Spinal Conditions (Scoliosis etc) Flashcards
Spinal stenosis is?
Spinal stenosis is a condition in which the spinal canal narrows and the nerve roots and spinal cord become compressed. Because not all patients with spinal narrowing develop symptoms, the term “spinal stenosis” actually refers to the symptoms of pain and not to the narrowing itself.
Narrowing can occur at different sites. Anatomic/radiographic classification can be applied differentiating between:
- Central stenosis: narrowing of the spinal canal
- Lateral recess stenosis: narrowing of the lateral recess (area underneath the facet joints)
- Foraminal stenosis: narrowing of the intervertebral foramen
In most cases stenosis occurs at the level of facet joints. At this level pathological changes in the disk and facets and hypertrophy of the ligamentum flavum cause the greatest amount of narrowing. At the level of the pedicles, stenosis is rather uncommon and indicates an underlying congenital of developmental stenosis of the bony canal
Central stenosis can be caused by degeneration of the vertebral disc. This can lead to narrowing of the spinal canal around the cauda equina . Symptoms usually involve buttocks and posterior thighs in a non-dermatomal distribution
Lateral recess stenosis can be related to the lateral recess. Symptoms are usually dermatomal because specific nerves are compressed. Patients may have more pain during rest and at night, but have more walking tolerance than patients with central stenosis.
Foraminal stenosis is related to a narrowing of the spinal foramina . It can be the result of a reduced height of the intervertebral space. Foraminal stenosis is also related to age-related degenerative disease of the lumbar discs and/or lumbar facet joints. This increases bone deposition (i.e. osteophytes) due to abnormal redistribution of load bearing in the lumbar spine. Thickening of the joint capsule, osteoarthritis of the facet joints and cyst formation can also narrow the spinal canal or IV foramen
Lateral and Foraminal Stenosis can lead to compression of the nerve roots leaving the spinal canal. The L4-L5 segment is most frequently affected by LSS], followed by L3-L4[a], L5-S1 and L1-L2. Spinal stenosis can cause compression of the nerve roots of blood vessels, which can be related to the painful symptoms of spinal stenosis.
Differential Diagnosis
Spinal stenosis epidemiology?
Spinal stenosis is one of the most common causes of nontraumatic spinal cord injuries[5] in people older than 50 years.[6] Because of the aging of the population, incidence rates of acquired (or degenerative) spinal stenosis have been increasing. This kind of stenosis is due to the degenerative changes (ligamentum flavum, discus intervertebrales and facet joints) related to aging and occurs at the age of 50 and beyon.
There are several types of spinal stenosis. Lumbar spinal stenosis and cervical spinal stenosis are the most common types and occur separately or combined. The thoracic spine is rarely involved. Epidemiological data suggests an incidence of 1 case per 100 000 for cervical spine stenosis and 5 cases per 100 000 for lumbar spine stenosis . The incidence of both types increases during the aging process .
Stenosis causes?
The acquired spinal stenosis onsets at another point in life and occur more frequently both in the cervical and lumbar tract. Several possible causes are known: spondylosis (Cervical Spondylosis and Lumbar Spondylosis), disk bulging or disc herniation (this is not lasting, the herniated part of the disc dystrofies), ligamentous degeneration (hypertrophy/ossification of the ligamentum flavum), spondylolisthesis or a combination of these disorders /
It may also be the result of systematic illneses, such as endocrinopathies (Cushing disease or acromegaly), calcium metabolism disorders (hyporarthyroidism and Paget disease), inflammatory diseases (rheumathoid arthritis and ankylosing spondylitis) and infectious diseases[
SS Differential Diagnosis
The differential diagnosis of spinal stenosis is broad and differentiation between several conditions may be complicated because of their frequent coexistence, certainly in the elderly. In these patients hip osteoarthritis and peripheral vascular disease are prevalent and could advance combined with spinal stenosis. Also a trochanteric bursitis is frequently observed in patients with symptomatic lumbar spinal stenosis
Lumbar spinal stenosis is related to neurogenic intermittent claudication. The symptoms of this diseaese (pain irradiation into the legs whilst walking and relief with standing) are similar to those of vascular claudication If the sypmtoms are triggered by lumbar extension and downhill walking and relieved by lumbar flexion, the patient probably suffers from neurogenic claudication (whether or not originated by lumbar spinal stenosis). In case no changes occur during lumbar flexion or extension, the patient has more difficulty walking uphill and complains of cramping that begins distally and progresses proximally, the person probably suffers from vascular claudication
Also degenerative disc/facet joint pain, ankylosing spondylitis, spinal compression fracture, metastatic disease of the spine, vertebral osteomyelitis or discitis, primary spinal.intradural/intramedullary tumour, epidural abscess, diabetic neuropathy, peripheral neuropathy and radiculopathy due to a herniated disc are others disease that could be confused with spinal stenosis
Symptoms of Cervical Spinal Stenosis?
