“CORRELATION BETWEEN CLINICAL AND MRI FINDINGS

WITH INTRAOPERATIVE FINDINGS IN LUMBAR

INTERVERTEBRAL DISC PROLAPSE”

BY

Dr. NAVIN BALAJI R, M.B.B.S

DISSERTATION SUBMITTED TO SRI DEVARAJ URS ACADEMY OF

HIGHER EDUCATION AND RESEARCH, KOLAR, KARNATAKA

In partial fulfillment of the requirements for the degree of

MASTER OF SURGERY
IN
ORTHOPAEDICS

Under the Guidance of

Dr. PRABHU E
MBBS, MS ORTHOPAEDICS
PROFESSOR & HOU
AND
Dr. ANIL KUMAR SAKALECHA. M
MBBS, MD RADIODIAGNOSIS
PROFESSOR & HOD

DEPARTMENT OF ORTHOPAEDICS
SRI DEVARAJ URS MEDICAL COLLEGE

TAMAKA, KOLAR-563101
 SRI DEVARAJ URS ACADEMY OF HIGHER EDUCATION AND

RESEARCH, TAMAKA, KOLAR, KARNATAKA

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “CORRELATION BETWEEN

CLINICAL AND MRI FINDINGS WITH INTRAOPERATIVE

FINDINGS IN LUMBAR INTERVERTEBRAL DISC PROLAPSE ” is a
Bonafide

and genuine research work carried out by me under the guidance of Dr. PRABHU E,
Department of Orthopaedics and Dr. ANIL KUMAR SAKALECHA M, Department of
Radiodiagnosis, Sri Devaraj Urs Medical College, Kolar, in partial fulfillment of University
regulation for the award “MASTER OF SURGERY IN ORTHOPAEDICS”. This has not
been submitted by me previously for the award of any degree or diploma from the university
or any other university.

Signature of the candidate

Dr. NAVIN BALAJI R
Postgraduate
Date: Department of Orthopaedics
Place: Sri Devaraj Urs Medical College
Tamaka, Kolar.
 SRI DEVARAJ URS ACADEMY OF HIGHER EDUCATION AND
RESEARCH, TAMAKA, KOLAR, KARNATAKA

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “CORRELATION BETWEEN

CLINICAL AND MRI FINDINGS WITH INTRAOPERATIVE

FINDINGS IN LUMBAR INTERVERTEBRAL DISC PROLAPSE ” is a

Bonafide

research work done by Dr. NAVIN BALAJI R, under my direct guidance and supervision at

Sri Devaraj Urs Medical College, Kolar, in partial fulfillment of the requirement for the

degree of “MASTER OF SURGERY IN ORTHOPAEDICS”

Signature of the Guide

Date: Dr. PRABHU E

Place: Kolar Professor

Department of Orthopaedics
Sri Devaraj Urs Medical College
Tamaka, Kolar – 563101
 SRI DEVARAJ URS ACADEMY OF HIGHER EDUCATION AND
RESEARCH, TAMAKA, KOLAR, KARNATAKA

CERTIFICATE BY THE CO GUIDE

This is to certify that the dissertation entitled “CORRELATION BETWEEN

CLINICAL AND MRI FINDINGS WITH INTRAOPERATIVE

FINDINGS IN LUMBAR INTERVERTEBRAL DISC PROLAPSE ” is a

Bonafide

research work done by Dr. NAVIN BALAJI R, under my direct guidance and supervision at

Sri Devaraj Urs Medical College, Kolar, in partial fulfillment of the requirement for the

degree of “MASTER OF SURGERY IN ORTHOPAEDICS”

Signature of the Co Guide

Date: Dr. ANIL KUMAR SAKALECHA
M
Place: Kolar Professor
Department of Radio Diagnosis
Sri Devaraj Urs Medical College
Tamaka, Kolar-563101
 SRI DEVARAJ URS ACADEMY OF HIGHER EDUCATION AND

RESEARCH, TAMAKA, KOLAR, KARNATAKA

CERTIFICATE BY THE HEAD OF DEPARTMENT

This is to certify that the dissertation entitled “CORRELATION BETWEEN

CLINICAL AND MRI FINDINGS WITH INTRAOPERATIVE

FINDINGS IN LUMBAR INTERVERTEBRAL DISC PROLAPSE ” is a

Bonafide

research work done by DR. NAVIN BALAJI R, under direct guidance and supervision of

DR. PRABHU E, Professor, Department of Orthopaedics at Sri Devaraj Urs Medical

College, Kolar, in partial fulfillment of the requirement for the degree of “MASTER OF

SURGERY IN ORTHOPAEDICS”.

Date: Signature of the Head of Department

Place: Kolar Dr. NAGAKUMAR J. S
Professor & HOD
Department of Orthopaedics
Sri Devaraj Urs Medical College
Tamaka, Kolar
 SRI DEVARAJ URS ACADEMY OF HIGHER EDUCATION AND
RESEARCH, TAMAKA, KOLAR, KARNATAKA

ENDORSEMENT BY THE HEAD OF THE DEPARTMENT OF

ORTHOPAEDICS AND PRINCIPAL

This is to certify that the dissertation entitled “CORRELATION BETWEEN

CLINICAL AND MRI FINDINGS WITH INTRAOPERATIVE

FINDINGS IN LUMBAR INTERVERTEBRAL DISC PROLAPSE ” is a

Bonafide

research work done by DR. NAVIN BALAJI R, under the direct guidance and supervision

of DR. PRABHU E, Professor, Department of Orthopaedics, Sri Devaraj Urs Medical

College, Kolar, in partial fulfillment of University regulation for the award “MASTER OF

SURGERY IN ORTHOPAEDICS”.

Signature of the Head of Department Signature of the Principal

Dr. NAGAKUMAR J. S Dr. PRABHAKAR K

Professor Principal
Department of Orthopaedics Sri Devaraj Urs Medical College
Sri Devaraj Urs Medical College Tamaka, Kolar – 563101
T Tamaka, Kolar – 563101

Date: Date:
Place: Kolar Place: Kolar
 SRI DEVARAJ URS ACADEMY OF HIGHER EDUCATION
AND RESEARCH, TAMAKA, KOLAR, KARNATAKA

COPYRIGHT DECLARATION BY THE CANDIDATE

I hereby declare that Sri Devaraj Urs Academy of Higher Education and Research, Kolar,

Karnataka shall have the rights to preserve, use and disseminate this dissertation in print or

electronic format for academic / research purpose.

Date: Signature of the Candidate

Place: Kolar DR. NAVIN BALAJI R

 ACKNOWLEDGEMENT

First and foremost, I express my profound gratitude to ALMIGHTY and

my Grandparent’s Dr. P.THANGARAJU, T.PUSHPA, Er

R.GOVINDARAJAN, G.POONGOTHAI for all the blessings I have

received till date.

Later I thank my parents Dr. G. RAVISHANKAR and T. VANITHA,

my sister Dr. R. HARSHA VARDHINI and my wife Dr. E. SURYA

PRABHA for giving me continuous encouragement, unfailing support

and unconditional love throughout my life.

I would like to acknowledge all those who have supported me, not only

to complete my dissertation, but throughout my post-graduation course.

I wish to express my heartful indebtedness and owe a deep sense of

gratitude to my mentor and guide Dr. PRABHU E Professor,

Department of Orthopaedics and my Co-guide Dr. ANIL KUMAR

SAKALECHA Professor and head, Department of Radiodiagnosis for

being very helpful throughout the study and offered their invaluable

guidance and support to fully understand and complete this study.

Through their vast professional knowledge and expertise, he ensured that

I understood everything before I apply the information in my study.

Without their constant supervision and advice completion of this

 dissertation would have been impossible. Their stature, sense of

punctuality, strict adherence to academic schedule, humility and

knowledge have been highly inspirational for the whole of my post

graduation period.

I am extremely thankful to Dr. NAGAKUMAR JS, Professor and Head of

Department, Orthopedics, for encouraging me to the highest peak, paying close

and continuous attention towards me to finish all tasks and providing his kind

support, valuable suggestions, immense patience and great care. His sense of

punctuality, strict adherence to academic schedule, humility and knowledge have

been highly inspirational for the whole of my postgraduation period.

It gives me immense pleasure to extend my sincere thanks to Professor

Dr. ARUN H.S, Professor and Head of the Unit, Department of

Orthopaedics. who is a pioneer in academics and teaching activities,

taking it to high standards for a post graduate student and keep

encouraging, guiding in correct path to be knowledgeable and successful

in the field of orthopaedics.

I wish to express my heartful sense of gratitude to Dr. HARIPRASAD.S

Professor, Department of Orthopedics for being helpful throughout the study.

He had offered his invaluable guidance and moral support during my entire

post-graduate course, which enabled me to complete my work.

 It gives me immense pleasure to extend my sincere thanks to Professor Dr.

SAGAR V for his guidance, motivation and moral support during my entire

postgraduate course which enabled to complete my work.

I am extremely thankful to Dr. MANOJ KUMAR, Dr. KARTHIK SJ, Dr.

ARUN KUMAAR, Dr. VINOD KUMAR K, Dr. ANIL KUMAR, Dr. NULAKA

HARISH, Dr. PUNITH for their constant help and guidance throughout the

course. They were the source of encouragement, support and for patient perusal,

to which I am deeply obliged.

My heartful thanks to my seniors Dr. B.V HRUSHIKESH, Dr.

VISHNUVARDHAN, Dr. SIYAD M NAZAR, Dr. JAGADISH, Dr. VYSHNAV,

Dr. KIRAN, Dr. TARUN for their support and help in carrying this study and

throughout the graduation course.

I express my sincere thanks to my colleagues and dear friends Dr. AKSHAY,

Dr. BASANTH, Dr. AYUSH, Dr. ARYADEV, Dr. GOWTHAM, Dr. GILS, Dr.

ROHITH for their constant support.

I thank my JUNIORS DR.ASHWIN, DR.MUTHUKUMAR, DR.RICHIK

SARKAR , DR.SHOBITH, DR.SIVA, DR. NIDHIL, DR.KAMAL, Dr.

ANJANI, Dr. JAYAVARDHAN, Dr. RAGHU, Dr. AJAY, Dr. RAHUL, Dr.

JHANAVI, Dr. KASHYAP, Dr. AMIT, Dr. ANKIT for providing support

throughout the study.

I am also thankful to all the INTERNS, OT, OPD and PARAMEDICAL STAFF

for their valuable help while performing this study.

I express my special thanks to all my PATIENTS and their families, who in

the final conclusion are the best teachers and without whom this study would

have been impossible.

