Term
Cervical Disease Syndromes |
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Definition
Classifications:
-Radiculopathy
-Myelopathy
-Segmental instability
-Neoplasms
-Trauma
-Pain Syndromes--strains / sprains
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Term
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Definition
Classifications:
-Radiculopathy
-Neurogenic Claudication
-Segmental instability
-Neoplasms
-Trauma
-Pain Syndromes--strains / sprains
-Adult / Pediatric-- scoliosis
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Term
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Definition
Etiology:
-Irritation of a nerve root (radix = radical), which is a lower motor neuron, as it leaves the spinal canal, resulting variably in:
-Pain
-Weakness
-Numbness
-Diminished reflex
in the distribution (dermatome or myotome) of the nerve root.
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Term
Radiculopathy Two Peaks of Incidence
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Definition
2 peaks of incidence
-30 - 50 yrs of age - Typical Disc Herniation
-60 – 80 yrs of age - Degenerative foraminal stenosis, esp @ L5
-Younger cohort has 80-90% chance of spontaneous improvement (Hippocrates)
-Etiology: Compressive vs. Chemical (glutamate)
-History and Exam are best diagnostic resources and best predict the outcome of surgery.
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Term
Cervical Radiculopathy History |
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Definition
-Insidious onset- Typically no history of injury
-“Shoulder pain” is neck pain until proven otherwise
-Extremity > axial pain; ~80:20 is typical
-Arm pain increases with neck extension or rotation toward the painful extremity (Positive Spurling’s sign)
-Decreased arm pain with placing hand on head
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Term
Lumbar Radiculopathy History |
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Definition
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¡History
-Insidious onset- +/- (-)history of injury
- If “Hip pain”= buttock pain, then is “back pain”
-Extremity > axial pain, ~80:20
-Leg pain increases with cough/sneeze/valsalva
-Increased leg pain with forward flexion (this is a self inflicted Straight Leg Raise test)
÷Braggard’s sign (confirms SLR)
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Term
Lumbar Radiculopathy Additional Tests |
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Definition
-X-rays
-Risk factors: Age > 50 or <18 yrs; neurologic deficit; bowel or bladder problems; history of cancer; pregnancy; IV drug use; steroid use; systemic symptoms(night pain, fever, chill, wt loss)
-EMG/NCS
-Useful for equivocal cases-helps determine involved level
-Poor substitute for history and exam: false positive/negative
-MRI
-“Let’s get one and see what’s going on in there”= BOGUS
-Very high false positive. Only 30% nl subjects have nl MRI!
-Not a screening tool
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Term
Cervical and Lumbar Radiculopathy Treatment |
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Definition
Options:
-Time
-NSAIDs (ibuprofen, naproxyn, celecoxib)
-Medrol dose pack (glucocorticosteroid)
-Selective nerve root injection (Steroid:Depo Medrol)
-Surgery
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Term
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Definition
-Indications
-6 weeks of pain without improvement
-< 6 weeks with unbearable pain
-“Failure” of epidural steroid
-Myelopathy or Bowel / bladder involvement
-Progressive weakness
-Results
-90-95% with arm pain resolved in PACU
-Some stay overnight
-Iliac crest pain common (biggest complaint) at three months---allograft bone use more common today
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Term
Lumbar Surgery-Microdiscectomy
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Definition
Indications
-6 weeks of pain without improvement
-Unbearable pain less than 6 weeks
-“Failure” of epidural steroid
-Cauda Equina Syndrome
-Progressive weaknes
Results
-90-95% with leg pain resolved in PACU
-In-town patients may go home same day
-Out of town patients may stay overnight
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Term
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Definition
-Narrowing of central canal of cervical (or thoracic) spine causing compression of the spinal cord (not the nerve root only),resulting in upper motor neuron compression and ultimately spasticity.
-Thoracic involvement causes the same lower extremity problems, but no upper extremity problems.
-Lumbar equivalent known as Lumbar Spinal Stenosis but this results in nerve root compression NOT spinal cord compression.
