Spinal disorders

Degenerative disc disease

Definition-
• Disc protrusion: Pressure on the vertebrae causes the gelatinous core, called the nucleus
pulposus to move and press against the annulus fibrosus This bulge compresses a  spinal
nerve and thus causes  pain.
• Disc herniation: (= disc extrusion or disc prolapse): A tear in the annulus fibrosus results in
extrusion of the nucleus pulposus and potential compression of the  spinal nerve
• Disc sequestration: Extrusion of the nucleus pulposus and separation of a fragment that enters
the spinal canal and may cause compression of the spinal nerve.
Epidemiology-

Age: most common at 30–50 years

Sex: ♂ > ♀
 
About 5% of back  pain is a consequence of
disc herniation
Lumbosacral disc herniation
L5–S1 (most common site)
L4–L5 (second most common site)
Cervical and thoracic disc herniations
are rare
Pathophysiology—

• The intervertebral disc consists of a dense outer ring (annulus fibrosus) and a gelatinous core

(nucleus pulposus).
• Compression, tension, shear, and torque stresses on the spinal disc → degenerative
changes (e.g.,dehydration, annular tear) → disc protrusion or herniation → adjacent nerve root
impingement → sensorimotoric deficits in affected  nerve root
• Usually, the affected nerve root is the one below the level of disc herniation (e.g., L4–L5
disc herniation leads to L5 radiculopathy).
• Disc protrusion almost always occurs posterolaterally because the longitudinal  posterior
ligament is thinner than the longitudinal anterior ligament.
Clinical feature

Acute onset of severe back pain Stabbing or resembling 

electric shock (most commonly of the lower back,
called lumbago) 
Radiates to the legs (sciatic pain) or the arms 
parestheisa of affected dermatome Muscle
weakness and atrophy Loss of deep tendon reflex in the
indicator muscles
pain increases with pressure (e.g., from coughing or
sneezing)
Short walks and changing position reduces the pain
Disc herniation and nerve root
compression
Physical examination (reflexes, motor strength, sensory deficits)
Straight leg-raising maneuvers 
• Straight leg raise test (losegues’s sign): straight leg of patient is raised → ↑ pain in the ipsilateralleg with
radiation to the motor or sensory area of the affected nerve root. 
• Bragard sign: straight leg of patient is raised → ↑ pain in the ipsilateral leg → leg is lowered to just
below this point → ankle is dorsiflexed → reproduction of pain
• Crossed straight leg raise test: opposite straight leg of patient is raised →
increased pain in contralateral leg with radiation into the motor/sensory area of the affected nerve root. 
Spurling's maneuver (neck compression test) 
Used for diagnosis of cervical spine radiculopathy
Forward flexion 
 , tilting, and rotation of the neck towards the affected side and application of downward pressure to the
head → reproduction of pain or paresthesia with radiation to the motor/sensory area of the affected nerve
root 
MRI
To confirm diagnosis
Disc degeneration: sclerosed, dehydrated disc that is hypointense on T2-
weighted images
Disc prolapse/herniation: herniation of disc tissue with surrounding edema
CT-myelogram
If MRI is unavailable or cannot be conducted
Better for analysis of bone structure (e.g. prior to surgery)
Plain radiographs: to exclude other pathologies (e.g., spine tumors, instabilities);
preoperatively
Conservative treatment
Physiotherapy with exercises strengthening the back 
No bed rest, but continuation of daily activities
Local heat
Analgesics (e.g., NSAIDs)
Periradicular therapy (PRT): CT-navigated injection of a
local anesthetic (e.g., ropivacaine) and glucocorticoids at the intervertebral
foramen to reduce inflammation and edema at the affected nerve root 
Surgical treatment
Emergency indications
Significant or progressive neurological deficits
Bladder or bowel incontinence
Cauda equina syndrome/conus medullaris syndrome
Elective indications: massive radicular pain which cannot be relieved by conservative
and/or medical treatment
Procedure: microsurgical intervention with nerve decompression 
Access: windowing of the ligamentum flavum as a dorsal limitation of the spinal
canal
Aim: removal of prolapsed disc material and potential sequestration
Surgical complications 
Damage of large prevertebral blood vessels (rare)
Post-dissection syndrome/ postnucleotomy syndrome: persistent back pain, radicular
pain, and paresthesia in approx. 5% of patients after disc surgery due to
scarring, vertebral instability, or arachnoid adhesions to nerve roots.
Ankylosing spondylitis
(Bekhterev's disease)
Definition--Ankylosing spondylitis (spondyloarthritis), a type of seronegative
spondyloarthropathy, is a chronic inflammatory disease of the axial skeleton that leads
to partial or even complete fusion and rigidity of the spine. 

