DEGENERATIVE SPINAL CORD DISEASES Cemre YILMAZ

Spinal Cord The spinal cord extends from the foramen magnum where it continues with the medulla to the level of the first or second lumbar vertebra. It terminates in a fibrous extension known as filum terminale. Terminal portion of the spinal cord is called the conus medullaris. Spinal nerves pass through the vertebral column by exiting the intervertebral foramen. However, because the spinal cord does not reach the end of the vertebral column, the lumbar and sacral spinal nerves exit only by first going downward and traveling inferiorly through the vertebral canal before reaching their corresponding intervertebral foramina. For this reason, there is a collection of nerve roots at the lower end of the vertebral canal. This collection of nerve roots is called the cauda equina due to a resemblance to a horse's tail

There are 31 pairs of spinal nerves 8 cervical 12 thoracal 5 lumbar 5 sacral 1 coccygeal The spinal cord has two enlargements Cervical(C3-T2):The cervical enlargement corresponds roughly to the brachial plexus nerves, which innervate the upper limb Lumbar (T11-L1) :The lumbar enlargement or lumbosacral enlargement corresponds to the lumbosacral plexus nerves, which innervate the lower limb

Spinal Cord

Vertebra There are features that are common to all vertebral segments and others that are unique to each level. With the exception of C1, each segment has a vertebral body, which is the anterior portion of the vertebral segment. The superior and inferior portions of the vertebral body are referred to as the end plates which provide nutrition to the adjacent disk. The body is connected to the posterior elements by bilateral pedicles which are linear bony struts. The posterior elements consist of the pedicles, lamina, facets (articular process), transverse process and spinous process.

Intervertebral Discs Each vertebral body segment(except C1-C2) is attached to the level above and below by an intervertebral disk The disk has several functions: 1) It serves as a connection between the vertebral bodies 2) It acts as a pivot point 3) Distribute compressive forces The disk is made of the nucleus pulposus and the annulus fibrosus

Degenerative Spine Conditions Herniated discs Spinal stenosis Degenerative disc disease Spondylo-lysis/listhesis Degenerative scoliosis Spondylosis

Risk Factors aging genetic smoking weight heavy lifting sedentary lifestyle

Symptoms Degenerative spine conditions vary widely in their presentation. Some cause no symptoms at all. When symptoms do occur, they often include back pain or neck pain. Other symptoms depend on the location and type of problem.

Disc Herniation Disc herniation occurs when the annulus fibrous breaks open or cracks, allowing the nucleus pulposus to escape. This is called a herniated nucleus pulposus or herniated disc. The most common sites are lumbar (L4-L5) herniated discs and cervical(C5-C6) herniated discs .Thoracic herniated discs are much less common. Herniations usually occur posterlaterally.

 protrusion: ​base wider than herniation confined to disc level outer annular fibres intact extrusion​: base narrower than herniation 'dome'may extend above or bellow endplates or adjacent vertebrae complete annular tear with passage of nuclear material beyond disc annulus disc material can then migrate away from annulus or become sequestered Sequestration extruded disc material that has no continuity with the parent disc is displaced away from the site of extrusion.

Cervical disc herniation most common site C5-C6 / C6-C7 Pain (neck and upper extremities) Numbness Muscle weakness Paresthesia Urinary incontinence , loss of bowel control(rare)

CT with myelogram –more sensitive but invasive Diagnosis Treatment Physical exam MRI – best CT with myelogram –more sensitive but invasive X-ray EMG Medication :NSAID Physical therapy Steroid injection Surgery Anterior cervical discectomy and spine fusion (ACDF) Posterior cervical discectomy Cervical artificial disc replacement.

Lumbar Disc Herniation Most common site L4-L5/L5-S1 Pain (lower back, buttocks, lower extremities) Numbness Foot drop Cauda equina syndrome

Most commonly affected nerve sciatic nerve (L3-S1)

Straight Leg Raise Test (Lasegue’s sign) Neurologic pain which is reproduced in the leg and low back between 30-70 degrees of hip flexion is suggestive of lumbar disc herniation at the L4-S1 nerve roots.

