This document discusses degenerative spine diseases, including anatomy of the intervertebral disc, degenerative changes, symptoms, diagnosis, and management. The intervertebral disc has two main components - the annulus fibrosis and nucleus pulposus. Degenerative changes include decreases in water and proteoglycan content as well as tears in the annulus fibers. Common symptoms are back and leg pain, numbness, and weakness. Diagnosis involves physical exam, imaging like MRI, and ruling out other causes. Treatment options include conservative measures like medication and physical therapy as well as surgery for severe cases.

1. Degenerative Spine Diseases
Mahmoud Saad MD.,
Associate Professor Neurosurgery
Mansoura College of Medicine

2. Anatomy of the intervertebral disc
Two major components
 Annulus fibrosis: thick, fibrous
“radial tire” called lamellae
 Nucleus pulposus: ball-like gel

3. Degenerative changes of the disc
Pathological changes:
1. Decrease :Water and proteoglycan content.
2. Distortion :Collagen fibers of AF.
3. Tears :in the lamellae.
Results in:
1. Decreased disc height and volume.
2. Decreased resistance to loads.

4. Glossary
1. Compression:
• Harmful compresion on the spinal cord or nerve roots.
• Bone spurs, thickened ligaments, and herniated discs
2. Myelopathy:
• A reduction in the spinal cord’s ability to send signals
between brain and body.
• (Gr. myelos = marrow, pertaining to the spinal cord, pathos = disease) results from spinal
cord damage.
• Compression of the spinal cord → weakness, numbness,
clumsiness, and/or bowel and bladder incontinence.
• Most common :Cervical spondylotic myelopathy (CSM)

5. Glossary
3. Radiculopathy:
• The consequence of nerve root damage (from any
cause)
• (L. radicula = little root; pathos = disease).
• A reduction in a nerve root’s ability to send signals
between spinal cord and body.
• → pain, weakness, or numbness in the area
supplied .
• A sharp shooting pain (may worsen with certain
movements) + numbness + weakness + tingling +
loss or change in sensation + loss of reflexes
• Most common radicular pain: sciatica – brachialgia

6. 4. Stenosis: a narrowing of the spinal canal → compress
spinal cord or nerve roots → myelopathy or neurogenic
claudication.
5. Arthritis: joint inflammation → pain and stiffness. The
most common type is osteoarthritis
6. Bone spurs: extra bone that may grow on joints
affected by osteoarthritis → compress the spinal cord or
nerve roots.

7. Symptoms
• Degenerative spine conditions vary widely in
presentation.
• Asymptomatic
• Symptomatic

8. Red Flags
1. Back pain + sphincteric incontinence + saddle shaped area
anesthesia → indicate cauda equina syndrome (urgent).
2. Myelopathy = Neck or back pain + weakness , numbness, or pins-
and-needles in the arms or legs
3. Radiculopathy = Neck or back pain that radiates (spreads) into the
shoulder, arm, hand, leg, or foot.
4. Neck or back pain +
• Fever.
• Gets worse during the night.
• Unexplained weight loss.
• Continues for several weeks or months.
• Following a fall, injury or other trauma.
5. Neck pain + difficulty breathing or swallowing.

9. Risk factors
1. Aging.
2. Genetic predisposition.
3. Smoking, diet, weight.
4. Occupational (heavy lifting).
5. Sedentary lifestyle.

10. IVD Degeneration
Disc
bulge
Annular
tear
Herniation

11. • X-ray: show spinal degenerative changes but not a
herniated disc; rule out obvious underlying problems.
• CT: relatively less used.
• MRI: The best.
Imaging

12. Disc Bulge
Type
Symmetrical
Displacement of
disc material is
equal in all
directions
Asymmetrical
Frequently
associated with
scoliosis.
Distribution
Generalized
circumferential
• Not considered a form of herniation

13. Asymmetrical bulge
Symmetrical bulge
Normal IVD
Can be associated with
scoliosis.Bulging discs are
not considered a form of
herniation.
The disc tissue extends
concentrically beyond the
edges of the ring apophyses
(50%–100% of disc
circumference).
Does not extend beyond the
edges of the ring apophyses
(black line).

16. Concentric Tears Transverse Tears /
Peripheral Tears Rim
Lesions
Radial Tears
Annular Tear
Disruption of concentric collagenous fibers comprising the
annulus fibrosus

17. MR Findings
• T1WI: Contrast-enhancing nidus in disc margin.
• T2WI: HIZ (high intensity signal zone) at edge of disc .

