Degenerative diseases of the spine

Disc herniation

An intervertebral disc herniation occurs when the soft core (nucleus pulposus) pushes through a damaged fibrous ring (anulus fibrosus). It is most common at the lumbar levels L4–L5 and L5–S1 and the cervical levels C5–C6 and C6–C7, but it can occur at other levels too. By extent, we distinguish bulging, protrusion, extrusion and sequestration, and the clinical picture depends on how the herniation relates to the nerve root, both mechanically and biologically.

The doctor assesses radicular syndrome and motor deficit on clinical examination and orders diagnostic tests, both conventional X-rays and magnetic resonance imaging. In the great majority of cases treatment is conservative: analgesics and non-steroidal anti-inflammatory drugs, a short course of corticosteroids if needed, an epidural or periradicular block, followed by an individual rehabilitation programme. A progressive motor deficit and cauda equina syndrome are urgent indications for surgery.

Sciatica (lumboischialgia)

Lumboischialgia is pain from the lumbar spine that spreads down the back or side of the leg, in the area supplied by the L5 or S1 root. The most common cause is disc herniation, followed by foraminal and lateral stenosis.

The doctor distinguishes radicular pain from pseudoradicular pain, which comes from the facet joints, the sacroiliac joint or the piriformis muscle, and from pain arising in the hip. This relies on the straight leg raise test (Lasègue), the neurological status and, if needed, MRI and electromyoneurography (EMNG). Treatment includes medication, nerve blocks and rehabilitation, from offloading and neuromobilisation to trunk stabilisation.

Cervical radiculopathy (cervicobrachialgia)

Cervical radiculopathy is compression or irritation of the cervical nerve roots, most often due to disc herniation or foraminal stenosis with uncovertebral arthrosis. Clinically it presents with radicular pain in the arm, paraesthesia, motor deficit and reduced reflexes.

The diagnosis is based on the neurological status, Spurling’s test and MRI, and, where there is a motor deficit, on EMNG. The doctor provides medical treatment, a periradicular block and a rehabilitation programme, and monitors the motor deficit as a possible indication for surgery.

Cervical spondylotic myelopathy

Cervical myelopathy is compression of the spinal cord due to degenerative stenosis of the cervical canal, hypertrophy of the ligamentum flavum or ossification of the posterior longitudinal ligament. It presents with clumsy hands, gait disturbance, spasticity, hyperreflexia and positive Hoffmann and Babinski signs.

The diagnosis is confirmed by MRI, and severity is assessed with the mJOA scale. The disease is progressive, so manipulation of the cervical spine is contraindicated. The doctor assesses the need for surgical decompression and leads rehabilitation of gait, balance and fine motor skills before and after surgery.

Spinal stenosis

Stenosis is narrowing of the central canal, the lateral recesses or the intervertebral foramina due to hypertrophy of the facet joints and ligamentum flavum, disc protrusion or spondylolisthesis. The typical symptom is neurogenic claudication: pain, tingling and weakness in the legs when walking and standing, which ease when sitting or bending forward.

The doctor distinguishes neurogenic claudication from vascular claudication by checking the pulses and, if needed, measuring the ankle-brachial index, and confirms the diagnosis by MRI. Treatment includes a flexion-based exercise programme, aerobic training on an exercise bike, medication for neuropathic pain and epidural blocks. If the neurological deficit progresses, the patient is referred for surgical decompression.

Osteochondrosis

Degenerative disease of the intervertebral disc with dehydration, loss of height and changes in the vertebral endplates (Modic changes). The doctor assesses how far the changes on the scan explain the symptoms, because they are also common in people without pain.

Spondylosis and facet syndrome

Degenerative changes of the vertebral bodies and arthrosis of the facet joints, with pain that worsens on extension and prolonged standing. The diagnosis can be confirmed with a diagnostic facet joint block, and it is treated with exercise, physical therapy and blocks.

Spondylolisthesis

Forward slippage of a vertebra relative to the vertebra below, either degenerative (most often L4–L5) or isthmic (most often L5–S1). The doctor assesses the degree of slippage and stability on functional X-rays, and rehabilitation is based on stabilisation of the deep trunk muscles.

Adult degenerative scoliosis

A deformity with a Cobb angle greater than 10°, caused by asymmetric degeneration of the discs and facet joints, often with lateral listhesis and stenosis. The work-up includes standing X-rays of the whole spine, MRI and bone densitometry, and treatment includes pain relief, blocks and a stabilisation programme, with monitoring for progression.