DEGENERATIVE DISEASES OF

SPINE
GROUP 6B (2015)

LEARNING OBJECTIVES
Anatomy of spinal cord, spine and
intervertebral disc
Common degenerative diseases of spine
1.

PROLAPSE INTERVERTEBRAL DISC (PID)

2.
LUMBAR SPONDYLOLYSIS
3.
SPONDYLOLISTHESIS
4.
SPINAL STENOSIS

ANATOMY OF SPINE

Vertebr
a

Vertebral
column
Composition
composed of
33 vertebrae

- 7 cervical

- 12 thoracic

- 5 lumbar
- 5 sacral

- 4 coccygeal

(fused)
(lower 3 fused)

Vertebra
Introduction
Is the central bony pillar
Supporting
-the head
-upper limb
-body trunk
Transmits body weight
-to lower limb
Protect
- the spinal cord &
- roots of spinal nerves

Curvatures
in sagittal plane
Primary curvature (concavity f/w)
Before birth only one curvature
with concavity f/w
Secondary curvatures
(convexity f/w.)
After birth

i.Cervical curvature
3 4 month
as the child b/c able to raise his head

ii.Lumbar curvature
t/w. the end of 1st.year
as the child begin to stand upright

Adult

Appearance of Secondary
curvatures

New born
3-4.month

1.year

Adult

Abnormal curvatures
(exaggerations of curvatures)

Lordosis

Normal

Exaggeration of
ant. Convexity in
lumbar region

kyphosis
Exag.of ant.
Concavity in
thoracic region

Scoliosis
Abnormal
lateral curvature

Scoliosis b/c.
accentuated

General characteristics of a
vertebra
Body
Vertebral arch
Vertebral foramen
Vertebral arch
pedicle
notches

-superior vertebral notch

-inf. Vtbr.notch

lamnae
processes
-1 spine
-2 tranverse
-4 articular
Inter vertebral foramen
-formed by supe.vtbr.notch &
inf.vtbr.notches of adjacent vtbra.

Vertebra

Vertebral foramen
(Vertebral canal) contains
Spinal cord

- ends at the level of

lower bder L1.(in adult)

Note;
intervertebral foramen
- transmits spinal nerves
- spinal nerve roots & gangloin are within the
i.v.fora.

Spinal nerves
innervations

Coverings of
Spinal Cord
There are 3 meningeal
layers: dura mater,
arachnoid mater and pia
mater covering the brain
and sp: cord
Dura mater is a outer, tough,
fibrous coat
Arachnoid mater is
translucent, collagenous
membrane
Innermost, pia mater is a
delicate, vascular
membrane firmly attached
to the brain and spinal
cord

Cervical vertebrae
Features of cervical vertebrae
i. Most reliable (unique) characteristic feature to
indentify cervical vertebra is
Presence of foramen transversarium inTranverse
processes ( of all cervical vtbrae)
- unique feature for all cervical vertebrae
& it transmits vertebral vessels
(except C7.which transmits vein only)
Other features of typical cvical vtbra include
ii. Spine
- bifid

iii.Body
- broader side to side

iv.Vertebral foramen
- large & triangular

v. Superior articular facet

-direced b/w & u/w.

Thoracic
vertebrae

i.unique characteristic feature is

presence of costal facets on the
sides of body
Other features typical thoracic
vtbra.include
ii. Body
- heart shaped

iii. Vertebral foramen

- small, circular

iv. T/v.process
- costal facets for tubercles
of ribs (except T11.& 12.)

v. Spinous process
- long ,tapering, d/w.

vi. Supe.arti.process
- b/w.lat.& u/w. (blu.)

Lumbar vertebra

massive

Body
- Kidney shaped ,large
Vertebral foramen
- triangular

T/v.process
- long, slender

Spinous process

- quandrangular

Spinous
process

Supe.arti.process
-directed medially

Sacrum
5 pieces fused together
Above articulate with
-L5.vtbra.

Lat. with
- ilium

Sacral promontory
-ant.& upper margin of 1st.S.vtbra

Sacral canal
- vertebral canal

Sacral hiatus
-lower opening of Sacr.canal

Sacral foramina (ant.& post.)

-for the passages of ant.& post.rami
of S1- S4.spinal n.

