€ Basic

anatomy € Definition € Epidemiology € Etiology € Degenerative disc disease € Lumbar spine stenosis € Spondylolisthesis.

The Vertebral column consists of 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused to form the sacrum), and 4 coccygeal (the lower 3 are fused) Descending in the cord, the spinal nerves become more oblique in their course. Spinal cord proper ends at L2 and the remaining spinal nerves, seeking their intervertebral foramen of exit form the cauda equina. At S2 the subarachnoid space ends

1. 2. Intervertebral disk: cartilagenous joint between the vertebral bodies. The vertebrae articulate with each other by 2 types of joints: Facet joints: synovial joints between the superior and inferior articular processes. . It acts as a shock absorber.

b. It is the part that acts as a shock absorber. .The intervertebral disc is composed of a. It is thinner posteriorly. Annulus Fibrosus: Tough outer layer composed of layers of parallel fibers that criss-cross to the next layer. Nucleus Pulposus: It is a fibrocartilagenous layer that has a high water content (80%).



€ 25% of people develop chronic low back pain.€ Degenerative spinal disorders are a group of conditions that involve a loss of normal structure and function in the spine. € usual age of presentation: 30s to 50s € . Epidemiology About 90% of population suffer from back pain at some point and 30% of these will develop leg pain due to lumber spine pathology.

These common disorders are associated with the normal effects of aging. muscle strains. but also may be caused by infection. . or arthritis. or osteoarthritis. tumors. Pressure on the spinal cord and nerve roots associated with spinal degeneration may be caused by disc displacement or herniation. cartilage breakdown at spinal joints. a narrowing of the spinal canal. spinal stenosis.

or the spinal cord at higher levels. the cauda equina in the lumbar region. herniation.€ Protrusion. or fragmentation of an intervertebral disc beyond its borders with potential compression of a nerve root. .

There is an increase in the ratio of keratan sulfate to chondroitin sulfate. The vertebral end plates also becomes thinner and more hyalinized. This degree of disk degeneration is considered a normal part of aging. The disc also loses its water-binding capacity and the water content decreases down to 70%. and the proteoglycans lose their close association with the disk collagen. . certain biochemical and structural changes occur in the intervertebral discs.€ With aging.

and regenerating chondrocytes and granulation tissue form in the area. Also. . Tears that extend through the outer anulus induce ingrowth of granulation tissue and accelerate the degenerative process. dense disorganized fibrous tissue replaces the normal fibrocartilaginous structure of the nucleus pulposus. Development of anular tears weakens the anulus and allows nucleus to protrude into the defect. leaving no distinction between the nucleus and anulus fibrosus. Advanced degeneration can lead to gas formation or calcification within the disk. fissures develop in the cartilaginous end plates.€ With more advanced degeneration.

a bulging disk that is eccentric to one side but < 3 mm beyond vertebral margin € Herniation .loss of disk water Prolapsed disc ± herniation of nucleus pulposus througha tear in annular fbrosus € Disk bulge .extension of nucleus pulposus through the anulus into the epidural space € Free fragment .disk protrusion that extends more than 3 mm beyond the vertebral margin € Extruded disk .Desiccation .circumferential enlargement of the disk contour in a symmetric fashion € Protrusion .epidural fragment of disk no longer attached to the parent disk € € .

€ Directions: * Posterolateral: most common. * 20 % degenerative (without tear). * Central: compresses cauda equina. . * Lateral: traps nerve root. € Causes: * 80 % traumatic (sudden sever strain).

Sciatica 3.€ Presentation: 1. Low back pain 2. Parasthesia 4. Weakness .

3. Focal tenderness. .€ Examination: 1. 2. loss of lumber lordosis. muscle spasm & atrophy & dystrophic skin changes. Inspection: scoliosis. Lumber back movement restriction ( due to pain ).

* Naffzigar test: pain increases with manual compression on both jugular veins simultaneously. Special tests: * Straight leg raising: pain in <60 deg. . * Valex test: pain increases upon pressing the buttocks or the sciatic n. 4. b) Crossed leg sign: elevation of the good leg elicit pain in the other one. a) Bragaard sign: pain increase with dorsiflxion of foot.€ Examination cont.

