Degenerative Spine and Disc Herniation Neurosurgery

Intervertebral Disc Anatomy

L: (Top to Bottom) Posterior Longitudinal Ligament,

Nucleous Puposus, Annulus Fibrosus, Cartilage
endplate, Anterior Longitudinal Ligament

R: Younger High Water content, Older Loss water

and starts to bulge out

Closer Picture

Annulus Fibrosus has so many layers so if there is

a tear it starts to get outs slowly herniated Disc
can impinged nerve that exiting at that area
Anterior Longitudinal Ligament complete sheath
Posterior Longitudinal Ligament extends from occiput
base last spinal vertebrae
(It thins out lateral segments and thick in central
prone to lateral herniation) also the PLL can thicken
and compress surrounding structures
Ligament Flavum
 Degenerative Spine and Disc Herniation Neurosurgery
Progression of Disc Degeneration: Healthy Disc Loss
of Height and Loosening of Ligaments Disc
protrusion Disc Degeneration and Ostephyte
formation
Cervical and Lumbar Mobile
Cervical small vertebrae compared to lumbar
Thoracic least common
Degenerative Disc /Spine Diseases :
Cervical Disc Herniation
Etiology:
Cumulative effects of microtrauma(ex.
Breakdance, circus) & macrotrauma to the spine
Osteoporosis (decrease estrogen)
Cigarette smoking
Stress on the spine including effects of excess
body weight
Loss of muscle tone (abdominal & paraspinals)
resulting in increased dependence on the bony
spine for structural support
Prolonged Seating (DOTA pa)
Pathogenesis Cervical Spine
Alterations in intervertebral disc biomechanics
and biochemistry (loss of water content) over
time have a detrimental effect on disc
The disc is less able to work as a spacer
between vertebral bodies or as a universal joint
(disc is the shock absorber)
Most disc herniation & degenerative changes
occur posterolaterally, the most common areas
involved are C5-C6 and C6-C7 (most mobile
areas)
o There is a direct correlation between the
anatomy of the cervical spine and the
location and pathophysiology of disc
lesion
o The nerve root that exited in the
intervertebral foramina is compressed
by the extruding disc material and/or the
osteophytes
Disc starts to bulge out
collagen goes out (?)
calcified osteophyte
The C1 root exits between the occiput and the atlas
(C1)
All lower roots exit above their corresponding cervical
vertebrae (the C6 root at the C5-C6 interspace), except
C8, which exits between C7 and T1
The C8 nerve roots exit via intervertebral foramina
that are bordered anteromedially by the intervertebral
disc and posterolaterally by the zygapophyseal joint/Facet
joint
The nerve affected is the same as the one exiting
Central herniation myelopathy (cord compression)
Cervical vs. Lumbar
Cervical has spinal cord unlike Lumbar
Can compress on spinal cord or nerve root (only
found in cervical)
Radioculopathy Nerve root compression
Myelopathy Cord compression
Cervical spondylosis means degenerative spinal
problem
o Spinal canal contains spinal cord and
usually it fits perfectly so if you have
thickening ligament of flavum and PLL
smaller canal compression
 Degenerative Spine and Disc Herniation Neurosurgery

o Inflammation can occur in the rootlets o Knee jerk (Hyper)

and facet joints

Spurlings Manuerver
Detect radicular pain
Extend neck away from the the lesion radicular
pain (neck to arm)
Unlike lumbar herniated discs, cervical herniated Note the pain is radiating and location
discs may cause myelopathy in addition to
radicular pain because of spinal cord in the
cervical region Radiologic Imaging
The uncovertebral joint tends to guide extruded Plain cervical spine
disc material medially, where cord compression CT scan of Spine demonstrate bone from
may also occur tissue
Individual disc herniations do not involve other MRSI demonstrate disc
roots but more commonly present some evidence EMG-MCV detect which nerve is affected
of upper motor neuron findings secondary to
spinal cord compression (Cervical spondylotic
myelopathy)
The development of symptoms depends on the
reserve capacity of the spinal canal, the presence
of inflammation, the size of the herniation, and
the presence of concomitant disease such as
osteophyte formation.
In disc rupture, protrusion of nuclear material
results in tension on the annular fibers and
compression of the dura or nerve root causing
pain.
Also important is the smaller size of the sagittal
diameter of the bony cervical spinal canal (spinal
canal stenosis) the more an herniated disc will
cause a motor dysfunction

Diagnosis
History + Maneuvers
Usually started as nape pain then radiating down
to the shoulder, arm and forearm (Radiculopathy)
There can also be paresthesias and/or paresis of
upper limb
Symptoms such as back pain, leg pain, leg
weakness, gait disturbance or incontinence
suggest compression of the spinal cord White thing inflammation or disc (containing water)
(Myelopathy)
Myelopathy Cervical Spondylosis
o UMN signs Narrowing of the intervertebral disc
 Degenerative Spine and Disc Herniation Neurosurgery

Sclerosis of the vertebral endplate

Osteophyte formation
Facet joint degeneration

(see last page for table)

