Download Degenerative Spinal Cord Disease

DEGENERATIVE
SPINE DISEASE
Merve Gürkök
Spinal cord
• The human spinal cord extends from the
foramen magnum and continues through to
the conus medullaris near the second lumbar
vertebra, terminating in a fibrous extension
known as the filum terminale.
• In the upper part of the vertebral column,
spinal nerves exit directly from the spinal cord,
whereas in the lower part of the vertebral
column nerves pass further down the column
before exiting. The terminal portion of the
spinal cord is called the conus medullaris. The
pia mater continues as an extension called
the filum terminale, which anchors the spinal
cord to the coccyx. The cauda equina ("horse's
tail") is the name for the collection of nerves in
the vertebral column that continue to travel
through the vertebral column below the conus
medullaris.
Vertebra anatomy
■
Each vertebra (the singular of vertebrae) is composed of two sections. One, the vertebral
body, is a solid, cylindrical segment, shaped something like a marshmallow. It provides
strength and stability to the spine. The other segment is an arch-shaped section of bone
called the vertebral arch. Projecting from the back of the vertebral arch are segments of
bones, called processes, that articulate with each other and provide attachment points for
muscles, ligaments and tendons. The vertebral arch is connected to the vertebral body by
two small columns of bone called the pedicles. Together, the vertebral body, the pedicles,
and the vertebral arch form a ring of bone around a hollow center. Stacked on top of one
another in the spinal column, these rings align to form a long, well-protected channel known
as the spinal canal.
Intervertebral discs
■ Intervertebral discs connect the
vertebrae. The intervertebral discs act
as cushions and shock absorbers
between the vertebrae. Each disc is
composed of a jelly-like core
surrounded by a fibrous outer ring.
■ Intervertebral discs consist of an
outer fibrous ring, the annulus
fibrosus disci intervertebralis, which
surrounds an inner gel-like center,
the nucleus pulposus.
■ The anulus fibrosus consists of
several layers (laminae)
of fibrocartilage made up of both type
I and type II collagen. Type I is
concentrated towards the edge of the
ring where it provides greater
strength. The stiff laminae can
withstand compressive forces.
■ The fibrous intervertebral
disc contains the nucleus
pulposus and this helps to
distribute pressure evenly
across the disc. This
prevents the development
of stress concentrations
which could cause damage
to the underlying vertebrae
or to their endplates. The
nucleus pulposus contains
loose fibers suspended in a
mucoprotein gel. The
nucleus of the disc acts as
a shock absorber, absorbing
the impact of the body's
activities and keeping the
two vertebrae separated. It
is the remnant of
the notocord.
■
Inside the well-protected spinal canal is
the spinal cord, the delicate bundle of
nerves and other tissue that connects
brain and body. The spinal canal also
houses the beginning of the spinal nerve
roots. These are the nerves that leave
the spine, exiting the spinal canal
through foramina (small openings) to
branch out to the body. The spinal cord
and nerve roots are suspended in a
liquid called the cerebrospinal fluid.
Membranes called the meninges act
somewhat like the casing on a sausage,
wrapping up the spinal cord, the nerve
roots, and the CSF inside the spinal
canal. The outermost layer of the
meninges is a tough tissue layer known
as the dura mater.
Glossary
■
Compression: means harmful pressure on the spinal cord or nerve roots. Bone spurs, thickened
ligaments, and herniated discs are all possible sources of compression. (Each of these
conditions can also exist without causing compression.)
■
Myelopathy: A reduction in the spinal cord’s ability to send signals between brain and body.
Causes weakness, numbness, clumsiness, and/or bowel and bladder incontinence. Can be
caused by compression of the spinal cord. The most common form of myelopathy in human,
cervical spondylotic myelopathy (CSM), is caused by arthritic changes (spondylosis) of the
cervical spine, which result in narrowing of the spinal canal (spinal stenosis) ultimately causing
compression of the spinal cord.
■
Radiculopathy: The consequence of nerve root damage (from any cause) is known as a
radiculopathy (L. radicula = little root; pathos = disease), whereas the syndrome of
"myelopathy"(Gr. myelos = marrow, pertaining to the spinal cord, pathos = disease) results from
spinal cord damage.