DR. NAVIN BALAJI. R

 ABSTRACT

Background

Low Back Pain is a musculoskeletal condition that arises in the lumbar area as a

result of significant stress. Disc herniation is a complex diagnosis since it involves

not only finding the specific structural abnormality causing the patient's pain, but

also comparing the individual's complaints and signs with MRI findings. Since

MRI tests have surpassed older investigative procedures, they have become the

gold standard for diagnosing herniated discs. It is now considered to be the

benchmark in herniated disc diagnosis.

Aim and Objective

To describe the clinical, MRI and Intra operative findings in Lumbar

Intervertebral disc prolapse among the study patients and to find out the

correlation between those findings.

Methodology

This prospective observational study included 47 patients hospitalized to RL

Jalappa hospital from September 2022 to December 2023, diagnosed with

Lumbar Intervertebral disc prolapse, and having had unsuccessful conservative

therapy for a minimum of eight weeks in the Orthopaedics department. The

clinical criteria that were used included LBP radiating to lower limb and presence

of neurological deficit. The MRI findings that were recorded included location,

type, migration, level of prolapse, high intensity zone along with presence of

lateral recess and foraminal stenosis. Patients who met both the clinical and MRI
criteria were selected for surgical treatment. Then intraoperative findings were

correlated with Clinical and MRI findings among patients.

Results

The average age of patients diagnosed as LIDP was 43.66 ± 9.38 yrs. The study

found that 78.7% of the subjects were male, while the remaining 21.3% were

female. Among the study participants with LIDP, bilateral radiculopathy was

found in 14.9% of them. Left radiculopathy was seen in 53.2% of the samples,

while right radiculopathy was observed in 31.9% of the patients. The MRI results

indicate that 59.6% of the subjects exhibited intervertebral disc prolapse at the L4-

L5 region. About 38.3% of the research participants had lumbar disc herniation in

the central position, the central and left paracentral location were the second most

frequently seen (21.3%), followed by the right paracentral location (12.8%). A

annular tear was seen in the MRI results of 59.6% of the individuals included in

the research. The MRI results indicate that among the study samples, 36.2%

exhibited LRFS on the left side, whereas 21.3% showed these conditions on the

right side. Among the study's samples, the most prevalent kind of lumbar disc

herniation observed after surgery was extrusion, accounting for 57.4% of cases.

The operative findings revealed that 34% of the research samples had a lateral

recess on the left side, whereas 21.3% of the study participants had it documented

on the right side. The research samples exhibited bilateral presence in

approximately 31.9% of cases. Operative findings revealed that 25.5% of the

research samples had foraminal stenosis on the left side, whereas 48.9% of the

studied samples exhibited bilateral presence. An 87.2% correlation was reported

between the clinical, MRI, and surgical data among the research participants in
this investigation. The study found that the most frequent occurrence of nerve root

compression among the patients was identified at the left Traversing L5 level.

Conclusion

The accurate representation of morphometric features in MRI scans makes them a

useful tool for preparing for surgery, and there is a robust positive correlation

between IOF and MRI results. Nevertheless, the choice to have surgery should

only be taken when a thorough examination of clinical evidence, together with

MRI results, enables a precise identification of the specific fragment causing the

problem and the sources of discomfort.

Keywords: Lumbar Intervertebral disc prolapse, Low back pain, Magnetic

Resonance Imaging, Correlation study, Straight Leg Raising Test

 TABLE OF CONTENTS

INTRODUCTION..............................................................................................12

OBJECTIVES.....................................................................................................15

REVIEW OF LITERATURE.............................................................................16

MATERIALS AND METHODS.......................................................................40

RESULTS...........................................................................................................47

DISCUSSION.....................................................................................................79

CONCLUSION...................................................................................................90

LIMITATION.....................................................................................................91

REFERENCES...................................................................................................95

ANNEXURE....................................................................................................104
 LIST OF TABLES

Table 1: Age distribution of study participants..................................................47

Table 2: Gender distribution...............................................................................49

Table 3: Assignment of enrolled samples based on the presence of radiculopathy.

............................................................................................................................51

Table 4: Assignment of enrolled samples based on level of lumbar intervertebral

disc prolapse as documented in MRI..................................................................53

Table 5: Assignment of enrolled samples based on lumbar disc herniation as

documented in MRI............................................................................................55

Table 6: Assignment of enrolled samples based on type of lumbar disc herniation

as documented in MRI........................................................................................57

Table 7: Assignment of enrolled samples based on migration of herniation

fragments as documented in MRI.......................................................................59

Table 8: Assignment of enrolled samples with respect to annular tear as

documented in MRI............................................................................................61

Table 9: Assignment of enrolled samples with respect to LRFS as documented in

MRI.....................................................................................................................63

Table 10: Assignment of enrolled samples with respect to type of lumbar disc

herniation as documented in operative Findings................................................65

Table 11: Allotment of enrolled samples with respect to migration of herniation

fragments as documented in operative Findings................................................67

Table 12: Allotment of enrolled samples with respect to the presence of annular

tear as documented in operative Findings..........................................................69

Table 13: Allotment of enrolled samples with respect to the lateral recess as

documented in operative Findings......................................................................71

Table 14: Allotment of enrolled samples with respect to the foraminal stenosis as

documented in operative Findings......................................................................73

Table 15: Allotment of enrolled samples with respect to the presence of

correlation between clinical, MRI and operative findings..................................75

Table 16: Allotment of enrolled samples with respect to nerve root compression.

............................................................................................................................77

Table 17: Comparison of basic characteristics of the study patients with similar

studies.................................................................................................................80

Table 18: Comparison of most common level of lumbar disc prolapse with similar

studies.................................................................................................................82

Table 19: Comparison of most common type of LDH with similar studies.......86

Table 20: Comparison of Percentage of Correlation between the clinical, MRI,

and surgical findings with similar studies..........................................................88

 LIST OF FIGURES

Figure 1: Section of a intervertebral disc. 18.......................................................16

Figure 2: Intervertebral Disc...............................................................................18

Figure 3: An older male patient is exhibiting a facet cyst at the L4-L5 level, in

addition to a disc bulge at the same level. The patient presented with

radiculopathy in the right leg..............................................................................20

Figure 4: Environmental variables influence disc degeneration by modifying the

balanced internal environment of the IVD.........................................................21

Figure 5: Disc degeneration gives rise to a sequence of events that are believed to

be responsible for discogenic pain......................................................................22

Figure 6: Michigan State University classification for LDH..............................24

Figure 7: The patient was a 67-year-old woman who complained of left L5

radiculopathy and shown DH at L5 and S1 level...............................................27

Figure 8: Age distribution of study participants.................................................48

Figure 9: Gender distribution of study participants............................................50

Figure 10: Assignment of enrolled samples based on the presence of

radiculopathy......................................................................................................52

Figure 11: Assignment of enrolled samples based on level of lumbar

intervertebral disc prolapse as documented in MRI...........................................54

Figure 12: Assignment of enrolled samples based on lumbar disc herniation as

documented in MRI............................................................................................56

Figure 13: Assignment of enrolled samples based on type of lumbar disc

herniation as documented in MRI.......................................................................58

Figure 14: Assignment of enrolled samples based on migration of herniation

fragments as documented in MRI.......................................................................60

Figure 15: Assignment of enrolled samples with respect to annular tear as

documented in MRI............................................................................................62

Figure 16: Assignment of enrolled samples with respect to LRFS as documented

in MRI.................................................................................................................64

Figure 17: Allotment of enrolled samples with respect to type of lumbar disc

herniation as documented in operative Findings................................................66

Figure 18: Allotment of enrolled samples with respect to migration of herniation

fragments as documented in operative Findings................................................68

Figure 19: Allotment of enrolled samples with respect to the presence of annular

tear as documented in operative Findings..........................................................70

Figure 20: Allotment of enrolled samples with respect to the lateral recess as

documented in operative Findings......................................................................72

Figure 21: Allotment of enrolled samples with respect to the foraminal stenosis as

documented in operative Findings......................................................................74

Figure 22: Allotment of enrolled samples with respect to the presence of

correlation between clinical, MRI and operative findings..................................76

Figure 23: Allotment of enrolled samples with respect to nerve root compression.

............................................................................................................................78
ABBREVIATIONS

S. No Abbreviation Explanation

1 LBP Low Back Pain

2 YLD Years Lived with Disability

3 MRI Magnetic Resonance Imaging

4 IV Intervertebral

5 NP Nucleus Pulposus

6 AF Annulus Fibrosus

7 LDH Lumbar Disc Herniation

8 CT Computed Tomography

9 HIZ High Intensity Zone

10 SLRT Straight Leg Raising Test

11 LIDP Lumbar Intervertebral Disc Prolapse

12 LRFS Lateral Recess and foraminal stenosis

13 HD Herniated Disc

14 IOF Intra-operative findings

14 MRIF Magnetic Resonance Imaging Findings

15 DP Disc Prolapse
 INTRODUCTION

Low Back Pain (LBP) is a prevalent issue in the healthcare sector, affecting 70-

80% of individuals at some point in their life. 1 Over the past several decades, it

has emerged as a prominent factor in the increase of years lived with disability

(YLD). The existing literature reports a prevalence that varies between 1.4% and

20% contingent upon the specific definition of low back pain (LBP) that is

employed.2

LBP, or low back pain, is a condition affecting the musculoskeletal system in the

lower back area, resulting from the application of strong pressures. Mechanical

tension leads to muscular strain. LBP can also arise from psycho-social variables

and faulty biomechanics. The degradation of the spinal structure alters the cellular

milieu of the disc, leading to cell-mediated degeneration and subsequent

development of low back pain. 3,4

The intervertebral disc facilitates limited movement between the vertebrae,

provides ligamentous support to the vertebrae, and acts as a shock absorbent for

the spine. 5 The disc can be readily ruptured due to several underlying diseases,

including degeneration as well as discitis. But DP is the disc disorder that affects
6
most people. A DP occurs when the NP manages to penetrate the AF layers.

Discs prolapse is the result of an impact or tension on the spine, particularly on

the disc, caused by factors such as trauma, improper posture, and long-term

damage. 7,8 There is a higher incidence of DP at the L4-L5 and L5-S1 levels.
Lumbar HD is a commonly detected abnormality that is often associated with
9
lower back pain (LBP). The clinical manifestation of this condition may

encompass LBP, muscle weakness, sensory complaints, or radicular discomfort.

These manifestations often follow the distribution of the affected nerve roots.

