Lumbar disk disease & Spondylolisthesispresented 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.
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 L5S1 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. Backache. Lower limb pain: made worse by coughing or straining. Numbness & paraesthesia. Muscle weakness. Bowel/bladder symptoms, particularly new urinary incontinence, suggest a cauda equina
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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 Surgical care Failure of nonoperative treatmentMinimum of 6 weeks in duration Can be months
Cauda equina syndrome: - urgent, within 24 hours toprevent 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>L3L4>L5-S1) Central stenosis Narrowing of the central part of the spinal canal (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 elements most 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