Diagnosis Treatment Physical exam—straight leg raise test MRI CT with myelogram X-ray EMG Ice application Medication : NSAID ,muscle relaxants Heat therapy Physical therapy Steroid injection Surgery Microdiscectomy

Cauda Equina Syndrome(CES) Cauda equina syndrome is caused by any narrowing of the spinal canal that compresses the cauda equina nerve roots . disc herniation spinal stenosis traumatic injury tumors infectious conditions arteriovenous malformation or hemorrhage iatrogenic injury

CES symptoms Back pain Saddle anesthesia Sciatica pain Bladder, bowel dysfunction Gait disturbance Anal and achilles reflex absent Sexual dysfunction

Surgery indications Severe pain Progressive neurological deficit Loss of bowel-bladder control

Spinal stenosis Spinal stenosis is part of the aging process Progressive narrowing of the spinal canal may occur alone or in combination with acute disc herniations. Congenital and acquired spinal stenosis place the patient at a greater risk for acute neurologic injury. Spinal stenosis is most common in the cervical and lumbar areas.

Spinal stenosis

Spinal stenosis The most common reason to develop spinal stenosis is degenerative arthritis, or bony and soft tissue changes that result from aging. The normal "wear and tear" of aging can cause arthritis in the spine that leads to spinal stenosis. This can be from bone spurs (osteophytes) forming, bulging and wear of the intervertebral discs, and thickening of the ligaments between the vertebrae.

Spinal stenosis Local and traveling pain, often described as a burning sensation Muscle weakness Numbness and tingling Loss of fine motor skills Limited mobility

Treatment pain medication Exercise Stretching Hot/cold therapy Epidural steroid injections Lifestyle changes like weight loss and quitting smoking Decompression surgery

Degenerative Disc Disease Gradual deterioration and thinning of the shock-absorbing intervertebral discs by age This condition can occur at any level of the spine and may cause a range of symptoms and intensity levels. Unless a degenerative disc places pressure upon an adjacent nerve, symptoms remain non-existent or strictly localized.

Degenerative Disc Disease Pain with activity bending, lifting, and twisting Severe episodes of back or neck pain (a few days to a few months Certain positions: sitting for lumbar degenerative disc pain

MRI Findings Disc space narrowing Fissures, fluid, vacuum changes and calcification Osteophytosis Disk herniation Malalignment Stenosis

DDD Treatment Pain control Exercise and physical therapy Lifestyle modifications Surgery

Spondylolysis Caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis present in ~5% of the population %90 at the L5 level higher in the adolescent athletic population commonly asymptomatic pain with extension and/or rotation of the lumbar spine.   65% of patients with spondylolysis will progress to spondylolisthesis

Spondylolysis Plain radiograph CT/MRI oblique limited sensitivity compared to SPECT and CT scotty dog sign CT/MRI Wide canal sign

Spondylolisthesis is most frequent at L5/S1 forward or backward slippage the vertebra Causes of spondylolisthesis include trauma, degenerative, tumor and birth defects. lower back or leg pain, hamstring tightness, numbness and tingling in the legs.

Treatment Bracing to immobilize the spine for a short period Pain medications and/or anti-inflammatory medication Physical therapy Decompressive laminectomy :reduces irritation and inflammation in the area (but increases spinal instability) A spinal fusion to provide stabilization of the affected area.

Spondylosis Spinal osteoarthritis With age, the bones and ligaments in the spine wear, leading to bone spurs Over 80% of people over the age of 40 have evidence of spondylosis on X-ray studies

Spondylosis Neck/back pain Stiffness Paresthesia weakness Standing Sitting Sneezing Coughing Tilting neck backward worsen the pain

Spurling’s test(cervical compression test) pain arising in the neck radiates in the direction of the corresponding dermatome ipsilaterally Shows cervical radiculopathy (many causes) Lhermitte’s sign electric shock-like sensation that occurs on flexion of the neck Reduced range of motion MRI-CT

Treatment (NSAIDs) exercise – such as swimming and walking Surgery bowel or bladder dysfunction spinal stenosis neurologic dysfunctions Unstable spine