Degenerative Spine Disease

Degenerative spine disease is a general term that refers to any disease of the spinal column that
results from the aging process and wear and tear that occurs to the bone and soft tissues of the
spine. While some of this type of spinal disease is normal with the normal aging process, some
people appear to be more prone to the development of this type of spine disease than others.
Additionally, people who put increased strain on their necks and backs can increase the rate at
which this wear and tear occurs.
The term degenerative spine disease does not refer to any one pathology of the spine, it is a general
term that encompasses many types of disorders, many of which can occur simultaneously in the
same patient. Some of these specific types of degenerative spine disease are listed here and more
details about each can be found on their own respective pages.

Some Types of Degenerative Spine Disease

•Herniated Discs: A herniated disc is a protrusion of an intervertebral disc, the "cushion" that sits
between each vetebral bone of the spine. It can happen suddenly with a trauma, but more
commonly occurs over years. It can cause pain and also compress nerves in the area, leading to
sensory or motor symptoms in the arm or leg, depending on the location of the herniation. The most
common sites are lumbar herniated discs (low back) and cervical herniated discs (neck). Thoracic
herniated discs (mid-back) are much less common.

•Spinal Stenosis: Stenosis is a term that describes narrowing of a structure. In this case, it is
narrowing of the spinal canal, in which the spinal cord sits. Over time, as this narrows from build up
of tissue around the spine, it can start to cause symptoms by compressing the nerves and spinal
cord. Stenosis occurs most commonly as lumbar stenosis and cervical stenosis. In addition, stenosis
is sometimes used to refer to Foraminal Stenosis, which is narrowing of one or more foramen, the
holes that the spinal nerves go through to exit from the spinal column.

•Spinal Instability: Normally, the spine and all its ligaments and muscular support are stable. It
moves only in certain ways and other types of movement is limited. Smooth bending and turning of
the column keeps the spinal cord and spinal nerves happy and safe. However, with severe
degenerative spine disease, this normal stability can become lax and lead to abnormal weakness in
certain areas. This is spinal instability. Instability can both lead to pain as well as injury to the spinal
cord or spinal nerves, both of which can cause neurological symptoms. Instability can also occur
acutely as the result of a trauma which tears supportive soft tissues or breaks bones of the spine.

What Types of Symptoms Are Typical?

The symptoms that are caused by degenerative disease of the spine vary tremendously depending
on the specific pathology a patient has. Pain, both in the back or neck and in the arms or legs, is a
common finding. Additionally, neurological symptoms due to compression of spinal nerves or even
the spinal cord itself can occur as well in some cases. This can typically cause sensory symptoms
(such as numbness, tingling, pain, etc.) as well as motor symptoms (weakness or paralysis, muscle
wasting, abnormal reflexes, etc.). Again, each patient and each pathology is different. You can learn
more for each of the types of degenerative disease listed above.
In general, lumbar (low back) disease will lead to low back and leg symptoms while cervical (neck)
disease can lead to neck and arm symptoms.

How Is The Diagnosis Typically Made?

Again, diagnosis varies depending on the specific pathology in each patient. However, many of these
disorders are at least partially recognized by the history of symptoms as well as a thorough
neurological examination. If these suggest spine disease, imaging studies of the spine are often
ordered. While many patients first get plain x-rays of the spine, CT scans and MRI scans are the best
for really elucidating the pathology of the spine.

In particular, CT scan is good for defining bony anatomy and any fractures or dislocations of bone
structures in the spine. It is not as good for demonstrating soft-tissue abnormalities.

The MRI gives the best resolution of soft tissues so that fine detail can be seen. It can easily
demonstrate herniated discs, stenosis, nerve compression and other more subtle findings.

Rarely, a myelogram is used as well. This study uses the injection of a contrast dye into the
cerebrospinal fluid in the spine to help elucidate some pathologies of the spine on x-ray or CT scan.

What Are Some Common Treatments?

Treatment for degenerative spine disease varies considerably depending on the specifics of each
case. Some patients benefit from conservative therapy with rest and physical therapy. Others benefit
from injections of the spine. Some cases require surgical intervention. You can learn more about
these for each of the specific types of disease on their respective pages. However, no generalizations
can be made as each patient and each disease is unique. Each patient should discuss their most
appropriate treatment plan with their personal physicians.
Herniated Disc ("Slipped Disc")

What Is It?

A herniated disc, sometimes referred to as a "slipped disc", is a bulging or rupture of an

intervertebral disc due to degenerative spine disease or trauma. It can cause nerve compression
which leads to neurological symptoms.

The intervertebral disc is a cartilaginous and fibrous structure that sits between vertebral bones of
the spine at each level. Their normal function can be thought of as shock absorbers for the spine,
helping to support the weight of the person and adapt to changes in posture and weight. Normally,
the outer rim of the disc is smooth. With age and degenerative changes in the spine with wear and
tear, some discs can become weak. Their outer rim becomes lax, leading to bulging of the disc, and
can even rupture or tear, leading to extrusion of the interior contents of the disc.

