Lumbar disk disease & Spondylolisthesis

presented by : Sinan A. Yacoub

Lumbosacral radiculopathy
Lumbosacral radiculopathy is a condition in which a disease process affects the function of one or more lumbosacral nerve roots. This produces sensory changes in the corresponding dermatome, and motor changes in the myotome supplied by that nerve root.

Epidemiology
Lumbosacral radiculopathy is one of the most common problems seen in neurologic consultation. Although data are limited, the estimated lifetime prevalence is approximately 3 to 5 percent for adults, with equal rates among men and women

Pathophysiology and Etiology

The most common etiology of lumbosacral radiculopathy is nerve root compression caused by a disc herniation or spondylosis (ie, spinal stenosis due to degenerative arthritis affecting the spine). Additional etiologies: nonskeletal causes of nerve root compression and noncompressive mechanisms such as: 1. infection. 2. inflammation. 3. Neoplasm. 4. vascular disease.

Lumbar Disc Herniation

The gelatinous nucleus pulposus squeezes through the fibres of the annulus fibrosus and bulges posteriorly or posterolaterally beneath the posterior longitudinal ligament. Local oedema may add to the swelling. This causes pressure on one of the nerve roots.

 This herniated material maybe central, posterolateral, or lateral.

A posterolateral disc protrusion will affect the traversing root, e.g. an L5-S1 disc protrusion affects the S1 nerve root.

 Over 90% of herniations occur at the L4-L5 or L5S1 levels. Why? Seventy-five percent of flexion and extension occurs at the lumbosacral joint . This level, on the other hand, has limited torsion. Twenty percent of flexion and extension occurs at L4-L5. The incidence of radiculopathies is split somewhat evenly between L4-L5 and L5-S1, as the lack of torsion at L5-S1 helps to increase its stability despite its higher degree of flexion and extension.

 Cauda equina syndrome: A large midline disc herniation may compress the cauda equina, leading to a syndrome defined by bowel and/or bladder difficulties, saddle anaesthesia and lower limb sensory and motor deficits.

Symptoms
Depend on the structure involved and the degree of compression. Backache. Lower limb pain: made worse by coughing or straining. Numbness & paraesthesia. Muscle weakness. Bowel/bladder symptoms, particularly new urinary incontinence, suggest a cauda equina

1) 2)

3) 4) 5)

Dermatomal

Physical Examination
The patient usually stands with a slight tilt to one side sciatic scoliosis. Loss of lumbar lordosis Lower back tenderness and paravertebral muscle spasm. Limited straight-leg raising and painful ipsilateral. Sometimes raising the unaffected leg causes acute sciatic tension on the painful side (crossed sciatic tension). L3-L4 prolapse femoral stretch test may be positive. Muscle weakness of affected myotome. Diminished reflexes and sensory loss corresponding to affected level.

L5 affected : weakness of big toes extension and knee flexion + dermatomal sensory loss. S1 affected: weak plantar flexion and eversion of the foot and a depressed ankle jerk + dermatomal sensory loss.

Imaging
* Magnetic Resonance Imaging (MRI).

Treatment

Treatment
Surgical care
Failure of nonoperative treatment
Minimum of 6 weeks in duration Can be months

Cauda equina syndrome: - urgent, within 24 hours to

prevent any irreversible damage.

Neurological deterioration within period of conservative management. Frequently recurring attacks.

Discectomy
Removal of the herniated portion of the disc Usually through a small incision High success rate

Spinal Stenosis
Narrowing of the spinal canal , nerve root canals , or I.V foramen due to spondylosis and degenerative disk disease (L4-L5>L3L4>L5-S1)
Central stenosis
Narrowing of the central part of the spinal canal (<12 mm)

Far lateral recess stenosis

Narrowing of the lateral part of the

 Causes: 1) Spondylosis:

the most common cause of lumbar spinal stenosis and typically affects individuals over the age of 60 years. Facet osteophytes, ligamentum flavum hypertrophy, and disc bulging can encroach on the central canal and the neural foramina. The L4-5 level is most commonly involved, followed by L5-S1 and L3-4.

2) Space-occupying lesions (lipoma, synovial and neural cysts, neoplasms). 3) Traumatic and postoperative causes (fibrosis). 4) Skeletal disease (Paget, ankylosing spondylitis, rheumatoid arthritis). 5) Congenital: dwarfism, spinal dysraphism.

