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Management of L4-L5 Disc Prolapse

May 10, 2:00 PM

The L4-L5 motion segment, with its significant load-bearing function and wide range of flexibility, may be more prone to injury and/or degenerative alterations than other lumbar segments. Referred pain from the joints and/or muscles, as well as radicular symptoms that pass through nerves, may be caused by the L4-L5 motion segment. Medical therapies aim to alleviate discomfort, but they do not address the fundamental cause of the problem. Join us as Dr. Chandrashekhar Gaike, Consultant Orthopedic Spine Surgeon, explains how to treat L4-L5 disc prolapse surgically.

[Music] uh good evening everyone this is doctor vishali from netflix and i would like to welcome you for this session on management of l4 l5 disc prolapse today we have with us dr chandrasekhar he's a consultant orthopedic spine surgeon at the spine care center aurangabad so we welcome you on behalf of netflix and our audience with this i will be handing over to you good evening everyone so today my topic is uh regarding n45 disc products so actually that topic is very small so today i will be elaborating the various spine issues and how to diagnose means what are the common symptoms and signs in spine spine diseases how to diagnose and how to recognize which symptom is a serious symptom so that uh we can tackle it properly okay so uh myself doctor chandrashev i am working as a spine surgeon in aurangabad since last seven to eight years okay so next so today uh we will so this is an overview of my presentation so today uh i will be speaking on spine anatomy the common symptoms and signs of spine diseases what and uh when and what investigations to be done we will discuss few interesting cases so that so the the aim is to just involve you in the presentation then i will be speaking about false myths about spine surgeries and lastly about minimally invasive spine surgery and endoscopic spine surgeries so as you all know the spine problem like neck pain back pain these are very common symptoms uh even we ourselves might have experienced these issues during our life so basically these are commonly seen issues in our opinion practice also that's why we must be able to know what are the basic symptoms that may be associated with neck or back pain we must know the basic spine examination and we must be able to pick up some abnormal findings or signs during our when we examine the patient with spine issues simply because the early diagnosis and if you refer uh the patient with some serious so that's uh the whole aim of this presentation okay so let us start with this final problem so on right hand side i have put a mri image and on the left side there is a schematic diagram okay so as you all know this spine is divided into basically uh four parts that we have cervical spine which has seven vertebrae we have uh then uh we have torso spine which has twelve vertices then we have lumbar spine which has total fiber dp and lastly we have sacrament process so let us have a close view of our spine so again on one hand side we have the mri image and others right hand side we have a schematic diagram so this is the side view of uh operation means we are seeing patient from side so this is called as such atom so front side we have uh whatever bodies and between between whatever bodies we have interval disc just posterior to introverted but this passes the spinal cord so this black ribbon like structure this is final cut and uh and again backside we have posterior elements of spine which are called which has spinous processes and facial joints so this is next is the axial curl axial cut means we are seeing patient from above from head end so again we have front side that is called as anterior side and back side that is posterior side so anteriorly same we have uh what we have what is the invertible disc just posterior to intervertebralis is spinal cord okay from spinal cord arises spinal nerves which exit our spine through neural foramen and posteriorly again posteriorly we have acetone and spinal processes now why knowing the anatomy is important this simply because uh if we know the anatomy properly the compression of each part like suppose compression of nerve will give rise to specific set of symptoms and compression of central part that is spinal cord or thicker side that gives rise to another set of symptoms okay that's why knowing the spinal dome is basic uh while while seeing spine patients and while diagnosing these fine patients okay right now next slide is what are the common symptoms and signs that will be associated with nepalese so first common symptom is a radiating pain that this patient may present to us with radiating pain or tingling or numbness in upper and lower legs upper lips knees up in hands and lower lips in in legs next patient may present to you with neurogenic claudication or myelopathy they may present to you with weakness in upper or lower limbs patient may present to us with instability during walking that will get instability they may present to us with symptoms of bowel bladder now let us see the meaning of each symptom is what do you what do you mean by radiculopathy what is what do you mean by the origin claudication what is myopathy okay so first is radiating pain or radiculopathy so radiating pain or radiculopathy first of all it arises due to compression of nerves okay uh so there are two types of radiculopathy one is cervical radiculopathy and another is lumbar radiculopathy so in cervical radiculopathy patient typically present to us with neck pain and