The degenerative disc and spine disease.

1. DEGENERATIVE SPINE
DISEASES
K mohamed rafi

2. TOPICS
 ANATOMY
 INVESTIGATION
 BACK PAIN
 CLINICAL FEATURES-WADDELL
SIGN
 SPINAL STENOSIS
 DEGENERATIVE DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESI
S
 MANAGEMENT

3. ANATOMY
 INVESTIGATION
 BACK PAIN
 CLINICAL FEATURES-WADDELL SIGN
 SPINAL STENOSIS
 DEGENERATIVE DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESIS
 MANAGEMENT
 POST OPERATIVE DISEASES

4. Anatomy
Elsevier items and derived items ©
2006 by Elsevier Inc.

5. Intervertebral Discs
 Intervertebral Discs
 23 narrow spongy shock
absorbers which fit
between the 24
separate bones of your
spine
 Each disc has a strong
fibrous outer casing - called
the annulus fibrosus - and a
soft, squashy, jelly-like
interior called the nucleus
pulposus - which is
reinforced with strands of
fibre.

6. Intervertebral Discs
 Intervertebral discs have very little in the way
of nerve supply and contain no blood. They
are made up largely of water.
 As we get older the amount of fluid in your
discs will diminish.
Although any disc in the entire spine can
prolapse or burst, the most common
ones to which this happens are the
lowest two, that is between the fourth
and fifth lumbar vertebrae and between
the fifth lumbar and the top of the

7. Nucleus Pulposus
 Type II collagen strand hydrophilic
proteoglycan
 Water content70 ~ 90%
 Confine fluid within the annulus
 Convert load into tensile strain on
the annular fibers and vertebral
end-plate

8. Annulus Fibrosus
 Outer boundary of the disc
 More than 60 distinct, concentric
layer of overlapping lamellae of
type I collagen
 Fibers are oriented 30-degree angle
to the disc space
 Helicoid pattern
 Resist tensile, torsional, and radial
stress
 Attached to the cartilaginous and
bony end-plate at the periphery of
the vertebra

9. Vital Functions
 Restricted intervertebral joint motion
 Contribution to stability
 Resistence to axial, rotational, and
bending load
 Preservation of anatomic relationship
Biochemical Composition
 Water : 65 ~ 90% wet wt.
 Collagen : 15 ~ 65% dry wt.
 Proteoglycan : 10 ~ 60% dry wt.
 Other matrix protein : 15 ~ 45% dry wt.

10. Vertebral End-Plate
 Cartilaginous and osseous component
 Nutritional support for the nucleus
 Passive diffusion

11. Spine Motion Segment
 Three joint complex
 Intervertebral disc + 2 facet joint
 Ligamentous structure, vertebral body

12. Facet Joint
 Synovial joint
 Rich innervation with sensory nerve fiber
 Same pathologic process as other large synovial joint
 Load share 18% of the lumbar spine

13.  ANATOMY
INVESTIGATIO
N
 BACK PAIN
 CLINICAL FEATURES-WADDELL
SIGN
 SPINAL STENOSIS
 DEGENERATIVE DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESI

14. IMAGING
 PLAIN X RAY
 MRI
 CT
 MYELOGRAM
 DISCOGRAM
 ELECTROMYOGRAM

15. Plain Films
 Beneficial in determining basic structure, integrity, and
alignment of spinal motion segments
 Whether a spinal disorder is acute or chronic can
frequently be determined on plain films
◦ adaptive changes (bony proliferation, endplate remodeling)
 Congenital of developmental disorders can be identified
 May be of particular benefit in patient under age 20 or
over age 50
 In most situations should be initial imaging study
ordered
 Routine films include antero-posterior, lateral, and
oblique projections
 Specialized views may be additionally ordered
◦ e.g. Coned down lateral view of lumbosacral junction to
evaluate L5-S1 disc space

16. 16
 MRI with Gadolinium contrast:
 Gadolinium is contrast material allowing enhancement
of intrathecal nerve roots
 Utilization:
 Assessment of post-operative spine---most frequent use
 Identifying tumors / infection within / surrounding spinal cord
 Diagnosis of radiculitis
 Post-operatively can take 2-6 months for reduction of
mass effect on posterior disc and anterior epidural soft
tissues which can resemble pre-operative
studies
 Only indications in immediate post-operative period:
 Hemorrhage
 Disc infection

