HERNIATED NUCLEUS PULPOSUS

Presenter
Banni Aprilita Pratiwi C111 12 286

Advisor :
dr. William Limoa
dr. Ricky F. Tambunan
dr. Moh. Asri Abidin
Supervisor :
dr. Jainal Arifin Sp.OT (K) Spine

Orthopaedics and Traumatology Department

Faculty of Medicine, Hasanuddin University
2018
DEFINITION

 Hernia is a protrusion of an organ or tissue through an

opening in its surrounding walls, especially in the
abdominal region.

 Nucleus pulposus is the inner core of the vertebral disc.

The core is composed of a jelly-like material that consists
of mainly water, as well as a loose network of collagen
fibers.

Kumala, Poppy. 1998. Kamus Saku Kedokteran Dorland. Jakarta. Edisi Bahasa Indonesia. Hal 505.
Company Saunder. B. W. 2000. Classification, Diagnostic Imaging, and Imaging Characterization of A Lumbar. Volume 38
DEFINITION

Hernia Nucleus Pulposus :

a condition in which part or

all of the soft, gelatinous
central portion of an
intervertebral disk is forced
or prolapse through a tear
in the surrounding annulus
fibrosis, resulting in back
pain and nerve root
irritation.
Lotke, Paul A dkk. 2008. Lippincott’s Primary Care Orthopaedics. China: Philadelphia.
EPIDEMIOLOGY

 The prevalence of a symptomatic herniated nucleus

pulposus is about 1-3% with the highest prevalence
among people aged 30 to 50 years.
 A male to female ratio of 2:1.
 In 95% of the lumbar disc herniation the L4-L5 and
L5-S1 discs are affected.
 The cervical disc herniation is most affected 8% of
the time and most often at level C5-C6 and C6-C7.
Pinzon, Rizaldy. 2012. Profil Klinis Pasien Nyeri Punggung Akibat Hernia Nukelus Pulposus. Vol 39. SMF Saraf RS Bethesda Yogyakarta. Indonesia. Hal 749-751.
ETIOLOGY

 Degeneration of the intervertebral disc (>>>)

 Trauma is a less common cause of disc herniation.

Moore, Keith L dan A. M. R. Agur. 2013. Clinically Oriented Anatomy. Philladhelpia: Lippincott Williams & Wilkins.
 Anatomy

Thompson, Jon C. 2010. Netter’s Concise Orthopaedic Anatomy, Second Edition. Elsevier Inc.
 Anatomy

Thompson, Jon C. 2010. Netter’s Concise Orthopaedic Anatomy, Second Edition. Elsevier Inc.
 Anatomy

Thompson, Jon C. 2010. Netter’s Concise Orthopaedic Anatomy, Second Edition. Elsevier Inc.
 Physiology

- -Nucleus
The annulus pulposus is composed
fibrosus consists of of aa highly
loose,
-nonorientated
The vertebral endplate
collagen framework is (mainly
the interface
type III
orientated densely packed collagen (mainly type
between
collagen),the disc and the of
which adjacent vertebral body
collagen) and consists
becomes aprogressively
sparse population
moreof
and
cells,consists
resemblingof achondrocytes,
layer of condensed
that arecancellous
embedded
compact and tougher at the periphery. The outer
bone and
in a gelatinousan adjacent
matrix thin
of various layer of hyaline
proteoglycans
annulus fibrosus forms numerous concentric
cartilage.
- rings
Proteoglycans Disc metabolism and nutrition is
of layers orattract andThehold
lamellae. fibreswater
of eachinring
the
dependent on diffusion
interverterbral discto of nutrients
to allow the disc toacross the
withstand
cross diagonally provide greater tensile
vertebral
a loadingendplate
force. The nucleus pulposus contains
strength.
approximately 80% water..

Herkowitz, Harry N. MD. et al. 2011. Rothman-Simeone The Spine, Sixth Edition. Elsevier Saunders:
Philadelphia.
Thompson, Jon C. 2010. Netter’s Concise Orthopaedic Anatomy, Second Edition. Elsevier Inc.
 Pathogenesis
Cellular and Biochemical Changes of the
Intervertebral Disc

• Annulus. The ratio and relative distribution of type 1 to type 2

collagen changes in the outer annulus. A decrease in collagen cross-
links occurs, making the annulus more susceptible to mechanical
failure
• Nucleus. Matrix changes occur including fragmentation of
proteoglycans (mainly aggrecan), decreases in proteoglycan and water
concentrations, and decrease in number of viable cells
• Endplate. Thickening and calcification in the endplate region leads to
decreased blood supply and impaired disc nutrition, which contributes
to tissue breakdown in the endplate region and nucleus

Herkowitz, Harry N. MD. et al. 2011. Rothman-Simeone The Spine, Sixth Edition. Elsevier Saunders:
 Pathogenesis
With aging, vascular channels start to fail and vascular diffusion of
nutrients decrease thus number of viable chondrocytes in the nucleus
pulposus diminishes

Synthesis rate & concentration of

proteoglycans decreases & proportion of
collagen increase in nucleus pulposus

Water binding capacity of the

nucleus decreases

Nucleus becomes more fibrous & stiffer

Nucleus is less able to bear & disburse load,

transferring load to the posterior annulus

ANNULUS ANNULUS
INTACT FAILS

Sivananthan S, Sherry E, Warnke P. 2012. Mercer’s Textbook of orthopedics and trauma 10th edition. Hodder Education, an Hachette UK
 Pathogenesis

ANNULUS Facet joints share even Facet joints undergo FACET JOINT
INTACT more of the axial load degenerative changes & develop SYNDROME
osteophytes

Expression of this degraded

ANNULUS Fissures develop across
annular lamellae may extend
FAILS
upto disc periphery
Internal disc disruption nuclear material through
DISC
HERNIATION
cause AXIAL PAIN these radial fissures

