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Dr.Farzad Ravari M.D Specialist Orthopedic Surgeon Cedars J.A Int.Hospital ANATOMY OF SPINE Intervertebral Disc The intervertebral disc absorbs shock, accommodates movement, provides support, and separates vertebral bodies to lend height to intervertebral foramina. The disc consists of an eccentrically located nucleus pulpous and a surrounding annulus fibrosis separating each segmental level between the C2-T1 vertebrae. No disc exists between C1 and C2, and only ligaments and joint capsules resist excessive motion DISC HERNIATION Pathophysiology of acute discopathy Acute disc herniation causes radicular pain through chemical radiculitis in which proteoglycans and phospholipases released from the nucleus pulposus mediate chemical inflammation and/or direct nerve root compression. Interleukin 6 and nitric oxide are also released from the disc and play a role in the inflammatory cascade. The chemical radiculitis is a key element in the pain caused by HNP as nerve root compression alone is not always painful unless the dorsal root ganglion is also involved. Herniation may induce nerve demyelination with resulting neurologic symptoms Pathophysiology of acute discopathy Acute Disc Herniation Release of PG,Interlukin 6,nitrous oxide From NUC.PUL. Nerve root compression Chemical inflamation Chemical radiculitis PAIN CERVICAL DISCOPATHY HNP DDD M=F M=F <40 yo >40 yo Etiology: Etiology repetitive cervical stress is part of natural aging a single traumatic incident poor nutrition vibrational stress, heavy Smoking lifting , prolonged sedentary position whiplash accidents Atherosclerosis job-related activities genetics. Clinical manifestation Discogenic pain without nerve root involvement typically is vague, diffuse, and distributed axially Pain increase after lifting &Valsalva maneuver & Vibrational stress from driving Pain decrease after lying supine radicular pain is deep, dull, and achy or sharp, burning, and electric. most commonly radiates to the interscapular region & to the occiput, shoulder, or arm Neck pain does not necessarily accompany radiculopathy and frequently is absent distal limb numbness and proximal weakness & Atrophy Dermatomes Physical Exam. displays decreased cervical range of motion (ROM). Pain is exacerbated by neck extension and rotation or by Spurling maneuver (patient's neck is extended, laterally bent, and held down) Pain improves with neck flexion or with abduction of the symptomatic upper limb over the top of the head (abduction sign). Decreased sensation to pain, light touch, or vibration Diminished or absent reflexes Increased upper and lower limb reflexes or other upper motor neuron signs suggest myelopathy Myofascial tender or trigger points Differential diagnosis Brachial Neuritis Paget Disease Cancer and Rehabilitation Psoriatic Arthritis Cervical Myofascial Pain Radiation-Induced Brachial Cervical Spondylosis Cervical Sprain and Strain Complex Regional Pain Syndromes Fibromyalgia Neoplastic Brachial Plexopathy Osteoarthritis Osteoporosis Plexopathy Rheumatoid Arthritis Rotator Cuff Disease Scheuermann Disease Thoracic Outlet Syndrome Traumatic Brachial Plexopathy Diagnosis & work up LAB: Rheumatoid factor (R.A) HLA-B27 (A.S) ESR( polymyalgia rheumatica) infection workup to evaluate for possible discitis, epidural abscess, and vertebral osteomyelitis, including the following tests: W.BC count with differential (elevated with a left shift in bacterial infection) Blood cultures (positive for the infecting organism) ESR(elevated in infection, but may be a nonspecific finding Plain radiographs Cervical spine trauma films use 7 views Flex/ext views: sublux, instability. Open-mouth views:the odontoid process and C1-C2 stability. AP views: tumors, osteophytes, and fractures. Lateral views:stability and spondylosis (ie, spurring, disc space narrowing). Oblique views reveal DDD, as well as foraminal encroachment by uncovertebral or Z-joint osteophytes CT scan:cervical spine fracture CT myelography MRI evaluates the spinal canal, the of choice to evaluate cervical spinal cord, and nerve root impingement from disc, spur, or foraminal encroachment superior to MRI in detecting lateral and foraminal encroachment HNP depict pathology larger than actual size Contraindications to MRI include patients with embedded metallic objects, such as pacemaker, surgical clips, spinal cord stimulators, or prosthetic heart valves that may be dislodged by MRI magnets. Nerve conduction studies (NCSs) or nerve conduction velocity(NCV)and electromyography (EMG) NCS(NCV)/EMG differentiating cervical radiculopathy from neuropathic conditions (eg, ulnar nerve entrapment, carpal tunnel syndrome, peripheral neuropathy, plexopathy). routine motor NCSs do not evaluate the C6 and C7 nerve roots, which are most commonly involved, or the levels above Somatosensory evoked potentials (SEPs) evaluate sensory conduction peripherally and centrally Lower limb SEPs involving tibial and peroneal nerves, which assess spinal cord conduction, are more sensitive in diagnosing myelopathy than are upper limb median and ulnar SEPs. TREATMENT The McKenzie system:3 mechanical syndromes that cause pain and compromise function: 1-The postural syndrome :pain when normal soft tissues are loaded statically at end ROM; pathology need not be present. Treatment aims to correct posture. 