SPINE Prolapse intervertebral disc Spinal Stenosis Spondylosis Spondylolysthesis spondylolysis

PROLAPSED INTERVERTEBRAL DISC (PID)

• In PID, gelatinous nucleus pulposus squeezes through the fibres of the annulus fibrosus and bulges posteriorly or postrolaterally beneath the posterior longitudinal ligament

• Causes: Herniation of intervertebral disc, senile degeneration of disc, obesity, sudden jerk, sprain, trauma to spine.

• History of: Over-straining of lumber spine, lifting weight, violent coughing, sudden stooping or twisting.

• Because intervertebral disc are largest in the lumbar and lumbosacral region, where movement are consequently greater, posterolateral herniation of nucleus pulposus are common here.

• Common site: disc at L4/L5, L5/S1 , L3/L4(rare)

Types of herniation (Anatomy)

posterolateral disc herniation – protrusion is usually posterolateral into vertebral canal, compress the roots of a spinal nerveprotruded disc usually compresses next lower nerve as that nerve crosses level of disc in its path to its foramen (eg.protrusion of fifth lumbar disc usually affects S1 instead of L5)         

central (posterior) herniation:in the lower lumbar segments, central herniation may result in S1 radiculopathyless frequently, a protruded disc above second lumbar vertebra may compress spinal cord itself or or may result in cauda equina syndrome

lateral disc herniation:may compress the nerve root above the level of the herniation L4 nerve root is most often involved & patient typically have intense radicular pain

CLINICAL FEATURES• Young adult• Back pain – Location: in lower back, radiates to gluteal region, back of

thigh, calf, foot ; worse by: flexion (bending forwards) movement, coughing, stooping, turning, walking ; better by: rest, extension.

• Compensatory scoliosis• Symptoms depend on the structure involved and degree of compression:

pressure on ligament – backache pressure on dural envelope of the nerve root – severe pain referred

to the buttock and lower limb (sciatica) pressure to the nerve itself – numbness, parasthesia,and muscle

weakness Compression of cauda equina – urinary retention

Signs• Midline tenderness of the low back• Paravertebral muscle spasm –

compensatory scoliosis• Straight leg raising test (SLR) +ve• Sciatic strecth test +ve• Cross SLR maybe +ve• Femoral strecth test maybe +ve (indicate

prolapse at L3/L4)

Investigation

X-Ray : lumbo-sacral spine• Narrowed disc spaces.• Loss of lumber lordosis.• Compensatory scoliosis.

CT scan lumber spine• Outline of soft tissues.• Bulging out disc.

MRI lumber spine• Intervertebral disc protrusion.• Compression of nerve root.

Management Rest, Reduction, Removal & RehabilitationConservative

Heat therapy, NSAIDsBed rests – During Acute attackIn severe cases- traction is applied to leg or pelvis, provided there is no cord compression.Regin mobility gradually.Advice on spinal posturalRestrict jerky movements, avoid forward bending, lifting weight, reduce weight if obese.

OperativeIndication :

1. Cauda equina syndrome does not clear up within 6hours of starting bed rest and traction ( emergency!)

2. Failed of conservative treatment3. Neurological deterioration4. Frequently recurring attack

Nerve decompression- Laminotomy+Diskectomy(through post approach between adjacent vertebral laminae, dural sac is retracted to one side and bulging disc exposed. The friable partially shredded material is removed. )

SPINAL STENOSIs

Definition : Narrowing of spinal canal results in cord/root compression.

Causes:Congenital stenosis - Idiopathic, osteopetrosis, achondroplasiaSpine degenerative - OA- narrowing spinal canal d/t hypertrophy of facet and lig flavum associated with osteophyte.Spine instability - supporting lig torn/ stretched from severe back injury- bone move forwardDisc herniationDegenerative spondylolisthesis - decreases its AP diameter Trauma

CLINICAL FEATURES

- Elderly – late 5th / 6th decade- Back pain - worse by extension,

relieved by sitting/ forward leaning

- Numbness and paraesthesia in thighs, legs or feet

- Spinal (neurological) claudication- Neurological symptom

exercebrated by walking / standing

Differentiating claudicationNeurogenic claudication Vascular claudication

Distance Walking distance variable Walking distance constant

Alleviation Change in position ( usually flexion, sitting, lying down)

Stop walking and rest

Time Relief in – 10 min Relief in – 2 min

Character Neurogenic +/- neurological deficit

Muscular cramping

Radiation From proximal to distal From distal to proximal

Peripheral pulse Present Absent

Sensory loss Segmental Stocking type

Investigation• Lateral view XRAYs- Look for degenerative

changes like spondylolisthesis, disc degeneration and disc height lost with osteophytes formation

• CT scans (with myelogram): canal narrowing

• MRI: evaluate cord/ root compression, extent of spinal cord narrowing

Management• Conservative: Control the symptoms

activity modification Physiotherapy - Instruction in spinal posture, flexion exercise Analgesia - NSAIDs, epidural injection Protect neurological function – Vitamin B complex

• Operative: Endoscopic spine decompression (laminectomy +/- facetectomy )

Degenerative

Disc Disease

• Degenerative disc disease involves the degeneration of intervertebral discs.