18. Disc Herniation
Localized displacement of disc material (nucleus,
cartilage, fragmented apophyseal bone, fragmented
annular tissue) beyond the limits of the intervertebral
disc space

20. • Majority of disc herniation occur in
Lumbar region (95% in L4-L5 or L5-S1).
• The second most common site is the
Cervical region (C5-C6, C6-C7).
• The thoracic region accounts for only
0.15% to 4.0% of cases.
• Herniations location : usually
posterolateral
• The anulus fibrosus is relatively thin
and is not reinforced by the posterior
or anterior longitudinal ligament.

23. Types of disc herniation
CT or MRI scans
Broad-based Focal
Protrusions: The base of the herniated disc material is broader than the apex.

25. Extruded Disc Herniations
Extrusion :The base of the herniation is narrower than
the apex (toothpaste sign)

27. Massive lumbar disc extrusion at L 5
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29. Migration – Sequestration
Migration:
Displacement of disc material away from the site of extrusion +
sequestrated .
Sequestration:
Displaced disc material has lost completely any continuity with the
parent disc

31. Lumbar Disc Herniation
• Epidemiology
• 95% involve L4/5 or L5/S1 levels
• L5/S1 most common level
• peak incidence is 4th and 5th decades
• only ~5% become symptomatic
• 3:1 male: female ratio
• Pathoanatomy
• Recurrent torsional strain leads to tears of outer annulus which leads
to herniation of nucleus pulposis
• Prognosis
• 90% of patients will have improvement of symptoms within 3 months
with nonoperative care.
• Size of herniation decreases over time (reabsorbed)
• Sequestered disc herniations show the greatest degree of spontaneous
reabsorption
• Macrophage phagocytosis is mechanism of reabsorption

32. Classification of LDH
Location
Central prolapse
• Often associated with back pain only
• May present with cauda equina syndrome which is a surgical emergency
Posterolateral (paracentral)
• Most common (90-95%)
• PLL is weakest here
• Affects the traversing/descending/lower nerve root
• At L4/5 affects L5 nerve root
Foraminal (far lateral, extraforaminal)
• Less common (5-10%)
• Affects exiting/upper nerve root
• At L4/5 affects L4 nerve root
• Herniated disc material directly compresses dorsal root ganglion
• Can manifest with more severe pain than traditional posterolateral disc
herniation
Axillary
• Can affect both exiting and descending nerve roots

33. Classification of LDH
Anatomical
Protrusion
• Eccentric bulging with an intact annulus
Extrusion
• Disc material herniates through annulus but remains continuous
with disc space
Sequestered fragment (free)
• Disc material herniates through annulus and is no longer
continuous with disc space

34. Protrusions Extruded Sequestered

35. Far lateral disc herniation

36. Cauda Equina Syndrome
• Is a serious neurologic condition
in which damage to the cauda
equina
• Loss of function of the lumbar
plexus (nerve roots) of the spinal
canal below the termination
(conus medullaris) of the spinal
cord.
• Lower motor neuron lesion.

37. Symptoms
Cauda equina syndrome (present in 1-10%)
1. Saddle anesthesia.
2. Bladder and bowel dysfunction.
3. Anal and Achilles reflex absent.
4. Sexual dysfunction.
5. Bilateral Severe leg pain
6. LE weakness

38. Diagnosis LDP
Physical examination
• Neurological exam (sensory-motor-reflexes).
• Provocative tests
Imaging
• MRI (usually provides the most accurate assessment of the
lumbar spine area).
• CT.
• X-ray.
Neurophysiological
• EMG.

39. Symptoms
1. Pain (lumbar, leg, foot,
nerve).
2. Numbness.
3. Muscle weakness
4. Foot drop (difficulty lifting
the foot when walking or
standing).
5. A loss of bladder or bowel
control, lower back pain,
numbness in the saddle
area, and/or weakness in
both legs are signs of a rare
but serious condition called
cauda equina syndrome.

42. Provocative tests
Straight leg raise:
• A tension sign for L5 and S1 nerve root
Contralateral SLR:
• Crossed straight leg raise is less sensitive but more specific
Lasegue sign:
• SLR aggravated by forced ankle dorsiflexion
Bowstring sign:
• SLR aggravated by compression on popliteal fossa
Kernig test:
• Pain reproduced with neck flexion, hip flexion, and leg extension
Naffziger test:
• Pain reproduced by coughing, which is instigated by lying patient
supine and applying pressure on the neck veins
Milgram test:
• Pain reproduced with straight leg elevation for 30 seconds in the
supine position

43. Straight leg raise
• Can be done sitting or supine.
• Reproduces pain and paresthesia in leg at 30-70 degrees hip flexion.
• Most important and predictive physical finding for identifying who is a good
candidate for surgery.

44. Radiographs
• Traction spurs.
• Disc space narrowing.

45. CT Scan

46. MRI
• The investigation of choice
• There is a 29% prevalence of disc
herniation in asymtomatic individuals.

47. Differential diagnosis
1. Secondary tumors and multiple myeloma of the
lumbar spine which usually cause vertebral
destruction with sparing of the discs.
2. Fractures and infections.
3. Sacroiliac joint dysfunction.