LBP often manifests as a widespread discomfort in the lower back area, perhaps

extending to the buttocks or upper thighs. 10

The clinical symptoms exhibited by people with disc prolapse exhibit significant

variability. Disc herniation of identical dimensions may exhibit minimal

symptoms in one individual while causing significant compression of the nerve

11
root in another individual. In addition to comparing MRI findings with clinical

indications and signs, pinpointing the specific anatomical abnormality causing the
12
person's discomfort can make disc herniation a difficult diagnosis to make.

Since MRI tests have surpassed older investigative strategies, they have become

the gold standard for diagnosing HD. It is now considered to be the benchmark in
13
HD diagnosis. We offer MRI tests at a variety of magnetic area intensities, the

most popular of which is 1.5 Tesla. The superior accuracy of this visual method

has been demonstrated by numerous investigations. 14–16

MRI can reveal a range of pathoanatomical abnormalities in lumbar disc prolapse.

Nevertheless, there is ongoing debate over the clinical importance of MRI results.

Although MRI is commonly performed on patients with suspected intervertebral

disc prolapse, it remains uncertain if specific MRI findings are clinically

significant and have both diagnostic and prognostic value. 16

In 2001, Borenstein et al definitively stated that MRI results cannot be used to

forecast the occurrence or duration of low back pain. They emphasized the need
 17
of clinical correlation. Therefore, there are inquiries that require responses. Is

magnetic resonance imaging (MRI) necessary for all individuals with lumbar disc

prolapse? Which MRI results are clinically meaningful and essential for treatment

purposes? While several research have shown a correlation between MRI scans

and clinical results, as far as we are aware, none of these studies have

incorporated intraoperative information as well. The purpose of this research was

to identify any correlations between LIDP patients' clinical variables, MRI

findings, and IOF. The aim was to understand the relevance of this correlation in

guiding treatment decisions.

 OBJECTIVES

1. To describe the clinical, MRI, Intra operative findings in Lumbar

Intervertebral disc prolapse.

2. To determine the correlation between clinical and MRI findings with intra

operative findings in Lumbar Intervertebral disc prolapse.

 REVIEW OF LITERATURE

Intervertebral Discs

The intervertebral discs are situated between the vertebral bodies, connecting

them. The underside of the upper vertebral body connects with the upper surface

of the lower vertebral body via intervertebral (IV) discs. The major joints of the

spinal column, which make approximately one-third of its height, are referred to

as the primary joints. The primary function of the spinal column is to

mechanically transmit stresses that result from body weight and muscular action.

They offer versatility by enabling bending, flexion, and torsion. In the lumbar area

of the spine, they have a thickness of around 7 to 10 mm and a width of 4 cm. 18

Figure 1: Section of a intervertebral disc. 18

The 25 discs that make up the spine account for about 25–33 percent of its entire

length. They are listed below:

  Cervical discs - 7,

 Thoracic discs - 12,

 Lumbar discs - 5,

 Sacral disc – 1

They enable the spine to maintain flexibility while retaining a significant amount

of strength. Additionally, they offer a cushioning effect within the spinal column

and hinder the gnashing of the vertebrae.

They consist of three major components:

1. the inner or nucleus pulposus (NP),

2. the outer or annulus fibrosus (AF), and

3. The cartilaginous endplates serve as anchors, connecting the discs to the

neighbouring vertebrae. 19

The intervertebral discs are intricate formations of a dense outer layer of fibrous

cartilage called the annulus fibrosus, which encloses a softer, gel-like center

called the nucleus pulposus. The nucleus pulposus is situated between cartilage

endplates both above and below.

Figure 2: Intervertebral Disc. 19

The lateral view displays the intervertebral disc situated between two adjacent

vertebrae. The superior perspective reveals the annulus fibrosis located in the

outer layer and the nucleus pulposus situated in the inner layer.

Low Back Pain

Low back pain (LBP) is a significant issue in both public and work environments,
20
causing substantial professional, financial, and social challenges. On average,

LBP affects nearly eighty percent of human beings at some point. 21 Sick days

were taken off in 20% of cases due to LBP. Back pain is responsible for 30% of
20
all sick days that last more than six months and 20% of all work crashes.

Chronic deteriorating disc disease as well as LBP are both caused by

21
intervertebral deterioration, the main cause of which is commonly LDH. LBP is

an indication of an underlying condition, rather than a specific diagnosis. Without

establishing a specific pathoanatomical reason, there is insufficient justification

for intervention.
LDH

It is the tearing of the tough outer layer of the intervertebral disc, which causes the

inner gel-like substance to protrude and put pressure on the spinal nerve and
22
cauda equina, resulting in an inflammatory reaction. The patient has clinical

manifestations including pain and neurological impairment. Due to shifts in work

and lifestyle patterns, there has been a significant rise in the number of LDH

patients, particularly among younger individuals. This has resulted in detrimental

effects on both the physical and emotional well-being of patients, making it a

23
prominent health concern. Hence, it is crucial to get a precise diagnosis of the

illness in order to administer specific treatment.

For a long time, researchers have studied LIDP and the sciatic pain it causes. It is

still a mystery to many doctors what causes sciatica, even though Mixter and Barr

suggested invasive disc removal as a treatment for radiculopathy pain in their

1932 paper and linked bulging discs to the condition. They attribute radicular

symptoms to a bulging disc but are unable to locate a clear herniated fragment

during surgical examination. The occurrence is due to physicians neglecting other

observations on the MRI scan that might also manifest clinically in a manner that

resembles sciatica, as seen in figure 3.

Figure 3: An older male patient is exhibiting a facet cyst at the L4-L5 level, in

addition to a disc bulge at the same level. The patient presented with

radiculopathy in the right leg. 24

Aetiology of lumbar disc herniation 24

 Elderly age

 Male have higher risk than female.

 Overweight and obesity

 Diabetes Mellitus

 High cholesterol levels

 Family history of disc herniation

 Physical Trauma

 Prolonged driving and sitting, heavy manual work,

 Mobility of lumbar spine compared to thoracic spine.

 Chain smoking.
Figure 4: Environmental variables influence disc degeneration by modifying

the balanced internal environment of the IVD. 25

Pathology of LDH

The central NP is a location where collagen is released and includes many

proteoglycans (PG), which help retain water, generating hydrostatic tension to

counteract the axial squashing of the spine. 25

The main component of the NP is predominantly comprised of type II collagen,

which constitutes 20% of its total weight when completely dehydrated. On the

other hand, the annulus fibrosus (AF) has the role of keeping the nucleus pulposus

(NP) in the middle of the disc with a little quantity of proteoglycans (PG). About

70% of its weight when it's dry consists mostly of concentric type I collagen

fibers. 25,26 In lumbar disc herniation (LDH), the narrowing of the space around the

thecal sac can occur due to three primary factors: protrusion of the disc through an

intact annulus fibrosus (AF), extrusion of the nucleus pulposus (NP) through the

AF while still retaining a connection with the disc space, or complete loss of

connection with the disc space and sequestration of a free fragment. LDH is
believed to be influenced by several alterations in the biology of the intervertebral

disc.

Figure 5: Disc degeneration gives rise to a sequence of events that are believed

to be responsible for discogenic pain. 25

While a direct connection between intervertebral disc and pain has not been

conclusively shown, the alterations in blood supply and structural integrity of the

disc that happen during the degenerative process indicate a potential association

between these alterations and the occurrence of back pain.

Classification of LDH

LDH can be categorized into three categories (central, paramedian, and foraminal)

based on the specific area of protrusion. The damage can be characterized as

bulging, protrusion, or extrusion in accordance with the degree of protrusion.

Furthermore, there are non-ruptured, ruptured, and sequestered classifications

depending on surgical Patho morphism. 27

The LDH was evaluated using T2-weighted axial MRI slices, according to the

Michigan State University (MSU) classification. Here, "1, 2, 3" mean the severity

of the condition, while "A, AB, B, C" mean the location of the herniated portion,

which typically corresponds to "central," "paracentral," "lateral," as well as "far

lateral" in this class.

The subgrouping techniques rely on an intra-facet line that is drawn horizontally

across the lumbar canal, connecting the medial borders of the facet joint

articulations on both the right and left sides. "1" and "2" refer to situations where

the LDH (lumbar disc herniation) reaches less than or more than 50% of the

distance from the non-herniated posterior portion of the disc to the intra-facet line.

On the other hand, "3" indicates that the LDH extends beyond the intra-facet line.

To determine the position of the LDH, three points are positioned along the intra-

facet line, splitting it into four equal sections. Subsequently, three vertical lines

are drawn between these points, resulting in the creation of four quadrants. The

letter "A" denotes the left and right central quadrants, while "B" symbolizes the

left and right lateral quadrants. The letter "C" signifies the region that extends

beyond the boundary of the lateral quadrants. Lastly, "AB" indicates that the

farthest protrusion is located on the right and left lateral vertical lines. The level

with the most significant herniation was chosen for assessment. 28

Figure 6: Michigan State University classification for LDH. 28

Clinical Presentation

The main indications of LDH include radicular discomfort, sensory abnormalities,

29
and weakening in the area covered by one or more lumbosacral nerve roots.

Additional signs of focal paresis, limited bending of the trunk, and heightened leg

discomfort during activities such as straining, coughing, and sneezing are also
29
suggestive. Patients often experience heightened discomfort while sitting, a
30
condition that is associated with a roughly 40% rise in disc pressure. The

dermatome affected varies depending on the extent and kind of herniation.

Paracentral herniations mostly impact the nerve root that passes through, while far

lateral herniations primarily harm the nerve root that exists. For instance, a

paracentral herniation at the L4-5 level would result in L5 radiculopathy, whereas

a far lateral herniation at the same level would lead to L4 radiculopathy.

Evaluation
Radiographs – X-ray

Plain radiographs are the primary imaging method used to evaluate low back pain.

Aside from anteroposterior (AP) and lateral pictures, flexion and extension

sequences are acquired to assess the impact of instability on the patient's

symptoms. Indications of LDH in this technique consist of compensatory

scoliosis, reduced intervertebral space, and the existence of traction osteophytes. 21

These are readily available at the majority of clinics and outpatient centers. If x-

rays indicate the presence of an acute fracture, further examination is required

using a CT scan or MRI.

Computed Tomography

Recent developments, such as MDCT, have brought CT's diagnostic skills up to

par with MRI's, despite the fact that CT was previously thought to be technically
31
disadvantaged compared to MRI in identifying LDH. CT myelography is

recommended by the North American Spine Society as a suitable diagnostic

32
method for verifying suspected LDH, serving as an alternative to MRI. CT

myelography is preferred over MRI in some conditions, such as when MRI is

neither accessible or feasible, and when patients would experience significant

discomfort.