Spinal Stenosis
Symptoms
Neurogenic (or pseudo) claudication is a hallmark of LSS Back pain Pain, dysthesias, anesthesias in the buttocks, thighs, and legs Unilateral or bilateral(68%, but often asymmetrical).

Physical examination
The neurologic examination is often normal in patients with LSS. The straight leg raising sign is present only in a minority of patients (10 percent).

However, in some patients with LSS, more prolonged or severe nerve root involvement may lead to fixed and/or progressive neurologic deficits.

 Imaging
MRI/computerized tomography (CT) scan.

Nonoperative care
Rest NSAID medication Physical therapy
Exercise/walking

Steroid injections

Spinal Stenosis
Surgical care
Failure of nonoperative treatment
Minimum of 3-6 months duration

Decompression
Bone removal to widen area
Laminectomy Foraminotomy

High success rate May require adjunct fusion to address instability

Segmental Instability (Spondylolisthesis)

Spondylolisthesis
Forward displacement

Retrolisthesis
Backward displacement

Lateral listhesis
Sideways displacement

Axial and rotational displacement

Segmental hypo- and hyper- kyphosis or lordosis

Segmental Instability
Spondylolisthesis
A forward translation of 1 vertebral body over the adjacent vertebra

Spondylolysis
A fracture or defect in the vertebra, usually in the posterior elementsmost frequently in the pars interarticularis

Spondyloptosis
Complete dislocation

Etiology
Congenital Isthmic
(spondylolysis)

Degenerative Traumatic Pathological

Etiology
Congenital :
Due to dysplastic sacral or lower lumber segments .

Isthmic :
Caused by the development of a stress fracture of the pars interarticuris. Its the commonest variant and is believed to affect 6-7 % of population , many of who are asymptomatic . Approximately 82% of cases occur at L5 S1 , another 11% occur at L4 L5 A genetic predisposition is believed to be linked with patients having thin pars or subtle hypoplastic facet joint . Most often occurs during the first and second decades of life.

Etiology
Degenerative :
Caused by facet degeneration accompanied by disk degeneration most commonly at the level of L4 L5 Occurs most commonly after age of 40 year

Traumatic
Is rare and caused by severe hyperextension stress placed on the pars which could produce fracture and instability.

Pathologic :
Can occur as a result of any bone lesion that might weaken the psterior elements .

Spondylolisthesis
Gradation of spondylolisthesis
Meyerdings Scale
Grade 1 = up to 25% Grade 2 = up to 50% Grade 3 = up to 75% Grade 4 = up to 100% Grade 5 >100% (complete dislocation, spondyloloptosis)

Spondylolisthesis
Symptoms
Low back pain
With or without buttock or thigh pain

Pain aggravated by standing or walking Pain relieved by lying down Concomitant spinal stenosis, with or without leg pain, may be present Other possible symptoms
Tired legs, dysthesias, anesthesias Partial pain relief by leaning forward or sitting

Spondylolisthesis
Diagnosis
Plain radiographs ( AP , lateral ,dynamic ,and calculating slip angle and percentage ) CT scan is excellent for confirming dx and ruling our more sinister pathology . MRI can visualize edema and identify nerve root compression.

Nonoperative Care
Rest NSAID medication Physical therapy Steroid injections

Spondylolisthesis
Surgical care
Failure of nonoperative treatment Accompanying neurologic deficit High grade slips ( > 50%) Traumatic spondylolisthesis Decompression and fusion
Instrumented Posterior approach With interbody fusion

Spondylolysis
Spondylolysis
Also known as pars defect or fracture. With or without spondylolisthesis A fracture or defect in the vertebra, usually in the posterior elements most frequently in the pars interarticularis

Spondylolysis
Symptoms
Low back pain/stiffness Forward bending increases pain Symptoms get worse with activity May include a stenotic component resulting in leg symptoms Seen most often in athletes
Gymnasts at risk Caused by repeated strain

Spondylolysis
Diagnosis
Plain oblique radiographs CT, in some cases

Nonoperative care
Limit athletic activities Physical therapy
Most fractures heal without other medical intervention

Spondylolysis
Surgical care
Failure of nonoperative treatment Operation: Posterior fusion
Instrumented May require decompression

Thank you