the which radiates in upper lip upper whole lip as seen as the in the schematic diagram uh along with pain patient may have sensory uh problems like numbness numbness or heaviness in uh upper lip or they they will be present with more touches what are changes or weakness in hands okay uh so as we can see in this uh mri picture and schematic diagram there is pressure over this these arrows are showing pressure was nerve roots okay so that means cervical radiculopathy radicular pain it occurs due to operation of nerves right the next one is lumbar radiculopathy now lumbar radiculopathy we also called it as sciatica or sciatica where patient complains compress of pain starting in buttocks or low back and which radiates down into the legs as shown in this ski body diagram this this arrow is showing uh the direction of sciatic pain okay so again same patient may have sensory disturbance like numbness or heaviness in the legs or they may present to you with weakness in foot or legs next patient may come to present to us with limping that is pain during walking right now next symptom is claudication now what do you mean by claudication so in publication patient typically complains uh that while it's after walking few distance suppose 50 meter 100 meters or 200 meters uh patient feel heaviness or numbness in his legs both legs and he has to sit for some time the symptoms uh release and again he can walk another hundred hundred to two hundred meters okay so that is typical symptom that is called as cloudication foreign it opens due to compression due to central compression over spinal cord at lumbar region so here we can see on left hand side it's the normal that that white uh structure it is thicker side or spinal cord that is a normal dimension and on right hand side we can see that arrow is showing that thicker side is totally compressed because of uh joint hypertrophy and soft tissue uh hypertrophy in the spinal canal so when such type of compression is present that temptation may completely it occurs due to compression spinal cord in cervical or uh dorsal spine okay so whenever there is compression of spinal cord patient present with us with symptoms of myelopathy so how they present uh it was clinically so clinically patient will complain that he is having numbness in hands and legs uh patient is having uh instability during walking they may present and when you examine them clinically uh when you examine the deep tender reflexes that reflexes will be exaggerated now on right hand side i put a mri picture here you can see that arrow is showing uh pronounced disc and this disc is compressing spinal cord that black ribbon structure disc is compressive okay so that so this is called as myopic now this is uh next important slide when to suspect some serious pathology some serious spine problem okay now this this slide is important because uh it will help us to uh during next two slides of interactive uh case discussion okay so uh first is pain in children so if children they complain of neck or back pain or some numbness and all thing that is not normal so whenever children come place of pain in neck or back so we must divide it further next is persistent pain in adults more than suppose more than 50 55 years if adults are complaining of pain in their back that should be evaluated further if patient is having a history of significant trauma this network batman started after trauma after falling down or after rotate accident that should be evaluated if patient is having history of malignancy okay some cancer history is there and now patient has started a new onset nicole backman that should be evaluated further then if you know compromised patients like hiv patients or hbcc positive patients and they also complain of network background that should be evaluated similarly if patient is having a history of weight loss or loss of appetite some non-mechanical pain non-mechanical painless while lying down or during night patient is having severe pain in neck or back that that also should be taken seriously similarly if along with network pacman patient has some neurological findings like numbness sciatica claudication or all baddest symptoms that should be even further uh as i spoke previously that should also be evaluated okay it should be evaluated miss what is what in restrictions to be done for that okay so they in in spine pathology the best investigation is mrs so when to advise uh mrs can so first whenever there are red flag signs red flag signs as i discussed in previous slides whenever if patient is having chronic symptoms uh say more than six weeks two months patients have persistent pain that time also and next is pain not responding to medicines restaurant physiotherapy also we should evaluate uh patient further with mrs okay so the most important advantage of mrs kennedy it identifies soft tissue pathology and compression over neural structures say in this example so on one hand side we have x-ray uh so whenever patient will come with this x-ray most of us will say no this this x is totally normal but when mr scan was done on the right hand side you can see the arrow is showing the soft tissue signal changes this space is totally reduced it is destroyed and along with that we can see edema and abscess uh in the spinal canal and enter the respect of spinals so that which so whenever patient is having red flag signs or pain not responding to medicines physiotherapy or if patient is having uh some neurological disturbances okay now uh next in next few slides we will discuss three to four cases when to conserve a patient conservatives when