When a disc herniates, it can press on neurological structures, most notably the spinal nerves that
are passing in and out of the spine at that level. This compression of the nerves can lead to
neurological symptoms.

A herniated disc can occur slowly over time due to aging and degenerative changes of the spine.
However, occasionally they can occur suddenly with trauma to the spine which ruptures the disc.
The most common locations for a herniated disc are in the cervical spine and in the lumbar spine.
thoracic disc herniations are much less common.

What Types of Symptoms Are Typical?

Symptoms vary from patient to patient depending on the severity of herniation, the timeframe and
the exact location of the disc herniation.

For one, disc herniation often causes pain. Pain in the neck or back in the area of the herniation can
be accompanied by pain that radiates into the arm or leg on the side of the herniation.

Other neurological symptoms can occur as the disc compresses spinal nerves. Symptoms include
numbness and tingling and muscle weakness in the distribution of that nerve. Typically these
symptoms are one-sided in one limb, correlating with the side and level of the herniation.

Cervical herniations: For more information about symptoms specifically related to cervical disc
herniation, see the Cervical Disc page.

Lumbar herniations: For more information about symptoms specifically related to lumbar disc
herniation, see the Lumbar Disc page.

Thoracic herniations: For more information about symptoms specifically related to thoracic disc
herniation, see the Thoracic Disc page.
How Is The Diagnosis Typically Made?

If a patient presents with pain and/or neurological symptoms which are consistent with a herniated
disc on physical examination, an imaging study of the spine is often ordered. Most commonly, an
MRI scan of the spine will reveal the herniated disc clearly and allow identification of its location on
the spine. In some patients, to confirm that their symptoms are related to disc disease, other studies
such as a discogram or nerve conduction studies can be performed as well.

What Are Some Common Treatments?

For most patients, a period of conservative treatment will be suggested first. This entails rest, anti-
inflammatory drugs and physical therapy. Spinal injections are also sometimes effective to decrease
inflammation and the pair associated with a herniated disc.

If these conservative measures fail, or if their symptoms are very severe, some patients will require a
surgical procedure to remove the disc herniation. Generally, a procedure called a discectomy is
performed. In the lumbar spine this can be done through a small microdiscectomy or through a tube
with endoscopic spine surgery. In the cervical spine it is usually performed from the front of the neck
as an anterior cervical discectomy and fusion. In either case, the goal is to remove the part of
herniated disc which is compressing nerves and causing symptoms.

Each case is different so each patient should discuss their diagnosis and treatment options with their
own physician.
Spinal Stenosis

What Is It?

Spinal stenosis is an abnormal narrowing of the spinal canal, the location of the spinal cord. While
the spinal cord usually has ample room around it, surrounded by fluid and then the bony and soft
tissue structures of the spine, with stenosis this room is reduced. Varying from mild to severe,
stenosis can cause symptoms as it gets progressively worse and causes compression of the nervous
system structures within, including the spinal cord and the nerves exiting the cord.

Spinal stenosis generally occurs as a part of degenerative spine disease. With aging and wear and
tear of the spine over years, the spine undergoes many changes. Ligaments and other soft tissue can
both become lax and also become over-grown, impinging on areas they should not be. The
intervertebral discs can bulge and even herniate, adding to the impingement of the spinal canal.
Likewise, the bone and joints can have degenerative changes that include over-growth of bone
called osteophytes.

All of these changes that occur in the spine can slowly reduce the diameter of parts of the spinal
canal. At some point, the stenosis can become symptomatic. Stenosis occurs most frequently in
either the cervical or lumbar spine.

Another form of stenosis in the spine is foraminal stenosis, which is narrowing of the small holes
through which nerves pass in and out of the spinal column. It can occur alone or concurrently with
spinal stenosis.

What Types of Symptoms Are Typical?

The symptoms caused by stenosis vary considerably from patient to patient depending on its
severity and location.

Cervical stenosis, in the area of the neck, often presents with neurological symptoms in the arms,
including but not limited to arm pain, numbness, tingling and occasionally weakness. Very severe
stenosis can compress the spinal cord itself, leading to spasticity, difficulty walking, clumsiness and
even problems with the normal control of bowel and bladder function.

Lumbar stenosis, in the area of the lower back, can cause low back pain and leg pain as well as
possible numbness, tingling and weakness or clumsiness of the legs. It can cause urinary and bowel
dysfunction as well. The pain and weakness in the legs often gets worse with prolonged activity. This
is sometimes termed neurogenic claudication.

Spinal stenosis generally causes symptoms on both sides of the body, although occasionally it can be
unilateral. This is in contrast to a herniated disc, for example, which most often only impinges on a
nerve to one side or the other.

How Is The Diagnosis Typically Made?

