This document discusses degenerative diseases of the spine and joints. It provides information on the anatomy of the spine and intervertebral discs. It describes various imaging modalities used to evaluate the spine, including MRI, CT and X-rays. It discusses pathophysiology of degenerative changes and covers topics like disc bulges, tears, herniations and classifications. Modic changes, posterior element degeneration and facet joint osteoarthritis are also summarized.

1. DEGENERATIVE DISEASES OF SPINE &
JOINTS
PRESENTER : Dr Mohammad Masood
MODERATOR : Dr Tariq Ahmad Gojwari
S/R INCHARGE : Dr Obaid Ashraf
Dr Junaid kazmi
SHER-E-KASHMIR INSTITUTE OF MEDICAL
SCIENCES,SRINAGAR,JK

4. ANATOMY OF SPINE

5. • The intervertebral articulation consists of a
three-joint complex
• from the axis to the sacrum – one between
the vertebral bodies and a pair between the
facets of adjoining vertebral arches
(zygapophysial joints, also called facet joints).

8. Anatomy of Intervertebral Disk
• inner nucleus pulposus.
• an outer annulus fibrosus.
• bordered by cartilaginous endplates.

10. Figs 1A to C: Sagittal T1-weighted (A) T2-weighted, (B) and axial T2-weighted, (C) MR images of
lumbosacral spine show normal intervertebral disk that is slightly lower signal intensity than
bone marrow on T1-weighted images and with higher T2 signal. The annulus is seen as a
peripheral region of low signal intensity on T2W images (arrow) and nucleus pulposus (N) is
hyper intense. A horizontal internuclear cleft is seen on T2W sagittal image.

13. IMAGING MODALITIES
• Radiography
• Diskography
• Conventional myelography
• CT myelography
• Nuclear scintigraphy
• Computed tomography
• Magnetic resonance imaging

14. • Plain films are
– Inexpensive
– Widely available
– Give panoramic view of
entire spine
– Bones directly visualized
– Information regarding
alignment and stability
obtained using dynamic
films

15. • Plain films are
– Inexpensive
– Widely available
– Give panoramic view of
entire spine
– Bones directly visualized
– Information regarding
alignment and stability
obtained using dynamic
films
• Myelography
– Patients with
contraindication for MRI
Or in whom subtle
instability is suspected
but not confirmed by
other imaging.

16. • Discography
– In selected patients before intervention
– When diagnosis of diskogenic pain must be
confirmed

19.  Magnetic Resonance Imaging
Imaging modality of choice in
evaluation of spine
Superior soft tissue contrast

20. • COMPUTED TOMOGRAPHY
–Superior spatial resolution
– improved conspicuity of osseous and
calcified structure

21. • Weight-bearing CT or MRI may be done by axial
loading performed in supine position.
• A hydraulic compressor is placed below a patient’s feet
and over the shoulders to apply a variable axial load.
This simulates static mechanical forces acting on the
spine in the upright position

22. Upright MRI
• Upright MRI has ability to perform Positional
Imaging which allows patient to be scanned in
positions such as sitting or lying down.
• Patient can be scanned in weight bearing
positions in their precise location of symptoms
or pain

25. PATHOPHYSIOLOGY
• Pathogenic mechanisms are multiple
• CHRONICOVERLOADis the most important factor
• OTHER are sequelae of
– Acute trauma
– Metabolic
– Toxic
– Genetic
– Vascular
– Infectious

26. • The distribution of axial load determines the
common sites of spine degeneration.

27. • The distribution of axial load determines the
common sites of spine degeneration.
• In the cervical spine, it is C5–C6 and C6–7 levels
as these are the sites of lordosis inversion.

28. • The distribution of axial load determines the
common sites of spine degeneration.
• In the cervical spine, it is C5–C6 and C6–7 levels
as these are the sites of lordosis inversion.
• The dorsal spine is rarely involved as it is less
mobile and less involved in dynamic load.

29. • The distribution of axial load determines the
common sites of spine degeneration.
• In the cervical spine, it is C5–C6 and C6–7 levels
as these are the sites of lordosis inversion.
• The dorsal spine is rarely involved as it is less
mobile and less involved in dynamic load.
• In the lumbar spine, L4–5 and L5–S1 are the
sites of highest dynamic and static overload and
hence most predisposed to degenerative changes.

