Lumbar disk disease &

Spondylolisthesis

presented by : Sinan A. Yacoub

 Lumbosacral radiculopathy
Lumbosacral radiculopathy is a condition in
which a disease process affects the function of
one or more lumbosacral nerve roots.
This produces sensory changes in the
corresponding dermatome, and motor
changes in the myotome supplied by that
nerve root.
 Epidemiology
Lumbosacral radiculopathy is one of the most
common problems seen in neurologic
consultation. Although data are limited, the
estimated lifetime prevalence is approximately
3 to 5 percent for adults, with equal rates
among men and women
 Pathophysiology and Etiology
The most common etiology of lumbosacral radiculopathy is
nerve root compression caused by a disc herniation or
spondylosis (ie, spinal stenosis due to degenerative arthritis
affecting the spine).

Additional etiologies: nonskeletal causes of nerve root

compression and noncompressive mechanisms such as:
1. infection.
2. inflammation.
3. Neoplasm.
4. vascular disease.
 Lumbar Disc Herniation
The gelatinous nucleus pulposus squeezes
through the fibres of the annulus fibrosus and
bulges posteriorly or posterolaterally beneath
the posterior longitudinal ligament.
Local oedema may add to the swelling.
This causes pressure on one of the nerve
roots.
 Maybe
described as:

1) Protrusion displaced disc

material remains in continuity with
the disc of origin and contained by
the annulus fibrosus.

2) Extrusion disc material migrating

through the annulus fibrosus but
contained by the posterior longitudinal
ligament.

3) Sequestered disc material lying

free in the spinal canal.
 This herniated material maybe central, posterolateral, or
lateral.

A posterolateral disc protrusion will affect the traversing

root, e.g. an L5-S1 disc protrusion affects the S1 nerve root.
 Over 90% of herniations occur at the L4-L5 or L5-S1 levels.
Why?

Seventy-five percent of flexion and extension occurs at the

lumbosacral joint . This level, on the other hand, has limited
torsion. Twenty percent of flexion and extension occurs at L4-
L5.

The incidence of radiculopathies is split somewhat evenly

between L4-L5 and L5-S1, as the lack of torsion at L5-S1 helps
to increase its stability despite its higher degree of flexion and
extension.
 Cauda equina syndrome:
A large midline disc
herniation may compress
the cauda equina, leading
to a syndrome defined by
bowel and/or bladder
difficulties, saddle
anaesthesia and lower
limb sensory and motor
deficits.
 Symptoms
Depend on the structure
involved and the degree of
compression.
1) Backache.
2) Lower limb pain: made
worse by coughing or
straining.
3) Numbness & paraesthesia.
4) Muscle weakness.
5) Bowel/bladder symptoms,
particularly new urinary
incontinence, suggest a Dermatomal
cauda equina syndrome.
 Physical Examination
The patient usually stands with a slight tilt to one side sciatic
scoliosis.
Loss of lumbar lordosis
Lower back tenderness and paravertebral muscle spasm.
Limited straight-leg raising and painful ipsilateral.
Sometimes raising the unaffected leg causes acute sciatic
tension on the painful side (crossed sciatic tension).
L3-L4 prolapse femoral stretch test may be positive.
Muscle weakness of affected myotome.
Diminished reflexes and sensory loss corresponding to
affected level.
 L5 affected : weakness of
big toes extension and knee
flexion + dermatomal
sensory loss.

S1 affected: weak plantar

flexion and eversion of the
foot and a depressed ankle
jerk + dermatomal sensory
loss.
 Imaging
* Magnetic Resonance Imaging (MRI).
 Treatment
Nonoperative Care
(for 6-12 weeks)

Nonsteroidal anti-
Initial bed rest inflammatory Physical therapy Steroid injections
(NSAID) medication

Exercise/walking
 Treatment
Surgical care
Failure of nonoperative
treatment
Minimum of 6 weeks in duration
Can be months
Cauda equina syndrome:
- urgent, within 24 hours to prevent
any irreversible damage.
Neurological deterioration within
period of conservative
management.
Frequently recurring attacks.

Discectomy
Removal of the herniated
portion of the disc
Usually through a small incision
High success rate
 Spinal Stenosis
Narrowing of the spinal
canal , nerve root canals ,
or I.V foramen due to
spondylosis and
degenerative disk disease
(L4-L5>L3-L4>L5-S1)
Central stenosis
Narrowing of the central
part of the spinal canal
(<12 mm)
Far lateral recess stenosis
Narrowing of the lateral
part of the spinal canal (
<2mm)
 Causes:
1) Spondylosis: the most common cause of lumbar spinal stenosis and typically
affects individuals over the age of 60 years. Facet osteophytes, ligamentum
flavum hypertrophy, and disc bulging can encroach on the central canal and the
neural foramina. The L4-5 level is most commonly involved, followed by L5-S1
and L3-4.
2) Space-occupying lesions (lipoma, synovial and neural cysts,
neoplasms).
3) Traumatic and postoperative causes (fibrosis).
4) Skeletal disease (Paget, ankylosing spondylitis, rheumatoid
arthritis).
5) Congenital: dwarfism, spinal dysraphism.
 Spinal Stenosis
Symptoms
Neurogenic (or pseudo) claudication is a hallmark of
LSS
Back pain
Pain, dysthesias, anesthesias in the buttocks, thighs,
and legs
Unilateral or bilateral(68%, but often asymmetrical).
 Physical examination
The neurologic examination is often normal in patients with
LSS. The straight leg raising sign is present only in a minority
of patients (10 percent).

