Acute Disc Prolapse
Definition
Used to be called sciatica
Epidemiology
Acute disc prolapse
Prevalence 5%
Age - 20-40y
Location: central, posterolateral or foraminal - most common L4-5, L5-S1 (90%)
Aetiopathogenesis
Disc degeneration --> low cell regeneration --> Annular tear+disc bulging --> prolapse --> chemical irritation by cytokines (IL-1, IL6, TNF-a) --> radiculopathy
Natural History
70% improve on its own
Clinical Features
Symptoms
Signs
Management
Manage pain + Reassurance
Anti-inflammatory
Nerve modulation (all sedatives)
Narcotics (SE: constipation)
Surgical (Sciatica + nerve root tension signs + no improvement 4-8/52 rx + CT/MRI +ve)
Details
Anatomy: Ring apophysis --> Anulus fibrosus (lateral) --> Nucleus pulposus (medial) --> H2O
Source
Dr David Edis 2014
Used to be called sciatica
Epidemiology
Acute disc prolapse
Prevalence 5%
Age - 20-40y
Location: central, posterolateral or foraminal - most common L4-5, L5-S1 (90%)
Aetiopathogenesis
Disc degeneration --> low cell regeneration --> Annular tear+disc bulging --> prolapse --> chemical irritation by cytokines (IL-1, IL6, TNF-a) --> radiculopathy
Natural History
70% improve on its own
Clinical Features
Symptoms
- "Sciatica" in dermatome/ myotome distribution
- Lateral foot = S1
- Great toe = L5
- Medial leg = L4 (L4 can extend to great toe)
Signs
- +ve straight leg raise/ Fatiguing calf/ --ankle jerk reflex/ S1 dermatome = S1
- Trendelenburg +ve = L5
- Foot drop = L4
Management
Manage pain + Reassurance
Anti-inflammatory
- Paracetamol/ NSAIDs
- Oral glucocorticoids (no evidence to show it's more effective)
- Nerve root sheath and epidural depot steroid
- Systemic anti-TNF (infliximab) --> expensive
- Nerve root sheath anti-TNF (etanercept) --> expensive
Nerve modulation (all sedatives)
- Amitriptyline (25mg nocte, 10mg mane)
- Carbemazepine, Na Valproate
- Gabapentin (Lyrica), pregabalin
- Duloxetine (Cymbalta)
Narcotics (SE: constipation)
- oral codeine, oxycodone, hydromorphine, Targin
- Tramadol (release 5HT and SNRI)
- Transdermal buprenophine (Norspan)
- Parenteral morphine and pethedine
Surgical (Sciatica + nerve root tension signs + no improvement 4-8/52 rx + CT/MRI +ve)
- In AUS, 6-12w refractory to conservative rx
- Earlier if significant neurology
Details
Anatomy: Ring apophysis --> Anulus fibrosus (lateral) --> Nucleus pulposus (medial) --> H2O
Source
Dr David Edis 2014