■
A reduction in a nerve root’s ability to send signals between spinal cord and body. Causes pain,
weakness, or numbness in the area served by that nerve root.
■
A sharp pain that may worsen with certain movements,a shooting pain, numbness,weakness
and tingling,loss or change in sensation,loss of reflexes
■
The most common symptom of radicular pain is sciatica (pain that radiates along the sciatic
nerve - down the back of the thigh and calf into the foot). C5-C6, followed by C6-C7, is the most
common location for radiculopathy in the neck.
■ Stenosis: a narrowing of the spinal canal. Stenosis can
compress the spinal cord or nerve roots and may lead to
myelopathy or neurogenic claudication.
■ Arthritis: joint inflammation that causes pain and
stiffness. The most common type is osteoarthritis, which
occurs when cartilage in the joints wears down.
■ Bone spurs: extra bone that may grow on joints affected
by osteoarthritis. Bone spurs may compress the spinal
cord or nerve roots.
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.
Red Flags
■
Back pain accompanied by bowel or bladder incontinence and/or numbness
in the areas that would sit on a saddle (so-called saddle anesthesia)—may
indicate cauda equina syndrome, a rare neurological condition that should be
treated promptly
■
Neck or back pain that includes weakness, numbness, or pins-and-needles in
the arms or legs–may indicate myelopathy
■
Neck or back pain that radiates (spreads) into the shoulder, arm, hand, leg,
or foot–may indicate radiculopathy
■
Neck or back pain accompanied by fever
■
Neck or back pain that gets worse during the night
■
Neck or back pain accompanied by unexplained weight loss
■
Neck or back pain that continues for several weeks or months
■
Neck pain accompanied by difficulty breathing or swallowing
■
Neck or back pain following a fall, injury or other trauma
Degenerative Spine Disease
■ Herniated discs
■ Degenerative disc disease
■ Spinal osteoarthritis
■ Spondylolisthesis
■ Spinal stenosis
■ Degenerative scoliosis
Risk factors
■ Aging
■ Genetic predisposition
■ Smoking, diet, weight
■ Occupational (heavy lifting)
■ Sedentary lifestyle
Disc Herniations
■ Spinal disc herniation, also known as a slipped disc, is a medical
condition affecting the spine in which a tear in the outer, fibrous
ring of an intervertebral disc allows the soft, central portion to
bulge out beyond the damaged outer rings.
■ Disc herniation is usually due to age-related degeneration of the
anulus fibrosus, although trauma, lifting injuries, or straining
have been implicated.
■ Tears are almost always postero-lateral in nature owing to the
presence of the posterior longitudinal ligament in the spinal
canal. This tear in the disc ring may result in the release of
inflammatory chemical mediators, which may directly cause
severe pain, even in the absence of nerve root compression.
Stages
■
1)Disc Degeneration: Chemical changes associated with aging cause intervertebral discs to weaken,
but without a herniation. This is part of the aging process discussed above, and it can cause the disc
to dry out, making it less able to absorb the shock from your movements. It can also become thinner
in this stage.
■
2)Prolapse: The form or position of the disc changes with some slight impingement into the spinal
canal or spinal nerves. This stage is also called a bulging disc or protruding disc.
■
3)Extrusion: The gel-like nucleus pulposus breaks through the annulus fibrosus but remains within
the disc.
■
4)Sequestration or Sequestered Disc: The nucleus pulposus breaks through the annulus fibrosus
and can move outside the interverterbral disc and into the spinal canal.
■ The majority of spinal disc herniation
cases occur in lumbar region (95% in L4L5 or L5-S1).
■ The second most common site is the
cervical region (C5-C6, C6-C7). The
thoracic region accounts for only 0.15%
to 4.0% of cases. Herniations usually
occur posterolaterally, where the anulus
fibrosus is relatively thin and is not
reinforced by the posterior or anterior
longitudinal ligament.
Cervical Disc Herniation
■ Cervical disc herniations occur in the neck, most often
between the fifth & sixth (C5/6) and the sixth and seventh
(C6/7) cervical vertebral bodies. Symptoms can affect the
back of the skull, the neck, shoulder girdle, scapula, arm, and
hand. The nerves of the cervical plexus and brachial plexus
can be affected.
