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
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DISC HERNIATION
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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
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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
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CERVICAL DISCOPATHY HNP DDD M=F 40 yo Etiology is part of
natural aging poor nutrition Smoking Atherosclerosis job-related
activities genetics.
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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
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Dermatomes
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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
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
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CT scan:cervical spine fracture CT myelography MRI evaluates
the spinal canal, the spinal cord, and nerve root impingement from
disc, spur, or foraminal encroachment superior to MRI in detecting
lateral and foraminal encroachment of choice to evaluate cervical
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.
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Nerve conduction studies (NCSs) or nerve conduction
velocity(NCV)and electromyography (EMG) NCS(NCV)/EMG Somatosensory
evoked potentials (SEPs) 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 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.
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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.
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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 soft- tissue injury pain. Hot packs, massage, and/or
electrical stimulation should be applied prior to traction to
relieve pain and relax muscles
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traction Traction include heavy weight-intermittent or light
weight-continuous. The neck is flexed 15-20 (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
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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.
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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.
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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
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SURGERY 1- neurogenic bowel or bladder dysfunction,
2-deteriorating neurologic function, 3- intractable radicular or
discogenic neck pain exists
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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
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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
middle- finger 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.
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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
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Ethiology: Age Trauma Smoking Obesity Sedentary lifestyle Poor
physical fitness
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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
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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
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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
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LUMBAR DISCOPATHY
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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.
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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
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X-RAY
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MRI
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TREATMENT
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INDICATION OF SURGERY 1-cauda equina syndrome 2-progressive
neurologic deficit during a period of observation 3-Persistent
sciatic pain, for 6-12 weeks
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NOT GOOD CANDIDATE FOR SURGERY A patient with unrelenting back
pain A patient with an incomplete workup A patient not provided
adequate conservative treatment
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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