30. • Pathological changes
– Water and proteoglycan content decreases
– Collagen fibers of AF become distorted
– Tears may occur in the lamellae

31. NOMENCLATURE AND
CLASSIFICATION
• The terminology to grade and report degenerative
disease of the spine has been controversial and
confusing.
• In 2001 a new nomenclature was proposed by the
Combined Task Forces of the North American Spine
Society, the American Society of Spine Radiology and
the American Society of Neuroradiology which
consists of a classification system for the reporting
on imaging studies based on pathology.

33. DEGENERATIVE
INTERVERTEBRAL DISC
CHANGES
• A. DISC BULGE
• B. ANNULAR TEAR
• C. HERNIATION
–PROTUSION
–EXTRUSION
–INTRAVERTEBRAL HERNIATION

34. • On MR, the earliest appearance of
degeneration of the nucleus is dessication,
manifest as low signal intensity on T2-
weighted images instead of high signal of
normally hydrated disks.
• the loss of height of the intervertebral space is
the earliest sign of disc degeneration on plain
radiographs.

35. Sagittal T2-weighted MR image of lumbosacral spine shows decreased T2
signal of L4/5 disk with loss of differentiation between nucleus and annulus
fibrosus suggestive of disk desiccation

36. • Other signs, including sclerosis of the vertebral
endplates, osteophytes, vacuum phenomenon
and calcification, are more reliable, though they
indicate late degenerative changes.

37. A ) DISC BULGE
• Generalized or circumferential disc displacement (involving
50% to 100% of the disc circumference) is known as
“bulging”, and is not considered a form of herniation

38. A ) DISC BULGE
• Generalized or circumferential disc displacement (involving
50% to 100% of the disc circumference) is known as
“bulging”, and is not considered a form of herniation
• Bulging can be symmetrical (displacement of disc
material is equal in all directions) or asymmetrical
( frequently associated with scoliosis)

39. • The term bulge refers to a morphologic characteristic
and is not correlated with etiology or symptomatology.

40. • The term bulge refers to a morphologic characteristic
and is not correlated with etiology or symptomatology.
• Bulging can be physiologic (e.g. in the mid-cervical
spine and at L5–S1), can reflect advanced degenerative
disc disease, can be associated with bone remodeling
(as in advanced osteoporosis), occur with ligamentous
laxity, or can be a “pseudo image” due to partial
volume averaging.

42. ANNULAR TEAR
• Disruption of concentric collagenous fibers
comprising the annulus fibrosus
MR Findings
• T1WI: Contrast-enhancing nidus in disc margin
• T2WI: High signal zone at edge of disc which has low
intrinsic signal

43. TYPES
• CONCENTRIC TEAR
TYPE 1
• RADIAL TEARS
TYPE 2
• TRANSVERSE TEARS
TYPE 3

44. CONCENTRIC TEAR
 Are circumferential lesions
which are found in the outer
layers of the annular wall.

45. CONCENTRIC TEAR
 Are circumferential lesions
which are found in the outer
layers of the annular wall.
 represent splitting between
adjacent lamellae of the
annulus, like onion rings.

46. CONCENTRIC TEAR
 Are circumferential lesions
which are found in the outer
layers of the annular wall.
 represent splitting between
adjacent lamellae of the
annulus, like onion rings.
 Most commonly
encountered in the outer
annulus fibrosus.

47. CONCENTRIC TEAR
 Are circumferential lesions
which are found in the
outer layers of the annular
wall.
 represent splitting
between adjacent
lamellae of the annulus,
like onion rings.
 Most commonly
encountered in the outer
annulus fibrosus.
• believed to be of traumatic
origin especially from
torsion overload injuries.

48. CONCENTRIC TEAR
 Are circumferential lesions
which are found in the
outer layers of the annular
wall.
 represent splitting
between adjacent
lamellae of the annulus,
like onion rings.
 Most commonly
encountered in the outer
annulus fibrosus.
• believed to be of traumatic
origin especially from
torsion overload injuries.

49. RADIAL TEAR
• an annular tear which
permeates from the deep
central part of the disc (nucleus
pulposus) and extends outward
toward the annulus, in either a
transverse or cranial-caudal
plane.
TRANSVERSE TEAR

50. RADIAL TEAR
• an annular tear which
permeates from the deep
central part of the disc (nucleus
pulposus) and extends outward
toward the annulus, in either a
transverse or cranial-caudal
plane.
• Morphological feature of DISK
DEGENERATION
TRANSVERSE TEAR
• “peripheral tears” or “rim
lesions,”
• Are horizontal ruptures of
fibers, near the insertion in the
bony ring apophyses.
• believed to be traumatically
induced and are often
associated with small
osteophytes.