when you can advise medicines rest physiotherapy and when uh to advise surgery or when you should refer patient to spine specialist okay so this is case scenario one a 50 years male uh he presents to you with compressive back pain after doing heavy work since three days uh you examined him clinically there is local pain over numbers by number region uh you did neurological examination it is totally normal motor sensory everything is normal so what next so this is just simple mechanical pains a patient did some work and after that it started so you can just advise some analgesics medicines rest and some physiotherapy so that patients should settle down now this is second case scenario 56 years female she complains of severe back pain since three months and more pain in night okay so here comes the red flags right pain is having pain is there since long since three months and next pain is more insignificant at night that means it's non-mechanical pain similarly there is another red flag she is having history of carcinoma breast is cancer breast four years back so this is another red flag and on clinical examination patient uh there is tenderness over thought of spinach but on neurological examination there is uh there are there are different places there is another okay so next step so there are a lot of red flags in this case so you should evaluate this patient with mrs scan and accordingly you should refer this patient to spine specialist okay so this patient underwent mri scan here you can see the d8 uh dorsal spine level it is showing metastasis to d8 whatever body so and ultimately this patient underwent surgery so here i did multiple school fixation the tumor debulking surgery and stabilization between two water bodies with cage okay now case scenario three this is 42 years main he presented to us with complaints of left leg numbness after walking few steps urinary hesitancy since two months so now here also there are two red flags first is there is claudication that means the patient is complaining after walking for some distance he feels a numbness in his leg and that clinic is cloudy similarly patient also has bladder symptoms he is an urinary hesitancy uh since two months on clinical examination uh he is limping while walking and next important he's having left foot weakness there is water weakness of food he's having weakness of food so there are a lot of red flags in this case so hence this patient should underscan and it should be referred to spy specialist so this patient uh underwent mri scan here you can see there's huge big disc collapse at l45 level so of course this patient underwent surgery so here you can see this huge discriminant was removed and nervous now another case scenario for 30 35 years she presented to us with numbness in hands and legs and similarly patient is having instability during walking also so what are the effects here so patient is having numbness enhanced legs and similarly here she is having a gate instability which indicates myelopathy that there there might be some compression in spinal cord okay when this patient underwent clinical examination she had this reflexes and she also had hand weakness so this uh this indicator this is uh some milo this patient is having some myopathy okay uh so this patient should underwent mrs scan and spine specialist okay so this is mr scan picture so here you can see this arrow is showing this prolapse at c3 c4 level and it is compressing spinal cord so similarly this patient underweight surgery anterior cervical spine surgery okay now next important slide is about safety of spine surgery so there are a lot of false myths uh like this spine surgeries have less success rate and whether patient will be able to walk after surgery or not after doing spine surgery patient will be paralyzed and he will have to take long duration bed rest after spine surgery right so uh if you see with input technology expertise and minimally invasive spine surgeries so spine surgeries are very safe in spine surgeon and at my institute and in my city we have almost 90 to 95 percent success rate in spine surgeries now these are certain research advances in spine surgeries like endoscopic and minimally invasive spine surgeries that means we do surgeries using endoscope microscope and minimally invasive options so what are the advantages of this research advantage advance advances first is patient has very small incision because of which patient experiences very less post-operative pain so that he can resume his work early and so we operate most of the spine surgery using endoscope or microscope and the cases where uh patients need screw fixation so we uh use percutaneous system also to put this screws that we will just i will show you next further slides okay now this is the case of this prolapse so uh so here you can see patient is having this prolapse at l45 level where this fragment it is prolapsed on the right side and is compressing the uh alpha nerve so this patient underwent endoscopic discriminant so this is a uh so this is another suggested view of mri scan here you can see uh at l45 level the l45 disk is products and it's compressing thicker side so this is a ot setup for endoscopic spine surgeries we have a dedicated cm we have endoscopic striker system uh to which we update right i'll play the videos huh yeah yes a small video showing endoscopic uh description so this is this program fragment which is removed can you play video again yes sir so this is prolapse this fragment which was from there is huge magnification right safely we can remove similarly uh we now in this