LOWER BACK PAIN AND

DEGENERATIVE
CONDITIONS OF THE SPINE
YUSRA HASHIM
UNG LIK HOE
SYED NADER NUQMAN

Anatomy of The Spine

THE SPINE
Function of the spine :
Enable us to stand upright
Gives our body structures and support
Allow us to move freely and bend with
flexibility
Designed to protect the spinal cord

 Spine is made up of 33
individual bones stacked up on
top of each other
Ligaments and muscles connect
and the bones together and
keep them aligned
Intervertebral discs act as a
cushion to absorbs shock

Spinal Curves
When viewed from the side,
and adult human spine has
a natural S-shaped curve
Cervical and lumbar regions
has a slight concave curve
Thoracic and sacral regions
has a gentle convex curve
Function:
Absorb shock
Maintain balance
Allow range of motion throughout the
spinal column

Motion Segments of The Spine

Also called as functional spinal unit (FSU)
Smallest physiological motion unit of the
spine
Consists of :

Two adjacent vertebrae

Intervertebral disc
Adjoining ligaments
Two facet joints

VERTEBRAE
Individual bone of the spine
Building blocks of the spinal
column
Vertebrae are numbered and
divided into regions :

Cervical
Thoracic
Lumbar
Sacral
Coccyx

Cervical Vertebrae
Cervical vertebrae is
numbered from C1 to C7
Main function is to
support the weight of the
head
C1 and C2 are
specialised vertebra that
connect to the skull

 Features of cervical vertebrae:

Presence of transverse foramen
Bifid spine
Triangular vertebral foramen
Superior articular facet is directed
backward and downward

Thoracic Vertebrae
It is numbered from T1-T12
Main function is to hold the rib cage
Features :
Presence of costal facets on the side of
the body
Small and circular vertebral foramen
Long and tapering spinous process

Lumbar Vertebrae

Numbered from L1-L5

Main function is to bear weight of the body
This vertebrae are much larger in size
Features:
Large, broad body
Quadrangular spinous process
Superior articular facet directed
medially

Sacral Vertebrae
Consists of 5 bones
fused together
Articulate with L5
and the ilium
Sacral promontory
-ant.& upper
margin of
1st.S.vtbra
Sacral hiatus
-lower opening of
Sacr.canal

Coccyx Vertebrae
Coccyx vertebrae
is made up of
four bones fused
together
Provides
attachment for
ligaments and
muscles of the
pelvic floor

Intervertebral Discs
Each vertebra is separated by an
intervertebral disc
Functions :
Act as a shock absorber between each vertebra
Allow the spine to bend
23 intervertebral discs:
6 in the cervical region
12 in the thoracic region
5 in the lumbar region

 The disks are made of

fibrocartilaginous material
The outside of the disk is
made up of a strong material
called the annulus fibrosus.
Inside this protective covering
is a jelly-like substance known
as mucoprotein gel, known as
the nucleus pulposus.
Vertebral endplate act as
growth plate for vertebral
body
Separates each of the
intervertebral disc superiorly and
inferiorly

Distribution of load

In normal, healthy disc:

nucleus distributes load
equally throughout the
annulus fibrosus.
Disc undergoes
degeneration: nucleus
loses some of its
cushioning ability and
transmits load unequally to
annulus fibrosus.
Severe degenerative discs:
nucleus lost all of its
cushioning ability disc

Ligaments of the Spine

The ligaments are strong fibrous bands that hold the
vertebrae together.
It also helps to stabilize the spine, and protect the discs.
The three major ligaments of the spine are :
ligamentum flavum
anterior longitudinal ligament (ALL)
posterior longitudinal ligament (PLL)

The ALL and PLL are continuous bands that run from the
top to the bottom of the spinal column along the
vertebral bodies
They prevent excessive movement of the vertebral
bones.
ligamentum flavum attaches between the lamina of each
vertebra.

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

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.
The ligamentum flavum also runs in front of the
facet joint capsules.

Spinal Cord
The spinal cord is a column of millions of
nerve fibres that run through your spinal
canal.
It extends from the brain to the area
between the end of your first lumbar
vertebra and top of your second lumbar
vertebra.
At the end of the spinal cord, the cord
fibers separate into cauda equina.

Spinal Nerves
Thirty-one pairs of spinal
nerves branch off the spinal
cord
Each spinal nerve has two
roots.
ventral (front) root carries motor
impulsesfromthe brain and the
dorsal (back) root carries
sensory impulsestothe brain.
The ventral and dorsal roots fuse
together to form a spinal nerve

 Spinal nerve travels down the spinal

canal, alongside the cord, until it
reaches its exit hole
intervertebral foramen

Once the nerve passes through the

intervertebral foramen, it branches.
Anterior primary ramus
Posterior primary ramus

Each branch has both motor and

sensory fibers.
Posterior primary ramus turns
posteriorly to supply the skin and
muscles of the back of the body.
Anterior primary ramus turns anteriorly
to supply the skin and muscles of the
front of the body and forms most of the
major nerves.

