L7: Spinal Degenerative Diseases Flashcards
1
Q
Anatomical Overview of the vertebra
A
2
Q
Pathology in Degenerative Disease of the Spine
A
3
Q
Compression of the spinal Cord
A
4
Q
Myelopathy
A
5
Q
Most Common Myelopathy
A
Cervical spondylotic myelopathy (CSM)
6
Q
Radiculopathy
A
7
Q
Most Common Radicular Pain
A
sciatica - brachialgia
8
Q
Stenosis
A
9
Q
Spinal Degenerative Diseases
- Arthritis
A
10
Q
Spinal Degenerative Diseases
- Bone Spurs
A
11
Q
Symptoms of Spinal Degenerative Diseases
A
12
Q
Red Flags of Spinal Degenerative Diseases
A
13
Q
Red Flags of Spinal Degenerative Diseases
- Cauda Equina Syndrome
A
14
Q
Red Flags of Spinal Degenerative Diseases
- Myelopathy
A
15
Q
Red Flags of Spinal Degenerative Diseases
- Radiculopathy
A
16
Q
Red Flags of Spinal Degenerative Diseases
- Others
A
17
Q
RF for Spinal Degenerative Diseases
A
- Aging.
- Genetic predisposition.
- Smoking, diet, weight.
- Occupational (heavy lifting).
- Sedentary lifestyle.
18
Q
Types of Spinal Degenerative Diseases
A
A) Disc bulge.
B) Annular tear.
C) Herniation.
19
Q
Def of Disc Bulge
A
20
Q
Normal IVD
A
21
Q
Classification of Disc Bulge
A
22
Q
Def of Annular Tear
A
Disruption of concentric collagenous fibers comprising the anulus fibrosus.
23
Q
Types of Annular Tear
A
24
Q
MRI of Annular Tear
A
25
Def of **Disc Herniation**
26
Types of **Disc Herniation**
Notes
27
Types of **Disc Herniation**
- Protrusion
The base of the herniated disc material is broader than the apex.
28
Types of **Disc Herniation**
- Extruded Disc Herniation
The base of the herniation is
narrower han the apex (toothpaste sign)
29
Types of **Disc Herniation**
- The Third Type?
30
Regions Affected by **Disc Herniation**
31
Epidemeology of **Lumbar Disc Prolapse**
32
Pathoanatomy of **Lumbar Disc Prolapse**
33
Prognosis of **Lumbar Disc Prolapse**
- 90% of patients will have improvement of symptoms within 3 months with nonoperative care
34
Reabsorbtion in **Lumbar Disc Prolapse**
- def
- Mechanism
- Type
35
Classification of **Lumbar Disc Prolapse**
- According to Location
- According to Anatomy
36
Classification of **Lumbar Disc Prolapse**
- Acoording to location
37
Classification of **Lumbar Disc Prolapse**
- Central Prolapse
- Often associated with back pain only
- May present with Cauda equina syndrome (surgical emergency)
38
Classification of **Lumbar Disc Prolapse**
- Posterolateral Prolapse (Paracentral)
39
Classification of **Lumbar Disc Prolapse**
- Foraminal Prolapse (Far Lateral, Extraforaminal)
40
Classification of **Lumbar Disc Prolapse**
- Axillary Prolapse
Can affect Both exiting and descending nerve roots
41
Classification of **Lumbar Disc Prolapse**
- According to Anatomy
42
Dx of **Lumbar Disc Prolapse**
- Physical Examination
- Imaging
- Neurophysiological
43
Dx of **Lumbar Disc Prolapse**
- Physical Examination
- Neurological exam (sensory-motor-reflexes).
- Provocative tests
44
Dx of **Lumbar Disc Prolapse**
- Imaging
45
Imaging in **Lumbar Disc Prolapse**
- MRI
**MRI (Investigation of choice)**
- Most accurate assessment of lumbar spine area
- There is a 29% prevalence of disc herniation in asymtomatic individuals.
46
Imaging in **Lumbar Disc Prolapse**
- CT
...