Role of MRI in diagnosis

Magnetic Resonance Imaging (MRI) is considered the most reliable method for

confirming suspected Lumbar Disc Herniation (LDH), with a diagnosis accuracy

32
of 97% and a high level of agreement among different observers. MRI is the

most crucial radiological inquiry because it accurately outlines the soft tissue

formations, as seen in picture 4.

Extraordinary, featured MRI of 1.5 Tesla make easier to:

1. Validate the identification of DH and exclude alternative pathological

conditions.

2. Displays the dimensions of the herniated disc.

Figure 7: The patient was a 67-year-old woman who complained of left L5

radiculopathy and shown DH at L5 and S1 level. 24

3. Illustrates the anatomical structure of herniation.

4. Indicates the precise position of herniation: centrally,

paracentral/subarticular, foraminal, extraforaminal.

5. Indicates if the disc herniation is confined or not confined.

6. Illustrates the movement of fragments: superior, inferior, axillary,

intradural.

7. Evaluate the degree of nerve root impairment.

8. Evaluate the overall condition of the remaining disks.

 9. Evaluate the dimensions of the intervertebral neural foramina.

10.Find out if decompression is required or if conservative treatment options

are viable for an individual.

11.Determine the surgical methodology for the surgery.

Uncertainty of MRI findings

It may be necessary to use diagnostic procedures like MRI or CT scan to

determine the root cause in circumstances where patients with DP have

substantial complaints. When it comes to diagnosing DP, the MRI is the gold

standard because of how precise it is. However, in certain cases, it may reveal

additional abnormalities in individuals who do not have any symptoms.. 33,34

MRI is a non-invasive imaging technique that does not employ ionizing

radiation.16 It has superior sensitivity in detecting soft tissues compared to a CT.

The MRI technique is a useful investigation because it can differentiate between

disc tissue as well as the spinal cord, precisely measure the amount of protrusion,

and evaluate the amount of water that is contained inside the disc on both sagittal

and axial drawings.

In spite of the fact that MRI is extremely sensitive, its specificity is still up for

debate because it can occasionally detect aberrant findings even when there are no

symptoms or indicators present. The link between imaging findings of disc illness

and the presence of complaints is minimal, despite the fact that MRI is valuable in

understanding the structure and chemical composition of disc disease.1

Multiple studies have demonstrated that MRI possesses a high level of sensitivity

when it comes to the identification of LDH. Nevertheless, there is a lack of strong

association between the clinical symptoms and MRI results in individuals with

LDH. Asymptomatic patients may exhibit MRI alterations that seem to be LDH. 10

MRI investigations conducted on specific individuals have revealed a 36%

occurrence of disc protrusion along with extrusion in individuals who do not have

any symptoms. This emphasizes the limited ability of these findings to accurately

forecast the onset of back and leg pain. 17,35

Management of LDH

The majority of symptomatic manifestations of LDH are temporary and typically

disappear within a period of six to eight weeks. As a result, initial management

usually involves conservative measures, unless there are red flag symptoms that

indicate the possibility of urgent conditions like progressive neurologic deficit or

cauda equina syndrome. Studies conducted in recent times have demonstrated that

conventional medical care and operative procedures have comparable outcomes in

both the short and extended term.

Conservative Treatment

The initial therapy of choice for individuals with indications of acute LDH is this

method. Doctors at PHC level may start treatment by prescribing a brief period of

rest, if necessary, along with providing relevant patient education, suggesting

physical activities, and prescribing pain medicines and physical therapy.

Typically, symptoms will show improvement after a few weeks. Therefore, it is

not advisable to undergo physical therapy until at least three weeks after the

symptoms first appear. Initiating pain treatment may involve the use of modest

nonsteroidal anti-inflammatory medicine. If this approach proves ineffective, the

next course of action would be the use of opioid analgesics. Nevertheless, it is

crucial to carefully examine and openly address the potential hazards and adverse

effects associated with opioids with the patient. Furthermore, it is advisable to

prescribe opioids for the shortest feasible period of time.

In cases when symptoms continue for more than six weeks, doctors may consider

using corticosteroid injections to provide temporary agony relief lasting 2 to 4

weeks for patients with LDH along with sciatica. Using contrast-enhanced

fluoroscopy is advised for achieving more precise administration of epidural

steroid injections. Medical and interventional therapy can enhance functional

results in the majority of cases with LDH along with sciatica that do not require

surgical intervention. 32,36

Surgical Treatment

Although surgical intervention is often seen as a last resort, discectomy as well as

laminotomy are procedures that are commonly carried out in order to treat sciatica

that is brought on by LDH. Surgery is recommended for individuals who have

chronic debilitating symptoms that do not improve with conservative and

medicinal treatment. The performance of operations within a period ranging from

six months to one year for a patient who is experiencing complaints that

necessitate surgical attention is associated with a more rapid recovery and

improved outcomes over the long run.

When it comes to doing an operating execution, there are a few different

approaches that can be taken, such as an open method as well as a less-invasive

approach. The open approach refers to the surgical technique known as open

microsurgical discectomy. Spinal surgery has increasingly relied on the minimally

invasive method during the past twenty years. The procedure can be performed
using minimally invasive techniques including minor incisions along with tube

access. It may be categorized into two primary innovations: endoscopic and

microsurgical. The surgical team selects the approach strategy for treating a

herniated disc depending on its form and location.

Minimally invasive methods are associated with shorter operational time, less

blood loss, and no significant differences in complications, reoperation rates, or

wound infections compared to open discectomy. Nevertheless, there is no

discernible disparity in the long-term patient-centered results between open and

minimally invasive operations. 32,37

Lumbar disc replacement has been employed as a substitute for lumbar fusion in

cases with degenerative disc degeneration. The utilization of this method for

lumbar disc herniation has not gained popularity due to its lack of superiority

compared to the open approach or the minimally invasive technique. 38

Differential Diagnosis 39
Relevant articles

Wittenberg et al. conducted a prospective study in Germany in 1997. The

study included 54 patients who had been experiencing sciatic pain for a mean of

12 months. The patients had MR imaging before microdiscectomy, and the

researchers found a correlation between imaging results and the patients' clinical
40
complaints both before and after the surgery. They noted that there was no

association between a neurological deficiency and the amount of the prolapse.

There was a direct relationship between the severity of canal blockage and the

extent of disc degeneration as detected by imaging for extrusions, subligamentous

disc sequestrations, and free sequestrations. 36% of the pictures showed

inflammation and swelling of the nerve root, which matched the surgical result of

32%. The researchers determined that MR imaging might be a valuable diagnostic

tool prior to surgery, since it can reveal structural alterations in the disc and

accurately identify the location and extent of the disc sequestration. However,

they found no connection between the imaging results and the clinical complaints.

Janardhana et al conducted a research in India in 2010 among 119

individuals who had been clinically diagnosed with lumbar disc prolapse. 16

Clinical complaints, DP extent, and neurological symptoms were cross-referenced

with the MRI findings. The occurrence of centro-lateral protrusion or extrusion,

together with significant narrowing of the foramen, is associated with clinical

signs and symptoms. However, central bulges and disc protrusions have a weak

correlation with patients’ complaints. The significance of neural foramen

impairment is greater in defining the patients’ complaints, but the relationship

between the kind of DH and patients’ complaints is weak.

 Dutta et al conducted prospective research in India in 2016. The study
41
comprised fifty participants with LDH during a 2-year period. The researchers

found that the MRI scan had a sensitivity of 100% and a specificity of 94.94% in

accurately identifying surgically significant levels. The SLR test yielded positive

results in 74% of samples, along with paracentral, central, and foraminal levels

showing rates of 85%, 43%, and 75% respectively. Among the MRI parameters,

only foraminal impairment showed a significant correlation with neurological

abnormalities. Individuals who had a high-intensity zone (HIZ) detected on their

MRI experienced a notable escalation in their back pain. Furthermore, 63% of

these individuals displayed observable annular rupture after the surgical

procedure. The anatomical results observed during the surgery closely matched

the findings from the MRI scan. Based on their observations during surgery, the

researchers concluded that MRI scan results correlate well with clinical features.

This suggests that MRI scans might be a valuable tool for surgeons when

planning a surgical procedure, since they provide an accurate representation of the

morphological traits.

In 2016, Thapa et al performed prospective analytical research in Nepal. The

study comprised 57 instances with lumbar disc prolapse that were presented to the
42
Department of Orthopaedics at Tribhuvan University Teaching Hospital.

Radicular leg discomfort was present in 71.9% of patients, specifically along a

particular dermatome. The magnetic resonance imaging revealed the presence of

104 lumbar discs at the degree of prolapse. There is an 85.5% occurrence of DP at

the L4 plus L5 as well as L5 plus S1 levels. The physical signs of radiating

discomfort and motor dysfunction were found to be associated with the

constricting of the neural foramina along with compression of the nerve roots,
according to the MRI results. The study's authors concluded that LIDP symptoms

were somewhat associated with the findings of MRI. However, it is important to

note that not all imaging abnormalities have a clinical meaning.

In 2019, Lakshmeesha et al did research in India including 58 individuals

who presented with symptoms of sciatica at the orthopaedic OP. These

individuals were diagnosed with prolapsed intervertebral disc and the diagnosis
43
was subsequently confirmed using MRI. The patients received conservative

treatment consisting of bed rest and analgesics for a duration of 6 weeks. Patients

who did not get relief from conservative therapy for a duration of 6 weeks were

chosen for surgical surgery. They found a good association between the clinical,

MRI results, and intraoperative findings in 55 out of 58 patients.

Saleem et al conducted a cross-sectional research in Pakistan in 2012, which

comprised 163 individuals with lumbar disc degeneration. 44 The prevalence of

disc degeneration was highest at the L4-L5 level, observed in 105 (64.4%)

individuals. The study found that of the six degenerative characteristics, HD was

the most common (109 cases, or 66.9%). Spondylolisthesis was often observed in

the L5-S1 level, with a prevalence of 10 cases (6.1%). It was mostly related with

lumbar spinal stenosis, which was found in 7 cases (18.9%).

Berry et al. discussed the diagnosis and management of Lumbar

45
Radiculopathy in the United States in 2019 in their review. The most effective

imaging technique for assessing radiculopathy is non-contrast MRI of the lumbar

spine, which can reveal nerve root compression. Contrast-enhanced MRI is

beneficial or recommended in situations including the presence of a tumor,

infection, or previous surgical procedure. If MRI is neither accessible or feasible,

a CT myelogram serves as a viable substitute.

