Acute Internal Disc Derangement - Done Flashcards
Which is more common, acute IDD or persistent IDD?
Persistent
Where is acute IDD rare?
- Rare in the thoracic spine
- Greater consequences in the t-spine due to narrowest canal
- Less than 1% of all symptomatic disc herniations
Where is acute IDD more common?
In the lumbar region
What percentage of IDDs are symptomatic?
1-3%
Persistent IDD is the source of pain in what percentage of LBP?
Less than 5%
What level is acute IDD most common in and in what age group?
- 95% at L4-S1
- Mostly 30 to 50 year olds
What is the most common area of the disc to be effected by acute IDD?
Posterolateral portion
What is weaker, thinner, with more vertical with less oblique annular fibers?
Posterolateral portion of the disc
The posterolateral portion of the disc is just lateral to the …
Posterior longitudinal ligament
What is the etiology of acute IDD?
Trauma such as axial compression, forward bending, or stooping without or with twisting/ lifting (lumbar spine does not full flex like you may think)
What is the resting lumbar lordosis?
20 - 45 degrees
Forward bending or stooping without or with twisting/ lifting leads to what?
- Less circumferential disc compression
- Unevenly distributed annular tension
- Increased and asymmetrical stress on weaker and thinner posterolateral annular and end plate fibers
- Less fixated end plate
- More anterior segmental shearing force due to the above plus pull of gravity, except less at L5, S1
What structures are involved in an acute IDD?
- More commonly outer annular tearing and end plate avulsion
- Less commonly inner annular tearing and nucleus pulposus herniation
What is the normal disc structure and function?
What becomes immunoreactive once damaged?
Disc structures
What kind of large autoimmune inflammatory responses occur when acute IDD is present?
- Excessive osmotic pressure or increased static fluid pressure in and around the disc and spinal nerve
- Static fluid consists of increased inflammatory chemicals that sensitizes spinal nerves and structures to pressure/ tension
- Radiculopathy/ Radicular signs and symptoms
- No lymphatic vessels in PNS or CNS so drainage is poor on its own
- Extended inflammatory phase
What are some typical posterolateral IDD symptoms?
- Dull/ achy spinal pain
- Radiculopathy
- Referred pain into the glutes and groin
What causes decreased pain from posterolateral IDD symptoms?
Unloading (standing/ walking and lying)
What causes increased low back pain and paresthesias from posterolateral IDD symptoms?
Loading (forward bending, sitting, lifting, coughing, and sneezing)
What part of the disc is highly innervated?
The annulus (so it is very painful when damaged)
What has more swelling, cervical disc or lumbar disc?
Lumbar has significantly more swelling than cervical disc to due higher number of GAGs
A radiculopathy such as possible segmental paresthesias within 24 hours into the distal extremity is a worse situation when?
There is presence of coldness indicating greater circulatory compromise
When is pain worse with acute posterolateral IDD, in the morning or the evening?
Increased pain in the morning due to pooling of swelling from static sleeping position
As with other conditions, a lot of the early symptoms are due to what?
Pressure and chemicals from swelling
What kind of observations might you see with acute posterolateral IDD?
- May see a lateral shift of shoulders on pelvis
- Side bend away from the pain
- Counter contralateral SB to level eyes
What kind of observations will you rarely see with acute posterolateral IDD?
- Rarely see smaller calf girth
- Wasting likely at 4-6 weeks and indicative of severe spinal nerve compression
- More of a sign for a persistent radiculopathy
What directions of ROM might cause pain for an acute posterolateral IDD?
All may increase pain
Flexion and possibly side bending away from the injured area of disc that is likely most limited, increases extremity and LBP due to what?
- Swelling being pushed toward spinal nerve like an H2O balloon
- Tension on torn annulus, end plate, and dura
Extension and possibly side bending towards the injured area of the disc that is possibly less limited may cause what?
- May increase LBP due to increased hydrostatic pressure on end plate flexion and high osmotic pressure of disc
- May centralize extremity pain (aka centralization), especially with repetition by squeezing swelling away from spinal nerve
Does rotation cause notable issues with acute posterolateral IDD?
Rotation is not consistent
What is centralization?
Abolition of distal and/ or spinal pain in a distal to proximal direction in response to repetitive motion(s) or sustained position(s)
What might you see in your scan with acute posterolateral IDD?