17. Electromyography
 Radicular pain

18. 18
 . Myelogram:
 Procedure of injecting contrast material into the
spinal canal with imaging via plain radiographs
versus CT
 In past, considered the gold standard for evaluation
of the spinal canal and neurological compression
 With potential complications, as well as advent of
MRI and CT, is less utilized:
 More common: Headache, nausea / vomiting
 Less common: Seizure, pain, neurological change,
anaphylaxis
 Myelogram alone is rarely indicated

19. 19
 . CT with myelogram:
 Can demonstrate much better anatomical detail
than myelogram alone
 Utilized for:
 Demonstrating anatomical detail in multi-level disease
in pre- operative state
 Determining nerve root compression etiology of disc
versus osteophyte
 Surgical screening tool if equivocal MRI or CT

20. 20
 . Discography (Diagnostic disc injection):
 Less utilized as initial diagnostic tool due to high
incidence of false positives as well as advent of
MRI
 Utilizations:
 Diagnose internal disc derangement with normal MRI / myelo
 Determine symptomatic level in multi-level disease
 Criteria for response:
 Volume of contrast material accepted by the disc, with normals of
0.5 to 1.5 cc
 Resistance of disc to injection
 Production of pain---MOST SIGNIFICANT
 Usually followed by CT to evaluate internal
architecture, but also may utilize MRI
 As outcome predictor of those with pain response
received benefit from surgery
 52 % of those with structural change received surgical
benefit

21. Discography

22.  ANATOMY
 INVESTIGATION
BACK PAIN
 CLINICAL FEATURES-WADDELL SIGN
 SPINAL STENOSIS
 DEGENERATIVE DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESIS
 MANAGEMENT
 POST OPERATIVE DISEASES

23. What is “back pain”?
 From the American Academy of
Orthopaedic Surgeons:
It is a loosely defined diagnosis that may refer
to multiple patterns of pain with complex issues
surrounding its diagnosis and treatment. There is a
paucity of evidence from the literature regarding its
cause, management and prognosis. The difficulty
of managing patients with low back pain stems
from the fact that there often is very little
association between physical findings and the
patient’s pain and disability.

24. Causes of Backache
Common causes
• Back muscle sprain
• Prolapsed lumber intervertebral disc
• Obesity
• Poor posture
• Facet joint arthritis
• Unaccustomed activities
• Occupational causes

25. Uncommon causes
1.Congenital causes
• Scoliosis
• Spondylolisthesis
• Spina bifida
• Spondylolysis
2.Infective conditons
• Osteomyelitis
• Tuberculosis
3.Traumatic causes
• Vertebral body injuries, posterior arch fractures
• Muscle sprain/strain
• Prolapsed disc
4.Inflammatory causes
• Rheumatoid arthritis
• Ankylosing spondylitis

26. 5.Neoplasms
• Benign-osteoid osteoma
• Malignant-secondaries, multiple myeloma, etc.
6.Metabolic causes
• Osteoporosis
• Osteomalacia
7.Degenerative conditions
• Osteoarthritis
• Lumbar spondylosis
8.Referred pain from
• Gynaecological diseases
• Genitourinary diseases
• Gastrointestinal conditions, etc.

27. Common causes of acute low
backache
• Improper posture
• Sudden twist
• Faulty weight lifting
• Bending
• Sudden weight lifting
• Faulty sitting

28. Differential Diagnosis for back Pain
20
yrsAnkylosing spondylitis
Pyogenic sacroiliitis
Herpes zoster
Osteoid osteoma
Vertebral sarcoidosis
Rheumatoid arthritis
Osteoblastoma
Sickle cell disease
Scoliosis
Lyme disease
30
yrs
40
yrsOsteoarthritis
DISH
Osteomyelitis/Disciitis
Paget’s
Chordoma
Sarcoma
Osteoporosis/fracture
Metastases

29. DDx. Age 50 and over
 More metastases:
◦ Lung cancer
◦ Breast cancer
◦ Prostate cancer
 Spinal stenosis
 Rheumatoid diseases
 Abdominal aneurysm
 Multiple myeloma

31. Lumbar strain or sprain – 77%
Degenerative Disk Disease – 10%
Herniated Disk – 4%
Compression Fracture – 4%
Spinal Stenosis – 3%
Spondylolisthesis – 2%
cancer
infection