47
Imaging in **Lumbar Disc Prolapse**
- X-ray
traction spurs & disc space narrowing
48
Dx in **Lumbar Disc Prolapse**
- Neurophysiological
EMG
49
Symptoms of **Lumbar Disc Prolapse**
50
Def of **Cauda Equina Syndrome**
Serious neurologic condition in which damage to the cauda equina
51
Pathophysiology of **Cauda Equina Syndrome**
- 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
52
Symptoms of **Cauda Equina Syndrome**
53
**Lumbar Disc Prolapse**
- L4
54
**Lumbar Disc Prolapse**
- L5
55
**Lumbar Disc Prolapse**
- S1
56
Provocative Tests in **Lumbar Disc Prolapse**
57
Provocative Tests in **Lumbar Disc Prolapse**
- Straight Leg Raise
58
Provocative Tests in **Lumbar Disc Prolapse**
- Contralateral SLR
Crossed straight leg raise is less sensitive but more specifid
59
Provocative Tests in **Lumbar Disc Prolapse**
- Lassegue Sign
SLR aggravated byforced ankle dorsiflexion
60
Provocative Tests in **Lumbar Disc Prolapse**
- Bowstring Sign
SLR aggravated by compression on popliteal fossa
61
Provocative Tests in **Lumbar Disc Prolapse**
- Kernig Test
Pain reproduced with neck flexion, hip flexion, and leg extension
62
Provocative Tests in **Lumbar Disc Prolapse**
- Nafziger Test
- Pain reproduced by foughing
- Instigated by lying patient supine & applying pressure on neck veins
63
Provocative Tests in **Lumbar Disc Prolapse**
- Milgram Test
- Pain reproduced with straight leg elevation for 3o seconds in the supine)position
64
DDx of **Lumbar Disc Prolapse**
65
Prognosis of **Lumbar Disc Prolapse**
66
Management of **Lumbar Disc Prolapse**
1) Conservative (Non operative)
2) Selective nerve root corticosteroid injections
3) Surgical
67
Management of **Lumbar Disc Prolapse**
- Conservative
68
Conservative Management of **Lumbar Disc Prolapse**
- Indications
1) First line of treatment for most patients with disc herniation
2) 90% improve without surgery
69
Conservative Management of **Lumbar Disc Prolapse**
- Methods
70
Selective Nerve Root Corticosteroids Injections of **Lumbar Disc Prolapse**
71
Selective Nerve Root Corticosteroids Injections of **Lumbar Disc Prolapse**
- Indication
Second line of treatment if therapy and medications fail
72
Selective Nerve Root Corticosteroids Injections of **Lumbar Disc Prolapse**
- Methods
- Epidural
- Selective nerve block
73
Selective Nerve Root Corticosteroids Injections of **Lumbar Disc Prolapse**
- Outcome
- Leads to long lasting improvement in 50% compared to ~90% with surgery)
- Results best in patients with extruded discs is opposed to contained
74
Surgical TTT of **Lumbar Disc Prolapse**
75
Surgical TTT of **Lumbar Disc Prolapse**
- Indications
76
Surgical TTT of **Lumbar Disc Prolapse**
- Methods
77
Complications of **Surgical TTT of Lumbar Disc Prolapse**
78
Comlications of **Lumbar Disc Prolapse**
- dural Tear
- If have tear at time of surgery then perform water-tight repair
- Has not been shown to adversely affect long term outcomes
79
Comlications of **Lumbar Disc Prolapse**
- 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
80
Comlications of **Lumbar Disc Prolapse**
- 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
81
Comlications of **Lumbar Disc Prolapse**
- Vascular Catastrophe
- Caused by breaking through anterior annulus and injuring vena cava/aorta
82
Comlications of **Lumbar Disc Prolapse**
- Instability
....
83
Comlications of **Lumbar Disc Prolapse**
- Discitis
......
84
Epidemeology of **Cervical Disc Prolapse**
- Most often between (C5/6) and (C6/7).
- The nerves of the cervical plexus and brachial plexus can be affected
85
Symptoms of **Cervical Disc Prolapse**
86
Symptoms of **Cervical Disc Prolapse**
- Sites Affected
1) Back of the skull
2) Neck
3) Shoulder girdle
4) Scapula
5) Arm and hand.
87
Symptoms of **Cervical Disc Prolapse**
- Examples
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).
