V Basic anatomy

V Definition
V Epidemiology
V Etiology
V Degenerative disc disease
V Lumbar spine stenosis
V Spondylolisthesis.
2he 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

 2he vertebrae articulate with each
other by 2 types of joints:
1. Facet joints: synovial joints between the
superior and inferior articular
processes.
2. Intervertebral disk: cartilagenous joint
between the vertebral bodies. It acts as
a shock absorber.
2he intervertebral disc is composed
of
a. Annulus Fibrosus:
2ough outer layer composed of layers
of parallel fibers that criss-cross to the
next layer. It is thinner posteriorly.
b. Nucleus Pulposus:
It is a fibrocartilagenous layer that has
a high water content (80%). It is the
part that acts as a shock absorber.
V Degenerative spinal disorders are a group of
conditions that involve a loss of normal structure and
function in the spine.

Epidemiology
V About 90% of population suffer from back pain at
some point and 30% of these will develop leg pain
due to lumber spine pathology.
V 25% of people develop chronic low back pain.
V usual age of presentation: 30s to 50s
2hese common disorders are associated with the
normal effects of aging, but also may be caused by
infection, tumors, muscle strains, or arthritis.
Pressure on the spinal cord and nerve roots
associated with spinal degeneration may be caused
by disc displacement or herniation; spinal stenosis, a
narrowing of the spinal canal; or osteoarthritis,
cartilage breakdown at spinal joints.
V Protrusion, herniation, or
fragmentation of an
intervertebral disc
beyond its borders with
potential compression of
a nerve root, the cauda
equina in the lumbar
region, or the spinal cord
at higher levels.
V vith aging, certain biochemical and structural
changes occur in the intervertebral discs. 2here is an
increase in the ratio of keratan sulfate to chondroitin
sulfate, and the proteoglycans lose their close
association with the disk collagen. 2he disc also loses
its water-binding capacity and the water content
decreases down to 70%. 2he vertebral end plates
also becomes thinner and more hyalinized. 2his
degree of disk degeneration is considered a normal
part of aging.
V vith more advanced degeneration, dense
disorganized fibrous tissue replaces the normal
fibrocartilaginous structure of the nucleus
pulposus, leaving no distinction between the
nucleus and anulus fibrosus. Development of
anular tears weakens the anulus and allows nucleus
to protrude into the defect. 2ears that extend
through the outer anulus induce ingrowth of
granulation tissue and accelerate the degenerative
process. Advanced degeneration can lead to gas
formation or calcification within the disk. Also,
fissures develop in the cartilaginous end plates,
and regenerating chondrocytes and granulation
tissue form in the area.
V |
 - loss of disk water
V þ 



 º herniation of nucleus
pulposus througha tear in annular fbrosus
V |
  - circumferential enlargement of the
disk contour in a symmetric fashion
V þ  
 - a bulging disk that is eccentric to
one side but < 3 mm beyond vertebral margin
V è  - disk protrusion that extends more
than 3 mm beyond the vertebral margin
V ?  



 - extension of nucleus pulposus
through the anulus into the epidural space
V ï    - epidural fragment of disk no
longer attached to the parent disk
V Directions:
* Posterolateral: most common.
* Lateral: traps nerve root.
* Central: compresses cauda equina.
V Causes:
* 80 % traumatic (sudden sever strain).
* 20 % degenerative (without tear).
V Presentation:
1. Low back pain
2. Sciatica
3. Parasthesia
4. veakness
V Examination:
1. Inspection: scoliosis, loss of lumber
lordosis, muscle spasm & atrophy &
dystrophic skin changes.
2. Focal tenderness.
3. Lumber back movement restriction (
due to pain ).
VExamination cont.
4. Special tests:
* Straight leg raising: pain in <60 deg.
a) Bragaard sign: pain increase with dorsiflxion of
foot.
b) Crossed leg sign: elevation of the good leg elicit
pain in the other one.
* Naffzigar test: pain increases with manual
compression on both jugular veins simultaneously.
* Valex test: pain increases upon pressing the buttocks
or the sciatic n.
5. Neurological deficit:
* L3/L4 prolepses:
1. veakness of quadriceps muscle.
2. Diminished sensations over ant. 2high &
medial aspect of lower leg.
3. Decreased or absent knee jerk.
* L4/L5 prolapse:
1. veak drsiflexion of foot.
2. Parasthesia in lateral foot & small toes.
3. No reflex changes.
 * L5/S1 prolapse:
1. veak planter flexion.
2. Parasthesia in lateral foot & small
toes.
3. Absent ankle jerk.
6. Buttocks: Assess for gluteal atrophy, anal
sensation & sphincter function.
- L5-S1 prolapsed disc: S1
‡ Pain along the posterior of the thigh, radiating to the heel.
‡ Occasionally, weakness of the planter flexion.
‡ Sensory loss in the lateral foot.
‡ Absent ankle reflex.
- L4-L5 prolapsed disc: L5
‡ Pain along the posterior-posterolateral aspect of the
thigh, radiating to the foot dorsum and the great toe.
‡ veakness of the foot and toe dorsiflexors.
‡ Reflex changes unlikely.
‡ Paraesthesia and numbness of the dorsum of the foot and
the great toe.
- L3-L4 prolapse: L4
‡ Pain in the ant. 2high.
‡ Quadriceps wasting.
‡ veakness of the quadriceps and dorsiflexors of the foot.
‡ Diminished sensation over the ant thigh, knee and med
aspect of the lower leg.
‡ Reduced knee reflex.
V DRI: most commonly used, shows the
size, configuration, position of the disc,
and any nerve root or thecal
compression.
V Lumber myelography. (rarely used now)
V High quality C2 scan (rarely used now)
D