case so this is with this on one right side there is a city scan showing fracture of this arrow is showing fracture of l2 vertical body okay now this patient needed the fracture fixation using screw now in this traditionally we used to do it using open technique but now we are shifted to percutaneous proof fixation now this is second slide the ot setup where we can see uh the multiple tubes through which we put these screws into the vertical bodies so this is second picture and here you can see a cm cm image uh where we had put a screw so this is an example of minimally invasive spine surgery okay now similar similarly this is another example uh here the this is one of the type of spine surgery that is still trans number uh sorry transformable number empty diffusion so here also you can see using tubes uh this surgery was performed so here you can see two holes on one side and another hole on other side and small incisions here the surgery was done right and downside there is a post of x-ray okay so uh take home message is being a clinicians or primary physicians we should be able to manage simple neck and back pain however uh i think after seeing all this uh presentation we should be able to pick serious spine uh problem uh after properly examine after taking proper history after uh properly examined patient we should be able to pick up a red flag signs and we should uh evaluate patient further using mrs and timely referral makes difference and next thing next thing the thing is this fine surgeries are safe now with improved technology and surgical expertise so being the doctor's wish i i request all of you to remove fear from your patient's mind as fine surgeries are safe are quite simple thank you so much thank you so much sir that was an interesting presentation the video was very good like one of our audience members said the view was very nice we could see it very clearly the video was nice for all our audience members please drop in your questions in the comment section if any one of you wishes to come on stage you may raise your hand i'll just go through the questions once [Music] we have questioned by dr shweta verma what is so myelopathy uh it occurs due to complexion spinal cord so because of central compression patient uh so biology is a scientific term and the set of symptoms are patient uh present to you with numbness in hands or legs and patients represent you with gait instability imbalance during walking so that those are set of symptoms and when you do mrs scan if you see the compression of spinal cord that indicates next question is by dr nisarg if you could please explain complications of endoscopy dicectomy okay so complications are very few as such since there is limited view sometimes we are unable to remove some hidden pressures in endoscopic spine surgeries that is one disadvantage so that time we always explain patient that if such things happen we may uh have to convert the endoscopic hydrospheric sensitive spine surgery into open surgery ultimately results are important we need to uh decompress the neural structures properly if uh while doing endoscopic surgery if you fail to uh if you see if if that pressure cannot be removed we have to do it open circuit so that is another thing uh that's all otherwise these endoscopic sciences are very safe no issues okay [Music] uh again a question by dr nissan how to differentiate central and peripheral gate changes in ortho pd peripheral peripheral and central gate changes yeah [Music] okay maybe uh in in central means the patient see uh peripheral gait changes means patient will have pain in a single leg and that patient will name that occurs because of nerve compression and central pathology is because of compression spinal cord patients will have just a dowel patient such type of gate will have in in myopathy that indicates myopathy that occurs because of compression spine so it would be more of like loss of balance when it comes to centers it would be like as if is injured or something yeah because of pain [Music] next question we have is an example of a standard prescription for lbp or neck pen on conservative treatment on conservative treatment so it depends on patient age also so if patient is a little bit younger so you can always give ac gluconators very small along with antacid and local gel for a local application if patient is agent so better to avoid nsaids that time you can give a plain tremendous parasimal combination next thing your patient has numbness or radiculopathy you can add pregabalin also that also has a soothing effect for patient physical uh that's all calcium and vitamin e okay i'm just accepting uh the raise and uh dr sawwik das i'm accepting your request you may turn on your audio and video when prompted to yes good doctor good evening sir good evening uh actually sir uh i am prosthetic orthotist from deradun so today i one patient will come and came and he having the surgery in spine in lumbar region okay before that already surgery done and [Music] due to this surgery he lost his uh about [Music] no no after surgery after spine after spinal surgery lower uh lumbar region after five uh surgery he also again uh done again second surgery uh due to accident uh loss okay so he can't straightly okay when a gate cycle is uh your gate is actual four point gate system just like with crutch uh auxiliary clutch okay so yeah i can give you one uh above me uh prosthesis is it possible to work without uh support after uh this spine surgery in lower level yes yes you can so you don't have any inflammation yeah because another side angle also is very uh