51. RADIAL TEAR TRANSVERSE TEAR

53. On a CT discography. The black arrows
point to the concentric annular tear in the
periphery of the annulus. The white arrows
points to the central radial tear
In Fig. #1 the injected dye (black) does not
leak out of the nucleus. This is normal.
Fig.#2 demonstrates a massive Grade 4
radial disc tear. Note how the contrast
(black) has leaked out from the center of the
disc through a massive complete radial tear.

54. L4-L5 CT diskogram demonstrating
a large left posterolateral radial
annular tear associated with a left
foraminal and extraforaminal
herniation

55. DISC HERNIATION
• Disc herniation is defined as a focal
displacement of disc material ( < 25% of the
disc circumference) beyond the limits of the
intervertebral disc space.
• A herniated disc can be contained (covered by
outer annulus fibrosus) or uncontained.

56. DISC HERNIATION
• Disc herniation is defined as a focal
displacement of disc material ( < 25% of the
disc circumference) beyond the limits of the
intervertebral disc space.
 . DISC PROTRUSION
 DISC EXTRUSION
 INTRAVERTEBRAL HERNIATION

57. PROTRUDED DISC
 used when the base of the disc
is broader than any other
diameter of the displaced
material .
EXTRUDED DISC

58. PROTRUDED DISC
 used when the base of the disc
is broader than any other
diameter of the displaced
material .
EXTRUDED DISC
 used for a focal disc extension
of which the base against the
parent disc is narrower than
the diameter of the extruded
disc material,measured in the
same plane.

59. PROTRUDED DISC
 used when the base of the disc
is broader than any other
diameter of the displaced
material .
EXTRUDED DISC
 used for a focal disc extension
of which the base against the
parent disc is narrower than
the diameter of the extruded
disc material,measured in the
same plane.

60. PROTRUDED DISC
 used when the base of the disc
is broader than any other
diameter of the displaced
material .
 FOCAL
(involving <25% of the disc
circumference
 BROAD BASED
(involving 25%–50% of the
disc circumference

61. a, b Protrusions: the base of the herniated
disc material is broader than the apex.
Protrusions can be broad-based (a) or
focal (b)
a
b

62. PROTRUDED DISC
 used when the base of the disc
is broader than any other
diameter of the displaced
material .
EXTRUDED DISC
 used for a focal disc extension
of which the base against the
parent disc is narrower than
the diameter of the extruded
disc material,measured in the
same plane.
Extrusion: the base of the herniation is
narrower than the apex (toothpaste
sign)

63. • Extrusion is also used when there is no continuity
between the herniated disc material beyond the disc
space and that within the disc space
• If the displaced disc material has no connection with
the parent disc, it is called a “sequestrated
fragment” (Fig. 6.19). This is synonymous with a
“free fragment

64. MIGRATION – SEQUESTRATION
• Migration
indicates displacement of disc material away from the
site of extrusion, regardless of whether sequestrated or not.
• Sequestration
indicate that the displaced disc material has lost completely
any continuity with the parent disc.

65. A,- Small subligamentous herniation (protrusion) without
significant disk material migration.
B, - Subligamentous herniation with downward migration of disk
material under the PLLC.
C, - Sub-ligamentous herniation with downward migration of disk
material and sequestered fragment (arrow).

67. INTRAVERTEBRAL HERNIATIONS
• Herniated discs in the cranio - caudal (vertical)
direction through a break in one or both of the
vertebral body endplates are referred to as
“intravertebral herniations” also known as
Schmorl’s nodes

68. INTRAVERTEBRAL HERNIATIONS
• Herniated discs in the cranio - caudal (vertical)
direction through a break in one or both of the
vertebral body endplates are referred to as
“intravertebral herniations” also known as
Schmorl’s nodes
• They are often surrounded by reactive bone
marrow changes.

69. INTRAVERTEBRAL HERNIATIONS
• Herniated discs in the cranio - caudal (vertical)
direction through a break in one or both of the
vertebral body endplates are referred to as
“intravertebral herniations” also known as
Schmorl’s nodes
• They are often surrounded by reactive bone marrow
changes.
• Nutrient vascular canals may leave scars in the
endplates, which are weak spots representing a route
for the early formation of intrabody nuclear
herniations.