* L4/L5 prolapse: 1. Weak drsiflexion of foot. Parasthesia in lateral foot & small toes. 3. 2. No reflex changes. Thigh & medial aspect of lower leg. . Decreased or absent knee jerk. Diminished sensations over ant. Weakness of quadriceps muscle. Neurological deficit: * L3/L4 prolepses: 1. 3. 2.5.

* L5/S1 prolapse: 1. Absent ankle jerk. . anal sensation & sphincter function. Buttocks: Assess for gluteal atrophy. Parasthesia in lateral foot & small toes. 2. 3. Weak planter flexion. 6.

Weakness of the foot and toe dorsiflexors. Paraesthesia and numbness of the dorsum of the foot and the great toe. L4-L5 prolapsed disc: L5 Pain along the posterior-posterolateral aspect of the thigh. Occasionally. Quadriceps wasting. Absent ankle reflex. Reflex changes unlikely. radiating to the heel. Reduced knee reflex. knee and med aspect of the lower leg. radiating to the foot dorsum and the great toe. Thigh. ‡ ‡ ‡ ‡  ‡ ‡ ‡ ‡ L5-S1 prolapsed disc: S1 Pain along the posterior of the thigh. Sensory loss in the lateral foot. weakness of the planter flexion. Diminished sensation over the ant thigh. Weakness of the quadriceps and dorsiflexors of the foot.  ‡ ‡ ‡ ‡ ‡ . L3-L4 prolapse: L4 Pain in the ant.

€ Lumber myelography. and any nerve root or thecal compression. (rarely used now) € High quality CT scan (rarely used now) . position of the disc. configuration. shows the size.€ MRI: most commonly used.

D. J Bone Joint Surg 1996:78:114-24 .Magnetic resonance imaging scans of a thirty-two-year-old subject who never had low-back pain or sciatica BODEN S.

4. 2. € Symptoms: 1. Leg pain: bilaterally. urethral sensation & anal sensation. 3. € . Sexual disturbance: impotence. Sphincter paralysis: loss of sensation from urinary bladder. Parasthesia.Compression of theacal sac below L1/L2 level causes a sort of lower motor neuron lesion bilaterally.

Absent ankle jerks on both sides. 2. Sensory loss: saddle sensation. .€ Signs: 1. 3. Motor loss: foot drop usually with complete loss of power in dorsi & plantar flexion of both feet.

b) Demonstrates disc disease. root compression. b) Hypertrophy of facet joints. c) Assess diameter of spinal canal ( done also on lateral x-ray). 2) CT.€ 1) MRI: a) MOST SENSITIVE METHOD. .scan: a) Detects disc protrusion & demonstrates the extent of n.

f) Associated spondilolithaisis.3) Plain lumbosacral x-ray: a) Narrowing of disc space ( chronic cases) b) Calcification. c) Degenerative change. post myelogram CT. 4) Other methods: Myelogram. ostyophytes. e) Loss of lordosis. . d) Scoliosis.

Degenerative disease. Spinal tumor. 3. Congenital anomalies. Infectious process. Lumber canal stenosis. 7. 6. 2. 5. : 1. Isolated neuropathy. Referred low back pain. .€ DDx. 4. Trauma. 8.

root causing neck pain. Lateral prolapse: presses on corresponding n. € Types: 1. Since each cervical spinal root emerges above it¶s vertebra. . parasthesia & radicular pain.€ Site: Most commonly at C5/6> C4/5> C6/7 > C3/4. disc prolapse compresses the corresponding n.

€ Causes: 1. root. loss of superficial abdominal reflexes. the spinal cord & the ant. Spinal artery & vein. increased tone & reflexes in lower limbs & upward planter reflex. LMNL at the same level.2. 2. UMNL at the levels below ( Myelopathy): results in spastic gait. . loss of fine movement of hand. Central prolapse: Compresses n. sphincter affection.