A patient with typical symptoms generally undergoes a thorough neurological examination followed
by some type of imaging study. Most commonly, an MRI scan of the neck or low back is performed
to evaluate for degenerative spine disease, including stenosis. The MRI is generally effective in
demonstrating the degree of narrowing of the spinal canal and which levels of the spine are
involved. Other studies such as nerve conduction studies may be performed in some patients to
evaluate which levels and areas are most affected.

What Are Some Common Treatments?

For milder cases, rest, physical therapy, anti-inflammatory drugs and/or epidural spinal injections are
often recommended. For patients who do not improve or for more severe cases, surgical treatment
is considered for some patients. The goal of surgery is generally to remove some of the tissues and
bone that are narrowing the spinal canal so that the nerves and/or spinal cord are no longer
compressed. In the lumbar region this usually involves a laminectomy with or without
foramenotomy.

A laminectomy is a procedure that removes part of the back part of the vertebra, the lamina. This
helps to open up the spinal canal so that it can expand posteriorly.

In the case of cervical spinal stenosis, either a posterior laminectomy or an anterior procedure
through the neck can be performed. The choice depends on several factors, including the specific
anatomy of the stenosis and whether most of the compression is from the front or the back.

Occasionally, large laminectomies will require concurrent or subsequent spinal fusion.

Every case is different, so each patient should consult their own physician about what the best
treatment plan is for them.
Foraminal Stenosis

What Is It?

Foraminal stenosis is a narrowing of the spinal foramen, the hole through which passes a spinal
nerve as it exits the spine (foramen basically just means "hole"). It is usually a form of degenerative
spine disease which occurs slowly over time with wear and tear of the spinal column. Arthritic
changes of the spine, including herniated discs and bulging discs, soft tissue swelling and bony
growth can all impinge on the formal foramen and compress the nerve within.

A foramen exists at each level of the spine with one on each side. At each level, a spinal nerve, a
nerve coming to or from the spinal cord, passes through the foramen. Because the foramen is a
relatively small area, anything impinging on that area can cause foraminal stenosis is pinch the
nerves inside the foramen.

While foraminal stenosis generally occurs in the setting of other degenerative disease of the spine, it
can present as the primary problem in some patients. It can cause symptoms as only one level or at
many at the same time if many foramina (the plural of foramen) are involved.

What Types of Symptoms Are Typical?

Because the narrowing (stenosis) of the foramen pinches a nerve, the primary symptoms related to
this disorder is directly related to that nerve which is affected. This obviously varies depending on
which foramina are involved.

Any one foramina contains one nerve which goes to specific parts of the body. A left-sided foramen
contains a nerve which only goes to the left side of the body. Therefore, the symptoms associated
with foraminal stenosis will always be on the side of the stenosis. It can affect both sensory and
motor function in the area that the nerve normally goes to (see below).

Generally, foramen disease in the lower part of the spine, called the lumbar region, will lead to
symptoms in the leg. Likewise, disease in the neck, called the cervical region, will lead to symptoms
in the arm.

The pinched nerve can lead to basically two classes of symptoms. First of all, sensory symptoms can
occur, including pain in the distribution of that nerve as well as numbness, tingling and other sensory
abnormalities.

Also, motor symptoms can occur, including weakness, abnormal reflexes and even paralysis in
severe cases. However, unlike paralysis that occurs from damage to the spinal cord itself, this
weakness or paralysis is one sided (unless the foramina of both sides are affected greatly) and
limited to the muscles that are normally controlled by that specific nerve.

How Is The Diagnosis Typically Made?

After a thorough neurological examination, an MRI scan of the spine is generally the preferred study
to evaluate the foramen and other subtle areas of the spine. While plain x-rays and CT scan can
show good detail of the bony structures of the spine, they are not as sensitive for the soft tissues
and smaller structures like the foramen and the nerve within.
A good MRI can demonstrate foraminal stenosis well, as well as evaluating other pathologies of the
spine.

What Are Some Common Treatments?

Treatment for degenerative spine disease varies considerably from patient to patient. In the case of
foraminal stenosis, the treatment varies as well. Most patients will be recommended to first undergo
a period of conservative therapy with rest, physical therapy and/or anti-inflammatory medications.
In some cases this is enough for the pressure on the nerve to abate and for the symptoms to
improve. Other options are spinal injections which help to decrease the inflammation in the area.
Finally, if all else fails or if the stenosis and symptoms are severe enough, some patients will be
offered surgical treatment. Surgery often involves other procedures to address other degenerative
disease of the spine that may be occurring at the same time. However, the procedure generally used
to specifically address foraminal stenosis is called a Foramenotomy. In effect, this procedure aims to
open up the foramen so that the nerve within has more room and is not compressed.

The specifics of each patient vary. Therefore, treatment decisions should not be generalized. Each
patient should discuss their unique case of spinal disease with their own physician to mutually
decide on an appropriate treatment plan.