Degenerative Spinal Diseases

Anatomy of
vertebral
column
Composed of 33 vertebrae:
7 cervical, 12 thoracic, 5 lumbar,
5 sacral, 4 coccygeal

Flexible structure due to:

Segmental structure
Joints
Intervertebral discs
of:
body & arch and has 7
processes
Intervertebral joints:
 Intervertebral discs:
Fibro-cartilaginous joints between 2 vertebral
bodies.
 Joints between 2 vertebral arches:
Synovial joints, between the superior and
inferior articular processes.
Intervertebral discs:
 Intervertebral discs form ¼ of the vertebral
column length.
 Thickest in the area of greatest movement,
cervical & lumbar vertebrae.
 No disc between C1/C2 or in the sacrum &
coccyx.
 Upper and lower surfaces of the vertebral
body are covered with thin layer of hyaline
cartilage, and the disc lies between them.
 Disc is formed from; Anulus fibrosus and
Nucleus pulposus.
Anulus fibrosus:
Composed of concentric layers of fibro-
cartilage arranged obliquely.
• Nucleus pulposus:
Ovoid mass of gelatinous material, large
amount of water + few collagen fibers &
cartilage cells.

With advancing age water content

decrease and replaced by fibro-
cartilaginous tissue, collagen fibers
degenerate, and disc become thin and less
elastic.
Cervical Disc Degeneration
Cervical degenerative disc disease = “cervical
spondylosis,”
1. Congenital spinal stenosis.
2. Degeneration of the intervertebral disc (“hard
disc or soft disc)
3. Hypertrophy of any of the following: lamina,
dura, articular facets, ligaments.
4. Subluxation: due to disc and facet joint
degeneration.
5. Alteration of the normal lordotic curvature
a) reduction of lordosis: straightening or kyphosis.
b) exaggerated lordosis (hyperlordosis)
Although the majority of individuals > 50
years old have radiologic evidence of
significant degenerative disease of the
cervical spine, only a small percentage will
experience neurologic symptoms.
Pathophysiology
1. direct cord compression.
2. ischemia due to compression of vascular
structures.
3. repeated local cord trauma by normal
movements.
Cervical Disc Prolapse
Most common between C6/C7
then C5/C6.
Less common than lumbar
region.
Mostly in posterolateral
direction.
Presentation
Pain: cervical discs cause painful
limitation of neck motion. Neck
extension usually aggravates pain.
lower motor neuron findings,
weakness usually in one myotome
group on one side.
Muscle bulk and tone: atrophy
and fasciculations may be present.
Sensation: with nerve root
compression, sensory loss will
follow a dermatomal pattern.
Muscle stretch reflexes
Mechanical signs: reproduction of
radicular symptoms with axial
loading of the head
Evidence of spinal cord
involvement (myelopathy)
a) Upper motor neuron findings,
usually in the lower extremities
● weakness may occur without
atrophy or fasciculations
● spasticity: poor control of the
legs when walking, scissoring of the
legs
b) Sensation: any loss below the
Radiologic evaluation
MRI: the study of choice for initial
evaluation for herniated cervical disc and
for imaging the spinal cord.
CT and myelogram/CT
Indications: when MRI cannot be done or
when more bony detail than what MRI
provides is required.
Treatment
Over 90% of patients with acute cervical
radiculopathy improve without surgery.
Adequate pain medication, anti-
inflammatory medication (NSAIDs or
short-course tapering steroids) and
intermittent cervical traction.
Surgery is indicated for those that fail to
improve or those with progressive
neurologic deficit while undergoing non-
surgical management.
Surgery
anterior cervical discectomy

posterior approaches
Cervical Spondylosis
It is a degenerative arthritic
process involving the cervical spine
and intervertebral discs.
Radiological findings are present in
75% of people over 50 years who
are asymptomatic.
Pathophysiology
Reduced water content and
fragmentation of the nuclear portion of
the cervical discs.
Stress on the articular cartilage of the
vertebral end-plates.
Osteophyte spur develop around the
margins of the disintegrating end-
plates. It is projecting posteriorly into
the spinal canal and anteriorly into the
prevertebral space.
Presentation
1- Neck pain
• Most common symptom.
• Remitting relapsing picture.
2- Radicular pain
Sharp, stabbing pain, worse on coughing,
may be superimposed on dull aching
background pain, radiate to shoulder,
periscapular region.
3- Paraesthesia
4- sensory loss in dermatomal distribution.
5- weakness and wasting and hyporeflexia
6- cervical myelopathy
Radiological work-up
Plain cervical x-ray
 narrowing of the disc space.
 osteophytosis
 subluxation; flexion- extention view may
be required.
MRI
 image of choice
Treatment
Rest
Soft collar
Analgesics
Surgery
There are different approaches; anterior or
posterior depending on the site of pathology.
Anterior pathologies like bars and osteophytes
treated from anterior.
Posterior pathologies like hypertrophy of
ligamentum flsvum , hypertrophied facets or
stenosis of foramina could be treated posteriorly.
Degenerative Lumber Diseases
 Lumbar Disc Prolapse