Symptoms
■ Pain(neck,shoulder,arm,hand)
■ Radiculopathy
■ Numbness
■ Muscle weakness
■ Paresthesia
■ Severe cases, a herniated disk can compress nerves that
control the bowel and bladder, causing urinary incontinence
and loss of bowel control
■ C4-C5 (C5 nerve root): A herniation at this level can cause
shoulder pain and weakness in the deltoid muscle at the top
of the upper arm, and does not usually cause numbness or
tingling.
■ C5-C6 (C6 nerve root): A C5-C6 disc herniation can cause
weakness in the biceps (muscles in the front of the upper
arms) and wrist extensor muscles. Numbness and tingling
along with pain can radiate to the thumb side of the hand.
This is one of the most common levels for a cervical disc
herniation to occur.
■ C6-C7 (C7 nerve root): A herniated disc in this area can cause
weakness in the triceps (muscles in the back of the upper arm
and extending to the forearm) and the finger extensor muscles.
Numbness and tingling along with pain can radiate down the
triceps and into the middle finger. This level is also one of the
most common areas for a cervical disc herniation.
■ C7-T1 (C8 nerve root): This level is located at the very bottom of
the neck, where the cervical spine meets the thoracic, or upper,
back. A herniation here can cause weakness with handgrip,
along with numbness and tingling and pain that radiates down
the arm to the little finger side of hand.
Diagnosis
■ Physical examination
■ MRI(The single best test to diagnose a herniated disc is an
MRI scan. An MRI scan can image any nerve root pinching
caused by a herniated cervical disc.)
■ CT with myelogram (it is more sensitive and can diagnose
even subtle cases of nerve root pinching)
■ X-ray
■ EMG
Threatment
■ Medications(NSAID)
■ Physical therapy and exercise
■ Steroid injection
■ Surgery
Surgery
■ Anterior cervical discectomy and spine fusion (ACDF) (This is
the most common method among spine surgeons for most
cervical herniated discs.)
■ Posterior cervical discectomy
■ Cervical artificial disc replacement
Lumbar Disc Herniation
■ Lumbar disc herniations occur in the lower back, most often between
the fourth and fifth lumbar vertebral bodies or between the fifth and
the sacrum. Symptoms can affect the lower back, buttocks, thigh,
anal/genital region (via the Perineal nerve), and may radiate into the
foot and/or toe. The femoral nerve can also be affected and cause the
patient to experience a numb, tingling feeling throughout one or both
legs and even feet or even a burning feeling in the hips and legs.
• The sciatic nerve is the most commonly
affected nerve, causing symptoms of
sciatica
• Usually, sciatica affects only one side of
the lower body and the pain radiates
from the lower back to the back of the
thigh and down the leg.
Symptoms
■ Pain(lumbar,leg,foot,nerve)
■ Numbness
■ Muscle weakness
■ Foot drop (difficulty lifting the foot when walking or standing)
■ A loss of bladder or bowel control, lower back pain, numbness
in the saddle area, and/or weakness in both legs are signs of
a rare but serious condition called cauda equina syndrome.
Cauda Equina
Syndrome
■ Cauda equina syndrome
(CES) is a serious neurologic
condition in which damage
to the cauda equina causes
loss of function of the
lumbar plexus (nerve roots)
of the spinal canal below the
termination (conus
medullaris) of the spinal
cord. CES is a lower motor
neuron lesion.
Symptoms
■ Severe back pain
■ Saddle anesthesia
■ Sciatica-type pain on one side or both sides
■ Bladder and bowel dysfunction
■ Gait disturbance
■ Anal and Achilles reflex absent
■ Sexual dysfunction
Diagnosis
■ Pyhsical examination (Leg raise test)
■ MRI (usually provides the most accurate assessment of the
lumbar spine area)
■ CT
■ X-ray
■ EMG
Lasègue's sign(Straight leg
raise)
■ If the patient experiences sciatic
pain when the straight leg is at
an angle of between 30 and 70
degrees, then the test is positive
and a herniated disc a possible
cause of the pain. A negative
test suggests a likely different
cause for back pain.(highly
sensitive)
Threatment
■ Pain medications
■ Ice application
■ Muscle relaxants
■ Heat therapy
■ Heat and ice
■ Physical therapy
■ Acupuncture
■ Epidural injections
■ Surgery
Surgery
Surgery may be recommended if:
■ There is severe pain and the person is having difficulty
maintaining a reasonable level of daily functions, such as
standing or walking.