Pain in neck
Pain and weakness in upper extremity
Pain intensifies during neck flexion
Deterioration in fine motor skills (clumsiness)
Inability to walk at a brisk pace
Heavy feeling in the legs
In neck, shoulder, arms and hands:
- Burning, tingling, numbness, pins& needles [
- Bladder and bowel dysfunction (in severe cases)
- Loss of function or paraplegie (rare
Symptoms of Lumbar Spinal Stenosis?
Low back pain
Pain and/or weakness in legs and buttocks
Pain intensifies during prolonged standing, back extension and (downhill) walking.
Pain decreases during sitting, stooping, lying and back flexion.
Associated numbness or weakness (symptoms of sciata)
Neurogenic intermittent claudication
Heavy feeling in the legs
Low back, buttocks and legs:
- Burning, tingling, numbness, pins&neeldes [15]
- Bladder and bowel dysfunction (in severe cases)[15] [17]
- Loss of function or paraplegie (rare)
Spondylolysis is?
Spondylolysis is a unilateral or bilateral bony defect in the pars interarticularis or isthmus of the vertebra. The term derives from the Greek words spondylos (vertebra) and lysis (defect). [ It can cause a slipping of the vertebra, in which case the term spondylolytic spondylolysthesis is used
Vertebrae consist of the vertebral body and a bony ring or arcus which protects the spinal cord. The arcus is formed by two pedicles which attach to the dorsal side of the vertebral body and two laminae, which complete the arch. The area between the pedicle and the lamina is called the pars interarticularis and is in fact the weakest part of the arcus. It is the pars interarticularis that is affected in spondylolysis
This condition appears in the first or second decade of life; the frequency of spondylolysis increases with age until 20 years. [ There is, however, no change in prevalence with increasing age from 20 to 80 years old. Men are affected twice as often as women
Common site of Spondylosis?
Spondylolysis is considered to be a stress fracture that results from mechanical stress at the pars interarticularis. These stress fractures occur due to repetitive load and stress, rather than being caused by a single traumatic event. The stress distribution at the pars interarticularis is the highest in extension and rotation movements. [ Spondylolysis occurs mostly at L5 (80-95%) due to repetitve hyperextension, which increases the contact between the caudal edge of the inferior articular facet of L4 and the pars interarticularis of L5.
Lumbar spondylolysis mainly concerns the L5 vertebrae which accounts for 85%-95% of all cases . This is thought to be due to the facet joint positioning of the L5/S1 vertebrae. The posterior facing facet of the S1 vertebrae creates a large anterior shear upon the pars interarticularis of the L5 vertebrae which increases in individuals with excessive anterior pelvic til
Spondylosis presentation
Onset of pain is gradual or acute (after intense athletic activity)
Possible history of local trauma (recent or historical)
Intense pain restricts activities of daily living or sporting performance
Symptoms become aggravated after a stressful event
Rest usually relieves the symptoms
Symptoms for lumbar spondylolysis are:
Focal low back pain with radiation into the buttock or proximal lower limb[
Symptoms can increase with movement specifically lumbar extension or rotation
Children under 13 years old show tenderness or pain on extension
Children can present a postural deformity or abnormal gait pattern
Spondylosis exam
The most common findings for lumbar spondylolysis are hyperlordotic posture and low back pain during lumbar extension.
The Michelis’ test or unilateral extension test can be performed to confirm diagnosis. The patient performs hyperextension of the lumbar spine while standing on one leg. In a positive test, pain is reproduced. Unilateral lesions often produce pain when standing on the ipsilateral leg.
