1. Approach to Degenerative Lumbar Spine
Tuanrit Sornsa-ard, MD.
Nakornping Hospital Chiang Mai

2. Ageing Society

3. Outline Background Diagnosis of degenerative lumbar spine disease
Management of degenerative lumbar spine disease
Prognosis of degenerative lumbar spine disease

4. Background
Degenerative lumbar spine disease (DLSD) includes spondylotic (arthritic) and degenerative disc disease of the lumbar spine with or without neuronal compression or spinal instability
DLSD is common, especially in the aging Western population
Imaging evidence of DLSD is seen in 100 percent of the population over the age of 40 years, being severe in 60 percent of those over the age of 70

5. Degenerative Lumbar Spine Disease ( DLSD )
Spondylotic (Arthritis)
Degenerative Disc Disease of Lumbar Spine
With Neuronal Compression
Without Neuronal Compression
With Spinal Instability
Without Spinal Instability

6. Clinical vs Radiographic
The correlation between the degree of degenerative changes on the scans and patients' symptoms however, is poor, with many patients experiencing few symptoms despite radiological evidence of DLSD
In symptomatic patients, a significant proportion of symptoms are due to bony, discal or ligamentous compression of neural elements at the spinal canal or nerve root exit foramina

7. Cauda Equina Syndrome
Cauda equina syndrome due to compression of the cauda equina by a herniated central lumbar disc is a specific condition requiring emergency neurosurgical attention

8. Cauda Equina Syndrome

9. Cauda Equina Syndrome
Acute central lumbar canal stenosis, usually due to a large prolapsed disc, may present with cauda equina syndrome

10. Aetiology
In most patients DLSD is the result of "normal" wear and tear associated with the aging process or overuse
Other causes include a congenitally narrowed spinal canal
Genetic predisposition to early disc disease
Trauma, infection, inflammation and rarer conditions such as ossification of the posterior longitudinal ligament.

11. Wear and Tear of Facet joints

12. Diagnosis of degenerative lumbar spine disease
The primary symptom of DLSD is axial spinal pain
"Back pain" has a prevalence rate of 12 to 35 percent in the Western world with 10 percent of patients becoming chronically disabled, representing a major socio-economic burden

13. Clinical Presenting Features
The Clinical presenting features of DLSD will depend on
The site of the disease
The degree of neural compression
The rate of development

14. Clinical of Spinal Stenosis
Central lumbar canal stenosis typically presents chronically and with signs and symptoms of multi-nerve root dysfunction, termed spinal claudication.
The patients complain of back and progressive leg pain, numbness and heaviness on walking with symptoms resolving at rest or on forward flexion
Intermittent claudication due to vascular insufficiency in the legs is an important differential diagnosis

15. Neurogenic Claudication
The patients complain of back pain
Progressive leg pain,
Numbness
Heaviness on walking
Symptoms resolving at rest or on forward flexion

16. Differentiation of Neurogenic and Vascular Claudication

17. Red Flag Sign of Cauda Equina Syndrome
The red flag signs are:
Sphincter dysfunction with painless urinary incontinence and reduced anal tone
Saddle numbness ( Saddle Anesthesia)
Bilateral sciatica
This is a neurosurgical emergency warranting urgent referral and treatment to avoid permanent neurological deficits

18. Sciatica
Lateral compression of a nerve root in the lumbar spine presents with characteristic dermatomal radicular pain, so called "sciatica“, with associated lower motor neuron signs and symptoms

19. Sciatica

20. Lumbar Spondylosis Degenerative disease of Lumbar Spine
Degeneration of Intervertebral Disc
weakness of Annulus Fibrosus
Leakage of Nucleous Pulposus
Annulus Fibrosus tear
Loss of elastic property
Lack of Shock absorbance

21. Loss of Lumbar Disc Space

22. Lumbar Spondylosis Decreased of Disc Space Decreased of Disc Height
Retrolisthesis of Upper vertebra
Osteoarthritis of Facets Joints
Marginal Osteophyte
Laxity of the Spinal articulations

23. Anatomy of the Lumbar Spine

24. Anatomy of the Lumbar Spine
Lumbar Spine have 5 member from L1-L5
Allow more Flexion/ Extension
The most mobility is L4-5
The Spinal cord ends at level of L1 lower end plate