Note;
Subarachnoid space ends at level of
S2.vtbra.

S.2

Differences among vertebrae

Cervical

Thoracic

Lumbar

Body

broader side to side

heart shaped

Large,
Kidney shaped

V.t.bral foramen

large,triangular

Small circular

triangular

Spine

bifid

tapering d/w.

quandrangular

T/v.process

*foramen
transversarium

facet for tbcle of rib

(except 11,12.)

long,slender

Upper articular
process

b/w.,u/w.

B.L.U.

*medially

*costal facet at the

side of body

Joints of vertebral
column in general
Between the bodies
-Secondary cartilagenous jt.

B/t.articular
peocesses
- synovial ,

plane jt.

Blood supply
Blood supply of back
Cervical
-occipital,vertebr.,deep c.vical

Thoracic
-post.intercost.

Lumbar
-subcost., lumbar

Sacral
-iliolumbar,lat.sacral

Venous drainage of vtbr.column

Internal venous plexus

-within vtbr.canal ,outside dura.

Communicates (above) with

Venous sinuses inside cranial cavity

Receives
-vertebae,meniges,spinal cord

Drains into
-external venous plexus (via vtbr.veins)
to vtbral,intercost,lumbar & lat.sacral
Note;
-no valves in the communicating channels
Thus increase in pressure inside abdo.or pelvic cavities venous
drainage to int.vtbr.plx - itracranial venous sinuses

Eg. Ca prostate int.vtbr.plx. intracra.vnous sinuses

Joints of vertebral column

Atlanto occipital jt.

Type
-synovial condylar
Ligaments
i. ant.atlan.occip.membr.
cont. of ant.long.lig.
ii. Post.atlan.occi.membr.
- lig. Flavum
Movements
1. flexion & extension (sign of
agreement)
2. lat.flexion

Muscles responsible for movements

Cervical
Flexion
Extension

Rotation
Lateral flexion

Thoracic

Longus cervicis,
Scalenus ant.,
St.mastoid

Rectus abd., Psoas

Post.vtbral muscles

Post.vtbral muscles

Stno.mastoid
(on one side)
Splenius(other side)

Scalenus
ant/med.,Trapez.
Stno.mastoid

Lumbar

Semispinalis
&Rotatores

Rotatores, Oblique
muscles of abd.wall

Obliq.abd.musc.

Post.vtbr.musc,
Q.lumborum,
Obliq.abd.musc.

FUNCTION OF SPINE

TO ACHIEVE THESE
FUNCTIONS,
WHAT SPINE MUST HAVE?

SPINE MUST HAVE

1. Resistance to axial loading forces,
accomplished by:
i. Curvature of the spine (kyphotic & lordotic)
ii. Increased mass of each vertebra from C1
to sacrum

2. Elasticity accomplished by:

i. Alternating lordotic and kyphotic curves
ii. Multiple MOTION SEGMENTS

MOTION SEGMENT
The FUNCTIONAL UNIT of spine which
composed of
1.
2.
3.
4.

Two adjacent vertebrae

The intervertebral disc
Connecting ligaments
Two facet joints and capsules

INTERVERTEBRAL DISC
(Disc between vertebral
bodies)

INTERVERTEBRAL DISCS
23 intervertebral discs
No disc between skull and C1 (between C1-C2)
Thickest in lumbar vertebrae and cervical
region (to enhances flexibility)
Functions:
Shock absorbers walking, jumping, running
Allow spine to bend

STRUCTURES (3)
Fibrocartilogenous structure
shock absorber
transmitting compressive load between
vertebral bodies

Compose of 3 main structures

1. Cartilogenous endplates
2. Nucleus pulposus
3. Annulus fibrosus

Cartilaginous endplates
Separated each of intervertebral disc
superiorly and inferiorly
Acts as growth plates for vertebral
bodies

Nucleus pulposus
Gelatinous material containing large
amount of water
Allows disc to cushion against
compressive load

Anulus fibrosus
Have tensile properties (collagen
fibre)
Allow nucleus to recover its original
shape and position

Distribution of load
(A)In normal, healthy disc- nucleus
distributes load equally throughout
the anulus
(B)Disc undergoes degenerationnucleus loses some of its
cushioning ability and transmits
load unequally to anulus
(C)Severe degenerative discs- nucleus
lost all of its cushioning ability
disc herniation

(ZYGAPOPHYSEAL)
FACET JOINT

Articulating surfaces of 2 vertebrae

Inferior articular process of a vertebra with

Superior articular process of vertebra
below

Synovial gliding joints

Allow flexion-extension, side bending and
rotational movement

Oriented in different planes depending on

their anatomic location

LIGAMENTS
1.
2.
3.
4.
5.

