lesion and dermatomal sensory %s && root impingement syndrome7 symptoms with condition "bjective Information <bservations postural assessment

palpation7 mm crossing affected level prish signs of inflammation 2cute >erniation - 2? 6 ,) )</ in c-spine or --spine - 2? flexion --$pine - slump - act# res# sensory tests - valsalva%s - kemp%s - kernig%s - straight leg raise, deep tendon reflexes -( lesion7 ankle dorsi-flex, heel walking weak sensory %s medial aspect of ankle -5 lesion7 gr# toe ext# weak sensory %s dorsum of foot $" lesion7 plantar-flex, toe walking weak sensory %s lat# aspect of ankle

+esting 333 - 2? 6 ,) )</ in c-spine or lumbar spine - 2) isometric testing $pecial +ests :-$pine - upper limb tension test - spurling%s - valsalva%s - deep tendon reflex

:5 lesion7 shoulder 2@3 weak sensory %s lat# forearm :6 lesion7 elbow flex, wrist ext# weak :A lesion7 elbow ext, wrist flex# weak :B lesion7 thumb abd# weak sensory %s little8ring finger +" lesion7 finger add# wear sensory %s medial forearm Differentiating Sources of Pain &eck 6 2rm ,ain "# facet 0oint irritation C kemp%s test 2# thoracic outlet syndrome adsons, eden%s, wright%s '# scalene +,%s scalene cramp 6 relief tests (# :arpal tunnel syndrome phalen%s test 5# tendonitis act# resisted test 6# osteoarthritis x-ray A# visceral pathologies Contra-In#ications

-ow @ack 6 -eg ,ain "# ?acet 0oint irritation kemp%s test 2# sacroiliac 0oint mobility motion palpation '# sacroiliac 0oint dysfunction gaenslen%s, faber, $" motion test (# hip pathologies faber 6 hip 9uadrant tests 5# spondylolisthesis 6# visceral pathologies

"# bladder, weakness, saddle anesthesia

2# '# (# 5# 6#

if no position relieves pain positions aggravate symptoms avoided do not mobili4e hypermobile 0oints do not remove protective spasming deep techni9ues avoided on atrophied //

Treatment $oals DDD ,ositioning7 prone, supine, sidelying pillow support pain free position >ydrotherapy7 heat to affected areas of fascial restriction - reduce pain and spasm - lower $&$ firing - reduce fascial restriction, >+, +,%s - mobili4e hypomobile 0oints - stretch short // - encourage circulation to overstretched // Self-Care DDD maintain )</ relieve compressive forces educate client refer client if needed Herniation maintain pain free )</ reduce herniation strengthen weak // educate client posture! refer client if needed TX Frequency 2x week for ' weeks then reassess "x week for " month ,ositioning7 prone, supine, side-lying depending on level of herniation >ydrotherapy7 ice reduce spasm and pain - reduce pain and spasm - reduce fascial restriction, +,%s