DEGENERATIVE SPINAL CORD

DISEASES

Rizal Daulay
Orthopaedic Surgeon
There are 31 pairs of spinal nerves
• 8 cervical
• 12 thoracal
• 5 lumbar
• 5 sacral
• 1 coccygeal
The spinal cord has two enlargements
• Cervical(C3-T2):The cervical enlargement
corresponds roughly to the brachial plexus nerves,
which innervate the upper limb
• Lumbar (T11-L1) :The lumbar enlargement or
lumbosacral enlargement corresponds to the
lumbosacral plexus nerves, which innervate the
lower limb
Spinal Cord
Degenerative Spine Conditions

Herniated discs
Spinal stenosis
Degenerative disc disease
Spondylo-lysis/listhesis
Degenerative scoliosis
Spondylosis
Risk Factors
aging
genetic
smoking
weight
heavy lifting
sedentary lifestyle
Symptoms
• Degenerative spine conditions vary widely in
their presentation. Some cause no symptoms at
all.
• When symptoms do occur, they often include
back pain or neck pain.
• Other symptoms depend on the location and
type of problem.
Disc Herniation
• Disc herniation occurs when the annulus fibrous breaks
open or cracks, allowing the nucleus pulposus to escape.
This is called a herniated nucleus pulposus or herniated
disc.
• The most common sites are lumbar (L4-L5) herniated
discs and cervical(C5-C6) herniated discs .Thoracic
herniated discs are much less common.
• Herniations usually occur posterlaterally.
protrusion:
• base wider than herniation
• confined to disc level outer
• annular fibres intact
extrusion:
• base narrower than herniation
• 'dome'may extend above or bellow endplates or adjacent
vertebrae
• complete annular tear with passage of nuclear material
beyond disc annulus
• disc material can then migrate away from annulus or become
sequestered
Sequestration
• extruded disc material that has no continuity with the parent
disc
• is displaced away from the site of extrusion.
Cervical disc herniation
• most common site C5-C6 / C6-C7
• Pain (neck and upper extremities)
• Numbness
• Muscle weakness
• Paresthesia
• Urinary incontinence , loss of bowel
control(rare)
Diagnosis Treatment

• Physical exam • Medication :NSAID

• MRI – best • Physical therapy
• CT with • Steroid injection
myelogram – • Surgery
more sensitive  Anterior cervical discectomy
but invasive and spine fusion (ACDF)
 Posterior cervical discectomy
• X-ray
 Cervical artificial disc
• EMG replacement.
• Most common site L4-
Lumbar
L5/L5-S1
Disc Herniation
• Pain (lower back,
buttocks, lower
extremities)
• Numbness
• Foot drop
• Cauda equina syndrome
• Most commonly affected nerve sciatic nerve (L3-
S1)
Straight Leg Raise Test
(Lasegue’s sign)
• Neurologic pain which is reproduced in the leg and low
back between 30-70 degrees of hip flexion is suggestive
of lumbar disc herniation at the L4-S1 nerve roots.
Diagnosis Treatment