In 2021, Banjade et al. did descriptive cross-sectional research in Nepal with

68 individuals with LBP. They established a correlation between the anomalies

found on MRI scans as well as the patients’ symptoms of LDH. 46 Neurological

symptoms were observed in 26 individuals, accounting for 38.23% of the total.

The MRI revealed a disc bulge in 48 cases (45.28%), protrusion in 46 cases

(43.39%), and extrusion in 10 cases (11.32%). Most of these cases were observed

at the L5-S1 level, accounting for 66.11% of the total. The clinical extent of pain

distribution had a strong correlation with the level observed in MRI scans.

However, it is important to note that not all disc bulges resulted in the

manifestation of symptoms.

Sahil Singla and his colleagues conducted a descriptive cross-sectional

47
research including 60 individuals diagnosed with lumbar disc prolapse. They

noted that 90% of the patients had radiculopathy, and in 82% of the cases, the

straight leg raise (SLR) test yielded positive results. All patients had aberrant MRI

results, with the most frequent finding being disc bulge (53.3%). The most levels

in which LDH noticed were L4 plus L5 as well as L5 plus S1. Disc degeneration

and neural canal impairment were also seen. This study has found a significant

correlation between MRI results and clinical symptoms in most patients.

However, it is important to note that not all MRI findings are associated with

clinical symptoms in patients.

Zafar et al performed a research in Pakistan in 2022 with 266 individuals

48
who either had or did not have Low Back Pain, with or without radiculopathy.
The researchers observed that MRI was highly precise in identifying many

diseases, including Disc Degeneration, Disc Herniation & Bulges, and Spinal

Canal Stenosis & Nerve Root Compression. The researchers determined that MRI

diagnosis is both meaningful and precise, hence eliminating the need for

additional interventional procedures. Of the degenerative alterations in the discs,

LBP is the highly prevalent symptom, radiculopathy is less common.

In 2009, Kamal et al. conducted a research in Dhaka including 40 individuals

49
who had suspicions of having lumbar disc herniation. The perioperative

observations were subsequently compared with the MRI results. Most of LDH

were observed in the L4 plus L5 level (57.5%) and the L5 plus S1 level (25%).

The sensitivity of the MRI was 94.28%, indicating its ability to correctly identify

positive cases. The specificity was 60%, indicating its ability to correctly identify

negative cases. The overall accuracy of the MRI was 90%, reflecting its overall

performance in correctly classifying cases. This study confirmed the utilization of

MRI as the radiological modality for identifying lumbar disc herniation.

Vroomen et al conducted a research in the Netherlands in 2000, which had

50
274 individuals experiencing discomfort spreading into the leg. An analysis was

conducted on the correlations between patient features, clinical symptoms, and the

compression of lumbosacral nerve roots on MR imaging. Results from history-

related questions have previously provided the majority of the medical data used

in the physical checkup, according to statistical analysis. The researchers

determined that there were many clinical observations that were linked to nerve

root compression on magnetic resonance imaging (MRI).

 Huang et al conducted a comprehensive study and meta-analysis in China up
51
till 2022. Their aim was to conduct a comprehensive assessment of the clinical

use of three imaging techniques, “Magnetic Resonance Imaging, Computed

Tomography, and myelography,” in diagnosing LDH. The researchers determined

that the three imaging exams have significant diagnostic value. Furthermore, as

compared to myelography, Magnetic Resonance Imaging shown superior

diagnostic efficacy.

Van der Graaf et al conducted a comprehensive analysis of MRI scans to

identify and establish the correlation between several observable aspects and
52
lower back pain (LBP) in the Netherlands by 2023. The collective searches

yielded a total of 4472 results, out of which 31 articles were included. The

researchers determined that the diagnostic lumbar MRI imaging characteristics

exhibit the highest likelihood of a robust correlation with low back pain (LBP).

Saini et al conducted a prospective observational research in 2022 in India,

10
focusing on 201 patients with Lumbar Disc Herniation. Among the 53 patients

who did not have radiculopathy, 79.2% had a bulge, 18.9% had a protrusion,

1.9% had extrusion, and none of the patients with sequestration had radicular

symptoms. Out of the 148 patients diagnosed with radiculopathy, 61.5% had a

protrusion, 21.6% had a bulge, 13.5% had extrusion, and 3.4% had sequestration.

None of the individuals included in this research had sequestration without

radicular discomfort. Most of our patients exhibited radiculopathy that was

strongly associated with MRI findings. Nevertheless, it was discovered that

26.4% of individuals exhibiting MRI disc alterations did not have radicular

discomfort. The majority of individuals without radiculopathy had Schizas grade

A2, while a majority of patients with radiculopathy had Schizas grade A3.
 MATERIALS AND METHODS

STUDY DESIGN:

This prospective observational study was carried out in patients with Lumbar

Intervertebral disc prolapse who required discectomy.

STUDY AREA:

The study focused on patients with Lumbar Intervertebral disc prolapse who

required discectomy and were admitted to the Orthopaedics department of RL

Jalappa hospital. This hospital is a teaching hospital affiliated with Sri Devaraj

Urs Medical College, which is an affiliated institution of Sri Devaraj Urs

Academy of Higher Education and Research, located in Kolar.

STUDY PERIOD AND DURATION:

The study was done from September 2022 to December 2023, spanning a duration

of 1 year and 4 months.

STUDY POPULATION:

All patients hospitalized to RL Jalappa hospital from September 2022 to

December 2023, diagnosed with Lumbar Intervertebral disc prolapse, and having

had unsuccessful conservative therapy for a minimum of eight weeks in the

Orthopaedics department. This treatment regimen consists of a well-organized

schedule of rest, accompanied by analgesic medication, and then followed by

physiotherapy.

SAMPLE SIZE CALCULATION

 (41),
According to the study by Shumayou Dutta et al Given a minimum correlation

coefficient of 0.4, we are considering the relationship between clinical and

radiological results and MRI findings specifically related to disc protrusion.

Given an alpha level of 5% (corresponding to a 95% confidence interval) and a

power of 80% (equivalent to a beta value of 0.20). The following formula was

used to get the sample size.

The study requires a minimum of 47 participants.

INCLUSION CRITERIA:

 Individuals aged 20-65 who have lumbar intervertebral disc prolapse.

 Chronic pain that does not respond to non-invasive therapy for a minimum

of eight weeks.

 Deteriorating neurological symptoms

 Cauda equina syndrome.

EXCLUSION CRITERIA:

 Those individuals who had previously undergone surgery at the same

surgical location as the current study.

 Those individuals with any other associated conditions like,

o Congenital abnormality

o Scoliosis

o Post traumatic spine deformity

o Infection

o Tumor

SAMPLING METHOD:

Between September 2022 and December 2023, all consecutive patients who were

diagnosed with lumbar intervertebral disc prolapse and required discectomy were

admitted to the Orthopaedics department of the RL Jalappa hospital.

DATA COLLECTION PROCEDURE

After obtaining their written and informed consent, patients who were eligible for

participation in the trial were recruited based on the requirements for inclusion

and exclusion that were established. They were told about the type of intervention

and therapy, as well as the potential outcomes and consequences.

Only in the event that a conservative treatment lasting at least eight weeks had

been failed was a patient believed to be qualified for surgical intervention. In the

course of this investigation, a methodical regimen consisting of rest, pain

medicine, and physical therapy is followed by the administration of the drug.

A comprehensive physical examination, including a thorough assessment of the

abdomen, hips, and sacroiliac joints, was conducted to rule out any potential

sources of discomfort and other symptoms. Lumbar spine radiographs were

obtained to exclude the conditions.

The clinical criteria that were used to evaluate these patients are:

 Low backache with radiation to the lower limb

 Radicular pain along a specific dermatome

 Straight leg raising test (SLRT) for nerve root tension.

 Presence of a neurological deficit

Patients who met these clinical criteria underwent MRI scanning. The MRI

findings that were recorded are the following:

 Prolapse level.

 Location (central, paracentral, foraminal, and extraforaminal)

 Type (bulge, protrusion, extrusion, and sequestration)

 Migration (superior and inferior)

 Annular tear

 Lateral recess

 Foraminal stenosis (thecal sac compression, nerve root contact, and nerve

root compression).

An MRI with 1.5 Tesla was performed on each and every patient. Both the axial

and sagittal planes were scanned in order to obtain the results. It was possible to
get axial sections by capturing them in parallel to each lumbar disc as well as the

superior and inferior endplates of the lumbar vertebrae. We utilized a slice

thickness of three millimeters. The magnetic resonance imaging (MRI) revealed a

significant amount of disc prolapse in cases where there was compression of the

thecal sac and the nerve root that was next to it, in addition to clinical symptoms.

An individual radiologist performed a painstaking analysis of each and every MRI

scan that was carried out for the entirety of the study.

Patients who met both the clinical and MRI criteria were selected for surgical

treatment. The indications for surgery were the following,

 Persistent pain unrelieved by conservative treatment at least eight weeks.

 Deteriorating neurological symptoms

Intraoperative findings that were noted are the following,

 Type

 Position of the fragment

 Migration

 Annular tear

 Lateral recess and foraminal stenosis.

Subsequently, these observations were contrasted with the MRI findings.

ETHICAL CONSIDERATION

In compliance with ethical norms, the Institutional Ethics Committee has given its

clearance. The researchers have maintained the privacy and confidentiality of the

participants by making sure that the data they have obtained is used exclusively

for the research aims that have been indicated throughout the study.
DATA ANALYSIS

 The data were imported into Microsoft Excel and subsequently analysed using

SPSS 23.0.

 To characterizing the data, descriptive statistics for discrete variables were

utilized. These statistics included frequency analysis and percentage analysis.

When dealing with continuous variables, the statistical measurements of mean,

median, along with S.D were utilized.

 RESULTS

Table 1: Age distribution of study participants

Age in years

Mean 43.66

Std. Deviation 9.386

Range 31

Minimum 27

Maximum 58

The average age of enrolled samples diagnosed with LIDP was 43.66 ± 9.38

years.
Figure 8: Age distribution of study participants.

Age distribution of study participants (n=47)

20

18

16

14

12
FREQUENCY

10

0
22-27 32-37 40-45 46-50 51-55 56-60

Age -Categorized in groups

Table 2: Gender distribution

The study found that 78.7% of the subjects diagnosed with Lumbar Intervertebral

disc prolapse were male, while the remaining 21.3% were female.
Figure 9: Gender distribution of study participants.

n=10 (21.3%) Female

n=37 Male
(78.7%)
Clinical Findings

Table 3: Assignment of enrolled samples based on the presence of

radiculopathy.

