Degenerative thoracolumbar spine Flashcards
Discogenic back pan herniated thoracic disc herniated lumbar disc synovial facet cyst Lumbar stenosis
What is discogenic back pain?
- Back pain associated with disc degeneration
- controversy over acceptance of cause of isolated back pain
What are the signs and symptoms of discogenic back pain?
- Axial loading back pain without Radicular symptoms
-
Pain excerbated by
- Bending
- sitting
- axial loading
Signs
- Straight leg raising negative
What investigations are useful in dx discogenic back pain?
Xrays
MRI
- degenerative disc without significant stenosis/herniation
Provocative Discography
- studies shosn can lead to accelerated disc degeneration and herniation, loss of height and endplate changes
What is the tx of discogenic back pain?
non operative
- NSAIDS, physical therapy , lifestyle modifications
- tx of choice in majority without neurology
Operative
-
Lumbar Discectomy w fusion
- controversial
-
Lumbar total disc replacement
- single level disease with disease free facet
What is the epidemiology of thoracic disc herniation?
- Uncommon
- makes up to 1% of herniated nucleus pulposa
- most seen 40-60 years
- As disc desiccates less likely to actually herniate
- location
- usually involves middle- lower levels
- T11-T12 most common
- 75% disc occur T8-T12
What are the risk factors for thoracic disc herniation?
- Scheuermann’s disease
Describe the types of herinated thoracic disc?
BY herniation
-
Bulging nucleus
- annulus intact
-
Extruded disc
- thru annulus by confined to Post LL
-
Sequestrated
- Disc material free in canal
By Location
- Central
- Posterolateral
- Lateral
What are the symptoms thoracic disc herniation?
Symptoms
-
Pain
- axial back or chest pain- most common
-
thoracic radicular pain
- band pain around course of intercostal n
- arm pain
-
Neurology
- Numbness, parathesia, sensory changes
- Myelopathy
- Paraparesis
- Bowel/ bladder changes- 15-20%
- sexual dysfunction
What are the signs of thoracic disc herniation?
- localised thoracic tenderness
- root symptoms
- dermatomal sensory changes- parathesia/dysesthesia
- cord compression & findings of Myelopathy
- weakness / mild paraparesis
- abnormal rectal tome
-
UMN signs
- Spascitity
- Hyperreflexia
- sustained clonus
- positive Babinski sign
-
Gait changes
- wide based
-
Horner’s syndrome
- seen with HNP T2-T5
What investigations are useful in thoracic disc herniation?
xrays
- lateral radiographs
- disc narrowing
- calcifications (ostephytes)
- MRI
- most useful and dx
- disadv high false positive rate at asymptomatic individuals
What are the tx for thoracic disc herniation?
Non operative
-
Activity modification, physical therapy, symptomatic tx
- majority of cases
- immobilisation & short term rest
- analgesic
- progressive activity restoration
- injections for radiculopathy
- majority improve non op
Surgery
-
Discectomy with possible hemicorpectomy or fusion
- minority of pt
- myelopathic findings, progressive
- persistent and intolerable pain
- debate regarding transthoracic /costotranvserectomy approach
What are the surgical techniques for disectomy of thoracic spine?
-
Transthoracic discectomy +/- fusion
- best approach fo rcentral disc
- complx- intercostal neuralgia
- ca be done video assisted surgery
-
Costotransversectomy +/- fusion
- lateral herniated discs
- extruded or sequestrated discs
- some studie suggest anterior or lateral costotransversectomy is better
What is the epidemiology of lumbar disc herniation?
- 95% involve L4/5 or L5/S1
- most common L5/S1
- peak incidence 40-50 years
- only 5% become SYMPTOMATIC
- male 3: 1 female
What is the pathoanatomy of lumbar disc herniation?
- Recurrent Torsional strain leads to tears in OUTER ANNULUS
- leads to herniation of NUCLEUS PULPOSIS
What is the prognosis of lumbar disc herniation?
- 90% of pts will have improvements of symptom within 3 months with non op care
-
Size of herniation decreases over time ( reabsorbed)
- Sequestered disc herniation- greatest degree of spontaneous reabsorption
- Macrophage phagocytosis is mechanism of reabsorption
Can you describe/draw the anatomy of the interverbral disc?
