Degenerative Spinal Disorders Summary

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Degenerative Spinal Disorders Summary

Degenerative Spinal Disorders

General Concepts

  • Involve the loss of strength, function, or mobility of the spine.
  • Often caused by normal wear and tear (aging), but influenced by lifestyle or other medical conditions.
  • Changes affect vertebral bodies, intervertebral discs, facet joints, and ligaments.
  • Intervertebral Disc: Acts as a shock absorber. Composed of an outer annulus fibrosus, a soft inner nucleus pulposus, and cartilaginous end plates.
  • Herniated Disc (Disc Prolapse): Occurs when the nucleus pulposus pushes through a weakened/ruptured annulus fibrosus. Graded from bulge to sequestration.

Common Conditions

Cervical Disc Prolapse and Cervical Spondylosis

Affected Levels

  • Most commonly C5-C6 and C6-C7.

Pathophysiology

  • Posterolateral prolapse leads to nerve root compression (Radiculopathy).
  • Central prolapse leads to spinal cord compression (Myelopathy).
  • Cervical spondylosis involves multi-level degeneration causing cervical canal stenosis.

Clinical Picture

  • Symptoms: Neck pain, radiating arm/hand pain (brachialgia), paresthesia (tingling/numbness), motor weakness.
  • Signs vary based on the affected nerve root.
  • Myelopathy Manifestations (Critical): Spastic quadriparesis, hyperreflexia below compression level, clumsiness, ataxia (coordination issues), gait disturbance, sphincter disturbance (bladder/bowel control issues).

Investigations

  • MRI: Best for soft tissue and neural structures (discs, cord, roots).
  • Plain X-ray: Shows general degenerative changes (bone spurs, disc space narrowing).
  • CT Scan: Better for evaluating bony structures.
  • NCS (Nerve Conduction Studies) & EMG (Electromyography): Help identify specific nerve root involvement.

Management

  • Conservative: Rest, cervical collar, physiotherapy, pain/anti-inflammatory medications.
  • Surgical Indications:
    • Radiculopathic pain unresponsive to conservative treatment.
    • Progressive neurological deficit from root compression.
    • Any manifestation of cord compression (myelopathy).
  • Surgical Procedures: Anterior Cervical Discectomy and Fusion (ACDF), Posterior Cervical Laminectomy.

Lumbar Disc Prolapse and Lumbar Spondylosis

Affected Levels

  • Most commonly L4-L5 and L5-S1.

Pathophysiology

  • Posterolateral prolapse causes root compression (Radiculopathy), often resulting in sciatica (pain radiating down the leg due to lower lumbar/lumbosacral root compression).
  • Large central prolapse can cause Cauda Equina Syndrome.
  • Lumbar spondylosis leads to lumbar canal stenosis.

Clinical Picture

  • Symptoms: Back pain, radicular pain (worsened by coughing/sneezing, relieved by bending knees/thighs), paresthesia, motor weakness, bladder symptoms.
  • Signs: Back signs (restricted movement, tenderness, muscle spasm), Radiculopathy signs (specific motor, sensory, or reflex changes depending on the root).

Important Clinical Tests

  • Straight Leg Raising Test (SLRT): Positive indicates irritation of lower roots (L5, S1) - common in lower disc prolapse.
  • Femoral Stretch Test: Positive indicates irritation of higher roots (L2, L3, L4) - common in higher disc prolapse.

Cauda Equina Syndrome (Surgical Emergency)

  • Symptoms: Saddle anesthesia (numbness in groin/buttocks), bladder issues (initially inability to urinate, later incontinence), bowel incontinence (late sign), diminished anal tone, sexual dysfunction (impotence).
  • Motor and reflex signs are typically Lower Motor Neuron (LMN) type (weakness, decreased reflexes).
  • Requires urgent surgical attention.

Investigations

  • MRI: Best for soft tissue and neural structures (discs, cauda equina, roots).
  • CT Scan: Better for bony evaluation and identifying canal stenosis.
  • Plain X-ray: Shows general changes, instability (like spondylolisthesis).
  • NCS/EMG: Evaluate nerve root function.

Management

  • Conservative: Rest, lumbar support/brace, physiotherapy, medications, epidural steroid injections.
  • Surgical Indications:
    • Radiculopathic pain unresponsive to conservative treatment.
    • Progressive neurological deficit.
    • Manifestations of Cauda Equina Syndrome (Urgent Surgery).
  • Surgical Methods: Discectomy (removing the herniated disc), Laminectomy (removing part of the vertebra to decompress nerves).

Spondylolysis and Spondylolisthesis

Definitions

  • Spondylolysis: A fracture or defect in the pars interarticularis (a specific part of the vertebra) without the vertebra slipping forward.
  • Spondylolisthesis: The forward slippage of one vertebra over the one below it.

Causes of Spondylolisthesis

  • Isthmic (due to spondylolysis), Degenerative (due to arthritis/disc degeneration), Congenital (present at birth), Traumatic, Pathologic.

Affected Levels

  • Usually occurs at L5-S1 and L4-L5.

Clinical Impact

  • Can cause spinal canal narrowing and nerve root compression.
  • May lead to symptoms similar to lumbar canal stenosis or radiculopathy.

Management

  • Conservative: Can be attempted for lower grades (less severe slippage) - includes rest, bracing, physiotherapy.
  • Surgical: Involves neural decompression (making space for nerves) and instrumented fusion (using screws/rods to stabilize the spine).

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