• Disc properties change lead to decrease mechanical properties With increasing age, the discs can lose flexibility, elasticity, and

shock absorbing characteristics. They also become thinner as they dehydrate. When all that happens, the discs change from a supple state that allows fluid movement to a stiff and rigid state that restricts your movement and causes pain.

Tiny tears or cracks in the annulus fibrosus may forced out the nucleus pulposus through the tears or cracks, which causes the disc to bulge, break or rupture.

• It can take place throughout the spine, but it most often occurs in the discs in the lower back (lumbar region) and the neck (cervical region).

• CF - chronic back or neckpain w/out radiculopathy• High risk : smoke cigarettes ,heavy physical work (repeated

heavy lifting), obese• A sudden (acute) injury leading to a herniated disc (such as a

fall) may also begin the degeneration process.• As the space between the vertebrae gets smaller, there is less

padding between them, and the spine becomes less stable. The body reacts to this by constructing bony growths called bone spurs (osteophytes). Bone spurs can put pressure on the spinal nerve roots or spinal cord, resulting in pain and affecting nerve function.

• Osteophyte on intervertebral foramina compress spinal nerve

• Hypertrophic changes at vertebral margins with spur formation

• Degeneration of lumbar IV disc

Disc Problems

Conservative: Rest, activity modification, NSAIDs, +/- muscle relaxants Physical therapy: stretching, strengthening, weight control Lumbar bracing

Operative: Lumbar fusion, disc replacement

Management

Spondylosis

• Spondylosis (spinal OA) - degenerative disorder that may cause loss of normal spinal structure and function.

• Degenerative changes in discs, facets, and uncovertebral joint• may affect the cervical (neck), thoracic (mid-back), or lumbar (low back)

regions of the spine.• CF:

Cervical (Neck) : axial, neck pain, UL pain (spread into the shoulder or down the arm), paresthesia +/- weakness. Site: disc at C5/C6, C6/C7

Thoracic (Mid-Back) : pain triggered by forward flexion and hyperextension

Lumbar (Low Back) : >40, Pain and morning stiffness , worse by movement

• Can result in cord or root compression : myelopathy/radiculopathy

Extensive thinning of cervical disc and hyperextension deformity with narrowing of intervertebral foramina

ManagementConservative

Physiotherapy Advice on lifestyle modificationNSAIDS

SurgerySurgical Indications: - intractable pain - progressive neurological deficit - severe deltoid or wrist extensor weakness - myelopathyLaminectomy, removal of osteophytes, discectomy, laminaplasty

spondylolysis

Defect or fracture of pars interarticularis (without slip)Pars interarticularis : portion of the neural arch that connects the superior and inferior articular facetCauses: hyperextension sports ( gymnasts, karate)Common in paediatricsCommon site : L5Common cause of spondylolisthesisCF: insidious onset low back pain, worse with activityXRAY : L-spine oblique view: “ scotty dog has a collar neck”Tx: rest, activity modification, physiotherapy, lumbar brace.

Scotty dog sign

spondylolisthesisDef: Slippage/ displacement of one vertebra on adjacent vertebraSpondylolisthesis can lead to a deformity of the spine as well as a narrowing of the spinal canal (central spinal stenosis) or compression of the exiting nerve roots (foraminal stenosis)

Type 1: The dysplastic (congenital) type represents a defect in the upper sacrum or arch of L5.Commonly associated with spina bifida occulta and have nerve root involvement.

Type 2: The isthmic (early) type results from a defect in pars interarticularis, which permits forward slippage of the superior vertebra, usually L5.

Type 3: The degenerative (late) type is an acquired condition resulting from chronic disc degeneration and facet incompetence, leading to long-standing segmental instability and gradual slippage, usually at L4-5. Spondylosis is a general term reserved for acquired age-related degenerative changes of the spine that can lead to this type of spondylolisthesis.

Type 4: The traumatic (any age) type results from fracture of any part of the neural arch or pars that leads to listhesis.

Type 5: The pathologic type results from a generalized bone disease, such as Paget disease or osteogenesis imperfecta or tumor

Types of spondylolisthesis

• XRAY - lateral view use to determine grade based on percentage of vertebral body slipped Grade 1: 0- 25% Grade 2: 25- 50% Grade 3: 50- 75 % Grade 4 : >75%

• TreatmentLow grade (1-2)- rest, activity modification, physiotherapy,

lumbar bracingHigh grade (3-4) – decompression and posterolateral fusion

Management

• Isthmic type • Anterior

subluxation of L5 on sacrum d/t fracture of isthmus

• Note that gap is wider and dog appear decapitated