Radiculopathy Frequency Percent

Bilateral 7 14.9

Left 25 53.2

Right 15 31.9

Total 47 100.0

Among the study participants with LIDP, bilateral radiculopathy was found in

14.9% of them. Left radiculopathy was seen in 53.2% of the samples, while right

radiculopathy was observed in 31.9% of the patients.

Figure 10: Assignment of enrolled samples based on the presence of

radiculopathy.

30

25
25

20
Frequency

15
15

10
7

0
Bilateral Left Right
Radiculopathy
MRI findings

Table 4: Assignment of enrolled samples based on level of lumbar

intervertebral disc prolapse as documented in MRI.

Level of lumbar intervertebral disc Frequency Percent

prolapse shown in MRI

L4-L5 28 59.6

L5-S1 19 40.4

Total 47 100

The MRI results indicate that 59.6% of the subjects exhibited intervertebral disc

prolapse at the L4-L5 region. The remaining 40.4% was detected specifically at

the L5-S1 level.

In our study we did not come across L2-L3, L3-L4 Level Disc bulge.
Figure 11: Assignment of enrolled samples based on level of lumbar

intervertebral disc prolapse as documented in MRI.

L5-S1,
n=19(40.4%)

L4-L5,
n=28(59.6%)
Table 5: Assignment of enrolled samples based on lumbar disc herniation as

documented in MRI.

Location of lumbar disc herniation Frequency Percent

shown in MRI

Central 18 38.3

Central And Bilateral Paracentral 4 8.5

Central And Left Paracentral 10 21.3

Central And Right Paracentral 1 2.1

Left Paracentral 8 17

Right Paracentral 6 12.8

Total 47 100

Approximately 38.3% of the research participants had lumbar disc herniation in

the central position, which was the most frequently seen site in the MRI findings.

The central and left paracentral location were the second most frequently seen

(21.3%), followed by the right paracentral location (12.8%).

Figure 12: Assignment of enrolled samples based on lumbar disc herniation as

documented in MRI.

20
18
18

16

14

12
10
10
8
8
6
Frequency

6
4
4

2 1
0
al

l
l

ra
ra

ra

ra
ra
tr

nt

nt
nt

nt

nt
en

ce
ce

ce

ce

ce
C

ra
ra

ra

ra

ra

Pa
Pa

Pa
Pa
P

ht
ft

ft
al

ht
e

Le
er

ig
ig
L
t

R
R
la

nd

nd
Bi

A
nd

al

al
tr
A

tr
en
al

en
C
tr

C
en
C

Location shown in MRI

Table 6: Assignment of enrolled samples based on type of lumbar disc

herniation as documented in MRI.

Type of lumbar disc herniation Frequency Percent

shown in MRI

Extrusion 23 48.9

Protrusion 19 40.4

Sequestration 5 10.6

Total 47 100

The MRI results of the study participants showed that extrusion LDH was the

most common type, accounting for 48.9% of the total.

Figure 13: Assignment of enrolled samples based on type of lumbar disc

herniation as documented in MRI.

n=5(10.6%)

Extrusion
n=23 Protrusion
(48.9%) Sequestration
n=19
(40.4%)
Table 7: Assignment of enrolled samples based on migration of herniation

fragments as documented in MRI.

Migration shown in MRI Frequency Percent

Caudal 3 6.4

Cranial 2 4.2

No 42 89.4

Total 47 100

Among the research samples, the caudal side was the most frequent location for

migration of herniation fragments, as evidenced in MRI results (6.4%). Among

the research patients, the migration of herniated fragments to the cranial side was

the second most prevalent, accounting for 4.2%.

Figure 14: Assignment of enrolled samples based on migration of herniation

fragments as documented in MRI.

45
42
40

35

30
Frequency

25

20

15

10

5 3 2
0
Caudal Cranial No
Migration shown on MRI
Table 8: Assignment of enrolled samples with respect to Annular tear as

documented in MRI.

Annular tear in MRI Frequency Percent

Present 28 59.6

Absent 19 40.4

Total 47 100

Annular tear was seen in the MRI results of 59.6% of the individuals included in

the research.
Figure 15: Assignment of enrolled samples with respect to high intensity zone

as documented in MRI.

n=19(40.4%)
Present
Absent
n=28(59.6%)
Table 9: Assignment of enrolled samples with respect to LRFS as documented

in MRI.

MRI showing LRFS Frequency Percent

Left Side 17 36.2

Right Side 10 21.3

Present Bilaterally 8 17

No 12 25.5

Total 47 100

The MRI results indicate that among the study samples, 36.2% exhibited LRFS on

the left side, whereas 21.3% showed these conditions on the right side. Only 17%

of the research samples exhibited bilateral presence.

Figure 16: Assignment of enrolled samples with respect to LRFS as

documented in MRI.

17
18
16
14 12

12 10

10 8
Frequency

8
6
4
2
0
e

lly

o
id

id

N
ra
S

tS

te
ft

h
Le

ila
ig
R

tB
en
es
Pr

MRI showing lateral recess and foraminal stenosis

Operative Findings

Table 10: Assignment of enrolled samples with respect to type of lumbar disc

herniation as documented in operative Findings.

Type of lumbar disc herniation as Frequency Percent

documented in operative Findings

Extrusion 27 57.4

Protrusion 14 29.8

Sequestration 6 12.8

Total 47 100

Among the study's samples, the most prevalent kind of lumbar disc herniation

observed after surgery was extrusion, accounting for 57.4% of cases. Protrusion

was the second most prevalent form, accounting for 29.8% of the patients in the

study.
Figure 17: Allotment of enrolled samples with respect to type of lumbar disc

herniation as documented in operative Findings.

n=
6(1
2.8
%)

n=14(29.8%)
n=27(57.4%)

Extrusion Protrusion Sequestration

Table 11: Allotment of enrolled samples with respect to migration of herniated

fragments as documented in operative Findings.

Migration of herniation fragments as Frequency Percent

documented in operative Findings

Caudal 4 8.5

Cranial 2 4.3

No 41 87.2

Total 47 100

Among the research samples, the caudal side was the most frequent location for

migration of herniated fragments, as indicated in operational results (8.5%).

Among the research patients, the migration of herniation fragments to the cranial

side was the second most prevalent (4.3%).

Figure 18: Allotment of enrolled samples with respect to migration of herniated

fragments as documented in operative Findings.

n=2
n=4
(4.3%)
(8.5
%)

Caudal
Cranial
No

n=41
(87.2%)
Table 12: Allotment of enrolled samples with respect to the presence of annular

tear as documented in operative Findings.

Annular tear documented in Frequency Percent

operative Findings.

Present 33 70.2

Absent 14 29.8

Total 47 100

An annular tear was seen in 70.2% of the surgical findings in the patients of the

research.
Figure 19: Allotment of enrolled samples with respect to the presence of

annular tear as documented in operative Findings.

Absent, n=14
(30%)

Present
Absent

Present, n=33
(70%)
Table 13: Allotment of enrolled samples with respect to the lateral recess as

documented in operative Findings.

Lateral recess Frequency Percent

Left Side 16 34

Right Side 10 21.3

Obliterated Bilaterally 15 31.9

No 6 12.8

Total 47 100

The operative findings revealed that 34% of the research samples had a lateral

recess on the left side, whereas 21.3% of the study participants had it documented

on the right side. The research samples exhibited bilateral presence in

approximately 31.9% of cases.

Figure 20: Allotment of enrolled samples with respect to the lateral recess as

documented in operative Findings.

18
16
16 15
14

12
10
10
Frequency

8
6
6

0
Left Side Right Side Obliterated No
Bilaterally
Lateral Recess
Table 14: Allotment of enrolled samples with respect to the foraminal stenosis

as documented in operative Findings.

Foraminal stenosis Frequency Percent

Present Bilaterally 23 48.9

Left Side 12 25.5

Right Side 6 12.8

No 6 12.8

Total 47 100

Operative findings revealed that 25.5% of the research samples had foraminal

stenosis on the left side, whereas 12.8% of the study participants had it on the

right side. Approximately 48.9% of the studied samples exhibited bilateral

presence.
Figure 21: Allotment of enrolled samples with respect to the foraminal stenosis

as documented in operative Findings.

23
25

20

15 12
Frequency

10
6 6

0
Present Bi- Left Side Right Side No
laterally

Foraminal stenosis
Table 15: Allotment of enrolled samples with respect to the presence of

correlation between clinical, MRI and operative findings.

Correlation Frequency Percent

Present 41 87.2

No 6 12.8

Total 47 100

An 87.2% correlation was reported between the clinical, MRI, and surgical data

among the research participants in this investigation.

Figure 22: Allotment of enrolled samples with respect to the presence of

correlation between clinical, MRI and operative findings.

AB-
SENT-6
(13%)

PRESE
NT- 41
(87%)
Table 16: Allotment of enrolled samples with respect to nerve root compression.

Nerve root Frequency Percent

Bilateral Traversing L5 2 4.3

Bilateral Traversing S1 5 10.6

Left Traversing L5 19 40.4

Left Traversing S1 8 17

Right Traversing L5 5 10.6

Right Traversing S1 5 10.6

No 3 6.3

Total 47 100

The study found that the most frequent occurrence of nerve root compression

among the patients was identified at the left Traversing L5 level, while the second

most common occurrence was noticed at the left Traversing S1 level.

 Frequency
Bi
la
compression.

te
ra
lT N
ra o

3
Bi
la ve
te rs
in
ra
lT g
L5

2
ra
R ve
rs
ig in
ht g
Tr S1

5
av
R er
ig sin
ht g
Tr S1
5
av
er

Nerve Root
Le sin
ft
Tr g
L5
5

av
Le er
sin
ft g
Tr S1
8

av
er
sin
g
L5
19

0
2
4
6
8
10
12
14
16
18
20
Figure 23: Allotment of enrolled samples with respect to nerve root
 DISCUSSION

This prospective observational study included 47 patients diagnosed with

Lumbar Intervertebral disc prolapse and having had unsuccessful conservative

therapy for a minimum of eight weeks in the Orthopaedics department. This

treatment regimen consists of a well-organized schedule of rest, accompanied by

analgesic medication, and then followed by physiotherapy.

The clinical criteria utilized encompassed the presence of pain in the back

that extends to the lower leg, as well as the existence of a neurological

impairment. The documented MRI results encompassed the location, type,

migration, amount of prolapse, high intensity zone, as well as the existence of

lateral recess and foraminal stenosis. Surgical intervention was administered to

patients who satisfied both the clinical and MRI criteria. Subsequently, the

intraoperative data were compared and analysed in relation to the clinical along

with MRI Findings of the patients.

