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 L5-S1 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.

1) Backache.2) Lower limb pain: made worse

by coughing or straining.3) Numbness & paraesthesia.4) Muscle weakness.5) Bowel/bladder symptoms,

particularly new urinary incontinence, suggest a cauda equina syndrome. 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>L3-L4>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 spinal canal ( <2mm)

• 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 elements

—most frequently in the pars interarticularis• Spondyloptosis

– Complete dislocation

EtiologyCongenital 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. It’s 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– Meyerding’s 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 spondylolisthesisDecompression 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