Anterior longitudinal ligament (ALL)

Posterior longitudinal ligament (PLL)
Supraspinous ligament
Interspinous ligament
Ligamentum flavum

Ligaments

Description

Anterior
Longitudinal
Ligament (ALL)
A primary spine
stabilizer

Runs the entire length of the spine from the base of

the skull to the sacrum
It connects the front (anterior) of the vertebral body
to the front of the annulus fibrosis

Posterior
Longitudinal
Ligament (PLL)
A primary spine
stabilizer

Runs the entire length of the spine from the base of

the skull to sacrum
It connects the back (posterior) of the vertebral body
to the back of the annulus fibrosis

Supraspinous
Ligament

This ligament attaches the tip of each spinous

process to the other

Interspinous
Ligament

This thin ligament attaches to another ligament

called the ligamentum flavum that runs deep into the
spinal column

Ligamentum Flavum
The strongest ligament

Runs from the base of the skull to the pelvis, in front

of and between the lamina, and protects the spinal
cord and nerves

DISTURBANCE IN THESE
FUNCTIONS,
WHAT WILL HAPPEN?
1.PROLAPSE INTERVERTEBRAL DISC
(PID)
2.LUMBAR SPONDYLOLYSIS
3.SPONDYLOLISTHESIS
4.SPINAL STENOSIS

LOW BACK PAIN

Pain in the lumbosacral region

CAUSES OFF LOW BACK

PAIN
EXTRASPINAL CAUSES
O&G cases
Renal
SPINAL CAUSES
Mechanical (defect in spinal structures)
Non-mechanical
-congenital: spinal bifida
-infection: acute, chronic (pott spine)
-tumor: primary (benign or malignant), secondary (commonest)
-metabolic

 Mechanical cause pain: increase in

severity
Non mechanical: consistent

INTERVERTEBRAL DISC
PROLAPSE

Etiology
Degeneration of intervertebral disc
Due to strenuous physical activity eg lifting
Common, painful disorder of the spine, in which
the annulous fibrosus ruptures and part of its
nucleus pulposus goes out (herniation)
About 95% of disc prolapses occur in the lumbar,
and some can occur in the cervical spine too
Commonly occur between L4, L5 and L5, S1

Disc
weakens and
degenerate

Increased
nuclear
pressure
cause
bulging with
some outer
annulus
intact

Fibrocartilaginous disc
material extruded
posteriorly and bulges
on one side of the
posterior longitudinal
ligament

Nucleus
sequestrate and
lie freely in spinal
canal or work its
way to
intervertebral
foramen

Clinical features
Fit adult aged 25-40 yo (above 25, the nucleus
becomes dehydrated, above 40, it becomes
fibrous, so less likely to herniate)
History of severe back pain during lifting/stooping
Pain in buttock and lower limb (sciatica)
Paraesthesia and numbness in leg/foot
Muscle weakness
Cauda equina compression rare but may cause
urinary retention and perineal numbness

Clinical features
Depends on site of herniation and
degree of compression
If it irritates the dural covering >
pain
If it compresses the spinal root >
numbness > eventually muscle
weakness

 Herniation in L4L5 will compress

L5 nerve root

L4/L5 Disc Prolapse

Pain along the posterior or posterolateral thigh
with radiation to top of the foot
Weakness of dorsiflexion of the great toe and foot
Paraesthesia and numbness of top of foot and
great toe
No reflex changes noted (knee L4, ankle S1)

L5/S1 Disc Prolapse

Pain along posterior thigh with radiation to
the heel
Weakness on plantar flexion (may be
absent)
Sensory loss in the lateral foot
Absent ankle jerk reflex (ankle S1)

Physical examination
Look
Sciatic scoliosis (bend test: structural vs postural)
Muscle wasting (seen in gluteal, calf)

Feel
Tenderness in midline of the affected side(palpate along
the spine, paravertebral mscle, check for any deformity)
Paravertebral spasm (bulging)
Muscle weakness
Diminished reflex
Sensory loss

 Move
Decrease ROM due to pain

Sciatic nerve stretch test/straight

leg raising test (+ve 20 -70)
Femoral stretch test positive
Irritation of higher nerve roots - L4 and
above.

