Degenerative

spine diseases
Spine team
Joyce,

Darshini,

Hema,

Andrew
Causes of back pain

 Prolapsed intervertebral disc

 Cauda equina syndrome

 Conus medullaris syndrome

 Lumbar stenosis

 Cervical stenosis
By : Darshini Supparao
Anatomy  The cervical spine is made up of 7  C3-C7 are more classic vertebrae,
vertebrae. having a body, pedicles, laminae,
spinous processes, and facet joints.
 designed for flexibility and

movement.

 cervical spine has a lordotic shape, or

a backwards “C” shape.

 C1 and C2, are highly specialized and

are given unique names: atlas and
axis, respectively.
 ‘spondy’ latin term for spine & ‘losis’ latin term of problem
 A cluster of abnormalities arising from chronic intervertebral disc
degeneration.
 Commonly called arthritis of neck (wear and tear changes)
 Most common in the lower two segments of cervical spine (C5/6
and C6/7) => area prone to intervertebral disc prolapse
 Risk factors
Age Genetics

• common in middle aged

• Family history of neck Smoking
pain or spondylosis
and elderly people (≥40)

Occupation
Previous injury
Excessive • Job with lots of Depression or
repetitive neck or trauma to the
driving anxiety
motion and overhead neck
works
 Subsequent Longitudinal ligament
Tears in
loss of water degenerate and form
posterolateral Decrease in disk
and bony spurs at their
region of the height
proteoglycans insertion into the
annulus
in the nucleus vertebral body

Prominent spurs results in

compression of both the
exiting nerve roots
(CERVICAL
RADICULOPATHY ) and
spinal cord (CERVICAL
MYELOPATHY)
Segmental instability
results in hyperthrophic
formation of osteophytes
by the uncovertebral joint
of Luschka and facet joints
Converging of cervical disk
space result in buckling of
the ligamentum flavum +
further narrowing of spinal
canal (SPINAL STENOSIS)
 Clinical features
 Neck pain and stiffness  Limited neck movements
 Gradual onset

 Often worse on first getting up

 Neurological deficits
 May radiate widely to the  Myelopathy
o occiput ,  radiculopathy
o back of the shoulder,

o down one or both arms

 Accompanied by paraesthesia , weakness and

clumsiness in the arm and hand
 CERVICAL RADICULOPATHY VS MYELOPATHY
CERVICAL MYELOPATHY CERVICAL RADICULOPATHY

Pathology Spinal cord Spinal nerve root

Site involved Bilateral Unilateral

Numbness / Tingling Diffuse non-dermatomal Dermatomal

Radicular pain No Yes

Neck pain Axial neck pain (rare) Often, radiate

Weakness Bilateral Unilateral

Signs LMN (at the lesion level) LMN

UMN (below the lesion)

Provocative test Lhermitte test Spurling test

Spurling test Lhermitte sign
 Investigations

 X-rays
 show narrowing of one or more intervertebral spaces, with spur
formation (or lipping) at the anterior and posterior margins of the
disc. These bony ridges (often referred to as ‘osteophytes’) may
encroach upon the intervertebral foramina.

 MRI
 is more reliable for showing whether the nerve roots are compressed
 CERVICAL X-RAY
– Degenerative changes of uncovertebral and
facet joints

– Osteophyte formation

– Disc space narrowing & endplate sclerosis

– Foraminal stenosis caused by osteophytes

(oblique)

AP view of cervical spine X-ray:

 Black arrows point to the small pyramidal shaped
normal uncovertebral joint.
 White arrows point to degenerative uncovertebral
Lateral view of cervical spine X-ray joints (enlargement of these joints with a
 a degenerative disc at C5-6. “mushroom head”)
 Black arrow points to narrowed disc.
 White arrow points to bone spurs projecting off the back of
the discs into the spinal canal.
 Magnetic resonance imaging (MRI)
– Disc degeneration and herniation

MRI reveals a large C5-6 left sided disc herniation compressing the exiting C6 nerve root
and flattening the left-sided spinal cord
 CONSERVATIVE (NON SURGICAL ) DEFINITIVE (SURGICAL)

Medications  Anterior cervical discectomy

- NSAIDS, gabapentin and fusion

Immobilization  Foraminotomy

- Hard collar in slight flexion

Physical therapy

- For neck strengthening, balance and gait training

PROLAPSED
INTERVERTEBRAL
DISC
DISC ANATOMY
• Stabilize and maintain spine by anchoring adjacent vertebral bodies.
• Allow flexibility and absorb/distribute energy
 NERVE ROOT ANATOMY
Cervical spine
• Nerve roots exit above corresponding pedicle
• Nerve root travel horizontally to exit (exiting nerves)

Thoracic spine
• Nerve root travel below corresponding pedicle

Lumbar spine
• Nerve roots descend vertically before exiting (traversing nerve)
• Nerve root travel below corresponding pedicle (exiting nerve)
DISTRIBUTION OF LOAD IN
THE INTERVERTEBRAL DISC

