Bulging, herniated or degenerative intervertebral disc and spinal stenosis

Question 1

What is a degenerative intervertebral disc?

Answer 1

A complex, multi-factorial, clinical condition characterised by low back pain with or without the concurrence of radicular lower limb symptoms in the presence of radiologically-confirmed degenerative disc disease.

The pain is exacerbated by activity, but maybe present in certain positions, such as sitting.

Question 2

What is the presentation of a degenerative intervertebral disc?

Answer 2

Symptoms worsen with forward flexion, coughing/sneezing, or heavy lifting; facet mediated pain is typically worse with extension.

Low back pain that worsens with axial loading (standing or sitting).

Pain is frequently referred to the paraspinal muscles, buttocks, and the back of the thighs.

Radicular leg pain resulting from nerve root compression.
Pain is exacerbated by motion and relieved by rest.

Question 3

How do you examine for a degenerative intervertebral disc?

Answer 3

Positive straight leg raises- pain is reproduced by passively raising the extended leg (positive Lasegue sign).

This is suggestive of compressive or inflammatory nerve root pathology (sciatia).

Question 4

What are the risk factors for degenerative intervertebral disc?

Answer 4

Increasing age
Genetic influence 
Occupation (excessive axial loads, vibrations from transportation)
Tobacco smoking
Facet joint tropism and arthritis 
Abnormal pelvic morphology 
Changes in sagittal alignment

Question 5

What are the investigations for bulging, herniated or degenerative intervertebral disc?

Answer 5

Erect lumbar spine x-ray (upright anteroposterior and lateral plain radiographs)

MRI spine (nerve root compression, canal compression due to hypertrophied ligamentum flavum, and the facet joints)

CT spine (indicated if MRI is contraindicated, in post-operative cases to assess the implant positioning or surgical fusion)

Question 6

What are the differentials of a bulging, herniated or degenerative intervertebral disc?

Answer 6

Spinal tumour 
Spinal infection 
Postural back pain 
Muscular pain secondary to lower extremity malalignment
Sacroiliac joint pathology 
Intra-abdominal pathology 
Pelvic pathology 
Myopathy

Question 7

What is the management of a bulging, herniated or degenerative intervertebral disc?

Answer 7

Neurological emergency (nerve root deficit or cauda equina syndrome)- neural decompression (A presumed diagnosis of cauda equina syndrome (CES) necessitates an urgent referral to the hospital. CES consists of saddle (perineal) anaesthesia, sphincteric dysfunction, bladder retention, and leg weakness. Emergency decompression of the spinal canal within 48 hours after the onset of symptoms is required.)

Acute back pain: <3 months duration from initial presentation or exacerbation of chronic pain
-1st line: paracetamol and/or oral NSAID (adjunct- topical analgesia (capsaicin or diclofenac), opioid analgesia (codeine), muscle relaxant (diazepam), physiotherapy, facer joint blocks, selective nerve root block or epidural injection (used in radicular leg pain associated with degenerative disc disease), neural decompression)

Chronic back pain: >3 months duration from initial presentation

• 1st line: Continued pain management (paracetamol and/or ibuprofen)
• Adjunct: pain clinic referral, functional/vocational rehabilitation, alternative therapies (acupuncture, acupressure and yoga), amitriptyline, physiotherapy, facet joint blocks, spinal fusion (in spinal instability like trauma, tumour, infection and deformity), pregabalin, selective nerve root block or epidural injection and neural decompression.

TENS is transcutaneous electrical nerve stimulation and applied small electrodes to the body via superficial skin electrodes to achieve analgesia. Based on the gate theory of pain, stimulation of large unmyelinated fibres at the level of the spinal cord blocks transmission of pain by small unmyelinated fibres at the level of the spinal cord. TENS may also increase endorphin levels in CSF. It is not curative but may be used if other treatments have failed.

Question 8

What is spinal stenosis?

Answer 8

Lumbar spondylosis refers to degenerative conditions of the lumbar spine that narrow the spinal canal, lateral recesses, and neural foramina.

Facet joint and ligamentous hypertrophy, intervertebral disc protrusion, and spondylolisthesis may all contribute to the stenosis, and symptoms result from neural compression of the cauda equina, exiting nerve roots, or both.

Patients present with symptoms of neurogenic claudication or radiculopathy.

Question 9

What is the presentation of spinal stenosis?

Answer 9

Intermittent pain radiating to the thigh or legs, worse with prolonged standing, activity, or lumbar extension.

Pain is typically relieved by sitting, lying down, and/or lumbar flexion.

Patient may describe intermittent burning, numbness, heaviness, or weakness in their legs, unilateral or bilateral radicular pain, motor deficits, bowel and bladder dysfunction, and back and buttock pain with standing and ambulation.

Question 10

How do you examine for spinal stenosis?

Answer 10

Patients walk with a forward flexed gait.

Patients with vascular claudication have diminished pulses and typical skin changes, such as mottled discolouration, thinning and shiny skin.

Question 11

Risk factors of spinal stenosis

Answer 11

Age > 40 years
Previous back surgery 
Previous injury 
Achondroplasia 
Acromegaly

Question 12

Investigations of spinal stenosis

Answer 12

X-ray- degenerative changes or spondylolisthesis.

MRI- Compression of the neural elements and soft tissue.

Question 13

Treatment of spinal stenosis

Answer 13

Significant acute neurological deficit: Surgical decompression

No significant acute neurological deficit: pain affecting quality of life

• Analgesics- ibuprofen, naproxen
• Non-pharmaceutical measures- short-term bed rest, avoid repetitive bending, lifting, or twisting movements until the pain subsides.
• Oral corticosteroids- prednisolone.
• Epidural corticosteroid injection

Chronic symptoms

• Analgesics
• Non-pharmaceutical measures- short-term bed rest, avoid repetitive bending, lifting, or twisting movements until the pain subsides.
• Chronic pain agents- Gabapentin, duloxetine, amitriptyline
• Surgery

Question 14

What is the secondary prevention of spinal stenosis?

Answer 14

Patients should be encouraged to take a daily walk; this serves not only to aid in physical conditioning but will create conditions under which patients will be better able to follow symptom severity.

Walking also improves core strengthening and cardiovascular fitness, both of which might help to control the symptoms of spinal stenosis.

Question 15

What are the complications of spinal stenosis?

Answer 15

Cauda equina compression

Permanent neurological deficit

Complications from immobility

Progression of spondylolisthesis after surgery