Imaging
Xrays: narrow disc space and small
osteophytes
Myelography: to confirm nerve root
distortion using iopamidol (Niopam)
but will cause side effects
CT & MRI: best choice

Management

Rest
Reduction
Removal
Rehabilitation

Management
Rest
In bed with hip & knee in slight flexion (so sciatic nerve
is not stretched).
NSAIDs

Reduction
Pelvic traction (20kg) for 2 weeks
Epidural injection of corticosteroid and LA
Chemonucleolysis (chymopapain): to dissolve
part of the disk and relieve the pain

Management
Removal (laminectomy and discectomy):
Indication:
Cauda equina compression syndrome
Neurological deterioration while in conservative treatment
Persistent pain and sign of sciatic tension

Laminectomy: procedure that removes part of a lamina

of the vertebral arch in order to decompress the
corresponding spinal cord and/or spinal nerve root.

Rehabilitation
Teach patient isometric exercises

LUMBAR SPONDYLOLYSIS

 There are defects that represents a stress

fracture in the pars interarticularis
Pars interarticularis is a narrow strip of bone
located between the lamina and inferior
articular process below, and the pedicle and
superior articular process above
It always between L4 and L5, or between L5
and the sacrum
It can occur unilaterally or bilaterally

Clinical features
Most common cause of low back pain in the
adolescent athlete
Accounts for up to 47 % of the
symptomatic back pain in this population
the extension range of motion is often
painful and stiff
The pain may also be brought on by having
the patient stand on one leg, then being
guided into extension

Definitions
Spondylolysis- dissolution of, or a defect in,
the pars interarticularis of a vertebra.
Spondylolisthesis- Anterior or posterior
slipping or displacement of one vertebra on
another.
Spondyloptosis- vertebra that is completely
or essentially completely dislocated.

The pars interarticularis

is found in the posterior
portion of the vertebra

Spondylolysis occurs when

there is a fracture of the
pars portion of the vertebra.

Pathophysiology
Spondylolysis is a defect in the pars
interarticularis that may or may not be
accompanied by forward translation of one
vertebra relative to another
(spondylolisthesis).

Causes
Genetics
An individual may be born with thin vertebral bone and
therefore may be vulnerable to this condition. Significant
periods of rapid growth may encourage slippage.
Overuse
Sports-gymnastics, weight lifting, and football, athletes
constantly overstretch (hyperextend) the spine resulting
is a stress fracture on one or both sides of the vertebra.
Pain usually spreads across the lower back and may feel
like a muscle strain.

Diagnosis

1. X-rays

A. Normal
L5 Pars defect

B.

the
the
the
the
the

On the oblique view

of the lumbar spine,
the outline of a
scottish dog can be
seen.
The parts of the dog
are as follows:

transverse process-the nose

pedicle-the eye
pars interarticularis-the neck
superior articular facet-the ear
inferior articular facet-the front leg

 A break in the neck of the dog, or a dog

collar, corresponds to a fracture in the region
of the pars interarticularis, which is specific
for spondylolysis. It is important to recognize
as it is a cause
low back
pain. but presents
Occasionally
no of
fracture
is seen,
as an elongated pars interarticularis. This is
thought to occur as a result of repeated
stress on the bone, resultant microfractures,
bony
healing, ultimately producing an
elongation of the bone.

2. Bone scanning with SPECT

If one suspects a "stress reaction" to be occurring in the
lumbar spine, and x-rays show no pathology, the most
accurate method of assessment, for a symptomatic pars
interarticularis, is bone scanning with SPECT.

