INTERVERTEBRAL DISC LESIONS AND THEIR MANAGEMENT..

Inter- Vertebral Disc Lesions and their Management

Bhaskar KS, Priyadarshini P

Inter-vertebral disc lesions are common disease condition relevant in practice of Naturopathy and Yoga with complaints of Back pain and associated Neurological symptoms. Here we are explaining etiological factors,Patho-physiology and their treatment by Physiotherapy and Acupuncture.

Breakdown in Annulus fibrous may occur with fatigue loading over time or with traumatic rupture (1,2).

Fatigue breakdown usually occurs with repeated overloading of spine in flexion with asymmetric forward bending and torsional stresses (1,2,3,4).

With torsional stresses, the annulus becomes distorted. Most obviously at the postero-lateral corner opposite the direction of rotation. Each layer then acts as separate barrier to the nuclear material. Eventually radial tear occur and there is communication of nuclear material in between the layers (3).

With repeated forward bending and lifting stresses the layers of annulus are strained. They become tightly packed together in the postero-lateral corners and by which radial fissures develop.

Following injury, there is tendency for the nucleus to swell and distort the annulus. Distortion is more severe in the region where annular fibres are stretched (1,5).

Healing is attempted but there is poor circulation in the disc. There may be self-sealing of a defect with a nuclear gel (6) or proliferation of cells of the annulus to seal the defect (5).

Axial Overload:
Axial overload of the disc usually results in end plate damage or vertebral body fracture before there is any damage to the annulus fibrosus (7).

Age:

Individuals are most susceptible to symptomatic injuries between 30–45 years of age.

Degenerative changes:

As the nucleus becomes more fibrotic it looses its capacity to imbibe fluid. Water content decreases and there is associated decrease in size of nucleus (8).


Effect on spinal mechanics:

Injury or degeneration of the disc affects the spinal mechanism in general (9).
Disc protrusion, tissue fluid stasis, diskogenic pain and swelling from inflammation are conditions that may occur from prolonged flexion postures, repetitive flexion micro- trauma or traumatic flexion injuries.

Signs and symptoms:

Neurological signs arise from pressure against spinal cord or nerve roots. The only true neurological signs are:
- Specific motor weakness
- Specific dermatome sensory changes
- Increased myo-electrical activity in hamstrings
- Decreased SLR
- Decreased tendon reflex

May be associated with referred pain stimuli from spinal muscles, inter- spinous segments, the disk and facet joints are not true signs of nerve root pressure (10, 11, 12).

Severe midline pain or pain radiating till thigh
A large postero-lateral protrusion may cause spinal signs such as loss of bladder control and saddle anesthesia.

The back pain may be worse than leg pain on SLR test. Poor resolution of this inflammatory stimulus may lead to fibrotic reactions and chronic pain (13,14,15).


Physiotherapy Management:

Principles of Treatment (16,17,18):

1. Effect of postural changes:

· In lying position least pressure is exerted
· Support for lumbar spine with trunk incline to 120 degree

2. Effect of flexion and extension:

passive spinal extension relieves signs and symptoms of vertebral lesions

3. Isometric activities: Forward bending should be avoided

4. Traction: Traction for more than 10 minutes should not be used

General Treatment goals:

1. To relieve pain and promote relaxation: rest with massage and traction
2. Relieve swelling: Repeated extension, ice application
3. Education of patient: Postural corrections


Acupuncture management: (19-25)

Mc Donald et al (1983) treated 17 patients with superficial acupuncture mock TENS. A VAS was used to measure pain and to assess activity, mood, percentage of pain relief and reduction in physical signs; it showed a significant benefit of Acupuncture over placebo in four out of five of the outcome measures. The pain score reduction (by vas) was not significant. The combined average reduction was however significant (p<0.01).>
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