Spinal Degenerative Disease
- Disc
Disease
- Disc
bulge –
affects 35% by age 30, 100% by age 60 (30% will have asymptomatic
herniation by age 60)
- Disc
Herniation
- Symptoms:
Pain with radicular radiation
- Epidemiology:
- 80% of
patients are male
- Rare
prior to age 25 or after age 60
- Most
present between ages of 40-60
- Most
common levels affected are C6-7, L4-5 and L5-S1
- Diagnosis:
- Radiating
pain in an appropriate radicular distribution
- Cervical
herniated discs will usually affect the higher numbered (exiting) nerve
root (C56 affects C6)
- Lumbar
herniated discs will usually affect the higher numbered nerve root that
exits the level below (L45 affect L5)
- Far
lateral lumbar herniated discs will affect the lower numbered (exiting)
nerve root
- Positive
straight leg raise in a clinical setting consistent with lumbar disc
herniation is 60% specific
- Positive
crossed straight leg raise is >95% specific
- Plain
spine films: 6% of patients will have anatomical variants in which
there are either 4 (sacralized lumbar spine) or 6 (lumbarized spine)
lumbar vertebral bodies
- MRI of
spine or CT myelogram
- If
patient has had previous surgery, need to give gadolinium to
differentiate scar tissue from new disc
- If
symptoms and imaging are not consistent, might consider EMG to better
differentiate root involvement.
- Treatment:
- If no
evidence myelopathy or bowel/bladder dysfunction – bed rest,
analgesics, NSAIDs, muscle relaxants
- For
acute herniations, quick steroid taper (Medrol dose pack) can decrease
inflammation and provide relief
- Cervical
– consider longitudinal cervical (Halter) traction
- Lumbar
– back school/PT may be helpful
- If
medical management fails or myelopathy or bowel/bladder involvement –
surgery to remove disc
- Surgical
options:
- Cervical:
- Anterior
cervical discectomy with fusion – best choice for large or central
discs
- Cervical
foraminotomy – only for disc material in foramen
- Thoracic
- Do
NOT do laminectomy – worsens deficit
- Posterolateral
approach (transpedicular or costotransversectomy)
- Anterior
approach
- Lumbar
- Discectomy
with or without fusion
- Anterior
lumbar interbody fusion
- Schmorl’s
Nodule –
herniation of disc through endplate into spongiosa of vertebra
- Cervical
Spondylosis
– Degenerative disease of cervical spine, with disc herniations and/or
bone spurs usually over multiple levels
- Osteophytes
(bone spurs) occur at insertion of Sharpey’s fibers
- Symptoms:
insidious onset of progressive neck pain, usually with radicular pattern
of radiation, and/or myelopathy
- Diagnosis:
- Plain
spine films show degenerative changes
- MRI of
cervical spine shows cord compression/canal narrowing
- CT
myelogram may be helpful in defining compression from bone spurs
- Extreme
care must be used in extending the neck under general anesthesia given
risk of cord injury
- Treatment:
- Surgical
decompression – multiple level vertebrectomy and fusion vs. decompressive
laminectomies
- Cervical
stenosis
- Cervical
spine normally 18 mm; symptomatic at 10 mm
- Congenital
stenosis caused by achondroplasia, Moquio’s syndrome (also hypoplastic
dens)
- Lumbar
Stenosis –
hypertrophy of superior articular facet
- Associated
with acromegaly, achondroplasia, Paget’s disease
- Symptoms:
- Aching
pain/numbness of legs with walking, prolonged standing, activities which
extend lumbar spine (“neurogenic claudication”)
- Pain
occurs with activity only
- Diagnosis:
- Must
rule out peripheral vascular disease (true claudication)
- Look
for evidence of PVD – decreased/absent peripheral pulses, trophic skin
changes
- Consider
non-invasive lower extremity Doppler studies
- Plain
LS spine films
- MRI
lumbar spine or CT myelogram
- Treatment:
Decompressive lumbar laminectomies
- Spondylolisthesis – anterior displacement of
superior body (usually L5) on inferior (usually S1)
- Caused
by Spondylolysis – congential absence of pars interarticularis
(between superior and inferior facet, so discontinuity of neural arch)
- Epidemiology:
- Seen in
approximately 5% of the adult population
- Male to
female ratio is 2:1
- 90%
occur at L5-S1; 5% occur at L4-5
- There
is a hereditary predisposition, with 25-30% of near relatives having
this entity
- Classification:
- Dysplastic
(congenital): Dysplasia of the L5 vertebral body and sacrum with
hypoplastic posterior elements and spina bifida
- Isthmic:
- Type A
(Lytic) – Defect in the pars interarticularis
- Type B
(Elongation of pars interarticularis without separation) – Caused by
repeated fatigue microfractures, which heal with elongation of the
isthmus
- Type C
– Acute fracture of the pars interarticularis
- Degenerative:
- Erosive
changes in facet joints associated with loss of structural integrity of
the disc
- Post-traumatic:
- Following
trauma, but in the absence of a fracture of the pars interarticularis
- Symptoms:
Pain (musculoskeletal and/or radicular), lumbosacral kyphosis, waddling
gait, hamstring tightness
- Grading
of spondylolisthesis:
- Grade I
= <25% displacement
- Grade
II = 25-50% displacement
- Grade
III = 50-75% displacement
- Grade
IV = >75% displacement
- “Grade
V” = >100% displacement (also called spondyloptosis)
- Diagnosis:
Lumbosacral plain films
- Progressive
displacement is infrequent, but is most commonly seen during childhood
and early adolescence
- Treatment:
- Postural
back exercises to strengthen abdominal musculature
- Analgesics
- LS
corset to alleviate symptoms
- Surgery
(spinal fusion)
- Indications
for surgery:
- Unremitting
pain
- Observed
progressive slip
- >50%
displacement (i.e., grade III or above) with postural abnormality
- Abnormal
gait secondary to tight hamstring
- Persistent
neurologic symptoms
- Failed
Back Syndrome (FBS) – The failure of surgery or medical therapy to relieve
the pain and incapacitation from low back or leg pain
- Etiology:
- Organic
– Spinal stenosis, persistent or recurrent herniated disc,
arachnoiditis, epidural fibrosis, nerve injury, spondylolysis,
spondylolisthesis, pseudoarthrosis, foreign body, chronic mechanical
pain
- Non-organic
– Psychosocial, drug, social, financial factors
- Treatment:
- Repair
surgical lesions
- TENS
(Transcutaneous electrical nerve stimulators)
- Provides
relief in approximately one-third of patients
- Epidural
spinal cord stimulators (ESCS)
- Thoracolumbar
epidural electrodes with an implanted stimulator
- Tends
not to work long-term for axial pain
- Intrathecal
morphine pump – last resort
- There
is no role for the use of ablative procedures in the treatment of
chronic pain of benign origin
- Ossification
of the Posterior Longitudinal Ligament (OPLL) – more common in Japan; usually at C3-5 or T4-7
- Anterior
to spinal cord, so best treated by anterior approach
- Ossification
of the Ligamentum Flavum – more common in Japan