Epidemyology-
Sex: ♂ > ♀ (3:1) 
Age: 15–40 years
Lifetime prevalence in the US: ∼0.5%

Etiology-
Genetic predisposition: 90–95% of patients are HLA-B27 positive. 
Articular symptoms
Most common presenting symptoms: back and neck pain
Gradual onset of dull pain that progresses slowly
Morning stiffness that improves with activity
Pain is independent of positioning, also appears at night
Tenderness over the sacroiliac joints
Limited mobility of the spine (especially reduced forward lumbar flexion)
Inflammatory enthesitis (e.g., of the Achilles tendon, iliac crests, tibial tuberosities):
painful on palpation
Dactylitis
Arthritis outside the spine ( hip , shoulder, knee joint) 
Extra-articular manifestations
Most common: acute, unilateral anterior uveitis (∼ 25% of cases) 
Fatigue, weakness, fever, weight loss
Restrictive pulmonary disease due to decreased mobility of the spine and thorax
Gastrointestinal symptoms: associated with chronic inflammatory bowel disease (∼ 5–10% of
cases, see also: ulcerative colitis or Crohn disease) 
Prostatitis
Rare 
Cardiac: aortic root inflammation and subsequent aortic valve insufficiency, atrioventricular
blocks
Kidney: IgA-nephropathy
Diagnostic approach 
Physical examination, patient history, and pelvic x-ray: If results are conclusive, no additional testing is required!
If inconclusive → HLA-B27 testing
If still inconclusive → pelvic MRI
Clinical tests

Chest expansion measurement: to monitor disease severity

Method: measure chest circumference in full expiration and inspiration
Pathological difference: < 2 cm
Physiological difference: > 5 cm
Spine mobility tests
Schober test 
: Mark two points, S1 and another point 10 cm above → patient touches toes (without bending the knees) →
distance between the two points increases by ≥ 4 cm → physiological test result; a smaller increase in
distance between these two points is pathological
Examination of the hip 
Mennell sign: tenderness to percussion and pain on displacement of the sacroiliac joints 
FABER test: FABER (Flexion, ABduction, and External Rotation) provokes pain in the ipsilateral hip
Schober test
Imaging

X-ray
Helps confirm a diagnosis and evaluate the severity of disease
Changes are generally more evident in later disease.
The changes usually occur symmetrically.
Pelvis (best initial test): to examine the sacroiliac joints 
Signs of sacroiliitis, including ankylosis (fusion of the articular surfaces) 
Spine
Loss of lordosis with increasing abnormal straightening of the spine
Sclerosis of the vertebral ligamentous apparatus
Syndesmophytes resulting in a so-called 'bamboo spine' in
anteroposterior radiograph in the later stages 
(see the table in “Differential diagnosis” below)
Signs of spondyloarthritis, including ankylosis of intervertebral joints 
Thorax: ankylosis of costosternal and costovertebral joints 

MRI
More sensitive than CT scan for detecting sacroiliitis 
Best method for early detection
Treatment--
Physical therapy
Consistent and rigorous physical therapy
Independent exercises
Medical therapy
First choice: NSAIDs (e.g., indomethacin)
Additional options 
Tumor necrosis factor-α inhibitors (e.g., etanercept, adalimumab) 
 [12]
In case of peripheral arthritis: DMARDs (especially sulfasalazine)
In severe cases: temporary, intra-articular glucocorticoids
Surgery: in severe cases to improve quality of life
Indications 
Severe deformity of the spinal column
Instability of the spine
Neurologic deficits
Procedures 
Osteotomy
Joint replacement
Spinal fusion