All About Herniated Discs Anatomy & Pathology

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1 All About Herniated Discs Anatomy & Pathology Conflict of Interest Disclosure DR. HABER CERTIFIES THAT, TO THE BEST OF HIS KNOWLEDGE, NO AFFILIATION OR RELATIONSHIP OF A FINANCIAL NATURE WITH A COMMERCIAL INTEREST ORGANIZATION HAS SIGNIFICANTLY AFFECTED HIS VIEWS ON THE SUBJECT ON WHICH HE IS PRESENTING. Objectives: Evaluate the societal impact of a bad back. Describe and discuss the anatomy of a normal disc. 1

2 The Disc Definitions The structural components and their role in life Gross Anatomy Radiographic Anatomy Plain films CAT(Computerized Axial Tomography) Anatomy MRI(Magnetic Resonance Imaging) Anatomy How does the spine age What goes wrong The spine C spine Lateral view Plain film 2

3 Anatomy of the Cervical Spine Definitions: Disc: Intervertebral Fibro-Cartilage which lies between adjacent vertebra 3

4 Definitions: Nucleus Pulposus: Hydrated gel-like matter that resists compression Definitions: Anterior and Posterior Spinal Ligaments: Ligaments running along the anterior and posterior aspect of the spine overlying the annulus fibrosis Definitions: Annulus Fibrosis: Radial tire-like structure that is made up of laminae composed of concentric sheets of collagen fibers at various angles. Its role is to enclose and protect the integrity of the Nucleus Pulposus 4

5 Definitions: Apophyseal Joints: Joints at the posterior aspect of the arch that add strength to the arch and articulate with the vertebral bodies above and below. Facets are those portions of the vertebral bodies that are part of the articulating joint. Each vertebral body has 2 facets. Definitions: Spinal Canal: Tube in which the spinal cord traverses Radiographic Anatomy CAT Scan Anatomy-Normal Cervical spine Dorsal spine Lumbar spine 5

6 Radiographic Anatomy MRI Anatomy-Normal Cervical Spine Dorsal Spine Lumbar Spine Anatomy of cervical Spine A-P view Anatomy of the Cervical Spine 6

7 C spine Lateral CT C spine Lateral view Degenerative spurring at C5-C6 Lumbar Spine Anatomy A-P View 7

8 Lumbar Spine Anatomy Lumbar Spine 8

9 CAT Scan with reconstructions MRI of the Lumbar Spine- sagittal view MRI Lumbar spine 9

10 Lumbar Spine Anatomy T2 transaxial of Lumbar Vertebral Body 1. Dessicated Discs with the exception of L5-S1 10

11 Torn Annulus Fibrosis 11

12 Blow- up of Sequestered disc at L5-S1 L5-S1 herniated disc treated with epidural steroid injection and time with near total resolution 1 of 2 images Disc dissolved after steroid injection 12

13 Thoracic Disc Extrusion Blow up of thoracic disc extrusion Calcified Thoracic Herniated Disc 13

14 Right foraminal Disc Herniation Blow-up of Rht foraminal Disc Herniation Sagital view of rht L3-L4 foraminal herniation 14

15 Thoracic Discitis The structural components and their role in life Why is there a intervertebral disc? What does it do? What occurs when it degenerates? What happens when it herniates? Definitions of Disc Pathology Classical Definitions that are used inconsistently Herniated Disc Tear or rupture of the Annulus Fibrosis with resultant rupture of the contents(nucleus Pulposus) Bulging Disc Extension of Annulus Fibrosis(not torn) and contained Nucleus Pulposus from the normal anatomic confines and extension 1) anteriorly 2) posteriorly 3) postero-laterally Protruding Disc lost in the wasteland of confusing contradictory terms 15

16 Definitions of Disc Pathology-continued Extruded Disc When the disc herniates that portion of the herniated disc increases in its vertical length and is expanded. It may move cephaled or caudad. Sequested Disc When a herniated disc losses its connection with its normal anatomic intervertebral space and migrates(extruded disc + lost connection) Dessicated Disc When a normally well hydrated disc losses water (frequently an assessment only made on MRI) Osteophyte/Discal Complex When the osteophytic spur and desiccated disc extend into the canal What do the definitions really mean? Answer: very little as precise indicators of pathology In reality It is far more important to discuss the impact that the pathology is having on structural components Thecal sac Neural foramina Nerve roots Clinically Relevant Data Does the disc appear new or old(water or dry)? Is there a tear at the Annulus Fibrosis? Does the disc compromise the Spinal Canal? Does it impact /pressure the Spinal Cord? Does it extend into the Neural Foramina? Is it a focal or broad based herniation? 16

17 Rht 3- L4 foraminal disc herniation Blow up of Rht L3 L4 foraminal herniation L1-L2 Foraminal Herniation 17

18 Recurrent Disc Herniation after Laminectomy Rht laminectomy with fibrosis or recurrent Disc on L C4 C4 extruded Disc after Chiropractic manipultation 18

19 Rht L4 Schwannoma Blow up of L4 Schwannoma L2 Schwannoma 19

20 Rht L3- L4 Hemangioblastoma Hemangioblastoma Rht L3-L4 Epidural Osteomyelitis L spine T1 contrast 20

21 Hangman s Fracture with Traumatic herniation of C2 C3 Disc Modic Changes-Type 1 Hypo T1, Hyper T2 Bone Marrow edema + inflammation Modic Changes Type 2 high T1, normal or high T2 Red marrow Yellow Marrow Ischemia 21

22 Modic Changes- Type 3 Low T1, Low T2 subchondral bone sclerosis Socio- Economic Implications Journal of Bone Joint Surgery Apr 2006 Total cost of low- back pain in the US exceed $100,000,000,000.(not million but billion) (remember this is 2006!!!) Each year only 5% of the patients who have an episode of low-back pain account for 75% of the total costs Science Daily June 29,2010 Economic impact in the US may be as high as 200,000,000,000(billion) 22

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