Treatment for Cervical Spondylosis

Medical Treatment (2-3 months)
>90% improved with therapy Removal of C5 Disc
Neck immobilization (with a soft collar,
Philadelphia collar, rigid orthoses, Minerva jacket,
or a molded cervical pillow for support
Muscle relaxants, such as cyclobenzaprine, to
treat muscle spasms
NSAID drugs, narcotics, such as hydrocodone,
for pain relief
Anti-epileptic drugs, such as gabapentin, to
relieve pain caused by nerve damage
Steroid injections, such as prednisone, to
reduce tissue inflammation, and subsequently Get the piece of iliac bone plant it at the removed are
lessen pain
Lifestyle modifications, manipulation, &
muscle strengthening exercises
Cervical traction for 4-6 weeks (10-15 lbs for
10-155 min, 2-3x daily)

Surgery
Posterior foraminotomy with discectomy
o Foraminotomy widens canal to
relieve nerve compression
o Discectomy removal of vertebral disc
Anterior disectomy and fusion
Artificial disc replacement Place cervical plate to ensure that it would not move
o Expensive example Gloria macapagal
has 4 artificial disc
Laminectomy
o Remove lamina
Indications for surgery
o Intractable radicular pain or failure of
medical / conservative management
o Neurologic changes (clinical & imaging
studies) progressive neurological
deficit or acute spinal cord compression
due to central disc
o Always verify with imaging studies
 Degenerative Spine and Disc Herniation Neurosurgery

Lumbar Spine Disc Herniation

Anterior Cervical Plating

Well established for trauma but not in
degenerative disease

Advantages
Decrease risk of graft extrusion
Increases rigidity for successful fusion
May limit necessity for halo immobilization Lumbar carries heavier weight compared to cervical
and has no spinal cord, only rootlets
Disadvantages
Possible stress shielding of interbody grafts Majority of movement: L5-S1 (Lumbosacral junction)
Loosening of plates and screws
Risk of neurologic or vascular injury

Artificial Disc
No limitation of movement but expensive

Pathogenesis
Nearly 75% of the lumbar flexion-extension and
total spinal movement occurs at the LS junction.
20% of lumbar flexion-extension occurs at the
L4/5 level and the remaining 5% is at the upper
lumbal levels
90%-98% of lumbar disc prolapses occur at the
lower two lumbar levels; the most frequently
affected disc is at the L4-L5 and L5/S1 levels
 Degenerative Spine and Disc Herniation Neurosurgery

Lumbar
Typical disc herniation radiculopathy on the
nerve exiting at the level below
LBP relief upon flexing the knee and thigh
Cough effect increase pain with coughing,
sneezing or straining at the stool (87%)
Increased pain also with sitting, driving, & walking
Bladder symptoms voiding dysfunction in 1-
18%

Lumbar Disc Herniation

Nerve root sensitivity can be elicited by any
method that creates tension
The straight leg-raising (SLR) test is the one
most commonly used
This test is performed with the patient supine

Treatment
Conservative for 4-6 months
Surgery for:
o Cauda equina syndrome
What exits below L3 is L3 but the nerve that will be Extreme pain
affected is L4. Why? Because the usually the disc o Progressive motor and sensory deficit
herniates posteriorly so the affected part is L4 o Failure of conservative management

But if the herniated disc is extreme lateral the affected

nerve is L3

Posterolateral disc herniation compresses the ipsilateral

nerve root at its exit from the dural sac, rather than in the
neural foramen, e.g. posterolateral left L4-5 disc herniation
compresses the left L5 nerve root.

If the disc herniation is more lateral, it compresses the

ipsilateral nerve root exiting thru the adjacent neural
foramen.

A far left L4-5 disc herniation compresses the left L4 nerve

root

An herniated lumbar disc (HLD) usually spares the nerve

root exiting at the interspace, and impinges on the nerve
exiting from the neural foramen one level below. e.g. a L5-
S1 HLD usually causes S1 radiculopathy

Central disc herniation you compress rootlet that is

going down (ex. Bet L4-L5 compress S1-S2: manifest
with bladder dysfunction)

Laminotomy

Lumbar Spinal Canal Stenosis

Narrowing of the spinal canal, nerve root canals,
or intervertebral foramina resulting in
compression of neural elements
(See last page for table)
Occurs more primarily in the elderly (more than
70 years old); Men > Women
Can be congenital (anatomical) or acquired
Acquired type more common
 Degenerative Spine and Disc Herniation Neurosurgery

