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Pyogenic Spinal Infection
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Acute pyogenic infection of the spine is
uncommon ,
diagnosis and treatment are often
unnecessarily delayed.
The elderly, chronically ill and immunodeficient patients are at greatest risk.
It might follow surgery in renal system.
Tuberculosis of spine:
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The spine is the most commonest site of skeletal
tuberculosis and the most dangerous .
It is blood – born infection settled in the vertebral bodies
, bone destruction and caseation follow with spread of
the infection to the adjacent disc space and adjacent
vertebrae.
As the vertebral bodies collapse , a sharp angulation or
(kyphos) develops. Caseation and cold abscess formation
may extend to the neighboring vertebrae or escape into
paravertebral soft tissue .
There is risk of spinal cord damage due to pressure by
the abscess or displaced bone or ischemia from spinal
artery thrombosis.
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Clinically there is long history of ill health and
back ache ; the deformity is some time the
dominant feature or the patient presented with
cold abscess pointing in the groin ; or with
parasthesia and weakness of the legs .
The characteristic feature in late cases is an
angular thoracic kyphosis .
Pott`s paraplegia is the most dangerous
complication of spinal tuberculosis .
Imaging :
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X- ray , the entire spine should be x- rayed to detect any
infection in other vertebrae . Earliest sign is local
osteoporosis of two adjacent vertebrae and narrowing of
intervertebral disc space ; then there will be bone
destruction and collapse of the adjacent vertebral bodies
lead to angular deformity.
Para spinal soft tissue shadow may be due to para
vertebral abscess . CT and MRI is very helpful
Investigation : Mantoux test is +ve ; ESR is high
Differential diagnosis :
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1 - pyogenic infection .
2- malignant disease .
Treatment :
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the aim of treatment is:
1- to eradicate the disease .
2- to prevent or correct the deformity .
3-to prevent or treat the major complication ,
mainly paraplegia .
The way of treatment will be by anti T.B
chemotherapy and surgical drainage of the pus
collection ; surgical curration of the diseased
bone ; anterior spinal fusion and bone grafting
sometimes used .
Intervertebral disc prolapse
The spine is a non-homogeneous complex-shape consist
of 24 vertebrae, separated by intervertebral discs with
numerous muscles and ligaments attached to them.
Intervertebral discs act as a kind of cushion to soften the
impacts caused by the movement of body.
The intervertebral discs make up about one fourth of
entire length of the vertebral column.
The discs absorb the stress and strain transmitted to the
vertebral column.
The intervertebral disc is a structure composed of the
gelatenus nucleous pulposus at the center surrounded by
annulus fibrosus .
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Sever stress and degeneration of the disc may lead to
herniation of the gelatinus nucleus pulposus through
the anulus fibrosus back ward so if it is on the right or
on the left it will compress the nerve roots leading to
rooting pain(sciatica), and if it herniated to the center it
will compress the cauda equina leading to cauda equina
syndrome and this include: bladder and bowel
incontinence , perineal numbness, bilateral sciatica,
lower limb weakness, crossed straight-leg raising sign .
Cauda equina lesion need urgent MRI and CT scan
and operate urgently if a large central disc is revealed.
clinical features:
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Acute disc prolapse may occur at any age, but is
uncommon in the very young and the very old. The
patient is usually a fit adult aged 20–45 years.
Typically, while lifting or stooping he has severe back
pain and is unable to straighten up. Either then or a day
or two later pain is felt in the buttock and lower limb
(sciatica).
Both backache and sciatica are made worse by coughing
or straining. Later there may be parasthesia or numbness
in the leg or foot, and occasionally muscle weakness.
Cauda equina compression is rare but may cause urinary
retention and perineal numbness.
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on examination: The patient usually stands with a
slight list to one side(‘sciatic scoliosis’).
All back movements are restricted, and during forward
flexion the list may increase. There is often tenderness
in the midline of the low back, and paravertebral
muscle spasm.
Straight leg raising is restricted and painful on the
affected side.
Neurological examination may show muscle
weakness(and, later, wasting), diminished reflexes and
sensory loss corresponding to the affected level.
Imaging
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1- X-rays : are helpful, not to show an
abnormal disc space but to exclude bone
disease. After several attacks the disc space
may be narrowed and small osteophytes
appear.
2- CT and MRI : These are now the
preferred methods of spinal imaging.
Treatment :
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symptomatic treatment include: Heat , analgesics,
and exercises strengthen muscles, but there are only
three ways of treating the prolapse itself –
rest,
reduction or
removal, followed by
rehabilitation.
Rest: With an acute attack the patient should be kept
in bed, with hips and knees slightly flexed. A
nonsteroidal anti- inflammatory drug is useful in most
of patients.
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Reduction: Continuous bed rest and traction for 2weeks may
reduce the herniation. If the symptoms and signs do not
improve during that period, an epidural injection of
corticosteroid and local anaesthetic may help.
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Removal: The indications for operative removal of a prolapse
are:
(1) a cauda equina compression syndrome , this is an
emergency.
(2) Neurological deterioration while under conservative
treatment.