• Physical exam—straight leg • Ice application

raise test • Medication : NSAID ,muscle
• MRI relaxants
• CT with myelogram • Heat therapy
• X-ray • Physical therapy
• EMG • Steroid injection
• Surgery
 Microdiscectomy
Cauda Equina Syndrome(CES)
Cauda equina syndrome is caused by any narrowing of the
spinal canal that compresses the cauda equina nerve roots .
 disc herniation
 spinal stenosis
 traumatic injury
 tumors infectious conditions
 arteriovenous malformation or hemorrhage
 iatrogenic injury
CES symptoms
• Back pain
• Saddle anesthesia
• Sciatica pain
• Bladder, bowel dysfunction
• Gait disturbance
• Anal and achilles reflex absent
• Sexual dysfunction
Surgery indications
• Severe pain
• Progressive neurological deficit
• Loss of bowel-bladder control
Spinal stenosis
• Spinal stenosis is part of the aging process
• Progressive narrowing of the spinal canal may occur
alone or in combination with acute disc herniations.
Congenital and acquired spinal stenosis place the patient
at a greater risk for acute neurologic injury.
• Spinal stenosis is most common in the cervical and
lumbar areas.
Spinal stenosis
Spinal stenosis
• The most common reason to develop spinal stenosis is
degenerative arthritis, or bony and soft tissue changes
that result from aging.
• The normal "wear and tear" of aging can cause arthritis
in the spine that leads to spinal stenosis. This can be
from bone spurs (osteophytes) forming, bulging and
wear of the intervertebral discs, and thickening of the
ligaments between the vertebrae.
Spinal stenosis
• Local and traveling pain, often described as a
burning sensation
• Muscle weakness
• Numbness and tingling
• Loss of fine motor skills
• Limited mobility
Treatment
• pain medication
• Exercise
• Stretching
• Hot/cold therapy
• Epidural steroid injections
• Lifestyle changes like weight loss and quitting
smoking
• Decompression surgery
Degenerative Disc Disease
• Gradual deterioration and thinning of the shock-
absorbing intervertebral discs by age
• This condition can occur at any level of the spine and
may cause a range of symptoms and intensity levels.
• Unless a degenerative disc places pressure upon an
adjacent nerve, symptoms remain non-existent or
strictly localized.
Degenerative Disc Disease
• Pain with activity bending, lifting, and twisting
• Severe episodes of back or neck pain (a few days
to a few months
• Certain positions: sitting for lumbar
degenerative disc pain
MRI Findings
• Disc space narrowing
• Fissures, fluid, vacuum changes and calcification
• Osteophytosis
• Disk herniation
• Malalignment
• Stenosis
DDD
• PainTreatment
control
• Exercise and physical therapy
• Lifestyle modifications
• Surgery
Spondylolysis
• Caused by repeated microtrauma, resulting
in stress fracture of the pars interarticularis
• present in ~5% of the population
• %90 at the L5 level
• higher in the adolescent athletic population
• commonly asymptomatic
• pain with extension and/or rotation of the
lumbar spine.
• 65% of patients with spondylolysis will
progress to spondylolisthesis
Spondylolysis
CT/MRI
Plain radiograph • Wide canal sign
• oblique
• limited sensitivity
compared to SPECT
and CT
• scotty dog sign
• Spondylolisthesis is most frequent at L5/S1
• forward or backward slippage the vertebra
• Causes of spondylolisthesis include trauma,
degenerative, tumor and birth defects.
• lower back or leg pain, hamstring tightness,
numbness and tingling in the legs.
• Bracing to immobilize the spine for a short
Treatment
period
• Pain medications and/or anti-inflammatory
medication
• Physical therapy
• Decompressive laminectomy :reduces
irritation and inflammation in the area (but
increases spinal instability)
• A spinal fusion to provide stabilization of the
affected area.
Spondylosis
• Spinal osteoarthritis
• With age, the bones and ligaments in the spine
wear, leading to bone spurs
• Over 80% of people over the age of 40 have
evidence of spondylosis on X-ray studies
Spondylosis

• Neck/back pain • Standing

• Stiffness • Sitting
• Paresthesia • Sneezing
• weakness • Coughing
• Tilting neck backward
worsen the pain
Spurling’s test(cervical compression test)
pain arising in the neck radiates in the direction of the
corresponding dermatome ipsilaterally
Shows cervical radiculopathy (many causes)
Lhermitte’s sign
electric shock-like sensation that occurs on flexion of the
neck
Reduced range of motion
MRI-CT
Treatment
• (NSAIDs)
• exercise – such as swimming and walking
• Surgery
1. bowel or bladder dysfunction
2. spinal stenosis
3. neurologic dysfunctions
4. Unstable spine