 The spinal nerves are numbered according to the

vertebrae above which it exits the spinal canal.

8 cervical spinal nerves are C1 through C8

12 thoracic spinal nerves are T1 through T12
5 lumbar spinal nerves are L1 through L5
5 sacral spinal nerves are S1 through S5
1 coccygeal nerve.

Covering of the Spinal Cord

There are 3 meningeal layers:
dura mater
arachnoid mater
pia mater

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

 Blood supply of the spinal cord :

1 anterior spinal artery

2 posterior spinal artery
Radicular branches
Artery of adamkiewicz

Common causes of
Backache

Can be categorised into :

Mechanical spinal conditions

Non-mechanical spinal conditions
Visceral disease

Degenerative causes of
Backache

Spinal osteoarthritis
Bulging disc
Herniated/Slipped disc
Spondylolisthesis
Degenerative scoliosis
Bone spurs
Spinal stenosis
Foraminal stenosis

Intervertebral Disc
Degeneration

Introduction
An age-related phenomenon that
occurs in over 80 % of people who
live for more than 50 years
in most cases it is asymptomatic.

Pathophysiology
With normal ageing the disc gradually dries
out:
nucleus pulposus changes to a brownish,
desiccated structure.
Annulus fibrosus develops fissures parallel
to the vertebral endplates
small herniations of nuclear material
squeeze into and through the annulus.
Glycosaminoglycans production is
diminished, leading to poor water retention

 As a result, the discs flatten down

and bulge slightly beyond the
margins of the vertebral bodies.
Where they protrude against the
ligaments, reactive new bone
formation called as osteophyte
In the adjacent vertebrae the end
plates ossify and become sclerotic;
fatty change occurs in the
subchondral bone marrow

flattening of the disc

space and marginal
osteophyte
formation

Secondary Effect
Due to degeneration, displacement of the
facet joints and forward or backward shifts of
adjacent vertebral bodies can occur
(spondylolithesis)
Displacement with increased stress in the
facet joints, may lead to osteoarthritis of the
facet joints.
new bone formation may narrow the lateral
recesses and the intervertebral foramina
causing root canal stenosis or spinal stenosis.

Intervertebral Disc
Prolapse

Introduction
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.
Commonly occur between L4, L5 and
L5, S1

Stage
Protrusion - a bulging disc with some
outer annulus intact.
Extrusion when outer annulus
rupture and it bulges toward the
posterior longitudinal ligament.
Sequestration when posterior
ligament rupture, part of the nucleus
may sequestrate and lie free in the
spinal canal

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 Feature
It can occur at any age
Typically, patient has a history of lifting or
stooping followed by severe back pain and is
unable to straighten up.
Patient can also complain of pain in the buttock
and lower limb (sciatica).
Both backache and sciatica are made worse by
coughing or straining.
Later there may be paraesthesia or numbness in
the leg or foot, and occasionally muscle
weakness.

Clinical Examination
Look
stands with a slight list to
one side (sciatic scoliosis)
Feel
tenderness in the midline of the
low back
paravertebral muscle spasm

Move
ROM are restricted
Special Test
Straight Leg Raising Test +ve
Femoral Stretch Test +ve suggest a high or mid
lumbar prolapse
Neurological Examination
muscle weakness
diminished reflexes
Sensory loss corresponding to the affected level.

Investigation
Xrays: narrow disc space and small
osteophytes
CT & MRI: best choice

flattening of the disc

space and marginal
osteophyte
formation

Management
4 principal: Rest, Reduction, Removal,
Rehabilitation
1. Rest

In bed with hip & knee in slight flexion

NSAID for pain

2. Reduction
Continuous bed rest and traction for 2 weeks
If the symptoms and signs do not improve
during that period, an epidural injection of
corticosteroid and local anaesthetic may help.

Management
3. Removal:
Indication for operative removal of a prolapse are:
Cauda equina syndrome not improve after 6 hour of bed
rest and traction
Neurological deterioration while in conservative treatment
Persistent pain and severe sciatica after 2 weeks of
conservative treatment
Frequently recurring attacks.

4. Rehabilitation
Teach patient isometric exercises
Teach how to lie, sit bend and lift
Advise to avoid heavy lifting tasks

Cauda Equina Syndrome

A large central rupture may cause
compression of the cauda equina
Features :
Bladder and bowel incontinence
Perineal numbness
Bilateral sciatica
Lower limb weakness
Crossed straight-leg raising sign

Treatment
1st by bed rest and traction
If not improved by 6 hours, operate

Nerve Root Compression

A posterolateral rupture presses on the
nerve root proximal to its point of exit
through the intervertebral foramen
Feature are: muscle weakness, diminished
reflexes and sensory loss corresponding to
the affected level.
Sciatica- protruded disc irritate the dural
covering of the adjacent nerve root
Treatment : same 4 principal, rest,
reduction, removal, rehabilitation

Lumbar Spondylolysis

Introduction
Defects in the pars interarticularis
It always between L4 and L5, or between L5
and the sacrum
It can occur unilaterally or bilaterally

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.