32. Additional Categories
. Neuropathic pain
 Radiculopathy
. Central Pain States
 Spinal stenosis
 Radiculopathy: disease of nerve
roots
◦ Radiculitis: inflammation of nerve
roots
◦ Pain, motor and sensory
abnormalities
 Plexopathy defined as involvement
of 2 or more roots

33. Risk Factors for Low Back Pain
 Gender
◦ Weak association with female sex
◦ Increased risk in pregnancy
◦ Stronger relation to occupation than sex
◦ Sciatica and disc operations more common
in men
 Height and weight
◦ Possible increased risk with height
◦ Weak correlation with weight

34. Other Risk Factors for LBP
 Smoking
◦ Inhibits metabolic processes in the disc
◦ Weak relation with heavy smoking
 Postural deformities
◦ Poor correlation
 History of back pain
◦ Increased risk of recurrence
◦ Previous surgery possible factor
 Epidural fibrosis
 Recurrent disc herniation
 Spondylodiscitis
 Arachnoiditis

35. Structural Basis of LBP
 Largest amount of scientific data
◦ Facet joints
◦ Discogenic pain
◦ Sacroiliac joint
 Smallest amount of scientific data
◦ Myofascial pain
◦ Ligament pain
◦ Trigger point pain

36.  ANATOMY
 INVESTIGATION
 BACK PAIN
CLINICAL FEATURES-
WADDELL SIGN
 SPINAL STENOSIS
 DEGENERATIVE DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESIS
 MANAGEMENT
 POST OPERATIVE DISEASES

37. Waddell’s Signs
 Dr. Gordon Waddell is an orthopedic
surgeon from Glasgow, Scotland
 Specializes in LBP and its disabilities
 Developed tests to help identify LBP
that is non-physiologic or possible
malingering

38. Waddell’s Signs
 To aid in assessing functional
(nonorganic) disorders
 5 signs:
◦ Tenderness
◦ Simulation (pressure or rotation)
◦ Distraction
◦ Regional disturbance (nonanatomic)
◦ Overreaction
 Significant if 3 or more positive

39. Waddell’s Signs
1. Pain on simulated tests for axial
loading – pushing down on the head
2. Pain with passive rotation of the
shoulders and pelvis in the same plane
3. Superficial tenderness
4. Non-dermatomal sensory loss
5. Overreaction during physical exam
6. Straight leg raise that improves with
distraction
7. Non-painful sitting SLR but painful
supine SLR

40. Some Definitions
 Sprain – torn or detached ligament
 Strain – torn muscle
 Radiculopathy – pain & neurological
deficit caused by injury to a nerve root
(radix=root)
 Sciatica – pain that radiates down
posterior or lateral leg; a type of
radiculopathy

41.  ANATOMY
 INVESTIGATION
 BACK PAIN
 CLINICAL FEATURES-WADDELL SIGN
SPINAL
STENOSIS
 DEGENERATIVE DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESIS
 MANAGEMENT

42. Spinal Stenosis

43. Cervical
• congenital
• acquired
Lumbar
• congenital
• acquired
Central
Foraminal
Lateral recess
Entranc
e
Mid
Exit
myelopathy
Radiculopathy

44. Spinal Stenosis
 Local, segmental, or generalized
narrowing of the central spinal canal,
the lateral recesses, or the neural
foramina by bony or soft tissue
elements
 Resultant narrowing may encroach
upon the neural structures

45. 45
Spinal Stenosis
 Clinical:
 CONGENITAL OR DEGENERATIVE
 Most common complaint is leg pain limiting walking
 Neurogenic / Pseudoclaudication = pain in lower
extremities with gait
 Relief can occur with:
 stopping activity
 sitting, stooping or bending forward
 Common are complaints of weakness and numbness of
extremities
 Usually becomes symptomatic in 6th decade

46. Spinal Stenosis
 Degenerative changes that most
commonly cause stenosis include
osteophytes of the vertebral body
endplates, uncinate processes, or
facet joints and hypertrophy of the
ligamentum flavum and anterior facet
capsule
 Initial size of spinal canal important
factor whether degenerative changes
will cause neural impingement or
compression

47. Cervical Stenosis
 MRI superior
 Can evaluate cervical spine
completely
 Can determine accurate size of central
spinal canal
 Best predictor of the clinical course of
myelopathic patients has been MRI
studies
◦ higher signal intensity within cord with
decreased cord volume seems to have
poorer prognosis