71. Vertebral Endplates and Bone Marrow
Changes
• The Modic classification describes degenerative and
inflammatory changes involving the vertebral endplates
and adjacent vertebral bodies as seen on MRI.

72. • Modic Type 1
• Modic Type 1 is seen as low signal intensity on T1WI and
high on T2WI, representing fibrovascular tissue,
inflammatory changes, and perhaps edema.
Type I changes may be chronic or acute.
• There is a correlation between low back pain and Modic
changes, especially Modic type 1

73. • Modic Type 2
Modic Type 2 is seen as high signal intensity on T1WI
and isointense or high on T2WI, representing bone
marrow replacement by fat.

74. • Modic Type 3
• Modic Type 3 is seen as low signal intensity on T1WI
and low on T2WI, representing reactive sclerosis.

76. Degenerative Changes of the
Posterior Elements
• 1. Facet Joints
• 2. Ligamentum Flavum
• 3. Spinal Canal
• 4. Spinous Process
• 5. Nerve root

77. Osteoarthritis of the Facet Joints
• Facet or Zygoapophyseal joints are synovium
lined joints,thus predisposed to arthropathy.
• Primary or secondary to disk degeneration.
• CT more sensitive for early changes
• FINDINGS are
– joint space narrowing
– Subchondral sclerosis and cyst formation
– Osteophyte formation
– Vacuum phenomenon
– Hypertrophy of articular processes

78. Weishaupt et al. refined the grading scale of Pathria et al. to grade facet joint
osteoarthritis on CT and MRI images

79. ■ Grading facet joint osteoarthritis. Axial reformatted CT images at L3–L4 (A) and L4–L5
(B). Grade 1 osteoarthritis of the right facet joint L3–L4 (mild hypertrophy) and grade 2
osteoarthritis of the left facet joint (narrowing of the joint space, moderate
hypertrophy and osteophytes, subarticular erosion) (A).
Grade 3 osteoarthritis of the right facet joint L4–L5 with joint space narrowing,
hypertrophy of the articular processes, large osteophytes and subarticular bone erosions
can be seen (B).

80. 2). LIGAMENTUM FLAVUM

81.  Degenerative Changes
 Partial ruptures, necrosis
and calcifications
 Negatively impact function
of motion segment

82. CYSTS OF THE LIGAMENTUM FLAVUM
• may be related to necrosis or myxoid
degeneration occurring in a hypertrophied
ligamentum flavum.
• Chronic degenerative changes in the
ligamentum flavum, followed by (repeated)
hemorrhage gives rise to small degenerative
cysts which enlarge and coalesce to form a
large cyst.
(Cakir et al.2004)

83. LIGAMENTUM FLAVUM
HYPERTROPHY
• Symmetrical thickening of the ligamentum
Flavum is a frequently observed finding in
facet joint arthropathy, contributing to
secondary spinal canal stenosis.

84. DISH
• DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS
• FORESTIERS DISEASE
• Bulky flowing ossification of anterior longitudinal
Ligament (ALL) involving thoracic and
enthesopathy.

87. Spondylosis Deformans & Intervertebral
Osteochondrosis
Spondylosis Deformans
• Paraphysiological
process/ageing process
Intervertebral Osteochondrosis

88. Spondylosis Deformans & Intervertebral
Osteochondrosis
Spondylosis Deformans
• Paraphysiological
process/ageing process
Intervertebral Osteochondrosis
• Pathological process

89. Spondylosis Deformans & Intervertebral
Osteochondrosis
Spondylosis Deformans
• Paraphysiological
process/ageing process
• Involves ANNULUS FIBROSIS
AND APOPHYSIS
Intervertebral Osteochondrosis
• Pathological process
• Involves NUCLEUS PULPOSIS
AND END PLATES

90. Spondylosis Deformans & Intervertebral
Osteochondrosis
Spondylosis Deformans
• Paraphysiological
process/ageing process
• Involves ANNULUS FIBROSIS
AND APOPHYSIS
• Hallmark is OSTEOPHYTOSIS
Bridging /traction osteophytes
Intervertebral Osteochondrosis
• Pathological process
• Involves NUCLEUS PULPOSIS
AND END PLATES
• DISC FISSURING ,SPACE
NARROWING,VACUUM
PHENOMENON ,END PLATE
EROSIONS and later
osteophtye formation

