This is a presentation of the common lower back problems

1. ORTHOPAEDIC
DEPARTMENT
ZAGAZIG UNIVERSITY
FACULTY OF MEDICINE
By
Dr. Tarek A. ElHewala
Lecturer of Orthopaedic Surgery
Faculty of Medicine, Zagazig University

2. Spinal Anatomy
• The Human spine is
formed of:
1. 7 cervical
vertebrae.
2. 12 thoracic
vertebrae.
3. 5 lumbar
vertebrae.
4. Fused sacral and
coccyx vertebrae.

3. Spinal Anatomy
• These bony structures
articulate through the
vertebral disc to
provide:
1. Protection of the
spinal cord and its
nerve roots.
2. Mobility of the
trunk.

4. Spinal Anatomy
• Schematic representation of a functional spinal unit
(motion segment) in lumbar spine.

5. Spinal Anatomy
• Mid-sagittal section through a healthy young
intervertebral disc. The white cartilage endplates, the
gel-like nucleus pulposus and the surrounding anulus
fibrosus can easily be distinguished.

6. Spinal Anatomy
The lumbar spinal canal anatomy and lumbar ligaments

7. Spinal Anatomy
Normal intervertebral
foramen relations and
contents.

8. Lumbar Disc Herniation
• Lumbar disc herniation is
most frequently found in the
3rd and 4th decades of life at
the level of L4/5 and L5/S1.
• The cardinal symptom of
lumbar disc herniation is
radicular leg pain with or
without a sensorimotor
deficit of the affected nerve
root.

9. Lumbar Disc Herniation
• The radiculopathy
is not only caused
by a mechanical
compression of
the nerve root but
also by an
inflammatory
process caused by
nucleus pulposus
tissue

10. Lumbar Disc Herniation
• MRI is the imaging modality of choice for the
diagnosis of disc herniation

11. Lumbar Disc Herniation
• In contrast to large disc extrusion and
sequestrations, disc protrusions are frequently
found in asymptomatic individuals

12. Lumbar Disc Herniation
• The best discriminator of symptomatic and
asymptomatic disc herniation is nerve root
compromise

13. Lumbar Disc Herniation
• Mild radiculopathy responds well to nonoperative treatment, but surgical treatment
results in better short-term results in selected
patients.
• Severe radiculopathy responds poorly to nonoperative treatment and should be treated
surgically.
• The surgical treatment of choice is an open
standard
interlaminar
discectomy
or
microsurgical discectomy.

14. Lumbar Disc Herniation

15. Lumbar Disc Herniation
• Cauda Equina Syndrome caused by a central
disc herniation.
• Symptoms include bilateral leg pain, loss of
perianal sensation, paralysis of the
bladder, and weakness of the anal sphincter
• Cauda equina syndromes require an
emergency decompression and should be
treated by complete laminectomy and wide
decompression.

16. Spinal Stenosis
• Lumbar spinal stenosis can be defined as any
narrowing of the spinal canal, lateral recess or
intervertebral foramen.

17. Spinal Stenosis

18. Spinal Stenosis
• Spinal stenosis most frequently results from
degenerative alterations of the motion
segment.
• Lumbar spinal stenosis is a common condition
in elderly patients.
• Spinal stenosis is often associated with
degenerative spondylolisthesis.
• Degenerative
spondylolisthesis
most
frequently occurs at the L4/5 level in females

19. Spinal Stenosis

20. Spinal Stenosis

21. Spinal Stenosis

22. Spinal Stenosis
• The cardinal symptom of spinal stenosis is
neurogenic claudication.
• Neurologic examination of a patient often is
remarkably normal.
• The most important differential diagnosis is
intermittent ischemic claudication.

23. Spinal Stenosis

24. Spinal Stenosis
• MRI is the imaging modality of choice.

25. Spinal Stenosis
• Conservative treatment may only relieve
symptoms for a short time period.
• Conservative treatment does not affect the
natural history of spinal canal narrowing.

26. Spinal Stenosis
• Surgery is generally accepted when the quality of
life is substantially limited because of the
neurogenic claudication.
• Selective decompression (laminotomy) with
preservation of the lamina is the preferred
technique in the absence of segmental instability.
• Instrumented fusion as an adjunct to
laminectomy improves the long-term results in
degenerative spondylolisthesis with spinal
stenosis.

27. Spinal Stenosis

28. Lumbar Spondylo-Listhesis
• The term spondylolisthesis comes from the
Greek spondylo, meaning “vertebra,” and
olisthesis, meaning “movement or slipping.”
• Spondylolisthesis describes the pathologic
state of one vertebra slipping on another; this
can be forward (anterolisthesis) or backward
(retrolisthesis).

29. Lumbar Spondylo-Listhesis
• Spondylolithesis:
• Spondylo = Spine.
• Lithesis = Dislocation.
• Spondylolithesis of L4 on L5
• Retrolithesis of L5 on S1
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30. Lumbar Spondylo-Listhesis
• Spondylolysis:
• Spondylo = Spine.
• Lysis = Disintegrate.
•Pars Defect.
• Spondylolysis of L5
• Spondylolysis of L5 with spondylolithesis of
L5 on S1
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31. Lumbar Spondylo-Listhesis

32. Lumbar Spondylo-Listhesis
• Mechanical LBP may result from abnormal load distribution.
• Discogenic, facet-joint and neurogenic, referred pain may
coexist in spondylolisthesis.

33. Lumbar Spondylo-Listhesis
• Physical findings:
– tight hamstrings
– sensorimotor deficits
– pain on backward bending and rotation (often
facet joint pain)
– pain on forward bending (often discogenic pain)
– pain on extension from the forward bent position
– limitation of walking distance

34. Lumbar Spondylo-Listhesis

35. Lumbar Spondylo-Listhesis

36. Lumbar Spondylo-Listhesis

37. Lumbar Spondylo-Listhesis

38. Lumbar Spondylo-Listhesis

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