€ Post myelogram CT. € Surgical treatment: Posterior approach: if > one level involved or with diffuse stenosis. € MRI (most important ). € Anterior approach: in single level involvement. € .Plain X-ray.

€ Types: 1. 2) Thickening of ligamentum flavum. Congenital: early fusion. thick short pedicles. € . 3) Disc bulge. 2. Factors sharing in canal stenosis: 1) Hypertrophy of facet joints. Acquired: hypertrophied facet joints.

they each produce distinct clinical entity.€ € € Narrowing of the lumbar spinal canal. . Verbiest. 1949 Altough lumbar canal stenosis and lumbar disc prolaps can be found in the same patient.

If it is < 2 mm then it is stenosed.€ According to diameter of the canal: 1. Diameter is about 4 mm normally. AP diameter is normally 12-16 mm. € Moderate (<10mm). € Mild (<12mm). Central stenosis. . € Severe (<8mm). Lateral recess stenosis: Lat. 2.

Levels affected: L4/5> L3/4> L5/S1. Clinical features: 1. 2. it may have a burning quality and relieved by setting.Pain: radiating diffusely into the legs. exacerbated by walking or standing. 3-sphincter problems may occur in severe stenosis € € .the patient often complains of a subjective feeling of weakness and a diffused µnumbness¶ and µtingling¶ radiating down the limb.

but muscular atrophy. € Physical .findings: examination of lower limb and back often reveals little or no abnormality. sensory desturbance and weakness may occur only in the most severe cases. depressed ankle jerk.

More on walking upstairs. Peripheral pulses are diminished. 3. 5. 4. .€ Vascular claudication: 1. 6. Relieved by standing still or sitting. More calf pain. 2. Skin changes. Claudication distance decreases.

MRI. Persistent pain in 10 %. Conservative treatment: The clinical features of LCS do not respond favorably to conservative treatment. Instability. Surgery will improve claudication distance but may or may not improve pain. (BEST ). Surgical Treatment: € Wide Lamectomy with root decompression. . Results & Complications: € € € Improvement in 90 %.High quality CT scanning.

Spondylolisthesis is graded according to how far the vertebral body moves forward on the one below (Grade 1 = 25%. . Grade 3 = 75%).€ € Spondylolisthesis refers to forward displacement of one vertebra over another. or of the fourth lumbar over the fifth. Grade 2 = 50%. usually of the fifth lumbar over the body of the sacrum.


€ refers to a cleft or break in the pars interarticularis of the vertebra. and most are bilateral. 93-95% occur at L5. mostly in males. . It is found in about 6% of adults. € The etiology is uncertain. but the current theory is that it represents a stress fracture from repeated trauma to the spine.

The anterior part slips forward. the intervertebral disk and the posterior-superior aspect of the vertebral body below encroach on the superior portion of the neural foramen. transverse processes. so that spinal canal stenosis is uncommon with isthmic spondylolisthesis. Exuberant fibrocartilage at the pars pseudarthrosis can further compromise the neural foramen and cause nerve root compression. laminae. The foramen is also elongated in a horizontal direction and may have a bilobed configuration. pedicles. but with progressive anterior subluxation. As a result. and spinous process). Grade I spondylolisthesis is often asymptomatic.€ The pars defect divides the vertebra into an anterior part (vertebral body. . and superior articular facet) and a posterior part (inferior facet. the spinal canal elongates in its anteroposterior dimension. leaving the posterior part behind.

usually over 60 years old. Subluxation at the facet joints allows forward or posterior movement of one vertebra over another. and symptoms of spinal stenosis are common. Hypertrophic facet arthrosis is a frequent cause of foraminal narrowing. It develops when there are severe degenerative changes and excess motion of the facet joints. .€ Occurs mostly in older age group. and it is more common in women at the level of L4-L5. A degenerative spondylolisthesis narrows the spinal canal.

€ Diagnosis: hx (back pain and leg pain. .MRI to demonstrate the degree of nerve compression. waddling gait. ³tight hamstring syndrome´). PhE € Investigations: 1-plain lumbar spine X-ray 2.



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