 

   
  
 
 

 
  
  

 


!""#$%&$!!'('
V Compression of theacal sac below L1/L2 level causes
a sort of lower motor neuron lesion bilaterally.
V Symptoms:
1. Leg pain: bilaterally.
2. Parasthesia.
3. Sphincter paralysis: loss of sensation from urinary
bladder, urethral sensation & anal sensation.
4. Sexual disturbance: impotence.
V Signs:
1. Sensory loss: saddle sensation.
2. Dotor loss: foot drop usually with
complete loss of power in dorsi & plantar
flexion of both feet.
3. Absent ankle jerks on both sides.
V 1) DRI:
a) DOS2 SENSI2IVE DE2HOD.
b) Demonstrates disc disease.

2) C2- scan:
a) Detects disc protrusion & demonstrates the
extent of n. root compression.
b) Hypertrophy of facet joints.
c) Assess diameter of spinal canal ( done also on
lateral x-ray).
3) Plain lumbosacral x-ray:
a) Narrowing of disc space ( chronic cases)
b) Calcification.
c) Degenerative change, ostyophytes.
d) Scoliosis.
e) Loss of lordosis.
f) Associated spondilolithaisis.
4) Other methods: Dyelogram, post myelogram C2.
V DDx. :
1. Referred low back pain.
2. Degenerative disease.
3. Lumber canal stenosis.
4. Spinal tumor.
5. 2rauma.
6. Isolated neuropathy.
7. Infectious process.
8. Congenital anomalies.
V Site: Dost commonly at C5/6> C4/5>
C6/7 > C3/4.
V 2ypes:
1. Lateral prolapse: presses on
corresponding n. root causing neck pain,
parasthesia & radicular pain. Since each
cervical spinal root emerges above itüs
vertebra, disc prolapse compresses the
corresponding n.
2. Central prolapse: Compresses n. root, the
spinal cord & the ant. Spinal artery & vein.
V Causes:
1. LDNL at the same level.
2. UDNL at the levels below ( Dyelopathy):
results in spastic gait, loss of fine
movement of hand, sphincter affection, loss
of superficial abdominal reflexes,
increased tone & reflexes in lower limbs &
upward planter reflex.
V Plain X-ray.
V Post myelogram C2.
V DRI (most important ).

Surgical treatment:
V Posterior approach: if > one level involved or with
diffuse stenosis.
V Anterior approach: in single level involvement.
V 2ypes:
1. Congenital: early fusion, thick short pedicles.
2. Acquired: hypertrophied facet joints.
V Factors sharing in canal stenosis:
1) Hypertrophy of facet joints.
2) 2hickening of ligamentum flavum.
3) Disc bulge.
V Narrowing of the lumbar
spinal canal.
V Verbiest, 1949
V Altough lumbar canal
stenosis and lumbar disc
prolaps can be found in
the same patient,they
each produce distinct
clinical entity.
V According to diameter of the canal:
1. Central stenosis. AP diameter is
normally 12-16 mm.
V Dild (<12mm).
V Doderate (<10mm).
V Severe (<8mm).
2. Lateral recess stenosis: Lat. Diameter is
about 4 mm normally. If it is < 2 mm then
it is stenosed.
V Levels affected: L4/5> L3/4> L5/S1.
V Clinical features:
1- Pain: radiating diffusely into the legs,
exacerbated by walking or standing. it may have
a burning quality and relieved by setting.
2- the patient often complains of a subjective
feeling of weakness and a diffused Anumbnessü
and Atinglingü radiating down the limb.
3-sphincter problems may occur in severe stenosis
V Physical findings:
examination of lower limb and back often
reveals little or no abnormality. but
muscular atrophy, depressed ankle jerk,
sensory desturbance and weakness may
occur only in the most severe cases.
V Vascular claudication:
1. Skin changes.
2. Dore calf pain.
3. Relieved by standing still or sitting.
4. Dore on walking upstairs.
5. Peripheral pulses are diminished.
6. Claudication distance decreases.
 High quality C2 scanning.
DRI. (BES2 ).

Conservative treatment:
2he clinical features of LCS do not respond
favorably to conservative treatment.
Surgical 2reatment:
V vide Lamectomy with root
decompression.

Results & Complications:

V Improvement in 90 %.
V Persistent pain in 10 %.
V Instability.
Surgery will improve claudication distance
but may or may not improve pain.
V  



refers to
forward displacement of one
vertebra over another,
usually of the fifth lumbar
over the body of the sacrum,
or of the fourth lumbar over
the fifth.
V Spondylolisthesis is graded
according to how far the
vertebral body moves
forward on the one below
(Grade 1 = 25%, Grade 2 =
50%, Grade 3 = 75%).
V refers to a cleft or break in the pars
interarticularis of the vertebra. It is found
in about 6% of adults, mostly in males,
93-95% occur at L5, and most are
bilateral.
V 2he etiology is uncertain, but the current
theory is that it represents a stress
fracture from repeated trauma to the
spine.
V2

















 
 








 










2
















 











 


 

 









  






 





















 

  








2





  


 


 
!

  







 

 





 



 

V r 




"#


 






$%$&
















 








'
( 





'
























 




 
)

  



*

 


V Diagnosis: hx (back pain and leg
pain, waddling gait, †tight hamstring
syndrome ), PhE
V Investigations:
1-plain lumbar spine X-ray

- DRI to demonstrate the degree of

nerve compression.
2