However, in some patients with LSS, more prolonged or

severe nerve root involvement may lead to fixed and/or
progressive neurologic deficits.
 Imaging
MRI/computerized
tomography (CT) scan.
Nonoperative care
Rest
NSAID medication
Physical therapy
Exercise/walking
Steroid injections
 Spinal Stenosis
Surgical care
Failure of nonoperative
treatment
Minimum of 3-6 months
duration
Decompression
Bone removal to widen
area
Laminectomy
Foraminotomy
High success rate
May require adjunct
fusion
to address instability
 Segmental Instability
(Spondylolisthesis)
Spondylolisthesis
Forward displacement
Retrolisthesis
Backward displacement
Lateral listhesis
Sideways displacement
Axial and rotational
displacement
Segmental hypo- and hyper-
kyphosis or lordosis
 Segmental Instability
Spondylolisthesis
A forward translation of 1 vertebral body
over the adjacent vertebra
Spondylolysis
A fracture or defect in the vertebra, usually in the posterior
elementsmost frequently in the pars interarticularis
Spondyloptosis
Complete dislocation
 Etiology
Congenital
Isthmic (spondylolysis)
Degenerative
Traumatic
Pathological
 Etiology
Congenital :
Due to dysplastic sacral or lower lumber segments .

Isthmic :
Caused by the development of a stress fracture of the pars interarticuris.
Its the commonest variant and is believed to affect 6-7 % of population ,
many of who are asymptomatic .
Approximately 82% of cases occur at L5 S1 , another 11% occur at L4 L5
A genetic predisposition is believed to be linked with patients having thin
pars or subtle hypoplastic facet joint .
Most often occurs during the first and second decades of life.
 Etiology
Degenerative :
Caused by facet degeneration accompanied by disk degeneration most
commonly at the level of L4 L5
Occurs most commonly after age of 40 year
Traumatic
Is rare and caused by severe hyperextension stress placed on the pars
which could produce fracture and instability.
Pathologic :
Can occur as a result of any bone lesion that might weaken the psterior
elements .
 Spondylolisthesis
Gradation of
spondylolisthesis
Meyerdings Scale
Grade 1 = up to 25%
Grade 2 = up to 50%
Grade 3 = up to 75%
Grade 4 = up to 100%
Grade 5 >100%
(complete dislocation,
spondyloloptosis)
 Spondylolisthesis
Symptoms
Low back pain
With or without buttock or thigh
pain
Pain aggravated by standing or
walking
Pain relieved by lying down
Concomitant spinal stenosis, with
or without leg pain, may be
present
Other possible symptoms
Tired legs, dysthesias,
anesthesias
Partial pain relief by leaning
forward or sitting
 Spondylolisthesis
Diagnosis
Plain radiographs ( AP , lateral
,dynamic ,and calculating slip
angle and percentage )
CT scan is excellent for
confirming dx and ruling our
more sinister pathology .
MRI can visualize edema and
identify nerve root
compression.

Nonoperative Care
Rest
NSAID medication
Physical therapy
Steroid injections
 Spondylolisthesis
Surgical care
Failure of nonoperative
treatment
Accompanying neurologic
deficit
High grade slips ( > 50%)
Traumatic spondylolisthesis
Decompression and fusion
Instrumented
Posterior approach
With interbody fusion
 Spondylolysis
Spondylolysis
Also known as pars defect or
fracture.
With or without
spondylolisthesis
A fracture or defect in the
vertebra, usually in the
posterior elementsmost
frequently in the pars
interarticularis
 Spondylolysis
Symptoms
Low back pain/stiffness
Forward bending
increases pain
Symptoms get worse
with activity
May include a stenotic
component resulting in
leg symptoms
Seen most often in athletes
Gymnasts at risk
Caused by repeated strain
 Spondylolysis
Diagnosis
Plain oblique radiographs
CT, in some cases
Nonoperative care
Limit athletic activities
Physical therapy
Most fractures heal without
other medical intervention
 Spondylolysis
Surgical care
Failure of nonoperative treatment
Operation: Posterior fusion
Instrumented
May require decompression
Thank you