critical condition is food drop conditions is not stable in uh ankles also residual side right so yeah that might be because of weakness right so you can do uh ankle foot uh that will reduce the imbalance in his low back low back and gates i can also get better input yeah okay thank you thank you dr rajendran uh i am accepting your raise and request kindly turn on your audio and video [Music] till then so we'll take a question dr vishwa is asking if after the surgery of the cervical spine laminectomy and ranges of the cervical flexion extension and rotations are restricted what to do to gain that uh no it totally depends what surgery is advised or done basically if multiple screws are put then don't ever try to regain the movements if just plain cervical laminator missile maybe after three months you can start doing neck resources [Music] will be possible because those the the rotation it opposite wants you to level [Music] so the whole scenario depends what surgery is performed yeah right dr vishwa i hope that answered your question in case you have a specific surgery in mind then you can just type it out and so will be answering that dr anvesha is asking are lumbar disc replacements done in india yeah it is done in india i think delhi has some centers who do number disreplacement the indications are very limited basically because in india uh the patient comes to us at later stage and there is severe disregeneration a lot of joint degeneration so that time it is not possible that surgery might fail if it is done in early stages that that definitely work dr sania would like to ask if patient has pain in bilateral thigh muscles and knee x-ray and it's showing osteo osteoarthritis changes patient is not relieved with the usual analgesics can this be due to a back problem so patient with uh so whenever patient present to you with high pain there might be two possibilities either hip hip problem hip issues so at that time you have to check the rotations of the hip and if rotations are normal the second issue can arise from psycho electron that you have to examine properly and next is low back obviously if you want to differentiate all these things you have to do mrs scan in mrs can the whole picture will is there any connection between pain of fibromyalgia and chord atrophy chord atrophy and fibromyalgia quad atrophy i didn't understand cause this malaysia exactly dr hindu if you could uh just elaborate more on the question dr said is asking after tlif for lysis and severe canal stenosis now the patient now the patient is complaining of contra lateral radiculopathy what would be the cause should an mris can be advised [Music] okay so uh there are two possibilities or two three possibilities either uh the opposite side might be getting irritated uh because of some screw mark positioning or the upper or lower level nerves might be getting compressed because of new onset this products so those are the possibilities so definitely you are the concerned spine specialist can comment on this so depending on the scenario uh a patient might uh have to undergo mrs can the city scan so imrs can see to look for any soft tissue compression is there on the road or not and cities can to look for school positioning so i think both restriction should be legal okay uh dr pankaj would like to ask does claudia clarification due to this prolapse in alpha s1 or indicator of surgery yeah definitely if a patient is having significant claudication this means suppose your patient can walk just 100 meters 200 because uh if the patient is having pain limbs if patient is having some bladder disturbances right and if that symptoms are causing disturbance it is activity of daily living definitely but the surgeon should release is asking what is the difference between gabapentin and free gaba free gaba line and when to use them both are neurotropic trunks belongs to different categories okay so usually we start with with trigaming some patients have significant uh symptoms and they if they don't respond to pregabalin then we switch to switch over to another group that that is government so all these are centrally active neurotrophic drugs the whatever pain uh sensing [Music] changes the pain sensing capacity of your brain so that's how they work they are not it just changes the perception of pain of our brain that's all [Music] regarding the chord atrophy question dr hindu has explained that the mri is showing atrophy of the spinal cord and patient is having body as well as difficulty in writing and fatigue but the diagnosis was made of fibromyalgia so is it same or is there any difference fibromyalgia involves pain in muscles and all and if patient is having some lighting difficulty or using hands that the additional component of [Music] can osteophytes be removed by endoscopy osteophytes if it depends he osteopaths the position of osteoporosis if osteopaths are present near the spinal canal safe acid joints or lamina or osteological ligament that is posterior aspect of disc those can be removed no issues and if osteopaths are not causing any symptoms suppose they if they are present anterior to the disc they should not be removed okay all right doctor uh ashwini kumar i'm accepting your raise and request please turn on your audio and video when prompted to do so hello hello my question is uh when to recommend spinal flexion exercises and spinal extension exercises okay so uh when when patient has a facet acetyl pain or pain arising from facet joint right right so that time you should advise friction exercises and if patient uh complains to you uh that he is having pain