88
Symptoms of **Cervical Disc Prolapse**
- C4/C5
89
Symptoms of **Cervical Disc Prolapse**
- C5/C6
90
Symptoms of **Cervical Disc Prolapse**
- C6/C7
91
Symptoms of **Cervical Disc Prolapse**
- C7/T1
92
Dx of **Cervical Disc Prolapse**
- Ex
- Radiology
93
Dx of **Cervical Disc Prolapse**
- Ex
94
Dx of **Cervical Disc Prolapse**
- Cervical Compression Test & (Spurling's test)
95
Dx of **Cervical Disc Prolapse**
- Lhermitte Sign
Feeling of electrical shock with patient neck flexion
96
Dx of **Cervical Disc Prolapse**
- Hoffman Sign
97
Dx of **Cervical Disc Prolapse**
- rads
98
TTT of **Cervical Disc Prolapse**
99
TTT of **Cervical Disc Prolapse**
- Conservative
- Medications (NSAID).
- Physical therapy and exercise.
- Steroid injection.
100
TTT of **Cervical Disc Prolapse**
- Surgery
101
Def of **Spinal Canal Stenosis**
Abnormal narrowing (stenosis) of spinal canal that may occur in any of the regions of the spine → restriction to the spinal canal → neurological deficit
102
Symptoms of **Spinal Canal Stenosis**
1) Pain
2) Numbness, paraesthesia
3) Loss of motor control.
103
Incidence of **Lumbar Canal Stenosis**
- Most common reason for lumbar spine surgery in pts > 65 yrs old
- seen in 20-25%
104
**Lumbar Canal Stenosis**
- Sex
- Age
* Sex: Slightly more common in males (D5:1)
* Age: Average age at presentation 5 65 years old
105
Location of **Lumbar Canal Stenosis**
Most commonly occurs at L4-5 (91%)
106
Risk Factors for **Lumbar Canal Stenosis**
1) Caucasian race
2) Increased BMI
3) Congenital spine anomalies (20%)
4) Failure of posterior elements to develop, short pedicles and laminae
107
Classification (Types) of **Lumbar Canal Stenosis**
1) Central stenosis
2) Lateral recess stenosis
3) Foramen stenosis
4) Extraforaminal Stenosis
108
Symptoms of **Lumbar Canal Stenosis**
109
Symptoms of **Lumbar Canal Stenosis**
- Neurogenic Claudication
110
Signs of **Lumbar Canal Stenosis**
111
Signs of **Lumbar Canal Stenosis**
- Kemp Sign
- Unilateral radicular pain from foraminal stenosis
- Worse by back extension
112
Signs of **Lumbar Canal Stenosis**
- SLR
Usually, negative
113
Signs of **Lumbar Canal Stenosis**
- Valsalva
- Radicular pain not worsened by Valsalva as is the case with a herniated disc
114
Signs of **Lumbar Canal Stenosis**
- Neuro Exam
- Patients may have no focal deficits
- cAs exam often takes place with patient seated and symptoms may be reproducible or exacerbated only with lumbar extension or ambulation
115
Radiology in **Lumbar Canal Stenosis**
116
Management of **Lumbar Canal Stenosis**
- Non-Operative
- Operative
117
Management of **Lumbar Canal Stenosis**
- Non-Operative
118
Non-Operative Management of **Lumbar Canal Stenosis**
- Modalities
Oral medications, physical therapy, and corticosteroid injections
119
Non-Operative Management of **Lumbar Canal Stenosis**
- Indications
First line of treatmen
120
Non-Operative Management of **Lumbar Canal Stenosis**
- Modalities (Explained)
**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 transforminal):**
- Found to be effective and may obviate the need for surgery
121
Surgical Management of **Lumbar Canal Stenosis**
122
Surgical Management of **Lumbar Canal Stenosis**
- Wide PTP Decompression
123
Surgical Management of **Lumbar Canal Stenosis**
- Wide PTP Decompression with instrumented fusion
124
Def of **Spondylosis**
- Broad term meaning degeneration of the spinal column from any cause.
- In the more narrow sense it refers to spinal osteoarthritis, age-related wear and tear of the spinal column (most common cause of spondylosis)
125
**Spondylotic osteoarthritis** mainly affects ........
* Vertebral bodies.
* Neural foramina
* Facet joints (facet syndrome).
126
**Spinal Instability**
...
127
Def of **Spondylolishthesis**
An anterior displacement of a vertebra relative to the vertebra below.
