Degenerative Disc Disease

Low Back Pain

Herniated Nucleus Pulposus
Cervical Spinal Stenosis
Lumbar Spinal Stenosis

WIDIYATMIKO ARIFIN P

Anatomy
The Spine
Composed of 33
vertebrae
7 cervical
12 thoracic
5 lumbar
5 sacral + 4
coccyx (fused)
Act to support the
trunk and transfer
muscular load
2

The Spinal Cord

Elongated cylindrical mass of

nerve tissue occupies the
upper 2/3 of the vertebral canal
(42-45 cm)
Conus medullaris conical distal
Filum terminale 1st seg. coccyx
Ascensus medullorum
Intumescentia cervicalis
(C 3 Th. 2)
Intumescentia lumbalis
(Th. 10 L2)

Segments of the Spinal

Cord

Composed of 31
segments :
8 cervical
12 thoracal
5 lumbalis
5 sacralis
1 coccygeus

Intervertebral Disc

nucleus pulposus
annulus fibrosus
hyaline cartilage
end plates

Facet Joints

Degenerative Disc
Disease and
Low Back Pain

Degenerative Disc
Disease (DDD)

Unfortunately, DDD seems to be sort

of a wastebasket term

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 lumbar imaging.

DDD
Degeneration of an individual disc
space typically refers to:
1.loss of disc height,
2.loss of water content,
3.fibrosis,
4.end plate sclerosis/defects,
5.osteophyte complexes, etc.

Degenerative Disc
Disease

The process is thought

to begin in the annulus
fibrosis with changes
to the structure and
chemistry of the
concentric layers
Over time, these layers
suffer a loss of water
content and proteoglycan,
which changes the discs
mechanical properties,
making it less resilient
to stress and strain

Normal
Anatomy

Degenerative Disc
Disease

The process is thought

to begin in the annulus
fibrosis with changes
to the structure and
chemistry of the
concentric layers
Over time, these layers
suffer a loss of water
content and proteoglycan,
which changes the discs
mechanical properties,
making it less resilient
to stress and strain

Degenerative
Anatomy

The Aging Disc

Thompson criteria

Loss of cells
Loss of H20/
proteoglycans
Type II/ Type I
collagen
Annular fissures
Mechanical
incompetence
Bony changes

II

III

IV

Degenerative Disease:
Facet Arthritis

Changes in disc
structure and function
can lead to changes in
the articular facets,
especially
hypertrophy
(overgrowth),
resulting from the
redirection of
compressive loads
from the anterior and
middle columns to
the posterior elements

Degenerative Disease:
Facet Arthritis

Facet Injections

Anesthetic effect
Relief may last for
several months or only
a few weeks, or a few
days

Degenerative Disease:
Osteophytes

There may also be

hypertrophy of the
vertebral bodies
adjacent to the
degenerating disc;
these bony
overgrowths are
known as osteophytes
(or bone spurs)

Degenerative Disc
Disease

Symptoms

Low back pain and/or

buttocks pain
If leg pain also exists,
there is likely an
additional cause, eg,
HNP, stenosis, etc
DDD is not usually the
sole diagnosis

Degenerative Disc
Disease:
Discogenic
Pain
Discogenic pain is
pain originating from
the disc itself; an
internally disrupted
disc may result in disc
material causing
chemical irritation of
nerve fibers

Degenerative Disc
Disease

Diagnosis

Patient examination
Xray
MRI
CT, in some cases, to
rule out other diagnosis
Discography

Nonoperative care

Rest for acute, low

back pain
NSAID medication
Physical therapy

Exercise/walking
Low-impact aerobics
Trunk strengthening

Degenerative Disc
Disease

Surgical care

Failure of nonoperative treatment

Minimum of 6 weeks

Fusion

Removal of disc and replacement with bone

graft, or a cage-filled bone graft, or a bone
graft substitute

Anterior approach
Posterior approach
Combined approach

Arthroplasty

Articulating disc replacement

Low Back Pain (LBP)

LBP is extremely common

~85% of LBP is idiopathic
Most patients with LBP improve on
their own in time

Physical therapy and pain meds (even

nonprescription such as NSAIDs) are
appropriate mainstays of initial
treatment.

Taking a history in a pt.

with LBP

Evaluation of patients with LBP

should be geared towards
identification of those patients with
a potentially serious underlying
etiology.
Cancer
Infection osteomyelitis, abscess, etc.
Fracture
Cauda Equina Syndrome

Things that should raise a

red flag

Previous dx of cancer, unexplained

weight loss
Immunosuppression, dx of steroid
use, dx of IV drug abuse, Dx of
skin/other infection(s)
Dx of recent falls or trauma
(including surgery)
Bladder dysfunction or fecal
incontinence, saddle anesthesia,
leg weakness
Pain that doesnt improve with rest;

Other things to check

with LBP

Social factors are important to ask

about.
Employment status
Any pending litigation?

Vitals can give clues (fever with

infection, etc).
Routine labs are usually sufficient.
Good physical exam should pick up
neurological compromise, if present.
Palpation of the spine looking for

Radiography

Currently, radiographic imaging is

not recommended for patients with
no red flags on history and
physical if they have had symptoms
less than 4 weeks duration.
If red flags present, or persistent
symptoms beyond 4 weeks,
radiographic evaluation is
recommended.

Then referral as/if appropriate.