while bending that means pain rs is from this component that then you avoid you do opposite exercises that is extension exercises okay and my second question is how to differentiate between peripheral artery disease claudication due to bad or spinal disease so there are one what is clinical parameter okay so clinically you can just [Music] are present or not whether those are bilaterally same or not so that is one criteria and on illustration right okay thank you thank you so much uh dr vishwa vatkama i'm accepting your exam request kindly turn on your audio and video [Music] hello good evening son my patient having a cervical [Music] foreign yes [Music] [Music] um our strength may foreign [Music] be might be uh before surgery itself he might be having some uh uh the ostrich fights in his cervical spine yes there is a calcification in the spine [Music] [Music] don't yeah that's all that will maintain his muscle strength that's all so don't try to achieve range of motion because spine already flows away okay yeah right thank you so much thank you so much [Music] there's a question by dr singh what should be prescribed to patient of calf muscle wasting secondary to severe s1 radiculopathy muscle testing for muscle destiny uh you just get physiotherapy like some muscle stimulation which is [Music] uh next question is by dr cena that generally in rural areas and the phc's all the patients of lpp sciatica and all they are generally given the conservative management so what should be the next line of recommendation especially when it comes to phds yeah that's what the whole purpose if you see it is just mechanical pain and [Music] there are no claudication uh no radiculopathy no weakness no bladder disturbances at that time it's okay uh you can just continue to conservative treatment like uh medicines and uh avoid some ex some some moments that uh that are ex means exaggerating their symptoms those those moments should be avoided that's all if you see that patient is having some red flag signs that the patient should underwent further evaluation like mrs scan and if there is severe nerve compression that patient can underwent surgery that's all okay uh dr nisserg is asking are there any contra indications for this final surgery contraindications if patient is not fit for surgeries see for for each surgery life matters first right so if patient is not fit for anesthesia that is the number one contradiction for surgery second is if if your spine specialist feels that this patient is not going to have any result after spine surgery that is second quantity indication now like say a patient has some fall from height his cord is totally damaged and patient presents two spine specialists very late that time also we refuse to operate because there is no hope uh in operating such patients so that is third quantitation right that's all nothing nothing else there's uh one raise request uh adobe i am accepting your raise and please turn on your audience dr ashwini is asking whether local infection i mean she i think she is also answering that the local infection would be a relative contraindication for surgery yeah local infection that however operative infection has suppose some fungal infection yes them better to avoid surgery because that infection may go inside the operative wound and cause secondary infection uh in the surgical site so first uh treat that local infection and then we can research surgery doesn't change the course of the disease we tell them [Music] [Music] foreign [Music] [Music] [Music] foreign yes thank you thank you so much doctor so last question for today i think uh doctor is asking uh there's a 60 year old female having burning sensation in interscapular region which is not responding to energetic yes yes sir she so a 60 year old female with burning sensation in interscapular region but not responding to analysis and pre-gabaline so what would be the further line of action if burning sensation first of all you will have to mrs if there is no chord compression or neural structure compression second cause might be because of osteoporosis 60 years age is such patients are known for osteoporotic pain also so you may have to start the antioxidant treatment after consulting your orthopedic surgeon and next thing physiotherapy also works in such patients so exercises uh heat therapy and osteoporosis osteoporosis yes so uh one of them asked like dr saniya has asked that is there any role of hot compresses if patient has pain years after surgery or compressions i mean if the patient is still having pain after many years of surgery yeah that pain might be because of some muscle component muscle pain or some acid joint pain so you can give hot water fermentation or some physiotherapy short way diathermy that should dissolve all right great sir i think those were the questions uh one was that in yoga when the rotation of hair is practiced is it injurious to spine or is it advisable rotations rotations within normal limit can be done not an issue but at some places we see that you can do stretching great thank you so much those were the questions uh i'm sure our audience has enjoyed a lot today we had many interactions we had many people coming on stage that itself indicates the presentation was great you've explained well everything so i would like to thank you for that big thank you from netflix for this session for taking out the time for the l4 alpha disc prolapse management uh i'd also like to thank all our audience members thank you for joining in thank you so much thank you so much

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