2-The dysfunction syndrome :pain when the patient, upon attempting full movement, mechanically deforms contracted scarred soft tissue. Consequently, therapy involves stretching and remodeling of such contracted tissue. 3-The derangement syndrome :intermittent pain when certain movements or postures occur. pain may become centralized or peripheralized because of discopathy. Therapy attempts to correct derangement . Conservative treatment Physiotherapy: Superficial heat >> relax muscle ,soft-tissue pain deep-heating modalities (eg, ultrasonography) should be avoided in acute cervical radiculopathy, because they augment inflammation and, consequently, exacerbate radicular pain and nerve root injury. Cervical traction may relieve radicular pain from nerve root compression. Traction does not improve softtissue injury pain. Hot packs, massage, and/or electrical stimulation should be applied prior to traction to relieve pain and relax muscles traction Traction include heavy weight-intermittent or light weight-continuous. The neck is flexed 15-20 º (ie, not extended) during traction. In the cervical spine, approximately 10 lb of force is necessary to counter gravity and 25 lb of force is necessary to achieve separation of the posterior vertebral segments. Light weight-continuous home traction is cost effective and provides the patient with more autonomy. Pneumatic traction devices afford greater patient comfort and, consequently, increased compliance. A soft cervical collar is recommended only for acute soft-tissue neck injuries and for short periods of time (ie, not to exceed 3-4 days' continuous use). Risks include limiting cervical ROM and losing neck strength if the collar is worn continuously for longer periods. When worn for radiculopathy caused by foraminal stenosis, the wide part of the collar is placed posteriorly and the thin part is placed anteriorly to promote neck flexion, discourage extension, and open the intervertebral foramina. Collars can be worn during certain activities, such as sleeping or driving, for longer periods. Although not commonly used, a Philadelphia collar can be worn at night to position the neck rigidly in flexion, thereby maintaining open foramina Manipulation , mobilization Spinal manipulation and mobilization may restore normal ROM and decrease pain, joint adjustment improves afferent signals from mechanoreceptors to peripheral and central nervous systems. Normalization of afferent impulses improves muscle tone, decreases muscle guarding, and promotes more effective local tissue metabolism. These physiologic modifications subsequently improve ROM and pain reduction. Studies document short-term improvement in the acutely injured patient and in those with cervicogenic headache and radiculopathy secondary to disc herniation. No evidence exists that manipulation confers long-term benefit, improves chronic conditions, or alters the natural course of the disorder. MEDICINE NSAIDs are first-line muscle relaxants to potentiate the NSAID analgesic effect Oral corticosteroids, No AVN when the total prednisone dose stayed under 550 mg. Tricyclic antidepressants (TCAs) decrease pain and reduce nonrestorative sleep, Side effects include dry mouth, constipation, and weight gain membrane-stabilizing agents (eg, gabapentin, carbamazepine). Gabapentin in treating diabetic peripheral neuropathic pain Other analgesics (acetaminophen, tramadol) provide pain relief without inflammation control. Injection: the epidural space (interlaminar) or along the nerve root (transforaminal) after precise radiologic, contrast-enhanced fluoroscopic localization. Adverse effects include : epidural hematoma, seizure, vertebral artery spasm, infection, temporary quadriparesis from anesthetic, and respiratory arrest serious CNS complications, including spinal cord injuries and strokes, due to occlusion of a vessel SURGERY 1- neurogenic bowel or bladder dysfunction, 2-deteriorating neurologic function, 3- intractable radicular or discogenic neck pain exists THORASIC DISCOPATHY Frequency: 1 in 1 million persons / year, =0.25-0.75% of all disc herniations Pathophysiology: The thoracic discs are stable due to the surrounding rib cage, with the stabilizing effect of the rib articulations. the blood supply at the T4-T9 watershed area, which is more prone to ischemic injury. The facet orientation in the thoracic spine is vertical, with a slight medial angulations. >>>>easier lateral bending and rotation versus pure bending,>>>> the thoracic spine discs are at a decreased risk of injury because of the decreased