What is a P.I.V.D or prolapsed Intervertebral Disc ?
The term PIVD /prolapsed intervertebral disk means that the protrusion or extrusion of the nucleus pulposus through a rent in the annulus fibrosus.
It has a four stages-
1.Bulging- At this early stage, the disc is stretched and does not completely come to its normal form once pressure is relieved. It retains a small bulge at one side of the disc. a number of the inner disc fibres could be torn and the soft jelly ( nucleus pulposus ) is spilling outwards into the disc fibres but not out of the disc.
2. Protrusion- At this stage, the bulge is incredibly prominent and therefore the soft jelly centre has spilled out to the inner edge of the outer fibres, barely held in by the remaining disc fibres.
3. Extrusion- in the case of a herniated spinal disc, the soft jelly has completely spilled out of the disc and currently protruding out of the disc fibres.
4.Sequestration- Here breaking off the jelly material is breaking off away from the disc into the surrounding space.
What causes a PIVD ?
Heavy manual labour
Repetitive lifting and twisting
Postural stress
obesity
Poor and inadequate strength of the trunk
Sitting for long hours
increasing age (a disc is more likely to develop a weakness with increasing age)
What are the symptoms of PIVD ?
Severe low-back pain
Pain radiating to the buttocks, legs, and feet
Pain made worse with coughing, straining or happy
Muscle spasm
PIVD Treatment
1.Conservative Management-
a) Rest: Rest and anti inflammatory and analgesics.
b) Reduction: Continue bed rest and traction for 2 weeks might cut back the herniation in over 90th cases. If no improvement with rest and traction, epidural injection of corticosteroid and native anaesthetic are given.
c) Chemonucleolysis: dissolution of the Nucleus Pulposus by percutaneous injection of a proteolytic enzyme (chymopapain). This enzyme has the property of dissolving fibrous and cartilaginous tissue.
2.Operative Management-
Indications for operative removal of disc.
i) cauda equina compression syndrome that does not clear up with 6 hours of starting bed rest and traction (emergency).
ii) neurological deterioration while below conservative management.
iii) Persistent pain and signs of sciatic tension when 3 weeks of conservative treatment.
The disc is removed by following techniques.
a) Hemilaminectomy/Partial laminectomy- a part of the lamina and ligamentum flavum on one aspect is removed, taking great care to not injury the facet joint.
b) Laminectomy- Laminae on both sides with spinous method are removed. Such wide exposure is required for giant, central disc producing cauda equina syndrome.
c) Microdiscectomy- finished an operating microscope. Exposure is very limited. Morbidity and hospitalization is less.
d) Fenestration- Ligamentum flavum bridging the 2 adjacent laminae is excised and spinal canal at affected level exposed.
e) Laminotomy- in addition to fenestration, a hole is formed in the lamina for wider exposure.
Physical Therapy Management in PIVD
Before coming up with the treatment, determine the position of comfort or symptom reduction i.e functional position.As there are scope for Physiotherapy treatment for PIVD in kolkata so the patient might have…
a) Extension bias: Patient’s symptoms are lessened in position of extension (bending back) and provoked in flexion (bending forwards) e.g PIVD.
b) Flexion bias: Patient’s symptoms are lessened in position of spinal flexion (bending forwards) and provoked in spinal extension (bending backwards) e.g spinal stenosis, spondylolisthesis and it can be cured in the best physiotherapy centre in kolkata.
Spinal Extension (bending back) is contraindicated if:
i) when no position or movement decreases or centralizes the pain.
ii) once saddle anaesthesia and/or urinary incontinence is present (could indicate spinal cord or cauda equina lesion due to large central disc herniation).
iii) when the patient is in such extreme pain that he rigidly holds the body immobile.
Spinal flexion (bending forward) is contraindicated if:
i) when extension relieves the symptoms.
ii) when flexion increases or peripheralises the symptoms.
