Done By :Mamoon Saleh

Degenerative Spine Diseases

*Vertebral column consists of 33 vertebrae.*The spinal cord is housed in the vertebral canal.* It’s continuous with medulla below the pyramidaldecussation and terminate as the conus medullaris at L2.*There are 8 cervical pairs of spinal nerve (C1-C8).*Cervical enlargement (C5-T1) : give rise to the rootlets that form the brachial plexus innervates upper limbs.*There are 12 thoracic pairs of spinal nerve (T1-T12). Which innervates most of the trunk.*There are 5 lumbar pairs of spinal nerves (L1 through L5).*Lumbar enlargement (L1-S2) gives rise to rootlets that form the lumbar and sacral plexuses innervate the lower limbs.*There are 5 sacral pairs of spinal nerves (S1-S5), innervate part of the lower limbs and the pelvis.* There is one coccygeal pair of spinal nerves

Anatomy

Anatomy of the intervertebral Disc :

1. External fibrocartilage ring : Annulus Fibrosus.

2.Inner soft elastic substance :Nucleus Pulposus.

Degenerative Disc Diseases:Gradual loss of normal structure and function of the disc over time.

Discs degenerate with:1. Age2. The fluid within the nucleus pulposus: gradually dries out and as the disc loses hydration, it offers less cushioning and becomes more prone to cracks and tears.

This is a natural part of aging and with time all people will exhibit changes in their discs but not all will develop symptoms as it is variable in nature and severity.

Pathophysiology*By the third decade of life, the nucleus pulposus

becomes replaced with fibrocartilage.*The distinction between the nucleus and the annulus

becomes blurred. *The proteoglycan, water, and noncollagenous protein

concentrations decrease, while the collagen concentration increases. *The increase in collagen concentration is more pronounced

in the nucleus and in the posterior quadrants of the disk. *It is more pronounced with age and moving caudally.

Cervical spine*The Cervical spine is compromised of

seven cervical vertebrae.

*These vertebrae begin at the base of the skull and extend to the thoracic spine.

Atlas C1

Axis C2

C7

*The intervertebral disc lies between adjacent vertebrae.

*There is no disc between(C1)and(C2). *These discs serve as the spine’s shock absorbing

system(absorb the impact of the body’s activities) accommodates movement, provides support, and separates vertebral bodies to lend height to intervertebral foramina. 

*Protect the vertebrae and allow some vertebral motion.

Cervical Degenerative Disc

Cervical Degenerative Disc

Cervical degenerative disc disease is oftenpresent with other spinal conditions, eitherdeveloping at the same time or in somecases one causes the other, such as:

1. Cervical Disc Prolapse.2. Cervical Spondylosis.

Cervical Degenerative Disc

A. Cervical Disc ProlapseIs a spine condition of the cervical segment that occurs when the gel-like center of a disc (nucleus pulposus) ruptures through a weak area in the tough outer wall (annulus fibrosus), causing irritation and/or compression of the adjacent nerve root.

The disc herniation occurs more frequentlyat C6/7 level.

Pathophysiology*Herniated disc can occur when there is enough

pressure from the vertebrae above and below*This can force some or all of the nucleus pulposus

through a weakened or torn part of the annulus fibrosus.

The four stages to a herniated disc:

*Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation.

*The form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion.

The gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.

The nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP).

1.Posterolateral disc Prolapse : 70 %It occurs usually in the Posterolateraldirection, because the posterior longitudinalligament prevents direct posteriorherniation.This herniation will compress on theadjacent nerve root at that level.

*Causes predominately motor changes

Direction of Prolapse

2. Central Disc Prolapse:

cervical disc herniate directly posteriorly, causing compression of the adjacent cervical spinal cord which is a neurosurgical emergency. results in cervical myelopathy.

*Sagittal magnetic resonance imaging (MRI) scan demonstrating cervical intervertebral disc protrusions at C3-C4 and C6-C7.

Causes*Injury

*Improper lifting

*Aging

Risk Factors:*Lifestyle choices such as tobacco use, lack of regular

exercise, and inadequate nutrition substantially contribute to poor disc health.

*Poor posture combined with the habitual use of incorrect body mechanics can place additional stress on the cervical spine.