bending potential in this segment of the spine. The spinal cord-to-canal ratio is 40% in the thoracic spine versus 25% in the cervical spine. The thoracic spine is also naturally kyphotic. These 2 facts make the thoracic spine more sensitive to cord compression from disc herniation Clinical manifestation: Thoracic disc disease may emulate the symptoms of lumbar disc disease. Shooting pain down the legs implies nerve root irritation versus cord compression. Pain in the thoracic area signifies mechanical pain that is possibly secondary to fractures, degenerative disc disease, tumors, or infections. Night pain that wakes the patient is suggestive of infection or an oncologic process. Cord compression is present with myelopathy, which requires immediate attention. Myelopathy is seen with the following: The presence of clonus or a positive Babinski reflex Bowel and bladder dysfunction (seen in up to 20% of symptomatic discs) High thoracic (T2-T5) herniation mimics cervical disc disease Patients can present with upper extremity involvement, including Horner syndrome. If myelopathy is present, a negative result from the Hoffmann test makes cervical spine involvement unlikely. A positive result from the Hoffmann test is seen when the middlefinger metacarpophalangeal joint and the proximal interphalangeal joints are kept extended; a flexion reflex of the thumb is seen when the distal interphalangeal joint is flicked or suddenly extended. This is known as the Hoffmann sign. Radicular symptoms include pain/paresthesias or dysesthesias in a dermatomal distribution. Dermatome T10 is usually involved. physical exam: Palpation>>>>>.>Entire spine.Muscle spasms. ROM>>>>hips, knees, and ankles for radiculopathy vs hip , knee pathology Arthritis>> pain increase by extension Radiculopathy>>> pain increase by flex Bilateral SLR Motor examination L2-L4 (knee extension), L4 (inversion), L5 (dorsiflexion), and S1 (eversion and plantar flexion) Sensory examination nipple =T4; xiphoid= T7; umbilicus= T10; inguinal region= T12. Reflex testing: knee (L4) ankle (S1) The abdominal reflexes and cremasteric reflex (check for symmetry and presence) for myelopathy and cord compression. Vascular examination of the dorsalis pedis artery, posterior tibial artery, and femoral artery can rule out other causes of the patient's sym Ethiology: Age Trauma Smoking Obesity Sedentary lifestyle Poor physical fitness Diagnosis: Radiography Should be the initial examination that is ordered Unable to distinguish actual disc herniation identify disc calcification infectious or oncologic causes for the patient's pain Magnetic resonance imaging (MRI) Both T1- and T2- imaging are needed Sensitive for identification of disc herniation T2-weighted images exaggerate findings. calcification by low signal in T1- and T2-images. bony inflammation with tumors/infection Computed (CT) myelogram Has improved bony visualization compared with MRI Not as sensitive for disc sequestration/migration Invasive relative to MRI Discogram Controversial Used for provocative testing for the level of involvement before surgery Treatment: 1-Physical therapy 2-Medicine 3-surgery Surgical Intervention Surgical decompression is indicated in patients with myelopathy (unless improving), progressive neurologic symptoms, and worsening symptoms or lack of improvement in the patient's symptoms by 4-6 weeks of conservative management LUMBAR DISCOPATHY FREQUENCY: male /female=2/1 clinical manifestation: often as a shooting or stabbing pain L3,L4>>>radiate into the groin or anterior thigh L5>>lateral and anterior thigh and leg pain S1>>cause pain in the calf and bottom of the foot pain usually improves in the supine position with the legs slightly elevated. Patients are more comfortable when changing positions. Short walks can bring relief. Long walks or extended sitting (especially driving) can aggravate the pain. Physical exam SLR +++VE less than 50’ More than 50’>>>>> hamestring spasm CROSS SLR++ve >>> more diagnostic Scoliotic spine abnormal gait Weakness of muscle vvvvv DTR X-RAY MRI TREATMENT INDICATION OF SURGERY 1-cauda equina syndrome 2-progressive neurologic deficit during a period of observation 3-Persistent sciatic pain, for 6-12 weeks NOT GOOD CANDIDATE FOR SURGERY A patient with unrelenting back pain A patient with an incomplete workup A patient not provided adequate conservative treatment COMPLICATION OF SURGERY The overall complication rate is 2-4% for the surgery. the wrong level>>>intraoperative radiographic confirmation Bleeding intraoperatively due to>Engorged venous epidural channels & malposition the anterior annulus is violated and a retroperitoneal vessel is injured Infections, usually skin infections postoperative discitis :increasing sedimentation rate, fevers, severe localized pain, and recurrent symptoms. Increased neurologic deficit is usually mild and is due to excessive retraction of the root nerve root is mistaken for a disc herniation and is removed