Axial, coronal or sagittal plane

3. CT (Computed Tomography)
Athletes
With
Unilateral
Spondylolysi
s

3. MRI (Magnetic Resonance Imaging)

 Bone scintigraphy using SPECT to be

the gold standard followed by a CT
scan
CT scans are able to distinguish
between an acute or chronic
spondylolysis and the type of
fracture, providing important
information with regards to making a

Treatment

Nonsurgical Treatment
Initial treatment for spondylolysis
The individual should take a break from the activities
until symptoms go away, as they often do.
Anti-inflammatory medications, such as ibuprofen, may
help reduce back pain.
Back brace and physical therapy may be recommended.
Stretching and strengthening exercises for the back and
abdominal muscles can help prevent future recurrences
of pain.

Stretching and strengthening exercises

Back brace

Treatment cont..
Surgical Treatment
May be needed if slippage progressively
worsens or back pain not respond to
nonsurgical treatment and interfere with
activities of daily living.
A spinal fusion is performed between the
lumbar vertebra and the sacrum. Sometimes,
an internal brace of screws and rods is used to
hold together the vertebra as the fusion heals.

SPONDYLOLISTH
ESIS

DEFINITION
Spondylolisthesis means forward translation
of one segment of the spine upon another.
Spondylo = Spine
Listhesis = Slide down a slippery path

The shift is nearly always between L4 and L5,

or between L5 and the sacrum.
Normal discs, laminae and facets constitute a
locking mechanism that prevents each
vertebra from moving forwards on the one
below.
Forward shift (or slip) occurs only when this
mechanism has failed.

DEFINITION

PATHOPHYSIOLOG
Y
Slippage
Instability
Ant. translation
Spinal canal narrowing
Neurological deficit

TYPES
DYSPLASTI
C

LYTIC /
ISTHMIC

DEGENERA
TIVE

POST
TRAUMATI
C

PATHOLOGI
CAL

POST
OPERATIVE

TYPES
TYPE 1 DYSPLASTIC
SPONDYLOLISTHESIS
The superior sacral facets are
congenitally defective (malformed)
Slow but inexorable forward slip
leads to severe displacement.
Associated anomalies
(usually spina bifida occulta) are
common

TYPES
TYPE 2 ISTHMIC /
SPONDYLOLYTIC
SPONDYLOLISTHESIS
The commonest variety (50%)
Type of defect:
Defect in pars interarticularis (micro fractures)
Repeated breaking and healing leads to new
bone formation filling the gap
Ends with stretched pars interarticularis and
pars elongation

Common in those whose spines are subjected

to extraordinary stresses (competitive
gymnasts, weight lifters)

TYPES
TYPE 3 DEGENERATIVE
SPONDYLOLISTHESIS
Consequence of the general
aging process in which the
lumbar facet joints degenerates
Laminae is intact
The alteration will allow forward
or backward vertebral
displacement

TYPES
TYPE 4 TRAUMATIC
SPONDYLOLISTHESIS
Associated with acute
fracture of posterior
structures (pedicle, lamina
or facets)

TYPES
TYPE 5 PATHOLOGIC
SPONDYLOLISTHESIS
occurs due to structural weakness of
the bone 2 to a disease process
(osteoporosis, infection, tumour)
TYPE 6 POSTOPERATIVE
SPONDYLOLISTHESIS
Occasionally, excessive operative
removal of bone in decompression
operations
results in progressive
spondylolisthesis.

MAKING A
DIAGNOSIS
HISTORY
CHILDREN

Painless
Carer will notice protruding abdomen & peculiar stance

ADOLESCENCE &
BackacheADULTS
(low back pain)

often intermittent
Coming after exercise or strain

nerve compression symptoms (numbness, tingling, slowed reflexes,

muscle weakness in the legs)

ELDERLY

Backache (low back pain)

Sciatica symptoms
Sometimes claudication due to spinal stenosis

MAKING A
DIAGNOSIS
PHYSICAL EXAMINATION
LOOK

Semi kyphotic posture

Atrophy of gluteal muscle (buttock looks flat)
Can lead to gait disturbances

FEEL

High Myerding grade type can result in tenderness at lower back

area
Palpable step-off can be felt over the spinous process at the level
above the slipped vertebra.