-
Annulus fibrosis
- type 1 collagen, water, proteogylcans
- extensibility & tensile strength
- high collagen/ low proteogylcan ratio
-
Nucleus Pulposus
- Composed type 2 collagen,water, proteoglycans
-
Compressibility
- low collagen/high proteoglycan
- Proteogylcan interact w H20 & resist compression
Can you describe the nerve root anatomy?
key difference between cervical and lumbar spine is
-
Pedicle/ nerve root mismatch
- C spine C6 n root travels Under C5 pedicle ( mismatch
- L spine L5 n root travels under L5 pedicle ( match)
- Xra C8 nerve root ( no C8 pedicle) allows transition
-
Horizontal (cervical) vs Vertical ( lumbar) anatomy of n
- vertical lumbar root a paracentral & formainal disc will affect different n roots
- Horzontal cervical root a central & foraminal will affect same n
Can you classify the herniation of the lumbar disc?
By location
-
Central prolapse
- assoc back pain only
- can cause Cauda equina
-
Posterolateral ( paracentral)
- most common 90-95%
- PLL is weakest here
- affects transversing n root
- at L4/5 affects L5
-
Foraminal ( far lateral)
- less common 5-10%
- affects exiting n root
- at L4/5 affects L4
-
Axillary
- Can effect exiting and descending roots
BY anatomy
-
Protrusion
- Eccentric bulding annulus fibrosis intact
-
Extrusion
- Tear in annulus, disc herniated thru but continous with disc space
-
Sequestered
- disc material thu annulus & no longer continuous with disc space
What are the symptoms of lumbar disc herniation?
-
Axial back pain
- discogenic/mechanical
-
Radicular pain
- worse with sitting coughing, improves with standing
-
Cauda equina syndrome 1-10%
- bilateral leg pain
- saddle anaesthesia
- LE weakness
- bowel/bladder dysfunction
What are the signs of lumbar disc herniation?
- Motor exam
- Dorsiflexion weakness- L4/5
- EHL weakness L5
- Hip abduction weakness- L5
- Ankle plantar flexion weakness S1
- provocation tests
- Straight leg weakness
- Lesegue sign- SLR aggrevated by forced ankle dorsiflexion
- Gait analysis
- Trendelenberg gait
- gluteus medius weakness - L5
- Trendelenberg gait
What imaging is useful in dx in lumbar disc degeneration?
Xrays
- may show lordosis, loss of height, spondylosis
MRI
- without gadolinium
- highly specific and sensitive
- dx from synovial facet cysts
- high rate of abnormal findings in normal people
- pt with pain >1 month not responding non op tx
-
red flags
- infection- iv du, fever, chills
- tumour- hx cancer
- trauma
- cauda equina- bowel/bladder changes
- MRI With gadolinium for revision surgery
- distinguish post surgical fibrosis ( enhances) vs recurrent herniated disc (doesn’t enhance)
Describe the tx of lumbar disc herniation?
non operative
-
rest. PT, anti-inflammatory
- 1st line
- 90% improve within 3 month
- bed rest then progressive activity
- extension exercises, pilates
- nsaids, ,muscle relaxants, oral steriod taper
-
Selective root corticosteriod injections
- 2nd line in medication fails
- epidural vs selective nerve block
- Long lasting improvement in 50%( surgery90%)
- Best in pts with extruded discs
Surgery
-
Laminotomy and discectomy ( microdiscectomy)
- for persistent disabling pain after 6wks non op
- progressive & significant weakness
- cauda equina syndrome
-
Far lateral microdiscectomy
- for far-lateral disc
- utilises paraspinal approach of wiltse
- avoids injury to lamina or facet joints
- complx- injury to dorsal root ganglia->dysesthesias.- abnormal sensation
What are the outcomes of surgery cf non op tx?
- 70% improvement in back pain
-
neurological recovery less predictable
- 50% motor/sensory recovery
- 25% reflex recovery
good outcome
- if leg pain chief complaint
- positive straight leg raise
- weakness correlates with n root impingment seen on MRI
- married status
- no workers compensation
Bad outcome
- workers compensation
- less relief from symptoms & less improvement in qulaity of life
What are the complications of lumbar spine surgery?
-
Dural tear- 1%
- if have at time of surgery preform water tight repair
-
Recurrent Herniated nucleus pulposus
- can tx non op
- outcomes for revision discectomy = primary
- Discitis- 1%
-
Vascular catastrophe
- break thru ant annulus- injury aorta/vena cava
What is synovial facet cyst?
- A rare cause of spinal stenosis in lumbar spine
What is the epidemiology of synovial facet cyst?
- Rare
- location
- usually Lumbar spine
- 60-90% at L4-L5 level
What is the pathophysiology of synovial facet cyst?
- Trauma
-
Microinstability of the facet leading to
- extruded synovium thru joint capsule
- myxoid degeneration of collagen tissue
- proliferation of fibroblasts with increased hyaluronic acid production
What are the associated conditions of synovial facet cyst?
- Degenerative Spondylolisthesis