Download Spinal stenosis

DEGENERATIVE SPINAL CORD
DISEASES
Cemre YILMAZ
Spinal Cord
The spinal cord extends from the foramen magnum where it continues with
the medulla to the level of the first or second lumbar vertebra.
It terminates in a fibrous extension known as filum terminale.
Terminal portion of the spinal cord is called the conus medullaris.
Spinal nerves pass through the vertebral column by exiting the intervertebral
foramen. However, because the spinal cord does not reach the end of the
vertebral column, the lumbar and sacral spinal nerves exit only by first going
downward and traveling inferiorly through the vertebral canal before reaching
their corresponding intervertebral foramina. For this reason, there is a
collection of nerve roots at the lower end of the vertebral canal. This
collection of nerve roots is called the cauda equina due to a resemblance to a
horse's tail
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
Vertebra
There are features that are common to all vertebral segments
and others that are unique to each level. With the exception of
C1, each segment has a vertebral body, which is the anterior
portion of the vertebral segment. The superior and inferior
portions of the vertebral body are referred to as the end plates
which provide nutrition to the adjacent disk. The body is
connected to the posterior elements by bilateral pedicles which
are linear bony struts. The posterior elements consist of the
pedicles, lamina, facets (articular process), transverse process
and spinous process.
Intervertebral Discs
Each vertebral body segment(except
C1-C2) is attached to the level above
and below by an intervertebral disk
The disk has several functions:
1) It serves as a connection between
the vertebral bodies
2) It acts as a pivot point
3) Distribute compressive forces
The disk is made of the nucleus
pulposus and the annulus fibrosus
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
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most common site C5-C6 / C6-C7
Pain (neck and upper extremities)
Numbness
Muscle weakness
Paresthesia
Urinary incontinence , loss of bowel
control(rare)
Diagnosis
• Physical exam
• MRI – best
• CT with
myelogram –more
sensitive but
invasive
• X-ray
• EMG
Treatment
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Medication :NSAID
Physical therapy
Steroid injection
Surgery
 Anterior cervical discectomy
and spine fusion (ACDF)
 Posterior cervical
discectomy
 Cervical artificial disc
replacement.
Lumbar Disc Herniation
• Most common site L4L5/L5-S1
• 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
raise test
• MRI
• CT with myelogram
• X-ray
• EMG
• Ice application
• Medication : NSAID ,muscle
relaxants
• Heat therapy
• Physical therapy
• 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
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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
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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 Treatment
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Pain 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
Plain radiograph
CT/MRI
• oblique
• limited sensitivity compared
to SPECT and CT
• scotty dog sign
• Wide canal sign
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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.
Treatment
• Bracing to immobilize the spine for a short 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
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Neck/back pain
Stiffness
Paresthesia
weakness
• Standing
• Sitting
• Sneezing
• 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
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bowel or bladder dysfunction
spinal stenosis
neurologic dysfunctions
Unstable spine