48. Midline sagittal
diameter less than
12mm considered
relative stenosis.
Diameter less than
10mm considered
absolute stenosis

49. Cervical Root Syndromes
Root Syndromes with Cervical Disc Herniation
Disc Space C4-5 C5-6 C6-7 C7-T1
Root affected C5 C6 C7 C8
Muscles
affected
Deltoid,
supraspinatus
Biceps,
brachioradialis
Triceps, wrist
extensors
Hand
intrinsics,
interossei
Area of pain
and sensory
loss
Shoulder,
anterior arm,
radial forearm
Thumb Thumb, middle
fingers
4th, 5th
fingers
Reflex
affected
Biceps Biceps,
triceps
Triceps Triceps

50. CSS- Myelopathy
 Myelopathy – from spinal cord
compression.
◦ The term “myelopathy” refers to pathological
changes of the spinal cord itself.
 Pain and sensory changes in the back of
the head, neck, and shoulders.
 Performing surgery relatively early
(within 1 year of symptom onset) is
associated with a substantial
improvement in neurologic prognosis
 Delay in surgical treatment can result in
permanent impairment

51. CSS - Myelopathy
 The goal here is to avoid missing
patients who are myelopathic,
because once stenosis has evolved to
the point that it is compressing (and
causing damage to) the spinal cord,
the progression of symptoms may be
variable…but it is going to progress.

52.  T2 weighted MRI, sagittal
view; This patient has
multilevel degenerative
changes of the cervical spine.
The bottom two arrows show
mild stenosis with CSF
(white, fluid signal) still
flowing around the cord.
However, the top arrow is
pointing to the C3/4 level
where there is severe cervical
spinal stenosis, no CSF
around the cord
(compression), and signal
change within the spinal cord
itself (indicating damage).

53. Stenotic Normal

54. T2- and T1-weighted sagittals at midspine showing spinal canal stenosis
from C4/C5/C6 level

55. Lumbar canal Stenosis
 Narrowing of canal increasingly
common
 1 per 1000 persons older than 65
years
 degeneration of vertebral motion
segment (intervertebral disk and facet
joints

56. Lumbar Stenosis
 Helpful to determine type of stenosis
present
◦ developmental
◦ acquired

57. Lumbar Spinal Stenosis
 Remember that the Spinal Cord ends
at the Conus Medullaris, which is
typically located at the L1/2 interspace
in adults.
◦ L1/2 is the lumbar level least likely to be
affected by Lumbar Spinal Stenosis.
 Thus, Lumbar Spinal Stenosis doesn’t
cause myelopathy; when it affects the
motor system, lower motor neuron
signs are what you’ll find.

58. Developmental Lumbar
Stenosis
 Growth disturbance of posterior
elements involving pedicles, laminae,
and facet joints
 Results in decreased volume of
central spinal canal or neural foramina
 Midline sagittal diameter less than
12mm considered relative stenosis
 Diameter less than 10mm considered
absolute stenosis

59. Acquired or Secondary
 Secondary (acquired) from degenerative
changes, iatrogenic causes, systemic
processes, and trauma.
 Degenerative changes - central canal and
lateral recess stenosis from posterior disc
protrusion, zygapophyseal joint and
ligamentum flavum hypertrophy, and
spondylolisthesis
 Iatrogenic - surgical procedures such as
laminectomy, fusion, and discectomy.
Systemic processes that may be involved in
secondary stenosis include Paget disease,
fluorosis, acromegaly, neoplasm, and
ankylosing spondylitis

60. Lumbosacral Root Syndromes
Root Syndromes with Lumbar Disc Herniation
Disc Space L3-4 L4-5 L5-S1
Root Affected L4 L5 S-1
Muscles
Affected
Quadriceps Peroneal, anterior
tibial, extensor
hallucis longus
Gluteus max,
gastroc, plantar
flexors toes
Area of Pain and
Sensory Loss
Anterior thigh,
medial shin
Big toe,
dorsum foot
Lateral foot,
small toe
Reflex Affected Knee jerk Posterior tibial
(medial hamstring)
Ankle jerk
Straight Leg
Raising
May not
increase pain
Aggravates
pain
Aggravates
pain

61. Foraminal Stenosis
 Important cause of radicular
symptoms
 If not addressed at surgery, common
cause of failed back surgery
 Neural foramen is a canal that
lengthens at level of lumbar spine

