DEGENERATIVE

DISEASE
Lecture by: M.K. Sastry
 Degeneration of one or more intervertebral disc(s) of the
spine.

 Disc degeneration is a disease of aging, and though for

most people is not a problem, in certain individuals a
degenerated disc can cause severe chronic pain if left
untreated.
 common complaint among adults.

 lifetime prevalence in working population up to 80%.

 60% experience functional limitation or disability.

 second most common reason for work disability.

 despite advances in imaging and surgical techniques LBP

prevalence and its cost are relatively unchanged.

 Fibrocartilage replaces the
gelatinous mucoid material
of the nucleus pulposus as
the disc changes with age.

 There may be splits in the

annulus fibrosis, permitting
herniation of elements of
nucleus pulposus.
 Shrinkage of the nucleus
pulposus that produces
prolapse or folding of the
annulus with secondary
osteophyte formation at
the margins of the
adjacent vertebral body.
 degree of disc injury (size of tear / herniation), nor
the degree of nerve root compression correlate with
subjective pain or functional disability.
Cervical Radiculopathy
 Lumbosacral Radiculopathy (Sciatica)

Important:
A herniated disc at (e.g.) L4-5 may impinge either the L4 or L5 nerve roots!
Degenerative Disc (and Facet Joint) Disease
Foraminal Thickening/Buckling of
stenosis Ligamentum Flavum
Age:
20-40  36% have degenerated disc.
50  85-95% have degenerated disc.
60-80  98% have degenerated disc.
**<60  20% have asymptomatic disc herniation.

Conclusion: Abnormal findings on MRI frequently DO NOT

relate to symptoms (and vice versa) !!
85-95% at L4-L5/ L5-S1.
5-8% at L3-L4.
2% at L2-L3.
1% at L1-L2/ T12-L1.

**Cervical: most common C4-C7.

**Thoracic: 15% in asymptomatic pts. at

multiple levels, not often symptomatic.
Separations between anular
fibers, avulsion of fibers
from their vertebral body
insertions, or breaks through
fibers involving one or many
layers of the anular lamellae.
The terms 'tear' or 'fissure'
does not imply that the
lesion is consequent to
trauma. In case of a
traumatic event the term
'rupture' is appropriate.a
Displacement of disc
material beyond the limits of
the intervertebral disc
space. A herniated disc can
be contained (covered by
outer anulus fibrosus) or
uncontained.
 Focal Herniation Broad based hernia
Is a herniated disc less than Is a herniated disc in
90? of the disc between 90?-180? of the
circumference. disc circumference.
 Is the presence of disc tissue
'circumferentially' (180?-
360?) beyond the edges of
Bulging Disc the ring apophyses and is
NOT considered a form of
herniation.
 Disc Protrusion
Indicates that the distance
between the edges of the
disc herniation is less than
the distance between the
edges of the base.
Disc Extrusion
present when the distance
between the edges of the
disc material is greater the
distance at the base.
 Migration
indicates displacement of
disc material away from the
site of extrusion, regardless
of whether sequestrated or
not.
Sequestration
used to indicate that the
displaced disc material has
lost completely any
continuity with the parent
disc
Protrusion Extrusion Extrusion
 Protrusion w/ Protrusion w/
Protrusion migration +
migration
sequestration
Lumbar Spinal Stenosis
 Lumbar Spinal Stenosis

Disc bulge, facet hypertrophy and flaval ligament thickening

frequently combine to cause central spinal stenosis.

Note the trefoil shape of stenotic spinal canal.

 Lumbar Spinal Stenosis

Disc bulge, facet hypertrophy and ligament flavum thickening frequently

combine to cause central spinal stenosis

Note the trefoil shape of stenotic spinal canal

 Foraminal Stenosis
Neural
foramen
Cervical Spinal Stenosis
 30 y.o. female presents with low back pain.
 Pain radiating down right leg.
 Initial onset approximately 1 year.
 Referred by orthopedic surgeon.
 On motrin, previously darvocet, flexeril and
valium.
 Previous treatments: chiropractic and physical
therapy.
• A-P / lateral Plain Film:
Degenerative disc height loss at L4-5 level.

• MRI:
 L4-L5: Large central disc herniation (9mm in AP X 10mm
Broad) effacing the ventral thecal sac and impressing upon
the central canal.
• This produces moderate canal stenosis.
 L5-S1: broad disc bulge with radial tear.
• mild effacement upon the ventral thecal sac.
Imaging
 Abnormal Disc
< 180º > 180º

Herniation Tear Bulge

90º–180º < 90º

Broad-based Focal Symmetric Asymmetric

Waist* No waist

Extrusion Protrusion

Sequestered Migrated Neither

*(In any plane)

Schmorl’s Nodes

protrusions of the cartilage of the

intervertebral disc through the
vertebral body endplate and into the
adjacent vertebra.
 Confusing “Spondy-” Terminology
Spondylosis = “spondylosis deformans” = degenerative spine.

Spondylitis = Inflamed spine (e.g. ankylosing, pyogenic, etc.).

Spondylolysis = Chronic fracture of pars interarticularis with

nonunion (“pars defect”).

Spondylolisthesis = anterior slippage of vertebra typically resulting

from bilateral pars defects.

Pseudospondylolisthesis = “degenerative spondylolisthesis”

(spondylolisthesis resulting from degenerative disease rather than
pars defects)
Spondylolysis / Spondylolisthesis
Current Therapies For Discogenic Pain Or
Disc Pathology

• Medication and limited activity

• Spinal rehabilitation.
• Interventional pain management.
• Spinal surgery.
Thank You