■ The person is experiencing progressive neurological
symptoms, such as worsening leg weakness. and/or
numbness
■ There is a loss of bowel and bladder functions.
■ Medication, physical therapy, and/or other nonsurgical
treatments have not significantly eased symptoms.
Surgery
■ Two minimally invasive procedures, microdiscectomy and
endoscopic microdiscectomy, are most commonly
recommended for lumbar herniated discs. These procedures
take the pressure off the nerve root and provide a better
healing environment for the disc.
Degenerative Disc Disease
■ Degeneration of one or more intervertebral disc(s) of the
spine, often called "degenerative disc disease" (DDD) or
"degenerative disc disorder," is a pathologic process of
certain pathology that may cause acute or chronic low back or
neck pain. The typical radiographic findings in DDD are black
discs, disc space narrowing, vacuum disc, end plate sclerosis,
and osteophyte formation. DDD can greatly affect the
sufferer's quality of life. Disc degeneration is a disease of
micro/macro trauma and of aging, and though for most
people is not a problem, in certain individuals a degenerated
disc can cause severe chronic pain if left untreated.
The two findings most correlated
with a pathological disc (a
degenerating disc that is painful)
are:
■ Cartilaginous end plate
erosion
■ Disc space collapse
MRI findings of spinal degeneration are
not specific causes of back pain. Typical
MRI findings may include:
■ Disc dehydration, also called disc
desiccation, and often referred to as a
dark disc or black disc, because a
disc with less water in it looks dark on
an MRI scan
■ Annular tears
■ Disc bulges
Symptoms
■ With symptomatic degenerative disc disease, chronic low
back pain sometimes radiates to the hips, or there is pain in
the buttocks or thighs while walking; sporadic tingling or
weakness through the knees, hands, and fingers may also be
evident. Similar pain may be felt or may increase while sitting,
bending, lifting, and twisting. Chronic neck pain can also
come from the cervical spine, with pain radiating to the head,
shoulders, arms and hands.
Threatment
■ Pain Control
■ Exercise and Rehabilitation
■ Lifestyle Modifications
■ Surgery
Spinal Stenosis
■
Spinal stenosis is an abnormal narrowing (stenosis) of the spinal canal that may
occur in any of the regions of the spine. This narrowing causes a restriction to the
spinal canal, resulting in a neurological deficit. Symptoms include pain, numbness,
paraesthesia, and loss of motor control. The location of the stenosis determines
which area of the body is affected. With spinal stenosis, the spinal canal is
narrowed at the vertebral canal.
■ Some people are born with a congenital form, but most
develop spinal stenosis as part of the degenerative cascade.
A few do not feel any effects of the narrowing, but as part of
the aging process, most people will eventually notice radiating
pain, weakness, and/or numbness secondary to the
compression of the nerves or spinal cord.
■ There are several types of spinal stenosis, with lumbar
stenosis and cervical stenosis being the most frequent. While
lumbar spinal stenosis is more common, cervical spinal
stenosis is more dangerous because it involves compression
of the spinal cord whereas the lumbar spinal stenosis involves
compression of the cauda equina.
■ Lumbar Spinal Stenosis
■ In lumbar stenosis, the spinal nerve roots in the lower back
become compressed and this can produce symptoms of
sciatica—tingling, weakness or numbness that radiates from
the low back and into the buttocks and legs—especially with
activity.
Symptoms
■ Standing discomfort (94%)
■ Discomfort/pain, in shoulder, arm, hand (78%)
■ Bilateral symptoms (68%)
■ Numbness (63%)
■ Weakness (43%)
■ Buttock / Thigh only (8%)
■ Below the knee (3%)
■ Cervical (spondylotic) myelopathy
■ Numbness
■ Intermittent neurogenic claudication
■ Cauda Equina Syndrome
Threatment
■ Posterior laminectomy/laminoplasti
■ Anterior Cervical Discectomy and fusion
Spondylolysis
■ Spondylolysis is a condition in which the there is a defect in a portion of
the spine called the pars interarticularis.
■ Spondylolysis is more common in children and teens participating in
sports that place a lot of stress on the lower back or cause a constant
over-stretching (hyperextending) of the spine, such as gymnastics,
weightlifting, and football. It is seen more often in males than in females.
