Disc prolapse and degenerative changes
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Transcript of Disc prolapse and degenerative changes
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DISC PROLAPSE AND DEGENERATIVE CHANGES
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Intervertebral DiscsIntervertebral Discs
Gel like Tissue between Gel like Tissue between each vertebraeach vertebra
fibro cartilaginous fibro cartilaginous cushionscushions serve as the spine's shock serve as the spine's shock
absorbing systemabsorbing system protect the vertebrae, brain, protect the vertebrae, brain,
and other structuresand other structures The discs allow some The discs allow some
vertebral motion extension vertebral motion extension and flexion. and flexion.
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Intervertebral DiscsIntervertebral Discs
The disc is made up of The disc is made up of 3 structures the 3 structures the
(1) Nucleus pulposus, (1) Nucleus pulposus, gelatinous centergelatinous center
(2) Annulus Fibrosus. (2) Annulus Fibrosus. Its job is to contain the Its job is to contain the nucleusnucleus
(3) Vertebral end plates (3) Vertebral end plates that attach the disc to that attach the disc to the vertebrae the vertebrae
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Process of wear and tear of intervertebral discs, vertebral bodies, and facet joints is called spondylosis
Commonest cause of entrapment spinal neuropathy
Usual age group >60 yrs
Usually asymptomatic
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DISC PROLAPSE
Extrusion of nucleus pulposus through posterior or posteriolateral radial tear in annulus fibrosis
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TYPES
Focal herniation is a herniated disc less than 90° of the disc circumference.
Broadbased herniation is a herniated disc in between 90°-180° of the disc circumference.
Bulging Disc is the presence of disc tissue 'circumferentially' (180°-360°) beyond the edges of the ring apophyses and is not considered a form of herniation
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AXIAL LOCALISATION OF HERNIATED DISCS
Central or medial posterior longitudinal ligament is thickest in this region,disc usually herniates slightly to the left or right of this central zone.
Paramedian or lateral recess PLL is not as thick in this region, this is common region for disc herniations.
Foraminal or subarticular It is rare for a disc to herniate into the intervertebral foramen.'Dorsal Root Ganglion' lies in this zone resulting in severe pain, sciatica and nerve cell damage.
Extraforaminal or lateral Disc herniations in this region are uncommon.
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IMAGING for disc prolapse
CT SCAN
Disc material is denser than CSF in thecal sac…… so clearly seen against epidural fat
BUT, very large extrusion may be missed.
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MRI
Extruded fragments brighter on T2
Enhance after contrast
Sometimes heavily calcified
More reliable in cervical spine where there is less epidural fat
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X-RAYS
Non specific findingsReduction of disc space or vertebral mal alignment or normal
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Axial T1-weighted image shows protrusion of a left paracentral disc with compression of left S1 root
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Axial T2-weighted image shows protraction of a left paracentral disc with compression of left S1 root
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CT axial.L3,4 disc space. Soft tissue mass in R. posterolateral aspect of disc encroaching into intervertebral foramen and extending lateral to it.arrow…L3 N
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T1W axial. L4,5 disc, disc fragment extends behind upper part of right side of body of sacrum. Displacing 1st sacral nerve root post and erodes sacral body.
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L5/S1 disc space.low signal mass protruding posteriorly and to the right from the posterior disc margin.This causes only minor compresion on the anterior margin of the theca (the bright, CSF containing sac in the spinal canal). The nerve roots within the theca are visible around its posterolateral margins and are not affected. However the neural foramen on the right is obliterated - compare with the other side where the higher signal fat, and the lower signal S1 nerve root are clearly seen
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Sagittal T2 weighted MRI images of 49-year male with history of radiculopathy. a. Pre-op image showing disc prolapse at C5/6 level. b,c,d are post-op images
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MRI of a patient showing disc prolapse between L5 and S1 vertebra
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DEGENERATIVE CHANGES
osteophytosis & marginal sclerosis
Mostly in lower cervical and lumbar region
reactive changes Degeneration in ligaments
ossification
calcification
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these changes occur in
post. longitudinal ligament
cruciform ligament
ligamenta flava
capsular ligament of facet joints
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Also include Ossification of post. long. Ligament
Retro-odontoid pseudotumor
Ossification of ligamentum flavum
Synovial cysts
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degenerative changes are seen in
Ochronosis
Charcot spine
Ankylosing spondylitis
Rheumatoid arthritis
Isolated phenomenon
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X-RAYS
most of the features of degeneration can be seen
If, sagittal diameter of spinal canal in cervical region <10mm…..spinal cord compressed
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CT SCAN / MRI
Deformation of spinal & intervertebral canals…CT / MRI
Better visualization of neural structures… MRI
Differentiation from infection….MRI… absent/ non-uniform high signal, irregularity/fragmentation.
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Sagittal T2W contrast.ossification of post. Longitudnal ligament
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SPINAL STENOSIS
Most common in
Achondroplasia
Acromegaly
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CT / MRI
Spinal canal is very narrow
Cross-sectional area less than 110mm²
No CSF signal on T2 weighted image
Reduntant coiling of intradural roots above stenosis…on MRI… entrapment of cauda equina
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Sagittal T2W ,with contrast. Stenosis of spinal canal at L4,5. no CSF signal at stenosis
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POST-OPERATIVE CHANGES Post-op recurrent myelopathy / radiculopathy
2 types
Discogenic
Reactive
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CT / MRI
Discogenic Typical mass continuous with disc substance
Reactive Contracting lesion standing around theca / nerve root,
continuing into soft tissue.
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T2W, disc higher signal than scar
Recent scar enhances faster, old scar less and slowly.
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