- Resistance testing and MMT: variable
- Stress tests: possible positive with compression/ distraction/ PA pressures/ and torsion
- Neuro tests: possible positive depending on severity and timing
- Diminished dermatomes
- Hyporeflexive DTRs
- Myotomal fatigue
- Positive Neurodynamic mobility tests
What might you see in your biomechanical exam with acute posterolateral IDD?
Possible positive stability tests
What are some unique signs and symptoms of central and posterior IDD?
- Cord or cauda equina signs and symptoms depending on the level
What is the typical lowest level of the cord
What are the PT implications of central and posterior IDD?
Immobilization and Emergency Referral
What are classic spinal cord signs and symptoms
Mechanical diagnosis and therapy was based on and developed by?
- Developed by Robin McKenzie, PT
- Based on the belief that most spinal pain comes from injuries to the disc which is not supported in the research
The classification system of mechanical diagnosis and therapy is depending primarily on what?
- Symptoms
- Specifically location of symptoms and positions that decrease symptoms
What is the most common directional preference (>70%)?
Extension/ Hyperextension
What should you match you mechanical diagnosis and therapy with?
Exercise and ADL positions
Directional preferences may be associated with what?
Centralization, decreasing severity, and improving function
What are the 3 classification syndromes and what do they focus on?
- Postural: focus on correcting poor posture
- Dysfunction: focus on stretches to improve end range motion
- Derangement: focus on using end range motion to improve the theoretical nucleus deformation in disc herniations
What is the dynamic disc theory?
- Deformation not migration in a normal disc
- Only predictable in asymptomatic lumbar spines when the annulus is intact and with normal hydration
- Limited and contradictory finding in the symptomatic disc and age-related disc disease with annular changes
What does flexion/ sitting do to anterior and posterior disc height and nucleus deformation?
- Anterior disc height: decreased
- Posterior disc height: increased
- Nucleus deformation: posteriorly
What does extension/ standing do to anterior and posterior disc height and nucleus deformation?
- Anterior disc height: increased
- Posterior disc height: decreased
- Nucleus deformation: anteriorly
When is the dynamic disc theory predictable?
Only predictable in asymptomatic lumbar spines when the annulus is intact and with normal hydration
Dynamic disc theory has limited and contradictory findings in what?
The symptomatic disc and age-related disc disease with annular changes
What might cause altered fluid dynamics leading to acute IDD?
- High osmotic pressure with large autoimmune swelling response
- Increasing hydrostatic pressure through repetitive motions,
most often extension
Repetitive motions can lead to what?
- Spine pain initially increases from the resistance of high osmotic
pressure being overcome by increased hydrostatic pressure - Swelling squeezed away from spinal nerve into the nucleus and the end plates for draining
- Centralizes pain, LE symptoms decrease, which is a priority
Is mechanical diagnosis and therapy the best treatment option for acute IDD?
- No RCTs comparing MDT to controls
- Not superior to other treatments for acute LBP/disability
- More needs to be done
Along with POLICED what directional preferences should you focus on for acute IDD?
Directional preference, likely ext, with centralization- 10-20 reps every 1-2 hrs. or as needed
Intermittent traction may be helpful for acute IDD with radiculopathy,
especially, if there is no what?
No centralization
What might help acute IDD if there is a directional preference?
Postural/ergonomic education/taping or bracing for likely ext preference
◦Limited to no sitting
◦Limited to no driving/FB
You should provide someone with acute IDD with a possible HEP for 1-2 weeks to avoid what?
Counterproductive sitting while driving
What is the ultimate goal for MET for acute IDD?
- MET ultimately for tissue proliferation and stabilization, particularly of local muscles
- Keeping the jelly or nucleus in a better location is NOT supported in the research
Does unweighted walking, lessening over time help with acute IDD?
Yes, Ex: Unloader, Aquatic, Anti-gravity systems (Altered G)
What is the prognosis for acute IDD?
- Refer to ligament and cartilage notes on healing and extend the timelines due to likely prolonged inflammatory phase
- 90% start to improve by 6 weeks and symptoms resolve by 12 weeks
What percentage of people with acute IDD will need surgery and what do the outcomes look like?
- Most will not require surgery
- Slower but the same overall outcomes without sx after two years