62. Foraminal Stenosis
 Degenerative ridges off posterolateral
margin of vertebral body endplate
 Size and location of ridges determines
operative approach and amount of
bone that needs to be removed to
decompress neural elements
 Facet degenerative changes may also
narrow neural foramen

63. Lateral Recess Stenosis
 Lateral region is compartmentalized
into entrance zone, mid zone, exit
zone, and far-out stenosis

64. Lateral Recess Stenosis
 Lateral recess stenosis (ie, lateral
gutter stenosis, subarticular stenosis,
subpedicular stenosis, foraminal canal
stenosis, intervertebral foramen
stenosis) - narrowing (less than 3-4
mm) between the facet superior
articulating process (SAP) and
posterior vertebral margin - impinge
the nerve root and subsequently elicit
radicular pain.

65. Entrance Zone
 The entrance zone - medial to the
pedicle and SAP – stenosis from facet
joint SAP hypertrophy.
 Other causes - developmentally short
pedicle and facet joint morphology, as
well as osteophytosis
 Disc prolapse anterior to the nerve root
 The lumbar nerve root compressed
below SAP retains the same segmental
number as the involved vertebral level
(eg, L5 nerve root is impinged by L5
SAP).

66. Mid Zone
 Mid zone extends from the medial to
the lateral pedicle edge. Mid-zone
stenosis arises from osteophytosis
under the pars interarticularis and
bursal or fibrocartilaginous
hypertrophy at a spondylolytic defect

67. Exit Zone
 Exit-zone stenosis involves an area
surrounding the foramen and arises
from facet joint hypertrophy and
subluxation, as well as superior disc
margin osteophytosis. Such stenosis
may impinge the exiting spinal nerve

68. Extra-canalicular Stenosis
 Far-out (extracanalicular) stenosis
entails compression lateral to the exit
zone
 Occurs with far lateral vertebral body
endplate osteophytosis and when the
sacral ala and L5 transverse process
impinge on the L5 spinal nerve

69. Synovial Cysts from Facet Arthrosis

70. Central Canal Stenosis

71. Lateral Recess Stenosis

72. Foraminal Stenosis

73. MR – T2W CER SPINE[SAG]
OPLL

74. AXIAL

75. CT LS SPINE L F CALCIFICATION

76. CT – CER SPINE

77.  ANATOMY
 INVESTIGATION
 BACK PAIN
 CLINICAL FEATURES-WADDELL SIGN
 SPINAL STENOSIS
DEGENERATIVE
DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESIS
 MANAGEMENT
 POST OPERATIVE DISEASES

78. Definition
 Degenerative Disk Disease – gradual
degeneration of the disk between
vertebrae, due to loss of fluid and tiny
cracks, part of normal aging process

79. Degenerative Disc Disease
(DDD)
 Unfortunately, DDD seems to be sort
of a “wastebasket term” that is often
used to describe age-related changes
on MRI, etc.
◦ While these changes are indeed
“degenerative,” this happens as we age
and is not necessarily indicative of any
significant underlying pathology or
condition.
◦ The majority of individuals > 60 will show
some type of degenerative change(s) on

80. DDD
 Degeneration of an individual disc
space typically refers to
 loss of disc height,
 loss of water content,
 fibrosis, end plate sclerosis/defects,
 osteophyte complexes, etc.

81. Degenerative Disc Disease
 Plain films of limited value
◦ associated changes include decreased
disc height, bony sclerosis, gas or
calcification within disc space, and
endplate hyperostosis
 MRI and CT provide excellent
delineation of disc herniation
 Process that begins in second or third
decade and progresses

82. Etiology
Degeneration
Facet arthropathy
Segmental instability
spinal stenosis foraminal
stenosisNERVE PAIN

83. Intervertebral Disc
Cellular and Biochemical Change
 Decrease proteoglycan content
 Loss of negative charged proteoglycan side
chain
 Water loss within the nucleus pulposus
 Decrease hydrostatic property
 Loss of disc height
 Uneven stress distribution on the annulus

84. Degenerative Disc Disease
 On T2 MRI, signal intensity of disc is
related to state of hydration of nucleus
pulposus
 Gradual desiccation into more solid
fibrocartilaginous structure with aging
and degeneration
◦ loss of signal intensity

