Degenerative Spinal disorders- Neurosurgery (NS) Flashcards
C/P of Cervical disc prolapse
Symptoms:
Neck pain and stiffness.
Pain radiating down the arm and hand (brachialgia) exacerbated by neck motion.
Paresthesia along the affected dermatome.
Motor weaknes
Signs:
Signs of radiculopathy depend on which root is compressed.
Manifestations of myelopathy: (cord compression)
Spastic quadriparesis
Hyperreflexia below the level of the compression
Clumsiness and ataxia of the extremities
Gait disturbance
Sphincteric disturbance.
Investigations used in cervical cord prolapse
- Plain x ray:
* Loss of lordosis.
* Narrowing of the disc space.
* Osteophytes.
* Instability - MRI:
* The best diagnostic technique and the best modality for soft and neural tissue evaluation. - CT scan: * better for bony evaluation.
- Myelography: not commonly used nowadays.
- Nerve conduction velocity and EMG:
* It will yield precise information on specific root affection.
Management of Degenerative spinal disorders (cervical)
Either conservative or surgical
a. Conservative:
Symptoms relevant to radiculopathy usually respond to conservative measures as:
* Rest & lifestyle modification
* Neck collar
* Physiotherapy
* Analgesics (e.g. NSAIDs)
* Antineuropathic pain medications (e.g. Gabapentin)
* Muscle relaxants
b. Surgical:
1) Anterior cervical discectomy with fusion (multiple levels may be included in case of spondylosis)
2) Posterior cervical foraminotomy.
3) Posterior cervical laminectomy with or without instrumentation in cases of myelopathy.
Indications for surgery:
1. Radiculopathic pain not responding to medical treatment.
2. Progressive neurological deficit due to root compression.
3. Manifestations of cord compression i.e. myelopathy.
clinical picture symptoms of lumbar prolapse
Back pain
Radiculopathic pain aggravated by coughing and sneezing.
Pain relief upon flexion of knee and thigh
Paresthesia occurs in the distribution of the affected root.
Motor weakness
Bladder symptoms
clinical picture signs of lumbar prolapse
A. Back signs:
Restricted spinal movement.
Local tenderness.
Scoliotic tilt.
Paravertebral muscle spasm.
Obliteration of lumbar lordosis.
B. Signs of radiculopathy:
Motor weakness
Dermatomal sensory changes
Reflex changes
Radiculopathy depends upon the root compressed
C. Clinical tests (nerve root tension signs)
D. Neurogenic claudication: pain and paresthesia in the lower extremities on prolonged standing or walking that improve on forward bending. It occurs in cases of lumbar canal stenosis.
E. Cauda equina syndrome
What are the clinical tests in lumbar prolapse
o Straight leg raising test (SLRT): Passive elevation of the fully extended leg is considered positive if the patients feel sciatica at an angle <60o. It is +ve in lower disc prolapse (L5 and S1 root irritation).
o Femoral stretch test (reverse SLRT): with patient in prone position, extends the hip joint. The patient feels a femoral pain. It is +ve in higher disc prolapse (L2, L3 or L4 root irritation).
Neurogenic claudication (C/P)
pain and paraesthesia in the lower extremities on prolonged standing or walking that improve on forward bending. It occurs in cases of lumbar canal stenosis.
Cauda equina syndrome
- Incapacitating back and lower extremity pain
- Numbness, dermatomal hypothesia and saddle area hypothesia.
- Profound weakness of the lower extremities (LMN) with marked hyporeflexia
- Inability to urinate (early) and urinary incontinence (later)
- Distention, constipation and bowel incontinence (late) and diminished anal tone.
- Sexual dysfunction (impotence)
Investigations in Lumbar prolapse
- Plain x ray:
* AP and lateral views as well as Dynamic study (flexion and extension views):
* Narrowing of the disc space.
* Osteophytes
* Obliteration of lumbar lordosis
* Scoliosis
* Instability - CT scan:
* Better for bony evaluation. It detects lumbar canal stenosis; hypertrophied facet joint, and narrow canal dimensions. - MRI:
* The best diagnostic technique and the best modality for soft and neural tissue evaluation. - Myelography: Not commonly used nowadays.
- Nerve conduction velocity and EMG: It will yield precise information on specific root affection
Management of lumbar prolapse
Either conservative or surgical
a. Conservative:
Symptoms relevant to radiculopathy usually respond to conservative measuresmas:
* Rest, lifestyle modification and reduction of body weight
* Lumbar support
* Physiotherapy
* Analgesics (e.g. NSAIDs)
* Antineuropathic pain medications (e.g. Gabapentin)
* Muscle relaxants
* Epidural steroid injections
b. Surgical:
Indications for surgery:
1. Radiculopathic pain not responding to medical treatment.
2. Progressive neurological deficit due to root compression.
3. Manifestations of Cauda equina syndrome. (urgent surgery)
Methods of surgical treatment:
a. Standard open laminectomy and discectomy
b. Microdiscectomy
c. Endoscopic discectomy
d. Wide laminectomy (± facetectomy) with or without instrumentation.
What is spondylolysis vs Spondylolisthesis
-a fracture of the pars interarticularis of a vertebra without vertebral displacement. The pars interarticularis is the part of the posterior neural arch of the vertebra that connects the superior and inferior facets
-a slipping forward of one vertebra over another
Management of Spondylosis and Spondylolisthesis
Either conservative or surgical
a. Conservative:
May be tried in lower grades of spondylolisthesis.
* Rest, lifestyle modification and reduction of body weight
* Lumbar support
* Physiotherapy
* Analgesics (e.g. NSAIDs)
* Antineuropathic pain medications (e.g. Gabapentin)
* Muscle relaxants
b. Surgical:
❖ Includes neural decompression and instrumented fusion of the involved levels. e.g. standard laminectomy, pedicle screw fixation and bony fusion.