Clinical features
Spondylolysis is commonly asymptomatic.
Only 25 % will have symptoms at some
time
Symptomatic patients often have pain with
extension and/or rotation of the lumbar
spine.
It is a common cause of back pain in
adolescents, and in particular athletes.

Spondylolysis may or may not be

accompanied by forward translation of one
vertebra relative to another
(spondylolisthesis).

Causes
1. Genetics
2.

Overuse

.Sports-gymnastics, weight lifting, and

football, athletes constantly
overstretch (hyperextend) the spine
result in repeated microtrauma, later
cause stress fracture of the pars
interarticularis.

Investigation

1. X-rays

A. Normal
L5 Pars defect

B.
(Scotty Dog Sign)

2. CT (Computed Tomography)
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 plan.

3. MRI (Magnetic Resonance Imaging)

69

Treatment
Nonsurgical Treatment
Inititally, rest
Anti-inflammatory medications to reduce
back pain.
Back brace and physical therapy
Stretching and strengthening exercises for
the back and abdominal muscles to help
prevent future recurrences of pain.

Stretching and strengthening exercises

Back brace

Treatment cont..
Surgical Treatment
Indication:
progressively worsens or interfere with activities
of daily living.
back pain not respond to nonsurgical treatment

 A spinal fusion is performed between

the lumbar vertebra and the sacrum.
An internal brace of screws and rods
is used to hold together the vertebra
as the fusion heals.

SPONDYLOLISTH
ESIS
SYED NADER NUQMAN

DEFINITION
Spondylolisthesis means forward
translation of one
segment of the spine upon another.
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
Pars
interarticularis
disrupted
Stress &
Instability
Ant. translation
Spinal canal narrowing
Neurological deficit

TYPES

DYSPLASTIC

POST
TRAUMATIC

LYTIC /
ISTHMIC

DEGENERATI
VE

PATHOLOGICAL

POST
OPERATIVE

TYPES
TYPE 1 DYSPLASTIC
SPONDYLOLISTHESIS
The superior sacral facets are
congenitally defective (malformed)
.
Associated anomalies
(usually spina bifida occulta) are
common

TYPES
TYPE 2 ISTHMIC / LYTIC
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
Degenerative changes in the facet
joints and the discs permit forward
slip despite intact laminae.
Common at L4/L5 and in women of
middle age.
Many of these patients have OA
and pyrophosphate crystal
arthropathy.

TYPES
TYPE 4 POST 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, malignancy)
TYPE 6 POSTOPERATIVE
SPONDYLOLISTHESIS
Occasionally, excessive
operative removal of bone in
decompression operations
results in progressive
spondylolisthesis.

CHILDREN

CLINICAL
FEATURES

Painless
Carer will notice protruding abdomen & peculiar stance
ADOLESCENCE & ADULTS

Backache (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

CLINICAL
FEATURES
On examination, the buttocks look curiously flat, the
sacrum appears to extend to the waist and transverse
loin creases are seen.
Lumbar spine is on a plane in front of the sacrum and
looks too short.
Scoliosis sometimes present.
A step can often be felt when fingers are run down the
spine.
Movements are usually normal in the younger patients

Picture (middle) : The transverse loin

creases, forward tilting of the pelvis
and flattening of the lumbar spine.

INVESTIGATIONS
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.

88

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

MEYERDING
GRADE

90

INVESTIGATION
CT SCAN
Better evaluation of bone pathology

MRI
Better evaluation of soft tissue pathology
Nerve compression
Spinal compression
Disc eruption

91

MANAGEMENT
CONSERVATIVE

Conservative treatment, similar to that for other

types
ofBACK
backBRACE
pain, is suitable for most patients
Limit the spine movement
ANALGESIC

NSAIDs
Steroid epidural injection
PHYSICAL THERAPY

Stabilization exercise
To strengthen abdominal and/or back muscles,
minimizing bony movements of spine

MANAGEMENT
SURGERY
INDICATION

If the symptom is disabling and interfere with daily

activities
If the slip is more than 50% and progressing
IfCHILDREN
neurological compression is significant
Posterior transverse fusion in situ almost always
successful
If neurological
signs appear, decompression can be
ADULT
carried out later
Decompressive laminectomy

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

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
1. Congenital vertebral dysplasia
2. Chronic disc protrusion and peridiscal fibrosis or ossification
3. Displacement and hypertrophy of
facet joint
4. Osteoarthritis of the facet joint
5. Hypertrophy, folding or ossification
of the ligamentum flavum
6. Bone thickening due to Pagets
disease
7. Spondylolisthesis

CLINICAL
FEATURES

Usually elderly male >50

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
Termed as neurogenic claudication
Patient may refer walking uphill than downhill
(spine is flexed)
Patient may have previous history of disc
prolapse, chronic backache or spinal operation

CLINICAL
FEATURES
On examination :
1.Ask patient to reproduce symptoms by walking
2.Neurological deficit may present in the lower
limbs
3.Intact pedal pulses would confirm claudication as
spinal rather than arterial

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.

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
2)Transverse <16mm

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