DEGENERATIVE SPINAL CORD DISEASES - PowerPoint Presentation

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DEGENERATIVE SPINAL CORD DISEASES

Cemre

YILMAZ

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Spinal Cord

The spinal cord extends from the foramen magnum where it continues with the medulla to the level of the first or second lumbar vertebra

.

It

terminates in a fibrous extension known as

filum

terminale

.

Terminal

portion of the spinal cord is called the

conus

medullaris

.

Spinal nerves pass through the vertebral column by exiting the intervertebral foramen. However, because the spinal cord does not reach the end of the vertebral column, the lumbar and sacral spinal nerves exit only by first going downward and traveling inferiorly through the vertebral canal before reaching their corresponding intervertebral foramina. For this reason, there is a collection of nerve roots at the lower end of the vertebral canal. This collection of nerve roots is called the

cauda

equina

due to a resemblance to a horse's tail

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There are 31 pairs of spinal nerves

8 cervical

12

thoracal

5 lumbar

5 sacral

1 coccygeal

The spinal cord has two enlargements

Cervical(C3-T2)

:The cervical enlargement corresponds roughly to the brachial plexus nerves, which innervate the upper limb

Lumbar (T11-L1)

:The lumbar enlargement or lumbosacral enlargement corresponds to the lumbosacral plexus nerves, which innervate the lower limb

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Spinal Cord

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Vertebra

There are features that are common to all vertebral segments and others that are unique to each level. With the exception of C1, each segment has a vertebral body, which is the anterior portion of the vertebral segment. The superior and inferior portions of the vertebral body are referred to as the end plates which provide nutrition to the adjacent disk. The body is connected to the posterior elements by bilateral pedicles which are linear bony struts. The posterior elements consist of the pedicles, lamina, facets (articular process), transverse process and

spinous

process.

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Intervertebral Discs

Each vertebral body segment(except C1-C2) is attached to the level above and below by an intervertebral disk

The disk has several functions:

1) It serves as a connection between the vertebral bodies

2) It acts as a pivot point

3) Distribute compressive forces

The disk is made of the nucleus

p

ulposus

and the annulus

fibrosus

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Degenerative Spine Conditions

Herniated discs

Spinal stenosis

Degenerative disc

disease

Spondylo-lysis

/

listhesis

Degenerative scoliosis

Spondylosis

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Risk Factors

a

ging

g

enetic

s

moking

weight

h

eavy lifting

s

edentary lifestyle

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Symptoms

Degenerative spine conditions vary widely in their presentation. Some cause no symptoms at all.

When symptoms do occur, they often include

back pain or neck pain.

Other symptoms depend on the location and type of problem.

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Disc Herniation

Disc herniation occurs when the annulus fibrous breaks open or cracks, allowing the nucleus

pulposus

to escape. This is called a herniated nucleus

pulposus

or herniated disc.

The most common sites are lumbar (L4-L5) herniated discs and cervical(C5-C6) herniated discs .Thoracic herniated discs are much less common.

Herniations

usually occur

posterlaterally

.

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protrusion

:

​base wider than herniation

confined to disc level outer

annular

fibres

intact

extrusion

​:

base narrower than herniation

'

dome'may

extend above or bellow endplates or adjacent vertebrae

complete annular tear with passage of nuclear material beyond disc annulus

disc material can then migrate away from annulus or become sequestered

Sequestration

extruded disc material that has no continuity with the parent disc

is displaced away from the site of extrusion.

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Cervical disc herniation

most common site C5-C6 / C6-C7

Pain (neck and upper extremities)

Numbness

Muscle weakness

Paresthesia

Urinary incontinence , loss of bowel control(rare)

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Diagnosis

Physical exam

MRI

–

best

CT with

myelogram

–

more sensitive but invasive

X-ray

EMG

Treatment

Medication :NSAID

Physical therapy

Steroid injection

Surgery

Anterior

cervical discectomy and spine fusion (ACDF)

Posterior cervical discectomy

Cervical artificial disc replacement.

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Lumbar Disc Herniation

Most common site L4-L5/L5-S1

Pain (lower back,

buttocks

,

lower

extremities)

Numbness

Foot drop

Cauda

equina

syndrome

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Most commonly affected nerve sciatic nerve (L3-S1)

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Straight

L

eg

R

aise

T

est

(

Lasegue’s

sign)

Neurologic pain which is reproduced in the leg and low back between 30-70 degrees of hip flexion is suggestive of lumbar disc herniation at the L4-S1 nerve roots.

