• No morphological correlate can be found in
• Peripheral tissue damage and neural
injuries changes in the pain pathways
abnormal responsiveness or function of the
dorsal root ganglion of the nervous system , as
• Reduction in pain threshold (allodynia)
• increased response to noxious stimuli
• increase in the duration of response to brief
stimulation (persistent pain) and a spread of
Syndromes which belong to this class of pain are
Irritable bowel syndrome
Non-cardiac chest pain
• Genetic predisposition and biopsychosocial
factors have a significant influence on pain
• Adjuvant drugs (e.g.
antidepressants, anticonvulsants, anxiolytics)
enhance the centraleffect of analgesics and
should be included for an adequate treatment of
moderate to severe pain .
Chronic pathological changes
Space occupying and destructive lesions
The Intervertebral Disc
start as small tears in the annulus fibrosus
increase in size to form radial fissures extend
into the nucleus pulposus loss of
proteoglycans and water content from the
nucleus loss of the height of the disc disc
collapses shortening the distance between the
two vertebral bodies vertebral sclerosis +
The cardinal symptoms of discogenic
back pain are :
1) predominant low-back pain .
2) pain aggravation in disc compression and
flexion by forward bending, sitting, coughing,
sneezing , walking.
3) non-radicular pain radiation in the anterior
thigh ( referred pain)
The facet joint
Begin with an inflammatory synovitis gradual
thinning of the cartilage subperiosteal
osteophytes enlarge both the inferior and
The cardinal symptoms of facet joint
pain are :
1) predominant low-back pain
2) osteoarthritis pain type (morning stiffness ,
improvement during motion- early stage)
3) pain aggravation in extension and rotation
(backward bending ,standing, walking
4) non-radicular pain radiation in the posterior
thigh (referred pain )
Treatment of the degenerative disc
and facet joint
The mainstay of non-operative management rests
on three pillars:
1) pain management (medication)
2) functional restoration (physical exercises)
3) cognitive-behavioral therapy (psychological
Compressive or rotational forces on the spine
tear of the annulus fibrosis the nucleus
pulposus may migrate through the tear, causing a
protrusion of the disc .
Degenerated discs that already have some degree
of annular tearing, have less
elasticity and are less able to withstand these
• If the disc herniation protrudes posteriorly in
the midline compression of the cauda
equina or spinal cord .
• If the disc protrudes laterally compression
on the nerve root .
• Radiculopathic symptoms.
• These symptoms must correspond to the
respective dermatome and myotome of
the compromised nerve root to allow for a
Conservative Measures for mild radiculopathy
1) Bed rest (< 3 days)
3) Anti-inflammatory medication
Operative Treatment for severe radiculopathy (
Cauda equina syndrom, severe paresis ,etc.)
Standard operations Laminotomy and
With or without neurological symptoms.
Operative and non-operaive treatment.
Chronic Pathological changes
The effects of acute and cumulative trauma
progressive degenerative changes that affect
both the intervertebral disc and the posterior
Degenerative changes significant stenosis of
the central canal and lateral foramina
disrupt function within the spinal cord and
A pathomorphological changes as:
1) hypertrophy of the ligamentum flavum
2) hypertrophy of the facet joints
3) osteophyte formations
4) disc herniation
5) vertebral displacements (anterior/lateral)
Symptoms are :
pain or numbness in the legs on activity and
which is relieved with rest, known as
Conservative treatment mild symptoms
1) medication (analgetics, NSAIDs, muscle
2) postural education and therapeutic exercise
with avoidance of extension .
3) epidural infiltration of corticosteroids .
Operative treatment Decompression
with or without instrumentation.
MUSCLE TRAUMA, IMMOBILIZATION
Pain due to degenerative changes reduces
the patients activity atrophy of the
• Muscle atrophy is visible within 3-4 weeks and
after 3 months completemuscle atrophy.
• The atrophied muscles is replaced by fibrous
• Muscle atrophy can cause functional pain.
Traumatic, congenital and degenerative
changes can all result in deformity of spinal
• The vertebral arch attaches to the vertebral body
through the pedicles. The laminae originate from
the pedicle at a comparatively weak area known
as the pars interarticularis or isthmus.
• In childhood and adolescence, this area is subject
to fatigue fracture, which may not heal properly
and can lead to a fibrous union rather than a
stable bony union.
• This can happen unilaterally or bilaterally.
• If it occurs bilaterally , it creates an area of
weakness between the anterior and posterior
components of the vertebral arch.
• If this is stable , it may not be clinically
important and can be an incidental finding
seen on X-rays and CT scan.
Bilateral spondylolysis , can separation of
the anterior and posterior elements of the
vertebral arch slippage of the superior
vertebral body on the inferior vertebral body
As the spondylolisthesis progresses
widening of the central spinal canal.
During the process of degeneration , there is a
period in which the two adjacent segments
are hypermobile slippage narrowing of
the central spinal canal
• Conservative for mild cases: pain relief
• Operative for severe cases: spinal fusion
(instrumented and non instrumented)
• Deformity of the normal vertical and/or sagital
alignment of spinal segments.
• The causes : congenital , spontaneous and
There are a number of systemic diseases that
impact on the spine and can result in changes
in bony structure, resulting in deformity.
Space-occupying and destructive
Tumors that affect the spine can be primary
benign or malignant .Primary or metastatic
tumors spreading from other organs .
The vertebral column , the intervertebral
discs, the dural sac or the space around the
spinal cord may become infected.
The infection may be caused by bacteria or