(3) persistent disabling pain and signs of sciatic tension after 2–
3 weeks of conservative treatment.
The two operations most widely performed are laminotomy and
microdiscectomy.
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Spondylolysis
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It is defect in the neural arch ( paras
interarticularis) of the 5th or 4th lumber
vertebra, it predispose to spondylolisthesis.
It might follow injuries ( fibrous non union
of fracture or stress fracture) or congenital.
X-ray in oblique view would shows the
defect.
Most of cases need no treatment, belt,
analgesia for short time and physiotherapy
may used some times.
Spondylolisthesis
forward displacement of one
vertebra over other vertebra
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‘Spondylolisthesis’ means forward translation of
one segment of the spine upon another.
The shift is nearly always between L4 and L5,
or between L5 and the sacrum, ( fig. . ).
Normal discs, laminae and facets constitute a
locking mechanism that prevents each vertebra
from moving forwards on the one below.
Forward shift (or slip) occurs only when this
mechanism has failed.
Classification: six types:
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Dysplastic (20 per cent) The superior sacral facets are
congenitally defective.
Lytic or isthmic (50 per cent) In this, the commonest variety,
there are defects in the pars inter articularis (spondylolysis), or
repeated breaking and healing may lead to elongation of the
pars.
Degenerative (25 per cent) Degenerative changes in the facet
joints and the discs.
Post-traumatic (Unusual fractures).
Pathological Bone destruction (e.g. due to tuberculosis or
neoplasm) may lead to vertebral slipping.
Postoperative (iatropathic) occasionally, excessive operative
removal of bone in decompression operations.
Clinical features
Backache is the usual presenting symptom; it is
often intermittent, coming on after exercise or
strain. Sciatica may occur in one or both legs.
On examination the buttocks look flat, the sacrum
appears to extend to the waist and transverse loin
creases are seen. A ‘step’ can often be felt when
the fingers are run down the spine.
In children the condition is painless but the mother
may notice protruded abdomen .In old age
intermittent claudication may occur due to
associated spinal stenosis.
Imaging :
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X-ray: 1- lateral view show the forward shift
of the upper part of the spinal column on the
stable vertebra below.
2- oblique views which is the best view to
see the gap in the pars interarticularis
(decapitated Scotty dog) sign.
In doubtful cases, CT may be helpful.
Treatment:
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Conservative treatment, analgesic antiinflammatory
drugs, avoiding lifting weights, using lumber built.
Operative treatment is indicated:
(1) if the symptoms are disabling.
(2) if the slip is more than 50 per cent and progressing.
(3) if neurological compression is significant.
Surgical treatment carried out by reduction, internal
fixation and spinal fusion
Spinal stenosis
The term spinal stenosis is used to describe abnormal
narrowing of the central canal, the lateral recesses or the
intervertebral foramina to the point where the neural
elements are compromised. When this occurs the
patient develops neurological symptoms and signs in
the lower limbs called neural claudication.
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The causes of spinal stenosis are:
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1- congenital.
2- chronic disc protrusion.
3- osteoarthritis of the facet joints.
4- spondylolisthesis.
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Clinical features
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The patient, usually aged over 50, complains of
aching, heaviness, numbness and parasthesia in
the thighs and legs; it comes on after standing
upright or walking for 5–10 minutes, and is
consistently relieved by sitting, squatting or
leaning against a wall to flex the spine (hence the
term ‘spinal claudication’).
The patient may prefer walking uphill, which
flexes the spine (and maximizes the spinal canal
capacity), to downhill, which extends it.
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Imaging
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X-rays will usually show features of disc
degeneration and proliferative osteoarthritis
or degenerative spondylolisthesis.
Measurement of the spinal canal can be
carried out on plain films, but more reliable
information is obtained from myelography,
CT and MRI. The MRI and CT is the
reliable and safe imaging nowadays.
Treatment:
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Conservative measures, including
instruction in spinal posture, reduce weight
may suffice. Most patients are prepared to
put up with their symptoms and simply
avoid uncomfortable postures. If discomfort
is marked and activities such as standing
and walking are severely restricted, operative
decompression is almost always successful
(laminactomy).
Spondylosis
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Spondylosis is osteoarthritis of spine, it is very common.
It result from degenerative changes, previous injuries and
spinal diseases. There is scleroses of facet joints, reduction of
joint space and osteophytes formation which might compress
the spinal canal and nerve roots.
Spondylosis may cause chronic backache after activities or
early morning, spinal stenosis or radiculopathy.
X-ray shows osteoarthritis changes in posterior facets joints and
reduction in intervertebral disc space.
The treatment depend on the severity of the symptoms and
disability, in the mild cases treatment is unnecessary, analgesia,
belt and physiotherapy may be used in moderate symptoms,
rarely surgery used in treatment of severe cases.
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Coccydynia
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Coccydynia is chronic painful condition in
the region of the coccyx, the pain persist for
many weeks or months , after local injury.
There is local tenderness, other causes of
pain in this region should be excluded.
It is self limiting condition, analgesia and
local steroid injection may used .