Comparison of basic characteristics of the study patients with similar studies

The average age of the enrolled samples diagnosed with LIDP was 43.66 ±

9.38 years. Our study found that 78.7% of the subjects were male, while the

remaining 21.3% were female.

The connection between MRIF and patients' reports of DP was investigated

in a 2012 study by Bajpai et al. in India. 1 With an average age of 44.5 years, the

gender distribution was as expected: 43 males as well as 32 women.

 In 2012, Saleem and colleagues carried out a research study in Pakistan

that was a cross-sectional study. The participants in this study were 163 people

who had LDH.44 The average age of the patients was 43.92 years, with a standard

deviation of 11.76 years. Females made up 41.7% of the entire population, while

males made up 58.3% of the overall population, with 95 people being males.

Table 17: Comparison of basic characteristics of the study patients with similar

studies

Study Mean age of participants in years Percentage of men

Present study 43.66 ± 9.38 78.7

Bajpai et al1 44.5 57.3

Saleem et al44 43.92 ± 11.76 58.3

Dutta et al41 49 58

Wittenberg et al40 41 60

In 2019, Lakshmeesha et al did research in India including 58 individuals

who presented with symptoms of LDH at the orthopaedic OP. These individuals

were diagnosed with LIDP and the diagnosis was subsequently confirmed using

MRI.43 The age range of 45 patients, out of 58 total patients, was between 30 and

50 years old. There were 55% male patients and 45% female patients among those

who were admitted.

 Dutta et al conducted prospective research in India in 2016. The study
41
comprised 50 samples with LDH during a 2-year period. For the purpose of this

investigation, the average age of the patients was 49 years old, with 58% being

male and 42% being female.

In the year 1997, Wittenberg et al. conducted a follow-up study of fifty-four

40
patients utilizing MRI prior to performing a microdiscectomy in Germany.

Their ages ranged between 19 and 72 years old, with the average being 41 years

old at the time of the treatment. This group consisted of sixty percent males.

Comparison of clinical features of the study patients with similar studies

Among the study participants with LIDP, bilateral radiculopathy was found

in 14.9% of them. Left radiculopathy was seen in 53.2% of the samples, while

right radiculopathy was observed in 31.9% of the patients.

In a study by Bajpai in 2012, there were a total of 48 patients, which is 64

percent of the total, who suffered LDH. Six patients, which is 8 percent, had

symptoms on both sides of their body, and the remaining 22 patients were on the

left side and 20 patients were on the right side. 1

Comparison of MRI findings of the study patients with similar studies

In our study MRI results indicate that 59.6% of the subjects exhibited

intervertebral disc prolapse at the L4-L5 region. The remaining 40.4% was

detected specifically at the L5-S1 level.

Table 18: Comparison of most common level of lumbar disc prolapse with

similar studies.

Study Commonest level of LDP Percentage

Present study L4-L5 59.6

Nasir et al3 L4-L5 31.3

Saleem et al 44 L4-L5 64.4

Lakshmeesha et al43 L4-L5 60.3

Sahil Singla47 L5-S1 55

In 2019, Lakshmeesha did research in India. 43 The MRI showed that the

level that was impacted the most frequently was the L4 and L5 level, which was

detected in 35 different people. There were seven individuals who had L5 and S1

observed, while there were two patients who had L3 and L4 viewed. A total of 14
individuals experienced prolapse of discs at two levels, with the most prevalent

levels being L4-L5 and L5-S1. Annular tear was seen in the MRI results of 59.6%

of the individuals included in this research.

In 2016, Dutta conducted a prospective study in India. The research

included 50 consecutive individuals with lumbar disc herniation who had

41
discectomy over a span of 2 years. A total of 16 individuals, accounting for

32% of the sample, exhibited annular tear on the MRI scan.

Among the research samples, the caudal side was the most frequent

location for migration of herniation fragments, as evidenced in MRI results

(6.4%). Among the research patients, the migration of herniated fragments to the

cranial side was the second most prevalent, accounting for 4.2%.

Bajpai conducted a study in India. 1 Among the 75 patients examined in

this investigation, 21 individuals exhibited the presence of herniated tissue

causing foraminal invasion at one or more levels. However, a total of 48

individuals had radiculopathy.

Our study found that the most frequent occurrence of nerve root

compression among the patients was identified at the left Traversing L5 level,

while the second most common occurrence was noticed at the left Traversing S1

level.

Janardhana et al conducted a study in India in 2010 with 119 persons who

had received a clinical diagnosis of lumbar disc prolapse. 16 According to the

results, neural foramen compromise was observed in 157 among the 290 levels of
DH in 119 different people. Nerve root compression was seen at 66 different

levels.

In 2019, Lakshmeesha conducted a study. The diagnosis was later verified

by MRI.43 A total of 72.4% patients were found to have neurological involvement,

whereas the remaining 27.6% patients did not exhibit any signs of having this

involvement.

In our study, about 38.3% of the research participants had lumbar disc

herniation in the central position, which was the most frequently seen in the MRI

findings. The central and left paracentral location were the second most frequently

seen (21.3%), followed by the right paracentral location (12.8%). Extrusion was

the type of LDH that was shown to be the most prevalent in the MRI findings of

the people who participated in the research. It accounted for 48.9% of the total.

Protrusion was the subsequent most seen form among the patients who

participated in the study, accounting for 40.4% of all instances investigated.

Saini et al conducted a prospective observational research in 2022 in

India, focusing on 201 patients with LDH. 10 As indicated on MRI scans, the study

found that among the group of people who had been diagnosed with LDH, 36.8%

of them presented a bulge, 50.2% of them had a protrusion, 10.4% of them had

extrusion, and 2.5% of them displayed sequestration. The study revealed that

38.3% of patients with LDH had a central location on MRI, whereas 31.8% had a

foraminal impression, 28.8% had a paracentral picture, and 1% had an

extraforaminal impression.

Janardhana conducted a research. 16 A total of 208 disc bulges were

observed among 119 individuals. A total of 56 levels (including 43 individuals)

exhibited disc protrusion. In a total of twenty-six cases, disc extrusion was seen,

and twenty of those cases displayed fragment migration. With regard to the 56-

disc protrusions, 31 were situated in the central region, 23 were situated in the

centro-lateral region, and two were situated in the far lateral region. Out of the

total of 26-disc extrusions, 10 were located centrally, while the remaining 16 were

situated in the centro-lateral region.

41
Dutta conducted follow up research. Using MRI, the research zeroed in

on the exact location of the 51 surgically corrected levels of DP. Out of the total,

33 were identified as paracentral, 14 as central, and four as foraminal.

Bajpai conducted a study 1. Protrusion was seen in 44 patients, extrusion

was present in 14 patients, sequestration was present in two patients, and 15

patients did not have any disc herniation.

Table 19: Comparison of most common type of LDH with similar studies.

Study Most common type of LDH

Present study Extrusion (48.9%)

Saini et al10 Protrusion (50.2%)

Bajpai et al1 Protrusion (58.6%)

Sahil Singla et al47 Bulge (53.3%)

Banjade et al46 Bulge (45.2%)

 Sahil Singla and his colleagues conducted a descriptive cross-sectional
47
research including 60 individuals diagnosed with lumbar disc prolapse. The L5

and S1 level has the highest prevalence of disc herniation, which is 55%. The L4

and L5 level has the second highest prevalence, which is 38.3%, followed by the

L3 and L4 level, which has 6.7%. The prevalent form of disc herniation is disc

bulging, accounting for 53.3% of cases, followed by protrusion at 36.7%, and

extrusion at 10%. Furthermore, the MRI revealed disc bulging in 48 cases

(45.28%), protrusion in 46 cases (43.39%), and extrusion in 10 cases (11.32%) at

various levels.

Banjade et al. observed that the L5 and S1 level had the highest prevalence of

LIDP, accounting for 66.11% of cases. 46

Comparison of this study correlation with other correlation studies

In our study 87.2% correlation was reported between the clinical, MRI,

and surgical data among the research participants with Lumbar Intervertebral disc

prolapse.

In 2016, Dutta conducted a prospective study in India. 41. The researchers

established a strong link between the results obtained from MRI scans and the

features noticed during surgery.

Table 20: Comparison of Percentage of Correlation between the clinical, MRI,

and surgical findings with similar studies.

Study Percentage of Correlation between the clinical,

 MRI, and surgical findings

Present study 87.2%

Lakshmeesha et al43 94.8%

In 2019, Lakshmeesha conducted a study in India. 43 It was found that

there was a substantial correlation between the patients complaints, the MRIF,

and the understandings acquired during the surgical operation in 55 out of 58

patients.

Wittenberg et al. conducted prospective research in Germany in 1997.

The study comprised a cohort of 54 individuals who had been enduring sciatic

pain for an average duration of 12 months. Prior to microdiscectomy, the patients

underwent MR imaging. The objective of the researchers was to establish a

relationship between the imaging findings and the patients' clinical symptoms,
40
both preoperatively and postoperatively. The neurological impairment,

assessment of straight leg raising, and examination of reflexes were conducted

throughout the follow-up period in a group of 49 patients. These findings were

then compared to the results of the MRI scans acquired before to the surgical

procedure. There was no substantial association observed between the clinical

complaints and the MRI results.

In 2022, Nasir et al conducted a correlational research 3. Their conclusion

was that there was no link between the MRIF and patients data of individuals with

LIDP at L2 and L3.

 CONCLUSION

In our study, 87.2% correlation was reported between the clinical, MRI, and

surgical data among the research participants admitted with Lumbar Intervertebral

disc prolapse. MRI is a valuable preoperative diagnostic tool that reveals

structural alterations in the disc, as well as the dimensions and location of the

extrusion or protrusion. The criteria for performing surgery in cases with

prolapsed intervertebral disc is well-established.

Nevertheless, the choice to do surgery should only be taken when precise clinical

observations, together with MRI results, enable the precise identification of the

responsible fragment and sources of discomfort.

 LIMITATION

 Given the limited number of people who participated and the restriction of

the research to a specific site, it is plausible that the findings may not be

applicable to the entire community.

 Functional outcome was not included in our study.

SUMMARY
This prospective observational study included 47 patients hospitalized to RL

Jalappa hospital from September 2022 to December 2023, diagnosed with

Lumbar Intervertebral disc prolapse, and having had unsuccessful conservative

therapy for a minimum of eight weeks in the Orthopaedics department. This

treatment regimen consists of a well-organized schedule of rest, accompanied by

analgesic medication, and then followed by physiotherapy.