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Term
Cervical Myelopathy History |
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Definition
History: Very subtle, often not sought or attributed to “age”
-Global hand numbness
-Diminished dexterity (buttons, esp collar)
-Dysgraphia
-Gait disturbance (tandem gait loss earliest sign)
-Neck pain
-May have associated radiculopathy
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Term
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Definition
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-Earliest finding is loss of tandem gait (sobriety test)
-Hoffman’s test (¡Middle finger is “flicked,” causing flexion of the other fingers), Reverse radial reflex
-Hyperreflexia (late presentation)
-Clonus (late presentation)
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Term
Cervical Myelopathy Treatment |
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Definition
Surgical
-Purpose:
-Decompress the spinal cord by increasing the size of the cervical canal
-Treat any associated radiculopathy
-Method:
-ACDF
-Posterior Laminectomy
-Posterior Laminoplasty
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Term
Cervical Myelopathy Treatment Outcome |
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Definition
Outcome
-Usually can tell that they can walk better immediately
-Upper extremity disturbances take longer to resolve.
-All problems usually do not resolve completely, due to permanent injury to spinal cord.
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Term
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Definition
Etiology:
-Narrowing of the central lumbar spinal canal causing a decrease in the venous outflow from the nerve roots, resulting in vague but severe pain in the low back, buttocks and / or thighs.
¡Older population usually >60yrs age
-Due to central lumbar stenosis--multilevel
-Very similar history to aorto-iliac insufficiency (Leriche Syndrome)
-Relentless progression
-Can severely curtail activity
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Term
Neurogenic Claudication History |
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Definition
History
-Back, bilateral buttock and thigh pain with standing/walking
-Occurs with standing or walking (central canal narrower in standing position)
-Better at grocery store pushing/leaning on cart
-Resolves in seconds after sitting – “Doc, I can sit forever!”
-Men may have a sitting stool in the shower
-Women may have a stool in front of the sink
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Term
Neurogenic Claudication Exam |
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Definition
Exam
-Usually normal except signs of degenerative disease
-Check pulses distally (dorsalis pedis and tibialis posterior); femoral pulses, abdominal pulsations.
-Dermatome numbness
-Myotome weakness
-Standing tolerance – time the pt before he/she needs to sit down.
-Walking tolerance – time the pt before he/she needs to rest.
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Term
Neurogenic Claudication Treatment |
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Definition
Treatment
¡Epidural steroids
÷Good short term improvement but not long term results
¡Surgery
-Multi-level spinal decompression
-Dramatic improvement, as in radiculopathy, but only after they get up and walk.
-Long term results excellent without fusion
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Term
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Definition
Measurable increase in motion between segments
÷> 4.5mm translation in lumbar spine
÷> 3.5mm translation in cervical spine
÷>110 more motion than adjacent segments
Usually due to:
÷Trauma
÷Isthmic spondylolisthesis
÷Occasionally tumors or infection
Frequently find associated radiculopathy but major symptoms usually axial pain in the neck or back.
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Term
Segmental Instability Treatment |
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Definition
Treatment is surgical:
-2 components of surgery
-Decompression to treat radiculopathy
-Fusion to treat axial pain and stabilize underlying instability.
Outcomes
-70% successful outcomes.
-Results proportional to the degree of stability achieved and surgical indications.
-Radiculopathy resolves first and over time the axial pain improves slowly as fusion occurs over 3-6 months.
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Term
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Definition
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Incidence
¡Metastatic tumors are far far far more common than primary spine tumors.
¡Skeleton - third most common site of mets after lung and liver.
¡Spinal column - most common skeletal site for mets
÷Breast, Prostate, Lung, Kidney, Thyroid
÷BLT w/ Kosher Pickle
÷70% mets found in Thoracolumbar spine
÷20% Lumbosacral and 10% Cervical spine
¡
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Term
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Definition
Primary tumors
-2000 primary skeletal tumors/yr
-6000 soft tissue sarcomas/yr
-Only 10% of primary tumors will involve the spine
-Many are asymptomatic and will remain undiagnosed
-Age and presentation important to differentiate benign from malignant
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Term
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Definition
Presentation
¡85% will have back pain as chief complaint
¡Onset of Pain is characterized as:
÷Slow
÷Gradual
÷Progressive
÷Pain at night > pain during day
÷Unrelated to mechanical factors – PAIN EVEN AT REST!
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