Extrusion ( herniation)
or protrusion ( bulge) of
nucleus pulposus
through the anulus
fibrosis.
Can occur at any age in
adults.
90% occur at L4/L5 and
L5/S1,
Why?
Pathophysiology
Posterolateral
herniation:
compress the nerve
root of the numerically
lower vertebra.
Lateral herniation:
compress the nerve
root of the numerically
upper vertebra.
Central herniation:
Cauda Equina
Clinical presentation
Patient presented with radicular pain.
Sciatica; pain, numbness, tingling in the
distribution of the sciatic nerve, radiating
down on the posterior aspect of the thigh
and lateral aspect of the leg to the foot.
Disc prolapse is the most common cause of
sciatica.
DD: Lumbar canal stenosis,
spondylolesthesis, tumors.
Pain
Site: low back.
Onset: sudden
Character: sharp, electrical, lancinating
Radiation: into the buttocks, posterolateral
thigh, below the knee to foot. It is more
sever than back pain.
Associated with numbness, tingling and
weakness.
Temporized by lying supine, hip flexion,
knee flexion, tilted to opposite side.
Exacerbated with coughing, sneezing,
valsalva, movement,
Pattern of radiation gives
clue to level of prolapse
S1 post thigh, post calf,
into heel.
L5 posterlateral thigh,
lateral leg, dorsum of foot
and hallux.
Examination
Patient in discomfort, lies tilted, with hip
and knee flexed.
Straight leg raising test:
With patient in supine position, test is
positive when sciatica is reproduced with
elevation of leg with extended knee to 10 to
60 degree.
Motor : look for wasting in muscle groups
weakness of ankle dorsiflexion, big
toe L5
planter flexion S1
Ankle Reflexes absence highly specific for S1
Sensory ex

At the end of patient must be examined in

prone position to look for wasting of
buttocks, sensation in posterior thigh and
perianal region and anal tone.
Investigations :
Plain x- ray with dynamic view to asses
stability.
MRI & CT myelography: urgent if there is
evidence of cauda equina, progressive
neurological deficit.
ESR & CRP
Treatment
Conservative treatment
bed rest,
analgesics,
antidepressants,
physiotherapy, swimming.

The resolution of symptoms explained by

reduction of prolapsed disc or adaptation of
nerve root to exteran compression.
If only pain with no neurological deficit we
can try nerve root block.
If all fail then surgery will be the ultimate
choice.
Microsurgical discectomy
Endoscopic discectomy
The goal of surgery is to remove the
herniated disc fragment.
Some patient need surgery for discectomy
and fusion with fixation.
Lumbar canal stenosis
Narrowing of the spinal canal.
It may occurs in
the central spinal canal
the area under facet joints
the neural foramina
Symptomatic LCS causing root compression
can be due to many causes.
L4/L5 level is the most common involved >
L5/S1 >L3/L4
Categories of lumber spinal
Congenital stenosis with shortened pedicles
Degenerative
Central due to disc degeneration,
ligamentum flavum hypertrophy.
Peripheral canal and lateral recess
due to facet OA.
Spondylolesthesis
Combination of congenital and
degenerative causes.
Iatrogenic post laminectomy or fusion.
Post-traumatic
Degenerative stenosis
Most frequently observed type LCS.
Age related degeneration of the lumber
disc and facet joints.
Loss of disc height with bulging and
infolding of ligamentum flavum.
Facet OA and hypertrophy lead to
osteophyte formation
Cysts protruded from facet joint
Pathophysiology
Compression
Ischemia
Effect of standing leading to reduction of
cross sectional area and increase in intra-
thecal pressure. Relieved by flexion.
Walking lead to increase of metabolic
demand beyond micro-vascular supply.
Clinical presentation
Neurologic claudication 90%: increase by
walking, standing and reduced by sitting or
flexion at the waist
Pain is the most common symptoms,
followed by numbness and weakness.
Symptoms mostly bilateral but asymmetric,
usually involving entire leg.
Low back pain 65% not necessarily
associated with claudication.
May demonstrate focal weakness, sensory
loss, in the distribution of one or more
nerve roots.
DD:
Vascular claudication
Non-specific back pain
Distal polyneuropathy
Hip OA
Trochanteric bursitis.
Inflammatory conditions involving the
lumbosacral nerve roots.
Imaging
MRI is the procedure of choice.
CT myelography when MRI is
contraindicated.
Criteria vary; area <100 mm2 moderate
stenosis
area < 76 mm2 sever
stenosis
 finding may present in asymptomatic
person (> 20% in pts > 60 years) so,
interpret result with caution.
Management
The definitive treatment for lumbar canal
stenosis is the relief of the compression by
surgery for patients who can not go along
with their daily activities, or who had
neurological deficits.
Conservative treatment can be utilized by
patients in the absence of the conditions
mentioned above or patients with medical
comorbidities which make the operation
hazardous.
Laminectomy and partial facetectomy.
Multiple laminotomies or fenestrations.
Additional lumbar arthrodesis (fusion ) or
interspinous distraction
The aim of operation is to decompress the
spinal canal and nerve roots with removing
osteophytes, and thickened ligamentum
flavum.
Spondylolesthesis
Subluxation of one vertebra on another
Types
congenital or dysplastic
isthmic
degenerative
traumatic
pathological
Presentation
Back pain and leg pain
Sciatica
LCS
Imaging
Treatment
Patients with only pain can be managed
conservatively with analgesic, rest till acute
attack subside, then physiotherapy to
strengthening muscles of the back and
abdomen.
Change in the life style with avoidance of
prolonged sitting and carrying heavy objects.
If conservative management fail or patient
presented with neurological deficits then
surgery will be needed.
Decompressive laminectomy with fixation
for the affected level.