■ Many people with spondylolysis have no symptoms and don't even know
they have the condition. When symptoms do occur, low back pain is the
most common.
On an anterior oblique radiograph of
the lumbar spine, the pars is the neck of
the imaginary Scottie dog; the Scottie
dog's eye is the pedicle, its hindlegs the
spinous process, its nose the transverse
process, its ear the superior articular
facet and its forelegs the inferior
articular facet.
Spondylolisthesis
■ Spondylolisthesis is the forward displacement of a vertebral
bone in relation to the natural curve of the spine, most
commonly occurring after a fracture, and most often the fifth
lumbar vertebra.
■
–
–
–
Isthmic spondylolisthesis is the most common form; also called
spondylolytic spondylolisthesis, it occurs with a reported prevalence of
5–7 percent in the US population. A slip or fracture of the intravertebral
joint is usually acquired between the ages of 6 and 16 years, but
remains unnoticed until adulthood. Roughly 90 percent of these isthmic
slips are low-grade (less than 50 percent slip) and 10 percent are highgrade (greater than 50 percent slip).It is divided into three subtypes:
A: pars fatigue fracture
B: pars elongation due to multiple healed stress fx
C: pars acute fracture
■
Degenerative spondylolisthesis is a disease of the older adult that
develops as a result of facet arthritis and joint remodeling. Joint arthritis,
and ligamentum flavum weakness, may result in slippage of a vertebra.
Degenerative forms are more likely to occur in women, persons older
than fifty, and African Americans.
■
Traumatic spondylolisthesis (secondary to a fracture of the neural arch)
■
Pathologic spondylolisthesis (from bone disease such as metastatic
disease, tumor, osteoporosis, etc.)
Symptoms
■ A general stiffening of the back and a tightening of the
hamstrings, with a resulting change in both posture and gait.
■ A leaning-forward or semi-kyphotic posture may be seen, due to
compensatory changes.
■ A "waddle" may be seen in more advanced causes, due to
compensatory pelvic rotation due to decreased lumbar spine
rotation.
■ A result of the change in gait is often a noticeable atrophy in the
gluteal muscles due to lack of use.
■ Generalized lower-back pain may also be seen, with intermittent
shooting pain from the buttocks to the posterior thigh, and/or
lower leg via the sciatic nerve.
Threatment
■ NSAID
■ Pysical therapy
■ Surgical(laminectomy)
Spondylosis
■ Spondylosis is a broad term meaning degeneration of the spinal column
from any cause. In the more narrow sense it refers to spinal osteoarthritis,
the age-related wear and tear of the spinal column, which is the most
common cause of spondylosis.
■ The degenerative process in osteoarthritis chiefly affects the vertebral
bodies, the neural foramina and the facet joints (facet syndrome).
■ If severe, it may cause pressure on nerve roots with
subsequent sensory or motor disturbances, such as pain, paresthesia,
and muscle weakness in the limbs.
Diagnosis
■ Cervical Compression Test a variant of Spurling's test, is
performed by laterally flexing the patient's head and placing
downward pressure on it. Neck or shoulder pain on the
ipsilateral side (i.e. the side to which the head is flexed)
indicates a positive result for this test. However it should be
noted that a positive test result is not necessarily a positive
result for spondylosis and as such additional testing is
required.
■ Lhermitte sign: feeling of electrical shock with patient neck
flexion.
■ Reduced range of motion of the neck, the most frequent
objective finding on physical examination.
■ MRI and CT scans are helpful for pain diagnosis but generally
are not definitive and must be considered together with
physical examinations and history.
■ Osteoarthritis of the spine is a
breakdown of the cartilage of the
joints and discs in the neck and
lower back.
■ Sometimes, osteoarthritis
produces spurs that put pressure
on the nerves leaving the spinal
column. This can cause weakness
and pain in the arms or legs.
Usually, the back discomfort is
relieved when the person is lying
down
■ For people younger than age 45,
osteoarthritis is more common
among men. After age 45,
osteoarthritis is more common
among women. Osteoarthritis
occurs more often among people
who are overweight. It also occurs
more frequently in those who have
jobs or do sports that put
repetitive stress on certain joints.