85. Spinal MRI – Disc disease
Nomenclature

86. Spinal Structures (Sagittal)
 Cord
 Disc – signal, height and contour
 Vertebral bodies and spinous
processes
 Nerve roots and neural foramina
 Central canal
 Ligaments (ALL, PLL, interspinous)
 Epidural space

87. Spinal Structures (Axial)
 Nerve roots and neural foramina
 Cord
 Disc contour
 Vertebral bodies
 Central canal
 Lateral recesses
 Ligaments (ligamentum flavum)
 Epidural space
 Facet joints

88. Normal Discs
 Well hydrated nucleus
◦ Intermediate signal on T1, high signal on T2
 Annulus fibrosus
◦ Low signal intensity on all sequences
 Posterior margins are mildly concave, or flat in
upper lumbar spine
 May be minimally convex at lumbosacral junction

90. Degenerative Disc Disease
 Asymptomatic patients of all ages can show
disc abnormalities on MRI
 do we differentiate pain generating lesions
from non-pain generators?

92. Vertebral End-Plate
 Become thinner and hyalinized
 Decrease permeability
 Inhibit nucleus metabolism
 Disc space narrowing
 Osteophyte formation at the end-plate and
annular junction
 Marrow change with increased axial
loading
 Subluxation and instability

93. Tears of the Annulus
 Most of these tears are not visible on MR imaging
 Some have granulation tissue and edema, leading to
high intensity on T2 images = High Intensity Zones
(HIZ)
 Known pain generators
 Usually seen in the posterior annulus of lower lumbar
discs
 Globular or horizontal lines of increased dignal
intensity on T2 and post-contrast T1

96. HIZ

97. Terminology
 Diffuse annular bulge
 Broad-based protrusion (focal disc bulge)
 Focal disc protrusion
 Disc extrusion,migration
 Disc sequestration

98. Diffuse Disc Bulge
 Symmetric and circumferential bulge more than 2 mm
in all directions
 Also called a diffuse annular bulge
 This is considered a “normal” finding in the aging
spine

99. Broad-Based Protrusion
(Or Focal Disc Bulge)
 Asymmetric bulge involving more than
90° of the disc circumference

100. Focal Disc Protrusion
 Focal, asymmetric extension of disc
 The base is broader than any other dimension
 Usually asymptomatic
 These are contained by the PLL

102. Disc Extrusion
 Usually symptomatic
 AP diameter is greater than base
 Maintains contact with parent disc
 Not contained by the PLL

103. Migration - Sequestration
 Migration indicates
displacement of disc
materialaway from
the site of extrusion,
 Sequestration is
used to indicate that
the displaceddisc
material has lost
completely any
continuity withthe
parent disc

104. Disc Sequestration
 Loss of continuity between extruded
disc and parent disc
 Usually symptomatic

105. Further Grading
 Subjective division into small, moderate or large
◦ Protrusions and extrusions can be measured, but
reliability is questionable
 What is happening to neural elements?
◦ Effacement
◦ Compression
◦ Displacement
 Note: a small herniation in a small canal may be
more significant than a large herniation in a
spacious canal

106. Location of Disc Abnormalities
 Central
 Paracentral
 Foraminal
 Extraforaminal
 Anterior

107. Clinical Correlation
 1/3 or more of asymptomatic people
have disc abnormalities on MRI
 Only 1% of asymptomatic patients
have extrusion on MRI
 90% of lumbar disc abnormalities are
central or paracentral

108. Modic Type I

109. Modic Type II

110. Modic Type III

111. MRI of Lumbar HNP

112.  ANATOMY
 INVESTIGATION
 BACK PAIN
 CLINICAL FEATURES-WADDELL SIGN
 SPINAL STENOSIS
 DEGENERATIVE DISC DISEASE
SPONDYLOSIS/SPO
NDYOLISTHESIS
 MANAGEMENT
 POST OPERATIVE DISEASES

113. Spondylolisthesis -Definitions
 Spondylolisthesis - anterior or
posterior slipping or displacement of
one vertebra over another

116. SPONDYLOLISTHESIS
 Slipping of one vertebra with respect to other.
 Types: (Wiltse) congenital
isthmic
degenerative
traumatic
pathologic
post surgical
 Usually assosciated with spondylolysis( which is fibrous
cleft within pars interarticularis)
 Prevalence : 4% of population
 Location : L5-S1 >L4-L5
usually bilateral

