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 Age Sex Religion Ethnic Education Civil Status

: Mrs. Neah : 45 years old : women : islam : sundanese : SMP : 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

CHIEF COMPLAINT
Pain on the back and waist that radiate to both low extremities

ADDITIONAL COMPLAINT
Numbness felt on both feet Weakness on both feet after walking for a short distance

HISTORY OF PRESENT ILLNESS

15 YEARS AGO - involved into an accident -> hit from her back ->felt into seated position -> didnt seek any medical treatment NOVEMBER 2013 complain felt the pain on her back, radiating from the waist to buttock and both lower legs, numbness on both her 3 MONTHS LATER: suddenly both legs numb and cant walk feet, worse when start walking and coughing, weak legs for walking, stiffness on her hip and knee joint 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

History of past illness

same problem before (-) Asthma (-), DM (-). Heart disease (-), kidney disease (-) Hereditary illness (-) Cancer in family(-)

History of past treatment Operation (-) warded at Cipto Mangunkusomo Hospital last 15 years ago.

Habits of history Seldomly exercise often lift heavy thing. balanced diet and eat thrice a day that contain rice, fish, chicken and also vegetables alcohol (-), smoking (-) herbal medicine twice a week

PHYSICAL EXAMINATION
General condition moderately illness Consciousness compos mentis Blood preasure 120/80 mmHg Heart rate 76x/min

Respiration rate 20x/min

Temperature 36.7oC

Weight 65kg

Height 155cm

BMI 27.08 (overweight)

Head

normalcephaly, black hair with normal distribution, difficult unpulg, no lesion and bump
normal shape, symmetric , pupile isokor, conjunctiva anemis(-/-), sclera icterik(-/-), direct light reflex(+/+) undirectly light reflex(+/+) 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(-/-) normal in shape, no deformity, septum deviation(-), concha hyperthrophy(-/-). secret(-/-) lips not dry trismus(-), tongue not dirty, teeth normal, good oral hygiene, Hyperemis pharynx (-) normal in shape, no palpable the enlargement of lymph node

Eyes

Ear

Nose

Mouth

Neck

Lung
Inspection movement of brething left and right symmetric , retraction intercostal space(-/-), lesion(-) vocal fremitus left and right symmetric, no compresive pain(-/-)
sonor in both side of lung sound of breathing right and left vesikuler, ronchi (-/-), wheezing(-/-)

Palpation

Percussion Auscultation

Heart
Inspection Palpation no pulsation of ictus cordis appearance ictus cordis palpable on intercostal space v, 1cm media from left midclavicle right border: intercosta space v right parasterna line Left border: intercosta space v, 1cm media from left midclavicula Upper broder: intercosta space ii from lef parasternal line sound of heart I-II reguler, gallop(-), murmur(-)

Percussion

Auscultation

Abdomen
Inspection
Auscultation Palpation

flat, smilling umbilicus(-), operation scar(-), veins dilatation(-), sound of intestine (+) 4x/min supel, no compresive pain(-), defens muscular(-), liver not palpable, spleen not palpable, kidney : ballotement(-/-), CVA(-/-) tympani, shiffting dullness(-)

Percussion

Upper extremity
Right
Muscle Tonus Mass Joints Eutrophy Normothony No abnormality No abnormality

Left
Eutrophy Normothony No abnormality No abnormality

Movements
Strenght Edema

Active
Normal No edema

Active
Normal No edema

Local status (thorax and lumbar vertebra)

The patient stand up

The colour of the skin was same like the other part of the body Scar (-), lesion (-), edema (-) Deformity : Scoliosis appearance (+)
Temperature equal like the other part of the body Tenderness (-) Deformity on spine contour (+) Spine joint Flexion = 50 (normal : 80) Extension = 15 (normal : 30) Lateral flexion = 35 (normal : 35) Sacroiliac joint : Pain on movement

LOOK

FEEL

MOVE

The patient lay down

FEEL Fossa iliac palpation Tenderness (-) Mass (-) Edema (-) Straight Leg Raising (SLR) Test Pain on 45 (normal : 60)

MOVE

NEUROLOGY STATUS

SENSORY
RIGHT Mid-anterior thigh(L2) Medial femoral condyle (L3) Medial malleolus (L4) 2 2 1 1 1 1 LEFT 2 2 2 1 1 1

Dorsum of the foot at the third metatarsal phalangeal joint (L5) Lateral heel (S1) Popliteal fossa in the mid-line (S2)

MOTORIC
RIGHT
Small finger abductors (abductor digiti minimi) T1 Hip flexors (iliopsoas) -L2 5 4

LEFT
5 4

Knee extensors (quadriceps) L3

Ankle dorsiflexors (tibialis anterior) L4 Long toe extensors (extensors hallucis longus) L5 Ankle plantarflexors (gastrocnemius, soleus) S1

4
4 4 4

4
4 4 4

MOTORIC
Passive movement Right Small finger abductors (abductor digiti minimi) T1 5 Left 5 Active movement Right 5 Left 5

Hip flexors (iliopsoas) -L2

Knee extensors (quadriceps) L3 Ankle dorsiflexors (tibialis anterior) L4

5
4 4

5
5 4

5
4 4

5
4 4

Long toe extensors (extensors hallucis longus) L5 Ankle plantarflexors (gastrocnemius, soleus) S1

4 4

4 4

4 4

4 4

REFLEX
Physiology reflex 1.Knee reflex 2. Achilles reflex Pathological reflex 1. Laseque 2. Kernig 3. Barbinsky Right Positive normal Positive normal Pain at 45 Negative negative Left Positive normal Positive normal Pain at 45 Negative Negative

LABORATORY FINDING
Value Hemoglobin Leucocyte Haematocrite Erythrocyte MCV MCH MCHC Different count : Basophile Eosinophile Rod Segment Lymphocyte Monocyte Trombocyte 13.7 g/dl 12. 500 /uL 41% 4.91 83 28 34 1 5 0 56 30 8 376.000 0-2 2-5 2-5 47-80 13-40 2-11 (140.000-440.000/ul) Normal Value 11,2-15,7 g/dl 3900-10 000/ul 39-45% 4.0-5.2 80-100 fl 27-34 pg

Erythrocyte sedimentation rate Blood Glucose Level Kidney function : creatine Ureum Uric acid Liver function : SGOT/ASAT SGPT/ALAT

26 sec 97

<10 sec 90-110

0.5 25 4.1 10 16

2.40-5.70 0,4-0,7 17-43

<37 <41

Immunoserologist - Rheumatoid factor

Fat Total cholesterol Triglyceride HDL cholesterol LDL cholesterol

Negative

Negative

181 109 36 124

<200 <150 >45 <133

CHEST X-RAY IMAGE

Description 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 L45 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
1. 2. 3. 4.

Base of diagnosis Anamnese Physical examination Laboratory finding Imaging finding

Differential diagnosis Canal stenosis Spondylolithesis

MANAGEMENT
Non 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 Ad sanationam Ad fungsionam

: bonam : dubia ad bonam : 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 AntiInflammatory 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).

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