Prolapsed Intervertebral Disc (PIVD) : Case & Review

Prolapsed Intervertebral Disc (PIVD) : Case & Review




Prolapsed Intervertebral Disc (PIVD) is a medical condition affecting the spine in which a tear in the outer fibrous ring of an intervertebral disc allows the soft, central portion to bulge out beyond the damaged outer ring. Commonest site of occurrence is at L4/L5 or L5/S1 . In this article we report a case of Prolapsed Intervertebral Disc ( PIVD)  in  64 year old male who presented with decreased sensation of left lower limb progressing up to knee.

64 Year old male non alcoholic, non smoker with no known history of hypertension and diabetes presented to our out patient department with complaint of decreased sensation of left lower limb for 16 days, which initially presented on the left foot,  eventually progressing upto left  knee. Later he also complained of the decreased sensation of the right lower limb. There was also  history of burning sensation and continuous muscle tightening over bilateral limbs associated with limping while walking. There was no history of trauma, fever , loss of consciousness. Bowel and bladder habit was normal.




On examination vitals were stable and cardinal signs were absent.  Higher mental function and cranial nerves were intact.  C-spine and Lumbar Spine was non tender. Straight leg raising test was less than 60 in left and less than 90 in right. Power was diminished over bilateral lower limbs. i.e  3/5 on the left leg and 4/5 on the right leg. Sensation was decreased on the outer aspect of bilateral leg and dorsum of the foot.  The  investigations revealed following :

 

LAB INVESTIGATIONS

Hemoglobin:- 14 gm/dl

Total leukocyte count:- 6,500 /cumm

Neutrophils :- 50% lymphocytes:-22%

ESR:- 02 mm/hr

Platelets:- 2,85,000 /cumm

Glucose random:- 82  mg/dl

Serum urea:-32mg/dl

Serum creatinine:- 0.94 mg/dl

MRI: Central disc prolapse at L4/L5 level with bilateral nerve displacement at L5 nerve root.

 

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The patient was admitted to orthopedic ward and PAC was done.  L4-L5 Laminectomy was done the next day. The patient then was  treated post operatively with IV fluids, Antibiotics, Aceclofenac, Omeprazole and Ketorolac. The post operative course was uneventful. The patient  then was subjected to physiotherapy.

 

CASE DISCUSSION : PROLAPSED INTERVERTEBRAL DISC(PIVD)

What is intervertebral disc?

Disc simply means the fibrocartilaginous structures that are squeezed between the adjacent vertebral bodies. These discs lend the limited flexibility to the spine. Each disc consists of an outer fibrous ring annulous fibrou which surrounds the inner gel like center nucleus pulpous.

The posterior edges of these discs lie on the anterior boundary of the spinal canal and postero laterally they skirt  the right and left intervertebral canal. Therefore the disc lesions are usually associated with the neurological symptoms.

 

What is Prolapsed Intervertebral Disc (PIVD)?

PIVD is a medical condition affecting the spine in which a tear in the outer fibrous ring of an intervertebral disc allows the soft, central portion to bulge out beyond the damaged outer ring. Commonest site of occurrence is at L4/L5 or L5/S1. The highest prevalence is among people aged 30-50 years, with a male to female ratio of 2:1.

 

What causes Prolapsed Intervertebral Disc (PIVD)?

The common etiological factors of PIVD include:

  • Degenerative disc disease
  • Wear and tear such as constant sitting or squatting, driving or sedentary life style
  • Lifting heavy loads
  • Abrupt bending or torsional movement of lower back.

 

How does Prolapsed Intervertebral Disc present?

Patient might give the history of a fore mentioned causes preceding the symptoms. There is usually history of back pain radiating towards lower limbs and/or buttocks. The pain gets aggravated on coughing and straining. Following pain the patient might develop parasthesia (abnormal sensation such as tingling, tickling, pricking, numbness or burning of a person’s skin with no apparent physical cause) in the leg or foot and occasionally muscle weakness.




If untreated the disease might progress into an emergency condition known as cauda equine leading to permanent dysfunction of sphincter control. On examination the patient stands with slight list to one side. The back movements will be severly restricted and during forward bending the list might increase. Tenderness in the midline of the lower back and paravertebral muscle spasm are also commonly observed. Straight leg raising tests painful and limited on the affected side.

Neurological examination will reveal muscle weakness followed by wasting. The reflexes might be diminished and the sensory loss corresponding to the affected level. (eg:  L5 impairment causes weakness of big toe extension, knee flexion with sensory loss on the outer side of the leg and the dorsum of the foot)

 

What investigations to send for the confirmation of diagnosis?

X-ray: It will reveal  narrowing  of the inter vertebral disc spaces accompanied by the osteoarthritic changes in the facet joint.

CT/MRI: In addition to disc changes, CT/MRI will rule out bone encroachment into the spinal canal and or intervertebral foramen.

 

What are the treatment options in Prolapsed Intervertebral Disc ?

If  symptoms are not severe conservatives measures are encouraged. These consists of instruction in modified activites, physiotherapeutic exercise, manipulation during acute episodes and if possible wearing of lumbar corset. The use of walking can sometimes relieve tension on paravertebral muscles and relieve pain. If these advice consistently applied cannot relieve the symptoms surgery must be considered.

 

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REFERENCES

1.
Jordan J, Konstantinou K, O’Dowd J. Herniated lumbar disc. BMJ Clin Evid. 2009;2009.
2.
Solomon L, Warwick D, Nayagam S. Apley’s System of Orthopaedics and Fractures, Ninth Edition. CRC Press; 2010.
3.
Schultz A, Andersson G, Ortengren R, Haderspeck K, Nachemson A. Loads on the lumbar spine. Validation of a biomechanical analysis by measurements of intradiscal pressures and myoelectric signals. J Bone Joint Surg Am. 1982;64(5):713-720.

 

 

 

Dr. Subhash Shrestha started his medical career an intern doctor in Orthopedics managing life threatening acute traumatic cases. He is currently working in Department of Pediatrics and Neonatology.