128
**Retrolisthesis**
"the reverse" the superior vertebra slips posterior to that below.
129
Grading of **Spondylolishthesis**
130
Etiological Classification of **Spondylolishthesis**
131
Etiological Classification of **Spondylolishthesis**
- Dysplastic
Congenital dysplasia of the articular processes.
132
Etiological Classification of **Spondylolishthesis**
- Isthmic
Defect in the pars articularis.
133
Etiological Classification of **Spondylolishthesis**
- Degenerative
Degenerative changes in the facet joints.
134
Etiological Classification of **Spondylolishthesis**
- Traumatic
Fracture of the neural arch other than the pars articularis.
135
Etiological Classification of **Spondylolishthesis**
- Pathological
Weakening of the neural arch due to disorders of the bone.
136
Etiological Classification of **Spondylolishthesis**
- Iatrogenic
* Excessive removal of bone following spinal decompression.
137
**Isthmic Spondylolishthesis**
- AKA
Spondylolytic Spondylolisthesis
138
**Isthmic Spondylolishthesis**
- Incidence
Most common form
139
**Isthmic Spondylolishthesis**
- Pathology
A bilateral defect in the pars interarticularis is present
140
What is **Pars interarticularis (AKA Isthmus)**?
- Pars interarticularis (AKA Isthmus) is the part of the neural arch that joins the superior and inferior articular processes
141
**Degenerative Spondoylolishthesis**
...
142
**Degenerative Spondoylolishthesis**
- Description
A lumbar spondylolisthesis without a defect in the pars
143
**Degenerative Spondoylolishthesis**
- Level
Most common is L4-L5
144
**Degenerative Spondoylolishthesis**
- INVx
Dynamic radiographs: Flexion-Extension X-rays
145
CP of **Spondoylolishthesis**
146
CP of **Spondoylolishthesis**
- Axial Back Pain
- Most common presentation.
- Pain usually has a long history with periodic episodes that vary in intensity and duration.
147
CP of **Spondoylolishthesis**
- Leg Pain
Usually a L5 radiculopathy (foraminal stenosis at the L5-S1 level).
148
CP of **Spondoylolishthesis**
- Neurogenic Claudication
* Caused by spinal stenosis.
* Characterized by buttock and leg pain worse with walking.
* N.B: Symptoms of neurogenic claudication rare because these slips rarely progress beyond Grade Il
149
CP of **Spondoylolishthesis**
- Cauda Equina Syndrome
Rare because these slips rarely progress beyond Grade II.
150
CP of **Spondoylolishthesis**
- L5 Radiculopathy
Physical Exam: Ankle dorsiflexion and EHL veakness
151
Management of **Spondoylolishthesis**
- Non Operatice
- Operative
152
Management of **Spondoylolishthesis**
- Non-Operative
153
Non-Operative Management of **Spondoylolishthesis**
- Examples
Oral medications, lifestyle modifications, therapy
154
Non-Operative Management of **Spondoylolishthesis**
- Techniques
1. Activity restriction.
2. NSAID.
3. Role of injections unclear.
4. Bracing may be beneficial especially in the acute phase.
155
Non-Operative Management of **Spondoylolishthesis**
- Indications
Most patients can be treated nonoperatively
156
Operative Management of **Spondoylolishthesis**
- L5-S1 Decompression & Instrumented Fusion +- Reduction
- L4-S1 Decompression & Instrumented Fusion +- Reduction
- ALIF
157
Operative Management of **Spondoylolishthesis**
- L5-S1 Decompression & Instrumented Fusion +- Reduction
158
Operative Management of **Spondoylolishthesis**
- L5-S1 Decompression & Instrumented Fusion +- Reduction (Indications)
159
Operative Management of **Spondoylolishthesis**
- L5-S1 Decompression & Instrumented Fusion +- Reduction (Reduction)
160
Operative Management of **Spondoylolishthesis**
- L4-S1 Decompression & Instrumented Fusion +- Reduction
161
Operative Management of **Spondoylolishthesis**
- L4-S1 Decompression & Instrumented Fusion +- Reduction (Indications)
162
Operative Management of **Spondoylolishthesis**
- ALIF
163
Operative Management of **Spondoylolishthesis**
- ALIF (Indications)
164
Operative Management of **Spondoylolishthesis**
- ALIF (Outcomes)