25. Anatomy of the Lumbar Spine

26. 1. Dysfunction Phase Pathophysiology Usually 30-50 year old
Beginning from Lumbar Disc dehydration
Degeneration of Nucleous Fibrosus and Annulus Fibrosus
Herniation of Nucleous Pulposus
Back pain and Sciatica
Chronic Back pain

27. 2. Instability Phase Pathophysiology Decreased Disc Height
Laxity of the Facet joint capsules
Laxity of both Facet Joint and Lumbar Intervertebral Disc
Ligamentum Flavum Hyperthrophy
Instability of Lumbar vertebra

28. Spondylolysis of Pars Interarticularis

29. Spondylolisthesis

30. Pathophysiology 3. Stabilization Phase
Reduced motion around pathologic spinal segment
Formation of marginal osteophytes
Distribution of compressive forces to surrounding osteophytes
Progression of Pain Numbness and Weakness

31. Investigations
In terms of investigations, imaging techniques are the most useful
Plain X-rays, especially performed in flexion and extension, will help to identify any spinal instability that may be present
The imaging modality of choice, however, is the MRI scan
MRI clearly demonstrates the neural elements and defines any areas of bony, ligamentous or discal degeneration and compression
CT scans remain a useful alternative in patients who are unable to tolerate a MRI scan or in whom MRI is contraindicated, such as those with pacemakers
CT scans are also useful if detailed information about the bone structure is required, particularly in patients who are to undergo instrumented spinal fixation

32. Flexion and Extension X-ray

33. MRI of Lumbar Spondylosis

34. Electrodiagnosis
Electrophysiological evaluation, such as nerve conduction studies, is helpful in determining the level of relevant pathology especially in patients with difficult clinical assessment and multi-level spinal disease on MRI.

35. Management of degenerative lumbar spine disease
Management of DLSD requires a multi-disciplinary team approach comprising of, at the least, neurosurgeons/spinal surgeons, a neuroradiologist, pain specialists and physiotherapists
This is important to provide the patients with the most effective treatment for their particular symptoms
Although patients with DLSD represent the biggest group of patients seen in a general neurosurgical clinic, only a small proportion will ever need surgery

36. Acute and Sub-acute Management
In patients presenting with acute/sub-acute isolated back pain, without neural compression or spinal instability, conservative measures are likely to settle the pain in the majority
Such measures include weight reductions structured exercise programes, analgesics such as paracetamol, non-steroidal anti-inflammatory drugs or opioids, physiotherapy
Spinal manipulation by qualified osteopaths or chiropractors and acupuncture still questionable

37. Chronic management
In patients with chronic pain (more than one year), epidural injections, transcutaneous electrical nerve simulation (TENS) and combined physical and psychological rehabilitation programes may be of additional benefit

38. Surgical Management
The role of surgery in such patients remains controversial
Spinal fusion may benefit selected patients
When instability (degenerative spondylolisthesis) complicates back pain, spinal fusion may achieve good pain control
Percutaneous spinal instrumentation systems now available, allow minimally invasive surgery with more rapid recovery and a shorter hospital stay

39. Time to Considerations for Surgery
In patients with DLSD and radicular pain, conservative measures are usually sufficient to improve the symptom in 6-8 weeks
If severe pain persists beyond this time, or if a motor neurological deficit, such as a foot drop, is present, serious consideration should be given to surgery

40. Surgical Management
The timing of surgery is particularly important if neurological recovery is to be achieved
The aim of surgery is to decompress the neural elements and the most common operations performed are lumbar laminectomy and lumbar microdiscectomy
The recent development of endoscopic discectomy technique allows day-case local anaesthetic surgery with the additional benefit of excellent cosmetic results
Spinal cord stimulation remains an effective treatment in patients with severe pain especially if pain persists despite decompressive surgery

41. Prognosis of degenerative lumbar spine disease
The prognosis of patients with DLSD depends on the underlying diagnosis, delivery of prompt treatment and psycho-socio-economic factors
Well motivated patients with a good social support network are more likely to recover well and resume work
Despite all the treatment available, some 10 percent of patients become chronically disabled, especially with back pain
In others, conservative and surgical measures are effective in improving the symptoms

42. Prognosis of degenerative lumbar spine disease
Spinal claudication and radicular pain respond well to surgery with up to 90 percent pain relief
When motor weakness is present or in patients with cauda equina syndrome, the timing of surgery is crucial in determining any neurological recovery with the best results seen in patients operated within 48 hours of presentation
The prognosis for recovery of sensory deficits such as numbness and paraesthesia is less predictable

43. Thank You for Your Attention!