91. Spondylosis Deformans & Intervertebral
Osteochondrosis
Spondylosis Deformans
• Paraphysiological
process/ageing process
• Involves ANNULUS FIBROSIS
AND APOPHYSIS
• Hallmark is OSTEOPHYTOSIS
Bridging /traction osteophytes
Intervertebral Osteochondrosis
• Pathological process
• Involves NUCLEUS PULPOSIS
AND END PLATES
• DISC FISSURING ,SPACE
NARROWING,VACUUM
PHENOMENON ,END PLATE
EROSIONS and later
osteophtye formation

92. Spondylosis Deformans & Intervertebral
Osteochondrosis
Spondylosis Deformans
• Paraphysiological
process/ageing process
• Involves ANNULUS FIBROSIS
AND APOPHYSIS
• Hallmark is OSTEOPHYTOSIS
Bridging /traction osteophytes
• Plain film is adequate for Dx

93. Spondylosis Deformans & Intervertebral
Osteochondrosis
Intervertebral Osteochondrosis
• Pathological process
• Involves NUCLEUS PULPOSIS
AND END PLATES
• DISC FISSURING ,SPACE
NARROWING,VACUUM
PHENOMENON ,END PLATE
EROSIONS and later
osteophyte formation
• MRI and CT

94. Spinous Process Abnormalities (Baastrup’s Disease)and
Associated Ligamentous Changes
• Baastrup’s disease, also known as kissing spine.
• a cause of low-back pain.
• characterized by close approximation and contact of adjacent
spinous processes with resultant enlargement, flattening and
reactive sclerosis of the apposing interspinous surfaces.
• Neoarthrosis between the spinous processes.
• Patients with Baastrup’s disease may experience pain.
• owing to irritation of the periosteum or adventitial bursae
between
abutting spinous processes.
• They may be treated with steroid injections .

96. COMPLICATIONS OF
DEGENERATIVE SPINAL
DISEASES
• SPINAL AND FORAMINAL
STENOSIS
• SCOLIOSIS AND KYPHOSIS
• SEGMENTAL INSTABILITY

97. Spinal and foraminal narrowing
• Usually the cervical and lumbar spine
• The diagnosis of SPINAL CANAL STENOSIS
should be considered if,
– AP diameter of the CERVICAL or LUMBAR CANAL is
LESS THAN 12mm .
– Ratio b/w canal sagittal dia &vertebral body
sagittal dia is ˂ 0.8
• Stenosis is severe if CSF signal is completely
effaced on axial T2WI or CT myelogram.
• Myelopathy is most serious complication of
canal stenosis.

99. Sagittal T2-weighted image of the cervical spine shows multiple disk
bulges and posterior longitudinal ligament thickening resulting in thecal
sac indentation with hyperintense signal within the cord suggesting
myelopathy.

100. OPLL
• Ossification of posterior Longitudinal
ligament.

101. SPONDYLOLISTHESIS
• Spondylolisthesis (also known as anterolisthesis) is
defined as an anterior displacement of a vertebra
relative to the vertebra below, whereas the reverse,
i.e. when the superior vertebra slips posterior to
that below, is called retrolisthesis.

102. SPONDYLOLISTHESIS
• Degenerative spondylolisthesis, (Newman 1955), most
frequently is found at the lumbar and cervical level.
• In contrast to what happens in isthmic
spondylolisthesis, particularly if bilateral, there is a
spinal canal stenosis due to arthritic facet joints and
hypertrophic yellow ligaments with associated
narrowing of the neural foramen and the lateral recess.
Obliterated anterior fat tissue, lost periradicular tissue,
and compression of the dural sac are observed. If
unilateral, the side of the degenerated facet joints is
mostly stressed (Osborn 1994).

103. GRADING OF LUMBAR
SPONDYLOLISTHESIS
• Method of Meyerding
 the anteroposterior (AP)
diameter of the superior
surface of the lower vertebra
is divided into quarters and a
grade of I– IV is assigned to
slips of one, two, three or
four quarters of the superior
vertebra,respectively.
• Method of Taillard.

104. GRADING OF LUMBAR
SPONDYLOLISTHESIS
• Method of Meyerding
 the anteroposterior (AP)
diameter of the superior
surface of the lower vertebra
is divided into quarters and a
grade of I– IV is assigned to
slips of one, two, three or
four quarters of the superior
vertebra,respectively.
• Method of Taillard.
 expresses the degree of
slip as a percentage of
the AP diameter of the
top of the lower
vertebra