o Hypertrophied facet joint, ligamentum

flavum
o Disc herniation
Degeneration the most common cause of
acquired spinal stenosis
Insidious onset and slow progression of pain
in the lower back, buttocks, and thigh. Patients
classically demonstrate signs of intermittent
neurogenic claudication.
o Pain, numbness, paresthesias in the leg
o Occurs with standing or walking
increases lumbar lordosis = infolding of
ligamentum flavum
Flexion of the spine typically relieves the
symptoms stretches the ligamentum flavum =
increased spinal canal diameter, distract the facet
joints that enlarges the neural foramina
Diagnosis:
o Xray Lumbar Disc Replacement
o CT and MRI most useful Remove the damaged disc and replace it with a
metal and plastic important
Surgical Intervention Absolute contraindications due to disc
Failure of non-operative treatment. Minimum of 3- replacement
6 months o Concomitant spinal deformity (scoliosis,
Decompression kyphosis)
o Bone removal to widen area o History of spinal infection
o Laminectomy o Posterior spinal arthritis
o Foraminotomy o Multilevel disc disease
o High success rate
Bone Chips
Cauda Equina Syndrome For them to fused
Cauda equina syndrome is associated with
compression of the spinal nerve roots (in Below artificial disc
cauda equina) that supply neurologic function to
the bladder and novel.
Rapid diagnosis and decompression of this
abnormally are essential to prevent permanent
neurologic dysfunction.
Clinical manifestations
Low back pain
Bilateral Sciatica or leg pain
Saddle hypoesthesia (loss of perianal sensation
Lower extremity motor weakness associated with
bowel and bladder syndrome
Cause central disc herniation at L4-L5
Treatment urgent surgical treatment is settle
o Permanent neurologic dysfunction
Delay in surgery beyond 48 hours was
associated with persistent severe motor deficit
persistent sciatica and sexual dysfunction
Cauda equina requires emergency diagnosis
and surgical decompression within a 48 hour
period to decrease the risk of permanent
neurologic disease

Surgical Intervention
Spine fusion
Lumbar disc replacement
 Degenerative Spine and Disc Herniation Neurosurgery

Usually cause root compression and tends to

involve the nerve exiting below the pedicle of the
anteriorly subluxed vertebra
Compression is usually due to upward
displacement of the superior articular facet of the
level below together with disc material
Symptoms neurogenic claudication or
radiculopathy

Classification of Spondylolisthesis:
Type 1: dysplastic congenital; 94% associated
with spina bifida occulta with no pars defect.
Upper sacrum of arch of L5
Type 2: Isthmic Spondylolisthesis AKA
Spondylolysis due to a failure of the neural arch
manifesting as a defect in the pars interarticularis
(neck of the scotty dog on oblique LS spin x-
ray)
o Lytic fatigue fracture of pars, pediatric
age group
o Elongated but intact pars repetitive
fractures and healing
o Acute fracture of pars
Type 3: Degenerative: due to long standing
Spondylitis inflammation (Pott disease) intersegmental instability (L4-5) with no break in
Spondylosis degenerative pars
Spondylolisthesis subluxation Type 4: Traumatic: due to fractures in areas
other than the pars
Spondylolisthesis Type 5: Pathologic: generalized or local bone
Anterior subluxation of one vertebral body on diseases
another
Usually L5 on S1, next common L4 on L5 Isthmic Spondylolisthesis (Spondylolysis) Grade 2
Pars interarticularis defect
Meyerding grading of subluxation in sagittal plane May present with radiculopathy with the nerve
Grade % Subluxation exiting under the pedicle at that level being the
I < 25% most vulnerable
II 25 50% May also present as low back pain although a
III 50 75% great majority are asymptomatic
IV > 100% Treatment:
o Conservative using Boston brace, a rigid
orthosis for > 3 mos.
 Degenerative Spine and Disc Herniation Neurosurgery

o Surgery if with myelopathy,

radiculopathy, or neurogenic
claudication
o Radical decompression of nerve roots
including removal of loose posterior
elements & total facetectomy, followed
by posteriolateral or interbody fusion
(transpedicular screw-root fixation)
Gill procedures
 Degenerative Spine and Disc Herniation Neurosurgery

Cervical Roots Syndrome

Level of cervical C3-4 C4-5 C5-6 C6-7 C7-T1

disc rupture
Root C4 C5 C6 C7 C8
compressed
Distribution of Side of neck to Around shoulder Forearm index Forearm and Forearm little
pain and the top of the and arm finger thumb ring finger finger
paresthesia scapula
Motor Diaphragm Deltoid Biceps Triceps Intrinsic muscles
weakness, extensors of of hand
sensory loss wrist and fingers
Reflex - Deltoid / Biceps Triceps -
entrapment Pectoralis

Lumbar Disc Herniation

Typical Clinical Features of Unilateral Lumbar Herniated Nucleus Pulposus
Disc Nerve Root Pain Paresthesias, Weakness Reflexes
Numbness
L3-4 L-4 Lower back, buttock, Anterior thigh, Quadriceps Knee jerk
3%-10% lateral / anterior anterior leg femoris (knee diminished or
Ave 5% thigh, anterior leg extension) absent
L4-5 L-5 Lower back, buttock, Anterolateral calf Dorsiflexion of Usually no
40%-45% lateral thigh, to great toe foot, extension of changes
anterolateral calf, great toe (foot
occasionally groin drop tibialis
anterior)
L5-S1 S-1 Lower back, buttock, Lateral calf to Plantarflexion of Ankle jerk
45%-50% lateral thigh and calf small toe foot diminished or
(Gastrocnemius) absent