Herniated
Nucleus
Pulposus

Concept

Intervertebral discs can be thought

of, conceptually, kind of like a jelly
donut. The outside is the annulus
fibrosus, and the inside jelly is the
more watery nucleus pulposus.

Intervertebral discs act as shock

absorbers between the vertebral
bodies.

Just like jelly donuts have a weak spot

where the jelly squirts out if you
squeeze them, the annulus of discs is
weak posteriorly where the nucleus
pulposus can herniate through, causing
symptoms.

Presentation

The classic presentation of

Herniated Nucleus Pulposus (HNP),
both for cervical and lumbar spine,
is radiculopathy.
The disc herniation impinges upon a
nerve root, causing characteristic pain.
Thoracic disc hernations are much,
much rarer.

Lumbar HNP

Sciatica is the classic

radiculopathy of lumbar HNP,
though the exact presentation
depends upon the nerve root(s)
involved.
Motor weakness can occur, which
again is representative of the nerve
root(s) involved.
L4 quadriceps (knee extension)
L5 tibialis anterior (foot dorsiflexion)
S1 gastrocnemius (foot plantar

Lumbar HNP

90% of herniated discs are

paracentral (slightly off to one side)
and affect the nerve root that
corresponds to the lower vertebral
level.

Example: a typical L4/5 disc herniation

would cause symptoms referrable to the
L5 nerve root.

Lumbar HNP when to

operate

The natural history of herniated

discs is to resolve over time.
If conservative management can
adequately treat a patients pain,
this is the preferred course of action.
If conservative management fails to
adequately control pain, surgery can
be performed (often times on an
outpatient basis).

Cervical HNP

Classic presentation is to wake up

with it. Usually no identifiable
factor.

Causes painful limitation of neck motion

and symptoms corresponding to the
affected nerve root(s)

The majority of cervical herniated

discs will catch the nerve root
corresponding to the lower vertebral
level.

Ex: A C6/7 disc herniation will impinge

upon the C7 root.

Cervical HNP

Just as is the case with Lumbar HNP,

conservative therapy is the mainstay
of treatment.
Surgery indicated for those that
dont improve with conservative
management, or with
new/progressive neurologic deficit.

Cervical Spinal
Stenosis

Cervical Spinal Stenosis

(CSS)

Stenosis a constriction or
narrowing of a duct or passage.

Cervical spinal stenosis, thus, is

narrowing of the spinal canal (within
which lies the cervical spinal cord).

This narrowing can be from any of a

multitude of causes. Usually, though, this is
referring to more chronic types of
processes, rather than acute or sudden
ones.

CSS when it causes

problems

Radiculopathy from nerve root

compression.

Myelopathy from spinal cord

compression.

The term radiculopathy refers to

disease of the nerve roots; LMN signs,
pain/parasethesias.

The term myelopathy refers to

pathological changes of the spinal cord
itself.

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
variablebut it is going to progress.

CSS myelopathy - History

Some patients attribute weakness to

getting old, and because they
arent having neck pain (many
myelopathic patients dont), they
dont realize theres a problem that
needs addressing.

Ask about fine motor movements, like

buttoning buttons, tying shoes, signing
checks, handwriting changes, using
utensils, etc. Clumsiness with fine
motor skills is common.

CSS myelopathy Physical Exam

Hyperactive reflexes are the most

common physical exam finding in
myelopathy.
Remember the difference between
Upper Motor Neuron and Lower Motor
Neuron signs.
Remember symmetry a Hoffmans on
one side, if not on the other, should
raise a red flag.
Remember that a Babinski reflex, if
present, is ALWAYS abnormal.

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

Surgery

The goal of surgery is to halt the

progression of myelopathy through
adequate decompression of the
area(s) of stenosis.
Once patients are clinically
myelopathic, complete return of
function and/or remission of
symptoms almost never occurs.

This is why they need to be identified

early!

Lumbar Spinal
Stenosis

Lumbar Spinal Stenosis

(LSS)

Just as we discussed with Cervical

Spinal Stenosis, Lumbar Spinal
Stenosis can occur secondary to
anything which narrows the lumbar
spinal canal

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

doesnt cause myelopathy; when it
affects the motor system, lower

LSS - presentation

The classic presentation of

Lumbar Spinal Stenosis is
Neurogenic Claudication (NC), or
pseudoclaudication. (~60%
sensitivity, but >90% specificity).

Gradually progressive back, thigh,

buttock, and/or leg pain that is relieved
by rest and/or, characteristically, a
change in posture; usually through
flexion at the hips (sitting or squatting,

Neurogenic Claudication

Neurogenic Claudication is thought

to arise from compression of,
irritation to, or ischemia of the
lumbosacral nerve roots.

This is in contrast to Vascular

Claudication (VC), which is
secondary to insufficiency of
vascular supply to meet demand of
muscles (pain is ischemic, but from
muscles).

Anthropoid
posture (walking
bent-over as
though theyre
pushing a
shopping cart) is
common in NC,
and pain may be
reproduced with
lumbar extension.
Vascular Lab
Studies may help
differentiate
between NC and
Table 14-18 adapted from Greenbergs
VC of Neurosurgery, 6 ed.
Handbook

th

Management

Unless there is severe neurological

deficit, conservative medical
management is usually tried prior to
pursuing surgery.

Pain meds, epidural steroid injections,

etc.

If medical management is
unsuccessful, surgery for Lumbar
Spinal Stenosis is aimed at removing

Thank You