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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