• In the normal, healthy disc, the nucleus

distributes the load equally throughout the
anulus.
• As the disc undergoes degeneration, the nucleus
loses some of its cushioning ability and transmits
the load unequally to the anulus.
• In the severely degenerated disc, the nucleus has
lost all of its ability to cushion the load, which
can lead to disc herniation
 PROLAPSED INTERVERTEBRAL
DISC
• Acute posterior or postero-lateral herniation of nucleus pulposus through annulus
fibrosus

• 95% involve L4/5 or L5/S1 levels

• Commonly due to physical stress ( flexion and compression )

 TYPES OF HERNIATION
anatomical classification
• protrusion
• posterior bulging with an intact annulus
• extrusion
• disc material herniates through annulus posteriorly but remains
continuous with disc space
• sequestration
• disc material herniates through annulus and is no longer
continuous with disc space
 LOCATION CLASSIFICATION

Central Posterolateral

• Presses on the
• may present with
nerve root
cauda equina
proximal to its
syndrome
point of exit
 CLINICAL FEATURES

• Common in 20-45 years adult

• Severe back pain when lifting or stooping , unable to straighten up. Pain in buttock
and lower limb
• Worsen by cough or straining

• Paresthesia or numbness in leg/foot

• Occasionally muscle weakness
• Urinary retention and perineal numbness- suspect cauda equina compression
Physical examination

• Stands with slight list- list increases with forward flexion

• Tenderness in midline of low back and paravertebral muscle spasm

Muscle weakness, diminished reflexes and sensory loss = corresponding level

• L5 impairment- sensory loss and weakness of knee flexion and big toe extension
• Paradoxically, the knee reflex may appear to be increased, because of weakness of the
antagonists (which are supplied by L5).
• S1 impairment- weak plantar-flexion and eversion of the foot, a depressed ankle jerk and
sensory loss along the lateral border of the foot.
 SPECIAL TEST : SLR

▪ Aim: To detect lumbosacral root tension

▪ Procedure: With patient lying supine, one of the examiner’s hand is placed over
knee to maintain knee in full extension and other hand of the examiner under
the heel. The examiner slowly raises the leg until pain is produced.

▪ Positive : Reproduces pain and paresthesia in leg at hip flexion

• Cross-SLR : pain in the affected side when normal lower limb is being raised
 BOWSTRIGING TEST

• Procedure : after straight leg raising test, flex the knee to relax the sciatic nerve. Press on the
lateral popliteal nerve behind lateral tibial condyle.
 FEMORAL STRETCH TEST

▪ Aim: To detect high lumbar lesions affecting the femoral nerve (L2-L4)

▪ Procedure: Patient is placed in prone position. The knee is flexed with the hip
extended.

▪ Positive : pain over anterior thigh which gets aggravated on further hip extension
INVESTIGATIONS
• Xray - exclude bone disease
• MRI – most useful investigation
 MANAGEMENT

Non-operative Operative

• 1. Rest • 1. Removal
• With hips and knees slightly flexed • Indications : cauda equina compression syndrome
• nonsteroidal anti-inflamatory drugs are useful : neurological deterioration
• 2. Reduction while on conservative
• Continuous rest and traction for 2 weeks- reduce management
herniation
• If no improvement, epidural injection of corticosteroid
: persistent pain and sciatic
and local anesthesia tension after2-3 weeks of
conservative management
1) Laminotomy
2) Microdiscectomy

• Rehabilitation
• Taught isometric exercises and how to sit, bend, lie and lift with least strain

• PERSISTENT POSTOPERATIVE BACKACHE AND SCIATICA

Persistent symptoms after operation may be due to:
(1) residual disc material in the spinal canal
(2) Disc prolapse at another level
(3) nerve root pressure by a hypertrophic facet joint or a narrow lateral recess (‘root canal
stenosis’)
 Cauda Equina
Syndrome
&
Conus Medullaris
Syndrome
 Spinal Cord
Runs from brain stem to conus
medullaris within the spinal
canal where it is protected.

Conus medullaris: tapered

termination of spinal cord at L1.

Cauda equina: formed by the

lumbar and sacral nerves roots
in the spinal canal before
exiting.
Cauda Equina Syndrome

– Cauda equina: also known as

“horse’s tail”
– A syndrome results from
compression of cauda
equina (L2 and below)
resulting in acute loss of
lumbar plexus function.
 Features
– Bladder and bowel dysfunction (retention)
– Sexual dysfunction
– Perineal numbness
– Bilateral sciatica
– Lower limb weakness
– Crossed straight-leg raising sign

*Scan urgently and operate urgently if a largecentral disc is revealed.

