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Degenerative disease of Lumbar spine
Sayun Sumethvanich M.D.
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Lumbar spine: Anatomy 5 vertebral segments: L1-L5 5 lumbar nerve root
The spinal cord terminates between T12 and L2
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Spinal ligament Intrasegmental Intersegmental Ligamentum flavum
Intertransverse ligament Interspinous ligament Intersegmental Anterior longitudinal ligament (ALL) Posterior longitudinal ligament (PLL) Supraspinous ligament
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Intervertebral disc Annulus fibrosus Nucleus pulposus
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Nerve
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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
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Degenerative disc herniation
Degenerative spondylolisthesis
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Normal Facet hypertrophy Ligamentum flavum hypertrophy
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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
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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?
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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
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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
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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
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Facet steroid injection
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Spinal stenosis Degenerative spinal stenosis is a progressive disorder
Cause : degenerative disc herniation, facet joint hypertrophy and calcification and hypertrophy of the ligamentum flavum
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Symptom : back pain(95%), sciatica (91%), sensory disturbance in the legs (70%), motor weakness (33%) and urinary disturbance (12%) Vascular claudication vs Neurogenic claudication
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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
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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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Thank You
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