Symptoms*Symptoms can vary depending on the location of the

herniation and the types of soft tissue that become involved.

*They can range from little or no pain if the disc is the only tissue injured, to severe and unrelenting neck that will radiate into the regions served by affected nerve roots that are irritated or impinged by the herniated material.

*The two most common levels in the cervical spine to herniate are the C6 -C7 (70%), C5 - C6 level (20%) and the C7-T1(10%).

Clinical presentation:* Due to the mechanical compression of the cervical nerve root: (Radiculopathy):

1. Neck pain 2. Arm pain3. Sensory Disturbances : numbness or tingling in

the distribution of the dermatome affected. * The nerve that is affected by the cervical disc

herniation is the one exiting the spine at that level, so at the C5-C6 level it is the C6 nerve root that is affected.

* Neck pain can radiate to an upper limb.*Character: deep, dull, aching pain.* Pain is usually unilateral but it may be bilateral.*Ask about speed of onset; Insidious onset of symptoms is

usual in cervical radiculopathy but it may be abrupt in acute injury.*pain & paresthesias may be intensified by neck movement,

especially by extension (Spurling’s maneuver) or by lateral flexion to side of herniation.*Activities that raise pressure in the disc, such as lifting or a

Valsalva maneuver, will exacerbate symptoms. *Lying down decreases pressure in the disc and eases pain.*Driving causes vibration that aggravates disc pain.* Pain can disturb sleep.

History:

Physical Examination:*If pain originates from the disc but there is no nerve root involvement, there will be normal neurological examination.*Signs of radiculopathy on examination:

1. Limitation of neck extension .2. Downward head compression increases pt's radicular pain &

paresthesias.3. Shoulder abduction relief test: significant relief of arm pain

with shoulder abduction.4. Spurling's Sign: gentle neck hyperextension with the head

tilted toward the affected side will exacerbate the symptoms or produce radiculopathy.

5. Upper limb weakness, paraesthesia, dermatomal sensory deficit and changes to reflexes can occur.

Signs of myelopathy on examination:1. Increased upper and lower limb reflexes or other upper

motor neuron signs suggest myelopathy.2. Upper motor neuron signs include:*Weakness.*Spasticity.*Hyperreflexia.*Positive Babinski's sign (up-going plantars).*Clonus.*Positive Hoffman's reflex (flicking a finger causes adjacent

fingers to flex).3. Cervical spine lesions can produce quadriplegia.

*Urgent evaluation and action are needed.

Diagnosis :1.History: For symptoms.2.Physical Examination.3.Imaging Confirmation :High-quality MRI is now the investigation of choice

Investigations: X-ray CT Scan MRI Electromyography (EMG) &Nerve

Conduction Velocity (NCV)

X-ray*Plain cervical spine radiographs evaluate chronic degenerative changes.*But can’t show herniation.

CT Scan

*axial computed tomography (CT) scan demonstrating right posterolateral protrusion.

MRI*The single best test to diagnose a herniated disc is a MRI.

*MRI can image any nerve root pinching caused by a herniated cervical disk.

EMG and NCVAn EMG is an electrical test that is done by stimulating

specific nerves and inserting needles into various muscles in the arms or legs that may be affected from a pinched nerve. If the muscles have lost their normal innervation, there will be spontaneous electrical activity.

These test can detect nerve damage and muscle weakness

Treatment

*Nonsurgical- Self care : Rest and restrict activity- Medication- Physical theraphy and exercise- Bracing- Cervical traction

*Surgical

Nonsurgical treatmentConservative non surgical treatment is the first step to recovery. Most cases of cervical pain do not require surgery and are treated using non-surgical methods.

In most case, the pain from herniated disc will get better within a couple days and completely resolve in 4 to 6 weeks.

Medication*NSAID, such as aspirin, naproxen, ibuprofen, etc used

to reduce inflammatory and relieve pain.*Analgesic, such as Acetaminophen can relieve pain but

don’t have the anti-inflammatory effect of NSAIDs.*Muscle relaxant such as methocarbamol may be

presribed to control muscle spasm.*Steroid may be prescribed to reduce swelling and

inflammation of the nerves. Taken orally in tapering dosage over a-five day period*Steroid injection into the area of herniated disc may

performed if the pain is severe.