48. Natural History
1. Prognosis of disc herniation is generally good regardless
of treatment.
2. Patients operated on for proven disc herniations
improved more rapidly than patients treated non
operatively.
3. Of all patients who sustain acute sciatica, less than 25%
will require surgery.

49. Management of lumbar disc prolapse
Conservative
Non operative
Selective nerve
root corticosteroid
injections
Surgical

50. Conservative treatment
Indications:
1. First line of treatment for most patients with disc herniation
2. 90% improve without surgery
Technique:
• Bedrest followed by progressive activity as tolerated
• Medications:
1. NSAIDS
2. Muscle relaxants (more effective than placebo but have side effects)
3. Oral steroid taper
• Physical therapy:
1. Extension exercises extremely beneficial
2. Traction
3. Chiropractic manipulation

51. Selective nerve root corticosteroid
injections
Indications:
• Second line of treatment if therapy and medications fail
Technique:
• Epidural
• Selective nerve block
Outcomes:
• Leads to long lasting improvement in ~ 50% (compared to
~90% with surgery)
• Results best in patients with extruded discs as opposed to
contained discs

52. Surgical
Indications:
1. Persistent disabling pain lasting more than 6 weeks that have
failed nonoperative options (and epidural injections)
2. Progressive and significant weakness
3. Cauda equina syndrome
Technique:
Laminotomy and discectomy (microdiscectomy)

54. Surgery

56. Complications
1. Dural tear (1%):
• If have tear at time of surgery then perform water-tight repair
• Has not been shown to adversely affect long term outcomes
2. Recurrent HNP:
• Can treat nonoperatively initially - revision rate a 8-yr-FU is 15%
• Outcomes for revision discectomy have been shown to be as
good as for primary discectomy
3. Chronic low back pain:
• Not completely understood but central sensitization may be a
factor
• Amplification of neural signaling within the central nervous
system (CNS) that elicits pain
4. Vascular catastrophe:
• Caused by breaking through anterior annulus and injuring vena
cava/aorta
5. Instability.
6. Discitis (1%).

57. Cervical Disc Herniation
1. Most often between (C5/6) and (C6/7).
2. Symptoms can affect the back of the skull, the
neck, shoulder girdle, scapula, arm, and hand.
3. The nerves of the cervical plexus and brachial
plexus can be affected.

58. Symptoms
1. Pain (neck, shoulder, arm, hand).
2. Radiculopathy.
3. Numbness.
4. Muscle weakness.
5. Paresthesia.
6. Severe cases: myelopathy + sphincteric disturbance
(urinary incontinence and loss of bowel control).

61. Diagnosis
1. Cervical Compression Test (Spurling's test):
• Laterally flexing the patient's head + placing downward pressure on it
• Positive test = Neck or shoulder pain on the ipsilateral side (i.e. the side to
which the head is flexed)
2. Lhermitte sign:
• Feeling of electrical shock with patient neck flexion.

63. MRI and CT scans:
• Helpful for CDP diagnosis
• Must be considered together with physical examinations + history.

64. Treatment
•Conservative:
1. Medications(NSAID).
2. Physical therapy and exercise.
3. Steroid injection.
•Surgery:
1. Anterior cervical discectomy and spine fusion (ACDF):
This is the most common method
2. Posterior cervical discectomy.
3. Cervical artificial disc replacement.

67. Spinal Canal Stenosis
• Abnormal narrowing (stenosis) of the spinal canal that may
occur in any of the regions of the spine → restriction to the
spinal canal → neurological deficit.
• Symptoms: pain, numbness, paraesthesia, and loss of motor
control.

68. Lumbar canal stenosis
Incidence:
Most common reason for lumbar spine surgery in pts > 65 yrs old
seen in 20-25%
Demographics:
Slightly more common in males (1.5:1)
Average age at presentation is 65 years old
Location:
Most commonly occurs at L4-5 (91%)
Risk factors:
Caucasian race
Increased BMI
Congenital spine anomalies (20%)
Failure of posterior elements to develop, short pedicles and
laminae

69. Classification
1. Central stenosis
2. Lateral recess stenosis
3. Foramen stenosis
4. Extraforaminal Stenosis

70. Symptoms
1. Back pain
2. Referred buttock pain
3. Leg pain : Often unilateral
4. Neurogenic claudication :
• Pain worse with extension (walking, standing upright)
• Pain relieved with flexion (sitting, leaning over shopping
cart, sleeping in fetal position)
5. Weakness
6. Bladder disturbances: Recurrent UTI present in up to
10% due to autonomic sphincter dysfunction
7. Cauda equina syndrome (rare)