MOVE

Hamstring tightness can result in abnormal gait

Patient unable to flex the hip with knees extended
Bending forward, backward or sideways are restricted due to pain

MAKING A
DIAGNOSIS
PHYSICAL EXAMINATION

MAKING A
DIAGNOSIS
INVESTIGATION
X-RAY
Lateral views show the forward shift of the
upper part
of the spinal column on the stable vertebra
Elongation of the arch or defective facets can
be seen.
The gap in the pars interarticularis is best
seen in the
oblique views.

MEYERDING
GRADE
The Meyerding Grading System is a commonly
used scale to categorize the varying degrees of
spondylolisthesis:

MEYERDING
GRADE

MAKING A
DIAGNOSIS
INVESTIGATION

CT SCAN
Better evaluation of bone pathology

MRI

Better evaluation of soft tissue pathology

Nerve compression
Spinal compression
Disc eruption

MANAGEMENT
CONSERVATIVE

Conservative treatment, similar to that for other types

of back pain, is suitable for most patients

BACK
BRACE
Limit the spine movement
ANALGESI
C
NSAIDs
Steroid epidural injection

PHYSICAL
THERAPY
Stabilization
exercise

To strengthen abdominal and/or back muscles, minimizing

bony movements of spine

MANAGEMENT
SURGERY

INDICATIO
If theN
symptom is disabling and interfere with daily activities
If the slip is more than 50% and progressing
If neurological compression is significant

CHILDREN

Posterior transverse fusion in situ almost always successful

If neurological signs appear, decompression can be carried out later

ADULT

Decompressive laminectomy
Remove part of bone pressing on nerve but can leave the spine unstable

Spinal (anterior / posterior) fusion

A piece of bone transplanted to the back of spine to stabilize it

MANAGEMENT
SURGERY

SPINAL
STENOSIS

DEFINITION
The lumbar spinal canal is normally round or oval in
cross-section
The term spinal stenosis is used to describe
abnormal narrowing of the central canal, the lateral
recesses or the intervertebral foramina to the point
where the neural elements are compromised
When this occurs, patient can develop neurological
symptoms and signs in the lower limb

ETIOLOGY
Congenital vertebral dysplasia
Chronic disc protrusion & peri-discal fibrosis
or ossification
Displacement & hypertrophy of facet joints
Osteoarthritis of facet joints

ETIOLOGY
Hypertrophy, folding or ossification
of ligamentum flavum
Bone thickening due to Pagets
disease
Spondylolisthesis

MAKING A
DIAGNOSIS
HISTORY
Usually elderly male
Complains of aching, heaviness, numbness &
paraesthesia in thighs and legs
Comes on after standing upright / walking for 5-10
minutes
Relieved by sitting, squatting or leaning against a wall
to flex the spine
Patient may refer walking uphill than downhill (spine is
flexed)
Patient may have previous history of disc prolapse,
chronic backache or spinal operation

MAKING A
DIAGNOSIS
PHYSICAL EXAMINATION
Ask patient to reproduce symptoms by walking
Neurological deficit may present in the lower
limbs
Intact pedal pulses would confirm claudication as
spinal rather than arterial

MAKING A
DIAGNOSIS
INVESTIGATION
X-rays will usually show features of disc degeneration
and proliferative osteoarthritis or degenerative
spondylolisthesis.
Measurement of the spinal canal can
be carried out on plain films, but more reliable
information is obtained from myelography, CT and MRI.

MAKING A
DIAGNOSIS
INVESTIGATION
How to measure any abnormal swelling or
narrowing of spinal canal?
Two measurements are used:
1) Mid-saggital
(anteroposterior)
2) Interpedicular (transverse)
Abnormal value:
1)Anteroposterior <11mm

MAKING A
DIAGNOSIS
INVESTIGATION
MRI can also be a choice in
confirming the diagnosis of
spinal canal stenosis.
Thickening of the ligamentum
flavum
Facet joint hypertrophy and
synovial cysts
Vertebral endplate osteophytes
and obliteration of perineural
fat in the neural foramina

MANAGEMENT
CONSERVATIVE
Advice patient to avoid uncomfortable
postures
OPERATIVE

Done if the discomfort worsens or daily

activities become restricted
Perform large laminotomy with flavectomy,
medial facetectomy and discectomy
At every relevant level, on every relevant side
Can relieve the leg pain but not the back pain

In patients under 60 the operation is

sometimes combined with spinal fusion

THE END
TQ~