1. DEGENERATIVE SPINAL CORD DISEASES
Cemre YILMAZ

2. 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

4. 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

5. Spinal Cord

6. 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.

10. 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

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

13. Risk Factors aging genetic smoking weight heavy lifting
sedentary lifestyle

14. 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.

15. 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.

17.  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.

18. 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)

20. 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.

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

22. Most commonly affected nerve sciatic nerve (L3-S1)

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

24. 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

25. 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

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

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

30. 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.

31. Spinal stenosis

32. 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.

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

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

35. 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.

36. 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

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

39. DDD Treatment Pain control Exercise and physical therapy
Lifestyle modifications
Surgery

40. 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

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

42. 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.

43. 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.

44. 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

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

46. 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

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