117. ISTHMIC TYPE
 MC type
 Lesion in pars interarticularis
 Subtypes : 1.lytic --- fatigue # of pars
interarticularis.
2.intact but elongated P.A
3.acute # of P.A
 Separation of two halves of vertebrae
anterior half--- ( body, pedicle &
superior articular facet )
posterior half--- ( lamina & inf articular
facet )

118. CONGENITAL(DYSPLASTIC)
Dysplasia of superior articular facet of sacrum
PATHOLOGIC
Pathologic # or bare softening.
Ex: pagets disease or osteogenisis imperfecta
DEGENERATIVE
Ex: osteo arthritis
Posterior facet joints became unstable and sublocate
TRAUMATIC/POST SURGICAL
Rare.

119. MEYERDING CLASSIFICATION
 Lateral X Ray- Measurement of the distance from
the posterior edge of the superior vertebral body to
the posterior edge of the adjacent inferior vertebral
body. Distance is reported as % of the
total superior vertebral body length.
 Grade I ----- 0-25%
Grade II ----- 25-50%
Grade III ----- 50-75%
Grade IV ------ 75-100%
 >100% ----- spondyloptosis ( vertebra completely
falls off the supporting vertebra)

120. IMAGING FEATURES
X-RAY:
1. LATERAL: Anterior displacement
2. OBLIQUE: Defect in pars interarticularis
In normal vertebra P.I appears like a “scotty dog”
i. If the appearance is that of scotty dog wearing
a
collar , the defect is the isthmus (P.I)
----- Spondylolysis
ii. If the head of the scotty dog is separated from
the
neck ---- Spondylolisthesis
3. AP : Napolean hat sign

125. CT :
•Pars interarticularis defect has to be located at
pedicle level ;has irregular margins & adjacent
sclerosis. (IV disc level = apophyseal joint )
•Elongated AP diameter of spinal canal.
MRI:
•Pars interarticularis defect
•Forward displacement
•Cord signal changes.

126. Facet (Zygapophysial) Joint Pain
 Lumbar facet joints recognized as a
source
◦ Facet syndrome: lumbosacral pain with or
without sciatica
◦ Pain after rotary movement or twisting
◦ Low back pain with radiation to thighs and
buttocks
◦ Poor clinical correlation with imaging or
exam

127. Facet Joint Pain
 Definitive diagnosis requires diagnostic
blocks
 Lumbosacral facet joints - 15 to 45% of
cases of low back pain
 Cervical facet joints - 54 to 67% of
cases of neck pain
◦ Common with “whiplash”
 Validity, specificity and sensitivity of
diagnostic facet joint nerve blocks are
considered to be strong

128. MRI

129. MRI

130. MRI Lateral Recess Stenosis

131. MRI

132. MRI

133.  ANATOMY
 INVESTIGATION
 BACK PAIN
 CLINICAL FEATURES-WADDELL
SIGN
 SPINAL STENOSIS
 DEGENERATIVE DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESI
S
MANAGEMENT
 POST OPERATIVE DISEASES

134. Backache
MANAGEMENT
 Conservative
 Surgery

135. Backache
CONSERVATIVE MANAGEMENT:
 Good posture
 Bed rest on hard bed
 IFT,SWD,TENS,IPT
 L.S belt application
 Exercises
 Stress therapy

136. Interventions/Nonsurgical
Management
 Williams position (Semi-fowler’s with
knees flexed; this takes pressure off lower
back)
 Firm mattress, or backboard under soft
mattress
 Exercise
 Drug therapy
 Heat and/or ice therapy
 Diet therapy (weight control to help reduce
chronic back pain)
(Continued)Elsevier items and derived items ©
2006 by Elsevier Inc.

137. POSTURE:
 The neck has a slight
natural curve, which sits
on top of the two curves in
the middle and lower back.
 Correct posture maintains
all three curves and
prevents undue stress and
strain by distributing body
weight evenly

138. STANDING POSTURE
 In correct, fully erect posture,
a line dropped from the ear
will go through the tip of the
shoulder, the middle of the
hip, the back of the kneecap
and the front of the
anklebone.

141. SITTING POSTURE
 When sitting in any
position, the three
back curves need to
be maintained.
 If you cannot sit
without slouching
forward or backward,
you need to support
yourself with hands
and arms or lean
against a wall or
chair back.