Sivananthan S, Sherry E, Warnke P. 2012. Mercer’s Textbook of orthopedics and trauma 10th edition.
Hodder Education, an Hachette UK company
 STAGES OF DISC PROLAPSE
Pathogenesis

Herkowitz, Harry N. MD. et al. 2011. Rothman-Simeone The Spine, Sixth Edition. Elsevier Saunders:
 Clinical Features
Herniated Nucleus Pulposus in Lumbar
segment
• Usually involves the L4 to L5 disc (the “backache disc”), followed
closely by L5 to S1. Most herniations are posterolateral
• Character of pain—referred pain in mesodermal tissues of the
same embryologic origin.
 Localizes to buttocks or posterior thighs
• Postural effects
 Disc pathology leads to pain in flexion or sitting(Flexion
holding weight is worst).
 Usually pain relieved in extension (Supine is best).

Herkowitz, Harry N. MD. et al. 2011. Rothman-Simeone The Spine, Sixth Edition. Elsevier
Herkowitz, Harry N. MD. et al. 2011. Rothman-Simeone The Spine, Sixth Edition. Elsevier Saunders:
 Physical examination

• Inspection, change in posture, gait

• Palpation of the posterior spine (spasm,
localized tenderness)
• Measurement of range of motion (decreased
flexion)

Herkowitz, Harry N. MD. et al. 2011. Rothman-Simeone The Spine, Sixth Edition. Elsevier
 Contralateral Straight Leg

Special Test
Straight Leg Raising Test
Raising Test

Braggard Test Bowstring sign

Buckup K, Dortmund K. 2011. Clinical test for the musculoskletal system.Thieme stutgart: New
RADIOLOGY
EXAMINATION
 NORMAL SPINE

COMPUTED TOMOGRAPHY CONVENTIONAL RADIOGRAPHY

Source: Herring, William. 2016. Learning Radiology: Recognizing The Basics, Third
Edition. Elsevier Inc.
HERNIATED NUCLEUS PULPOSUS
 Disc protrusion Source: Weyreuther, Martin. et al. 2006. MRI Atlas Orthopedics and
Neurosurgery The Spine. Springer: German.

Midline sagittal T2-weighted, change Midline sagittal T1-weighted

signal intensity of the L5-S1 disc of normal T9-10 to S2
HERNIATED NUCLEUS PULPOSUS
 Disc protrusion
Source: Solomon, Louis MD, David Warwick MD, Selvadurai Nayagam
BSc. 2010. Apley’s System of Orthopaedics and Fractures, Ninth Edition.
Hodder Arnold: United Kingdom.

(a) Radiculogram in which the gap in the contrast medium (arrow)

shows where a disc has prostruded. (b) CT scan showing how disc
protrusion can obstructed the intervertebral foramen. (c) MRI, axial
view, showing the relationship of the disc protrusion to the dural sac and
intervertebral foramen
HERNIATED NUCLEUS PULPOSUS
 Disc extrusion Source: Weyreuther, Martin. et al. 2006. MRI Atlas Orthopedics and
Neurosurgery The Spine. Springer: German.

Midline sagittal T2-weighted, change Midline sagittal T1-weighted

signal intensity of the L4-5 disc of normal T9-10 to S2
HERNIATED NUCLEUS PULPOSUS
 Sequstration Source: Weyreuther, Martin. et al. 2006. MRI Atlas Orthopedics and
Neurosurgery The Spine. Springer: German.

Midline sagittal T2-weighted, disc Midline sagittal T1-weighted

fragment posterior to the L2-3 interspace of normal T9-10 to S2
 TREATMENT

Source: Thompson, Jon C. 2010. Netter’s Concise Orthopaedic Anatomy, Second Edition. Elsevier Inc.
 DIFFERENTIAL DIAGNOSED

There are two diagnostic aphorisms:

 Lower limb pains not always the sciatica of root compression;
frequently it is referred pain from backache and can occur in other
lumbar spine disorders.
 Disc rupture affects at most two neurological levels
 Inflammatory disorders such as infection or ankylosing spondylitis
 Vertebral tumours cause severe pain
 Nerve tumours such as a neurofibroma of the cauda equina

Source: Solomon, Louis MD, David Warwick MD, Selvadurai Nayagam BSc. 2010. Apley’s System of
Orthopaedics and Fractures, Ninth Edition. Hodder Arnold: United Kingdom.
 COMPLICATION
 Cauda Equina Syndrome

Clinical diagnosis of cauda equina

syndrome:
•Perineal sensory deficit (saddle
anesthesia)
•Bowel or bladder incontinence
•New onset lower extremity sensory
deficit
•New onset or progressive lower
extremity motor deficit
Source: Herkowitz, Harry N. MD. et al. 2011. Rothman-Simeone The Spine, Sixth Edition. Elsevier Saunders:
Philadelphia.
 COMPLICATION
 Recurrent disc herniation -> 0-18% of cases

The distinguishing histologic features of recurrent disc herniation :

 Presence of large collagen bundles
 Fibrillar framework
 Granulation tissue

Source: Herkowitz, Harry N. MD. et al. 2011. Rothman-Simeone The Spine, Sixth Edition. Elsevier Saunders:
Philadelphia.
 PROGNOSIS
 Patient who are not responding to non operative treatment, can be evaluating in
interval 2 to 16 months, except for patient with progressive neurologic deficit or cauda
equina syndrome
 Patient with symptom duration more than 2 months had a statistically significantly worse
outcome than patients operated on within 2 months

Source: Herkowitz, Harry N. MD. et al. 2011. Rothman-Simeone The Spine, Sixth Edition. Elsevier Saunders:
Philadelphia.
THANK YOU