*Acute cauda equina syndrome is an emergency!
 Conus Medullaris Syndrome

– A syndrome caused by an incomplete spinal

cord injury to conus medullaris and lumbar
nerve roots between T12 and L2 vertebrae.
Features
– Low back pain
– Unilateral/ bilateral sciatica
– Perineal numbness
– Lower limb motor weakness, paraesthesia and numbness (mixed upper
and lower motor neurone pattern)
– Bowel& bladder disturbances
Causes

– Prolapsed intervertebral disc

– Spinal stenosis
- secondary to spinal disorders such as ankylosing
spondylitis, spondylosis and spondylolisthesis
Trauma
- Leads to fracture/ subluxation can lead to compression of cauda equina

Neoplasm
- Primary tumours (eg: myxopapillary ependymoma, schwannoma, paraganglioma)
- Metastatic tumours

Inflammatory and infectious conditions

- Infectious causes (pyogenic/ non-pyogenic), epidural abscess

Iatrogenic
- Complications of spinal instrumentation, continuous spinal anaesthesia & etc.
 Investigations
Imaging
- Plain radiography (in cases of traumatic injury)
- Chest Xray (to rule out pulmonary source of
pathology that could affect lumbosacral spine)
- MRI (diagnostic test of choice as it can show
evidence of nerve root compression, disc
herniation/prolapse, abscess)
- CT with lumbar myelogram (can see bone
compression)
Management

– Based on causes
- Traumatic fracture: methylprednisolone, 30mg/kg initial dose, then
5.4mg/kgx23 hours
- Surgical decompression of cauda equina
- Herniated disc: discectomy
- Neoplasm: if etiology is unknown, consider biopsy
- Stenosis: Consider corticosteroids. Consider laminectomy and decompression
- Abscess: drainage.
*Cauda equina syndrome known as surgical emergency, thus surgical
decompression need to be done within 48 hours after onset of symptoms, and
preferably within 6 hours of injury.

If presentation or decompression is delayed:

– sexual dysfunction
– urinary dysfunction requiring catheterization
– chronic pain
– persistent leg weakness (residual weakness)
 Lumbar
Stenosis

ANDREW
 Brief Anatomy of Lumbar
Vertebrae
– 5 Vertebrae: L1-L5
– Spinal Cord terminates at L1.
– Thus, If any spinal cord lesion occurs around
L1, it may involve the spinal cord or nerve
root, giving rise to specific clinical
presentation.
 Spinal Stenosis

– Definition: Abnormal narrowing of the central

canal, the lateral recesses or the intervertebral
foramina to the point where the neural
elements are compromised
– So, what is Lumbar stenosis then?
– Stenosis occur in lumbar region.
Spinal Stenosis is further
subdivided into:
Foraminal Stenosis/ Root canal
Central canal Stenosis stenosis
Central Stenosis Foraminal Stenosis/ Root canal
Stenosis
Causes

– Spondylosis = degenerative process of the intervertebral disc and facets

– Prolapsed intervertebral disc
– Spondylolisthesis.
– Spinal Metastasis.
– Disc degeneration → altered biomechanics and increased loading forces on the
facet joints → facet joint osteoarthritis → facet joint hypertrophy with
osteophyte encroachment into the canal → spinal stenosis
– Loss of disc height → buckling, infolding & thickening of ligamentum flavum
 SPONDYLOLISTHESIS
– Forward translation of one segment of the spine upon another
– Always between L4 and L5 , or L5 and the sacrum
– Due to failure of locking mechanism  normal disc , laminae and
facet prevents the vertebrae from moving forward on the one below.
Clinical features
• > 50 years old
• Complains of numbness and paraesthesia in thighs and legs
• May have h/o PID, chronic backache/spinal operation
• ***Always enquire history of urinary/bowel incontinence,
sexual dysfuntion.
Neurogenic claudication Vascular claudication

Claudication Variable – position Consistent

distance dependent
Back pain Common Uncommon
Walking Walking uphill Walking downhill
Relieving factor Pain relieved on sitting Pain relieved by resting
(where spine is flexed)

Relieved by 10 mins Relieved in 2 mins

Pulse Present Absent
Sensory loss Segmental sensory loss Stocking type sensory loss
 Investigation (Imaging)

– X-ray: Lateral view (show degenerative spondylolisthesis, disc

degeneration, osteoarthritis)
– CT Myelography
– MRI

Two measurements will be taken:

1. Mid-sagittal (AP) diameter of spinal canal
2. Interpedicular (transverse) diameter of spinal canal

* If hard to measure in X-ray, use CT scan

 Management

1. Conservative:

– Educate patient on spine posture

– Analgesics
– Transforaminal injection.

2. Surgical (when marked discomfort & restricted activity)

– Decompression (eg. Laminectomy)

References

– Harry B.Skinner, Patrick J. McMahon , Current diagnosis and treatment of

Orthopaedics, Lange , 5th Edition
– Apley’s System of Orthopedics and fractures, 9th Edition