Bracing and Cervical traction

A cervical collar or brace may be recommended tohelp provide some rest for the cervical spine.

Surgical Treatment:*For patient whose pain doesn’t improve with the

nonsurgical treatment.*continuing severe arm pain for more than 6 months

without benefit from conservative therapy*chronic or relapsing arm pain.

* Significant weakness in the upper limb that does not resolve with conservative therapy.

*Evidence of a central disc prolapse causing cord compression—this should be investigated urgently

The goal of surgery is to remove the portion of disc that is pushing on the nerve.

Surgical procedure to remove the disc called Discectomy

The two most commonly performed operations for cervical disc prolapse are:

1.Cervical foraminotomy with excision of the disc prolapse.

2.Anterior cervical discectomy, with subsequent fusion.

Cervical foraminotomyA surgery performed to remove bone

and/or portions of a herniated disc for widening the area where the spinal nerve roots exit the spinal column.

(Posterior Approach)

Anterior cervical discectomy*anterior approach to remove the cervical disc and the prolapse. *Formal fusion at the level using bone taken from the

iliac crest, bovine bone, usually filled with bone chips. *The fusion may be supplemented by a metal (usually

titanium) plate screwed onto the anterior vertebral surface, bridging the disc space.*An anterior approach with disc excision is mandatory for a

central disc protrusion..

B. Cervical Spondylosis/ Cervical Osteoarthritis:

• It is a degenerative arthritic process affecting the cervical intervertebral discs.

As a result of chronic degeneration, spurs or abnormal growths called Osteophytes may form.

The mobile cervical spine is particularly subject toosteoarthritic change and this occurs in morethan half the population over 50 years of age; ofthese approximately 20% develop symptoms.Relatively few require operative treatment

Risk Factors :

1.Aging, By the age of 60, most women and men show signs of cervical spondylosis on x-ray.

2.Previous neck injury3.Severe arthritis4.Past spine surgery

A.Cervical Spondylotic Myelopathy (CSM)The formation of osteophytes and the spondyliticprocesses causes narrowing of the spinal canal(spinal stenosis) that leads to myelopathy.

Symptoms:1.Neck stiffness and arm pain.2. Numbness or tingling in arms,or hands and

fingers.3. weakness of arms and legs.4.Loss of fine motor skills – ex. Difficulty in

handwriting5. Stiff legs – Difficulty in walking steadily.6. Loss of control over the bladder.

B. Cervical Radiculopathy:

*Pain: a sharp stabbing pain, worse on coughing, may be superimposed on a more constant deep ache radiating over the shoulders and down the arm.*Paraesthesia: Numbness or tinglingfollows a nerve root distribution.*Root signs:– Sensory loss, i.e. pin prick deficit in theappropriate dermatomal distribution.

*– Muscle (l.m.n.) weakness and wasting in appropriate muscle groups,

e.g. C5, C6 . . . biceps, deltoid: C7 . . . triceps.*– Reflex impairment/loss, e.g. C5, 6 . . . biceps,

supinator jerk: C7 . . . triceps jerk.*– Trophic change: In long-standing root compression,

skin becomes dry, scaly, blue and cold.

Although the clinical features may be almost indistinguishable from those due to an acute soft disc prolapse, the process is usually not as acute and the patient often has a history of intermittent or chronic pain, so wasting of a muscle group in the appropriate nerve root distribution may be found.

Investigations for Cervical Spondylosis :- The following tests may be done:

1. cervical spine MRI (investigation of choice).

2. neck x-ray.3. EMG – Electromyography.4. X-ray or CT scan after dye is injected into the spinal column (myelogram)

*Plain X-ray of cervical spineLook for:

– disc space narrowing mostly at C6-C7- osteophyte protrusionFlexion/extension views may be required.

X-ray

MRI

CT Scan

*Management :Conservative- Analgesics and muscle relaxants.- Cervical collar.- Physical Therapy.

*Symptoms of radiculopathy, whether acute or chronic, usually respond to these conservative measures.

Operative techniques1. Anterior decompression and fusion2. Posterior approach

*Indications for Surgical Intervention :

1. Progressive neurological deficit – myelopathy or radiculopathy that causes functional disability.

2. Severe Pain that doesn’t respond to analgesics.3. Chronic or recurrent Pain.