142. SITTING POSTURE

143. SITTING POSTURE:

144. LYING POSTURE:
 Avoid propping
head or upper body
up on an arm and
hand.
 Head should
remain relaxed.
Legs should be
together.

147. Spinal exercises

148. BackacheEXERCISES:
 Cat Back
 Fetal Position
 Arm exercises

149.  Alternate Leg
Slides
 Alternate Leg
Raises

151. TENS
 Transcutaneous electrical nerve
stimulation
◦ Endorphin modulated
◦ Altered CNS transmission of pain

152. Traction
 Enlarges foramen
 Vacuum effect
 PLL traction
 Relaxation of spasm
 Decreases intradiscal pressures up to
30%

153. Chiropractic Care
 Most common “alternative medicine”
 Up to 30% of back pain sufferers
 Manipulation under anesthesia

154. Trigger Point Injections
 Myofascial back pain
◦ Responds better to stretching, local
modalities
 Used when other treatments fail
 Anesthetic +/- steroid
 Limit the number of injections
 Prolotherapysclerosing agent
◦ No scientific evidence

155. Injection Therapy
 Anesthesia plus anti-
inflammatory effect
 Epidural injection
◦ Good for nerve root irritation
◦ Unclear in mechanical back
pain
 Effective for facet joint
arthropathy, sacroiliac
disease
 Radiofrequency dorsal
rhizotomy

156. Braces
 Indicated with
fracture, instability
 No evidence to
support long term use
 Weakening of
postural muscles
 Do not really
immobilize

157. RELIEVE STRESS
 Yoga
 Meditation

158. Surgical Management
 Discectomy
 Laminectomy
 Spinal fusion
 Minimally invasive lumbar procedures:
◦ Percutaneous lumbar discectomy
◦ Microdiskectomy
◦ Laser-assisted laparoscopic lumbar
diskectomy
Elsevier items and derived items ©
2006 by Elsevier Inc.

159. Nucleus Pulposus Replacement

160. Discectomy
 the removal of a
herniated disk to
relieve pressure on a
nerve root
 Window in the lamina-
retract nerve-removal
of herniated disc
material-healing by
scar tissue
- Fenestration discectomy
- Endoscopic discectomy

161. Laminectomy
 derived from lumber
(lower spine), lamina
(part of the spinal
canal's bony
structure) and -
ectomy (removal).
 The operation is
performed to relieve
pressure on one or
more spinal nerve
roots

162. Herniated Disc Repair
Elsevier items and derived items ©
2006 by Elsevier Inc.

163. Elsevier items and derived items ©
2006 by Elsevier Inc.
 .

164. Elsevier items and derived items ©
2006 by Elsevier Inc.

165. TOPICS
 ANATOMY
 INVESTIGATION
 BACK PAIN
 CLINICAL FEATURES-WADDELL SIGN
 SPINAL STENOSIS
 DEGENERATIVE DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESIS
 MANAGEMENT
POST OPERATIVE
DISEASES

166. Prior Disc Surgery
 If persistent or recurrent symptoms,
MRI exam is optimal method to detect
presence of discal abnormality
 Specificity limited in first six months
after surgery
 Routinely performed with and without
contrast
◦ enhancement of fibrotic material will be
pheripheraly

167. Treatment Failures
 Failure to respond to conservative
measures (6 weeks)
 Progression to involve radiculopathy
 Rapidly progressive neurologic
symptoms
 Chronic pain (> 12 weeks)

168. Failed Back Syndrome
 Present with variety of post-operative
findings
 Epidural fibrosus
 Recurrent disc herniation
 Osseus regrowth (stenosis)
 Foraminal stenosis
 Status of fusion
 Infection

169. Fusion itself can accelerate the severity of adjacent level
degeneration as compared with non-fusion.
But there was no correlation in the incidence of
symptomatic adjacent segment diseases according to the
fusion in single level anterior cervical arthrodesis for the
degenerative cervical diseases.
Adjacent segment disease is more a result of the natural
history.

170.  ANATOMY
 INVESTIGATION
 BACK PAIN
 CLINICAL FEATURES-WADDELL
SIGN
 SPINAL STENOSIS
 DEGENERATIVE DISC DISEASE
 SPONDYLOSIS/SPONDYOLISTHESI
S
 MANAGEMENT

171.  Image gallery

181. THANK YOU for
this opportunity
 Ref
 1.ROSS
 2.EDELMAN
 INTERNET