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Diagnosis

Physical

exam—straight leg raise test

MRI

CT

with

myelogram

X-ray

EMG

Treatment

Ice application

Medication : NSAID

,muscle relaxants

Heat therapy

Physical therapy

Steroid injection

Surgery

Microdiscectomy

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Cauda Equina Syndrome(CES)

Cauda

equina

syndrome is caused by any narrowing of the spinal canal that compresses the

cauda

equina

nerve

roots

.

disc herniation

spinal

stenosis

traumatic

injury

tumors infectious conditions

arteriovenous

malformation or

hemorrhage

iatrogenic

injury

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CES symptoms

Back pain

Saddle anesthesia

Sciatica pain

Bladder, bowel dysfunction

Gait disturbance

Anal and

achilles

reflex absent

Sexual dysfunction

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Surgery indications

Severe pain

Progressive neurological deficit

Loss of bowel-bladder control

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Spinal stenosis

Spinal stenosis is part of the aging

process

Progressive

narrowing of the spinal canal may occur alone or in combination with acute disc

herniations

. Congenital and acquired spinal

stenosis

place the patient at a greater risk for acute neurologic injury.

Spinal

stenosis is most common in the cervical and lumbar areas.

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Spinal stenosis

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Spinal stenosis

The most common reason to develop spinal stenosis is degenerative arthritis, or bony and soft tissue changes that result from

aging

.

The

normal "wear and tear" of

aging

can cause arthritis in the spine that leads to spinal stenosis. This can be from bone spurs (osteophytes) forming, bulging and wear of the intervertebral discs, and thickening of the ligaments between the vertebrae.

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Spinal stenosis

Local and traveling pain, often described as a burning

sensation

Muscle weakness

Numbness

and

tingling

Loss

of fine motor

skills

Limited

mobility

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Treatment

pain

medication

Exercise

Stretching

Hot

/cold

therapy

Epidural

steroid

injections

Lifestyle

changes like weight loss and quitting

smoking

Decompression surgery

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Degenerative Disc Disease

Gradual

deterioration and thinning of the shock-absorbing intervertebral

discs by age

This condition can occur at any level of the spine

and

may cause a range of symptoms and intensity levels.

Unless

a degenerative disc places pressure upon an adjacent nerve, symptoms remain non-existent or strictly localized.

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Degenerative Disc Disease

Pain

with activity

bending, lifting, and twisting

Severe

episodes of back or neck pain

(a

few days to a few months

Certain positions: sitting for

lumbar degenerative disc

pain

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MRI Findings

Disc space narrowing

Fissures

, fluid, vacuum changes and calcification

Osteophytosis

Disk herniation

Malalignment

Stenosis

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DDD Treatment

Pain control

Exercise and physical therapy

Lifestyle modifications

S

urgery

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Spondylolysis

Caused by repeated

microtrauma

, resulting in

stress fracture of the pars

interarticularis

present

in ~5% of the population

%90 at the L5 level

higher

in the adolescent athletic

population

commonly asymptomatic

pain

with extension and/or rotation of the lumbar spine.  

65% of patients with

spondylolysis

will progress to

spondylolisthesis

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Spondylolysis

Plain

radiograph

oblique

limited

sensitivity compared to SPECT and CT

scotty

dog

sign

CT

/

MRI

Wide canal sign

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Spondylolisthesis

is most frequent at L5/

S1

forward or backward slippage

the vertebra

Causes

of

spondylolisthesis

include trauma, degenerative,

tumor

and

birth defects

.

lower back or leg

pain, hamstring tightness, numbness

and tingling in the legs.

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Treatment

Bracing to immobilize the spine for a short period

Pain

medications and/or anti-inflammatory

medication

Physical therapy

Decompressive

laminectomy

:reduces

irritation and inflammation in the area (but increases spinal instability

)

A

spinal fusion to provide stabilization of the affected area.

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Spondylosis

Spinal osteoarthritis

With age, the bones and ligaments in the spine wear, leading to bone spurs

Over 80% of people over the age of 40 have evidence of

spondylosis

on X-ray

studies

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Spondylosis

Neck/back pain

Stiffness

Paresthesia

weakness

Standing

Sitting

Sneezing

Coughing

Tilting neck backward

worsen the pain

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Spurling’s

test(cervical compression test)

pain arising in the neck radiates in the direction of the corresponding dermatome

ipsilaterally

Shows cervical radiculopathy (many causes)

Lhermitte’s

sign

electric

shock-like sensation that occurs on flexion of the

neck

Reduced range of motion

MRI-CT

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Treatment

(

NSAIDs

)

exercise

 – such as swimming and

walking

Surgery

bowel

or bladder

dysfunction

spinal stenosis

neurologic dysfunctions

Unstable spine