Degenerative disease of Lumbar spine Sayun Sumethvanich M.D.

Lumbar spine: Anatomy 5 vertebral segments: L1-L5 5 lumbar nerve root The spinal cord terminates between T12 and L2

Spinal ligament Intrasegmental Intersegmental Ligamentum flavum Intertransverse ligament Interspinous ligament Intersegmental Anterior longitudinal ligament (ALL) Posterior longitudinal ligament (PLL) Supraspinous ligament

Intervertebral disc Annulus fibrosus Nucleus pulposus

Nerve

Lumbar spondylosis The deterioration of spinal components The most common conditions developed by lumbar spondylosis Degenerative disc disease Spinal stenosis Arthritis of the spine Bone spurs Spondylolisthesis

Degenerative disc herniation Degenerative spondylolisthesis

Normal Facet hypertrophy Ligamentum flavum hypertrophy

Low Back Pain Cause of pain Source of pain Parevertebral muscle Fascia & ligament Facet joint Vertebral body Intervertebral disc Nerve root Vascular Visceral organ Psychosis Muscle strain / ligament sprain Postural disorder Fibromyalgia Trauma Tumor Infection : discitis, psoas abscess Inflammation : rheumatoid, ankylosing spondylitis Degenerative disorder Deformity Vascular dissection

Approach History Site of pain Characteristics of pain Mechanical / Rest pain Burning, Tingling sensation Radicular pain Duration & progression Aggravating factors Associated symptoms What treatment has been administered?

Red flags in neck/back pain Previous history malignancy Age 20 < or >55 with new onset pain Weight loss (unexplained) Fever Thoracic pain Non-mechanical pain Bowel bladder dysfunction Progressive neurological deficit Disturbed gait

Recent longstanding steroid use Night pain Diagnosis of inflammatory disease Saddle anesthesia Obvious structural spinal deformity Persistent severe restriction motion History of high energy trauma Low energy trauma in patient with ankylosing spondylitis

Therapy Non-operative treatment Medication : NSAID, muscle relaxant, nacrotics or anti-depressants Avoid heavy lifting, trunk twisting, vibrations Intensive exercise improves function and reduces pain Massage therapy  some promising results Systematic reviews of acupunture have shown little benefit Transcutaneous electrical nerve stimulation (TENS) and facet joint injections – minimal effective

Facet steroid injection

Spinal stenosis Degenerative spinal stenosis is a progressive disorder Cause : degenerative disc herniation, facet joint hypertrophy and calcification and hypertrophy of the ligamentum flavum

Symptom : back pain(95%), sciatica (91%), sensory disturbance in the legs (70%), motor weakness (33%) and urinary disturbance (12%) Vascular claudication vs Neurogenic claudication

Treatment 50% of patients treated nonoperatively report improved back and leg pain Non-operative treatment Pain management with medications; NSAID, opioid, anti-depressant and gabapentin/pregabalin Lifestyle modifications Trunk-stabilization exercise program Traction-minimal effectiveness Epidural steroid injection

Decompressive laminectomy with or without fusion and instrumentation Operative treatment The failure of a good conservative treatment regimen Severe neurological deficit “Lumbar spinal stenosis does not result in paralysis, only decreased ambulatory capacity” Inability to tolerate the restricted lifestyle Decompressive laminectomy with or without fusion and instrumentation

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