The clinical criteria utilized encompassed the presence of pain in the back that

extends to the lower leg, as well as the existence of a neurological impairment.

The documented MRI results encompassed the location, type, migration, amount

of prolapse, high intensity zone, as well as the existence of lateral recess and

foraminal stenosis. Surgical intervention was administered to patients who

satisfied both the clinical and MRI criteria. Subsequently, the intraoperative data

were compared and analysed in relation to the clinical along with MRI Findings

of the patients.

The average age of patients diagnosed as LIDP was 43.66 ± 9.38 yrs. The study

found that 78.7% of the subjects were male, while the remaining 21.3% were

female. Among the study participants with LIDP, bilateral radiculopathy was

found in 14.9% of them. Left radiculopathy was seen in 53.2% of the samples,

while right radiculopathy was observed in 31.9% of the patients.

The MRI results indicate that 59.6% of the subjects exhibited intervertebral

disc prolapse at the L4-L5 region. About 38.3% of the research participants had

lumbar disc herniation in the central position, the central and left paracentral

location were the second most frequently seen (21.3%), followed by the right

paracentral location (12.8%). A high intensity zone was seen in the MRI results of
59.6% of the individuals included in the research. The MRI results indicate that

among the study samples, 36.2% exhibited LRFS on the left side, whereas 21.3%

showed these conditions on the right side.

Among the study's samples, the most prevalent kind of lumbar disc

herniation observed after surgery was extrusion, accounting for 57.4% of cases.

The operative findings revealed that 34% of the research samples had a lateral

recess on the left side, whereas 21.3% of the study participants had it documented

on the right side. The research samples exhibited bilateral presence in

approximately 31.9% of cases. Operative findings revealed that 25.5% of the

research samples had foraminal stenosis on the left side, whereas 48.9% of the

studied samples exhibited bilateral presence.

An 87.2% correlation was reported between the clinical, MRI, and surgical

data among the research participants in this investigation. The study found that

the most frequent occurrence of nerve root compression among the patients was

identified at the left Traversing L5 level.

The accurate representation of morphometric features in MRI scans makes

them a useful tool for preparing for surgery, and there is a robust positive

correlation between IOF and MRI results. Nevertheless, the choice to have

surgery should only be taken when a thorough examination of clinical evidence,

together with MRI results, enables a precise identification of the specific fragment

causing the problem and the sources of discomfort.

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 ANNEXURE

ANNEXURE - 1
SRI DEVARAJ URS ACADEMY OF HIGHER EDUCATION AND RESEARCH,
TAMAKA, KOLAR - 563101.
PATIENT INFORMATION SHEET

STUDY TITLE: “CORRELATION BETWEEN CLINICAL AND MRI FINDINGS WITH INTRA
OPERATIVE FINDINGS IN LUMBAR INTERVERTEBRAL DISC PROLAPSE”

Study location: R L Jalappa Hospital and Research Centre attached to Sri Devaraj Urs Medical College, Tamaka,
Kolar.

Details- Patients with suspected Lumbar Intervertebral disc prolapse presenting to Department of Orthopaedics of
R.L.JALAPPA HOSPITAL AND RESEARCH CENTRE, attached to SRI DEVARAJ URS MEDICAL
COLLEGE, TAMAKA, KOLAR
Patients in this study will have to undergo routine blood investigations (CBC, RFT, serum electrolytes, blood grouping,
HIV&HBsAG), chest x ray, ECG and MRI of Lumbar spine.
Please read the following information and discuss with your family members. You can ask any question regarding
the study. If you agree to participate in the study we will collect information (as per proforma) from you or a
person responsible for you or both. Relevant history will be taken. This information collected will be used only for
dissertation and publication.

All information collected from you will be kept confidential and will not be disclosed to any outsider. Your
identity will not be revealed. This study has been reviewed by the Institutional Ethics Committee and you are free
to contact the member of the Institutional Ethics Committee. There is no compulsion to agree to this study. The
care you will get will not change if you don’t wish to participate. You are required to sign/ provide thumb
impression only if you voluntarily agree to participate in this study.

CONFIDENTIALITY
Your medical information will be kept confidential by the study doctor and staff and will not be made publicly
available. Your original records may be reviewed by your doctor or ethics review board. For further information/
clarification please contact

Dr.NAVINBALAJI R(Post Graduate),

Department of ORTHOPAEDICS,
SDUMC, Kolar
CONTACT NO: 9003599992

ANNEXURE - II
SRI DEVARAJ URS ACADEMY OF HIGHER EDUCATION AND RESEARCH,
TAMAKA, KOLAR - 563101.

INFORMED CONSENT FORM

Case no: UHID no:
TITLE: CORRELATION BETWEEN CLINICAL, MRI AND INTRA OPERATIVE FINDINGS
IN LUMBAR INTERVERTEBRAL DISC PROLAPSE

I,________________________________________________ aged _____________ ,after being

explained in my own vernacular language about the purpose of the study and the risks and complications
of the procedure, hereby give my valid written informed consent without any force or prejudice for
Clinical examinations, MRI Scanning and Surgical procedure which is to be performed on me or
_______ under any anaesthesia deemed fit. The nature and risks involved in the procedure (surgical and
anaesthetical) have been explained to me to my satisfaction.
I have been explained in detail about the Clinical Research on
‘’CORRELATION BETWEEN CLINICAL, MRI AND INTRA OPERATIVE FINDINGS IN
LUMBAR INTERVERTEBRAL DISC PROLAPSE” being conducted. I have read the patient
information sheet and I have had the opportunity to ask any question. Any question that I have asked,
have been answered to my satisfaction.

I consent voluntarily to participate as a participant in this research. I hereby give consent to provide
my history, undergo physical examination, undergo the operative procedure, undergo investigations and
provide its results and documents etc to the doctor / institute etc.

For academic and scientific purpose the operation / procedure, etc may be video graphed or
photographed. All the data may be published or used for any academic purpose. I will not hold the
doctors / institute etc responsible for any untoward consequences during the procedure / study. All the
expenses estimated for the patients for above procedure will be beared by the primary investigator.

A copy of this Informed Consent Form and Patient Information Sheet has been provided to the
participant.

(Signature & Name of Pt. Attendant) (Signature/Thumb impression & Name of patient)

(Relation with patient)---------

Witness: ---------------------------
 ANNEXURE-III

ANNEXURE - IV
SRI DEVARAJ URS ACADEMY OF HIGHER EDUCATION AND RESEARCH,
TAMAKA, KOLAR - 563101.

UHID No: CASE NO:

TITLE: “CORRELATION BETWEEN CLINICAL, MRI AND INTRA OPERATIVE
FINDINGS IN LUMBAR INTERVERTEBRAL DISC PROLAPSE “

1. BASIC DATA
 Name:
 Age/Sex:
 Address:
 Mobile No:
 Date of Procedure:
 Date of Admission/OP:
 Date of Discharge:

History:

General physical examination:

Vitals: Pulse- BP-
RR- Temp-
Systemic examination:
CVS- PA-
RS- CNS-

Preexisting systemic illness:

Local examination:

 Swelling :
 Tenderness :
 Right
Left

 SLRT :
  Power:
L2 (Hip Flexion)

L3 (Knee Extension)

L4 (Ankle Dorsiflexion)

L5 (EHL)

 Deep S1 (Ankle Plantarflexion)

tendon reflexes :
 Distal sensations :
 Peripheral pulsations :
RADIOLOGICAL INVESTIGATIONS:
MRI LS SPINE:

2. DIAGNOSIS:

3. INVESTIGATIONS:
• CBC - • Sodium –
• BT - • Potassium –

• CT - • RBS -

• Blood grouping - • HIV, HBsAg, HCV –

• Blood urea -
• Serum creatinine -

4. MRI FINDINGS:

 Prolapse level -

 Location -

 Type -

 Migration (superior and inferior) -

 Annular tear -

 Nerve Root Involvement -

  Lateral recess -

 Foraminal stenosis -

5. OPERATIVE TREATMENT:
 Operation date:
 Type of anaesthesia:
 Approach used:

6. INTRAOPERATIVE FINDINGS:
 Type

 Position of the fragment

 Migration

 Annular tear

 Lateral recess and foraminal stenosis -

7. DATE OF DISCHARGE:

ANNEXURE- V

MRI AND INTRAOPERATIVRE IMAGES

CASE 1:

A B
 C D

Figure 24 (A, B, C & D): A,B & C shows MRI T2 Sagittal & right parasagittal section of
lumbar spine and axial section at L4-5 level with disc protrusion compressing thecal sac and
cauda equine causing severe spinal canal stenosis (yellow arrow), narrowing of bilateral lateral
recesses & neural foramina and abutting right traversing nerve root (green arrow). D shows
intra-operative disc protrusion at L4-5 level.

CASE 2:

A B
 C D

Figure 25 (A, B & C) shows MRI T2 Sagittal & right parasagittal section of lumbar spine and
axial section at L5-S1 level with shows central disc protrusion causing severe spinal canal
stenosis (yellow arrow), narrowing of bilateral lateral recesses & neural foramina and
compressing right traversing nerve root (green arrow). D shows Extracted disc from L5-S1
level.

CASE 3:
A

FIGURE 26: A,B shows MRI saggital section of lumbar spine and axial section at L5-S1 level
showing asymmetrical disc protrusion predominenetly in right para-central location causing
moderate spinal canal stenosis, narroeing of right lateral recess and compressing right traversing
nerve root. C shows Intraoperative image of disc extraction from L5-S1 level.

CASE 4:
Figure 27 (A & B): MRI T2 Sagittal section of lumbar spine and axial section at L4-S5 level
with shows asymmetrical disc protrusion (yellow arrow) with left para-central annular tear
(blue arrow) causing severe spinal canal stenosis, narrowing of bilateral lateral recesses (left >
right) & neural foramina and abutting left exiting nerve root.

CASE 5:
Figure 28 (A & B): MRI T2 Sagittal section of lumbar spine and axial section at L4-S5 level
showing diffuse asymmetrical disc bulge with disc extrusion at right para-central location with
caudal migration compressing thecal sac and causing severe spinal canal stenosis. There is
obliteration of bilateral lateral recess, moderate bilateral foraminal narrowing, compression of
bilateral traversing nerve roots and abutment of right exiting nerve root. C Shows Extraction of
extruded disc from L4-L5 level.

ANNEXURE VI

KEY TO MASTER CHART

M- MALE
F- FEMALE

RT- RIGHT

LT- LEFT

B/L- BILATERAL

LR & FS -LATERAL RECESS AND FORAMINAL STENOSIS

AT- ANNULAR TEAR