Disc Herniation - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim's educational animated video illustrates spine concept associated with low back pain.
Acute low back pain: or low back pain with sciatica:
- where the pain radiates to the leg and foot, both conditions are treated conservatively for at least 6 weeks by physiotherapy, anti-inflammatory and limited activity, even if there is a big disc in the MRI.
- 90% of the patients will resolve the symptoms in 1 month.
- Smoking, depression, vibration will increase the incidence of low back pain.
- Intra-discal pressure will change with position, the lowest pressure is when the patient is supine, the highest pressure is when the patient is sitting leaning forward and holding weight.
- If the patient comes with a low back pain and a history of cancer, you need to get an x-ray & MRI, especially if the pain is at rest at night.
- In case of renal tumor, you will need to do arteriography and do embolization to the spine lesion.
- The spine is a common place for metastatic tumors, the metastasis occur in the vertebral body and goes to the pedicle.
- Infection will occur in the disc space, ESR & CRP will be elevated, 50% of the patients will have fever, & less than 50% will have increased WBC count.
- Get blood culture, its positive in 24% of the cases.
- Get MRI and give antibiotics.
- In the case of epidural abscess, we’ll do surgery.
- Osteoporotic fracture: start with wrist then spine, then hip.
- After 1 year of treatment with medications you decrease the incidence of vertebral fracture by 60%, and after 2 years decrease by 40%.
- Get x-rays if there is red flags only: older patient, patient with history of cancer, infection is suspected, trauma, osteoporotic fracture due to steroid use.
- Ankylosing spondylitis: it starts at the SI joint, get HLA-B27; you find marginal syndesmophytes with diffuse ossification of the disc space without large osteophyte formation. This is different from the DISH (diffuse idiopathic skeletal hyperostosis) in diabetic patients where you get HbA1c and the syndesmophytes are nonmarginal & they have larger osteophytes.
So you get an MRI of the spine at a certain point, but you need to start with x-rays.
MRI may be a little problem: there are abnormal MRI in asymptomatic patients, false positive:
- 35% in patients less than 40 years of age.
- 90% in asymptomatic patients over 60 years of age.
MRI with gadolinium dye:
- Gadolinium will differentiate a disc from a scar.
- Both granulation tissue and the recurrent disc could look alike on routine MRI.
- There will be contrast enhancement when there is granulation tissue because it is vascular.
- When there is a disc herniation the dye will not enhance because the disc is dead piece of tissue (avascular).
- When you try to differentiate between a recurrent disc and a scar, you will inject the dye and get the MRI.
- If there is a vascular enhancement then it is granulation tissue and you will need to sit tight and not do surgery.
- If there is no enhancement then it is a recurrent disc and it is avascular which is why it doesn’t enhance.
- If the recurrent disc is causing a lot of pain or symptoms to the patient, then you probably need to do surgery.



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