71. Clinical Findings
1. Kemp sign
• Unilateral radicular pain from foraminal stenosis made
worse by back extension
2. Straight leg raise (tension sign)
• Usually, negative
3. Valsalva test
• Radicular pain not worsened by Valsalva as is the case with
a herniated disc
• Normal Neurologic Exam
• Patients may have no focal deficits, as exam often takes
place with patient seated and symptoms may be
reproducible or exacerbated only with lumbar extension or
ambulation

74. Nonoperative
Oral medications, physical therapy, and corticosteroid
injections
• Indications: First line of treatment.
• Modalities :
1. NSAIDS, physical therapy, weight loss and bracing.
• Preoperative opioid use associated with prolonged hospital
stays and increased postoperative pain.
2. Steroid injections (epidural and transforaminal):
• Found to be effective and may obviate the need for surgery.

75. Surgical Treatment
1. Wide pedicle-to-pedicle decompression:
• Indications
1. Persistent pain for 3-6 months that has failed to improve with
nonoperative management
2. Progressive neurologic deficits (weakness or bowel/bladder)
2. Wide pedicle-to-pedicle decompression with
instrumented fusion
• Indications
1. Segmental instability (isthmic spondylolisthesis, degenerative
spondylolisthesis, degenerative scoliosis)
2. Surgical instability:Created by complete laminectomy and/or
removal of > 50% of facets
3. Risk of adjacent segment degeneration >30% at 10 years

76. Spondylosis
1. Spondylosis is a broad term meaning degeneration of the spinal column
from any cause.
2. In the more narrow sense it refers to spinal osteoarthritis, age-related
wear and tear of the spinal column → the most common cause of
spondylosis.
3. Osteoarthritis chiefly affects the vertebral bodies, the neural foramina and
the facet joints (facet syndrome).

77. Spinal Instability
• Spondylolisthesis (AKA anterolisthesis) = Anterior displacement
of a vertebra relative to the vertebra below.
• Retrolisthesis: The superior vertebra slips posterior to that
below.

79. Type Cause
Dysplastic Congenital dysplasia of the articular processes
Isthmic Defect in the pars articularis
Degenerative Degenerative changes in the facet joints
Traumatic Fracture of the neural arch other than the pars articularis
Pathological Weakening of the neural arch due to disorders of the bone
Iatrogenic Excessive removal of bone following spinal
decompression
Aetiological Classification of Spondylolisthesis

80. Isthmic Spondylolisthesis
• Most common form; AKA Spondylolytic Spondylolisthesis
• The pars interarticularis (AKA Isthmus) is the part of the neural arch that
joins the superior and inferior articular processes.
• A bilateral defect in the pars interarticularis is present.

82.  A lumbar spondylolisthesis without a defect in the pars
 Most common : L4–L5 level
Degenerative Spondylolisthesis

84. Dynamic radiographs
•Flexion-Extension X-rays.

88. Clinical picture
1. Axial back pain:
• Most common presentation.
• Pain usually has a long history with periodic episodes that vary in
intensity and duration.
2. Leg Pain:
• Usually a L5 radiculopathy (foraminal stenosis at the L5-S1 level).
3. Neurogenic Claudication:
• Caused by spinal stenosis.
• Characterized by buttock and leg pain worse with walking.
• Symptoms of neurogenic claudication rare because these slips
rarely progress beyond Grade II.
4. Cauda Equina Syndrome:
• Rare because these slips rarely progress beyond Grade II.
5. Physical Exam.:
• L5 radiculopathy: Ankle dorsiflexion and EHL weakness.

89. Treatment
• Nonoperative:
Oral medications, lifestyle modifications, therapy
• Indications:
• Most patients can be treated nonoperatively.
• Techniques:
1. Activity restriction.
2. NSAID.
3. Role of injections unclear.
4. Bracing may be beneficial especially in the acute phase.

90. Operative
• L5-S1 decompression and instrumented fusion +/- reduction
• Indications:
1. L5-S1 low-grade spondylolisthesis with persistent and
incapacitating pain that has failed 6 months of nonoperative
management (most common).
2. Progressive neurologic deficit.
3. Slip progression.
4. Cauda equina syndrome.
• Reduction:
 Improved sagittal balance with reduction.
 Risk of stretch injury to L5 nerve root with reduction.

91. Operative
• L4-S1 decompression and instrumented fusion + reduction
• Indications:
 High-grade spondylolithesis L5-S1 + persistent , incapacitating
pain
 Failed nonoperative management for 6 months
• ALIF
• Indications:
1. Low-grade isthmic spondylolisthesis +radicular symptoms
2. Cannot be used to treat high grade isthmic spondylolisthesis
due to translational and angular deformity
• Outcomes:
• Studies have shown good to excellent results in 87-94% at 2 years

94. Thank You