Spine Injury Lecture (2nd Lec) 2023 - دار الأطباء PDF

# Spinal Pathologies ## 1) Spine Injury ### 1.1) Spinal Pathologies - Atlas (C1) - Axis (C2) - T12 - LT - Sacrum (S1-S5) - Coccyx | | UMNL | LMNL...

# Spinal Pathologies ## 1) Spine Injury ### 1.1) Spinal Pathologies - Atlas (C1) - Axis (C2) - T12 - LT - Sacrum (S1-S5) - Coccyx | | UMNL | LMNL | | :---------- | :--------------------------------------------- | :------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Paralysis | Below the level of lesion | At the level of lesion | | Muscle State | Minima wasting | Maximal wasting | | Tone | Increased | Decreased | | Clonus | Present | Absent | | Fasciculation | Absent | Present | | Reflexes: | | | | Deep | Hyperreflexia | Hyporeflexia | | Superficial | | | | Abdominal | Absent | Present | | Plantar | Extensor (+ve Babinski) | Flexor or absent | | Sphincters | Urgency and automatic, Spastic bladder. | Retention with over flow, hypotonic & Flaccid bladder. | ### 1.2) Remember that: - Any lesion affects central of cord “till T1” = UMNL. - Lesion in lumbar = LMNL. - Any lesion affects root of cord = LMNL. - Cervical root → leave canal above corresponding vertebrae. - Thoracic & lumbar roots → leave below corresponding vertebrae. - MC cause of spine injures → fall from high place, traffic road accident. ## 2) Cervical Disc Prolapse - Cervical spine exhibits a great deal of mobility but little weight-bearing function. - Intervertebral discs serve as mechanical buffers that absorb axial loading, bending and shear forces. - More common in → C5-C6 & C6-C7 levels. ### 2.1) Clinical picture: - Prolapse is usually posterolateral & causes root compression (radiculopathy). - Prolapse is central it will cause cord compression (myelopathy). - In case of root and cord compression radiculomyelopathy occurs. ### 2.2) A) Symptoms: - Neck pain and stiffness. - Pain radiating down arm and hand (brachialgia) exacerbated by neck motion (extension). - Paresthesia, tingling, numbness along affected dermatome. - Motor weakness. - Sphincteric dysfunction. ### 2.3) B) Signs → Radiculopathy: | Level | C3-C4 | C4-C5 | C5-C6 | C6-C7 | C7-D1 | | :-------- | :--------- | :--------- | :--------- | :--------- | :---------- | | Root Compressed | C4 | C5 | C6 | C7 | C8 | | Sensory Loss | C4 | C5 | C6 | C7 | C8 | | Motor Deficit | Diaphragm | Deltoid | Biceps | Triceps | Hand Muscles | | Reflex Lost | Biceps & Brachioradialis | Triceps | | | | ### 2.4) Investigations: - Plain x ray - Narrowing of spinal canal. - Narrowing of disc space. - Loss of lordosis. - Osteophytes. - MRI: the best diagnostic technique. - CT scan - Cord compression. - Root obliteration. - Myelography - Filling defect due to disc prolapse. ### 2.5) Management → either conservative or surgical #### 2.5.1) a) Conservative - Symptoms relevant to radiculopathy usually respond to conservative measures as: - Bed rest. - Physical therapy. - Avoidance of heavy lifting. - Analgesics. - Neck collar. - Muscle relaxant. #### 2.5.2) b) Surgical - Indications for surgery: - Brachialgia not responding to medical treatment. - Progressive neurological deficit due to root compression. - Manifestations of cord compression i.e. myelopathy. - Surgical procedures include: - Anterior cervical discectomy. - Posterior cervical laminectomy with or without forminotomy. - NB: make Hoffman's sign or reflex كان الدكتور قاله. ## 3) Lumbar Disc Prolapse (LDP) ### 3.1) Anatomy 1. Inter vertebral disc consists of: - Two cartilaginous end plates. - Nucleus pulposus (softer form of cartilage). - Annulus fibrosus (concentric layers of fibrous tissue & fibrocartilage). ### 3.2) Lumbar Disc Prolapse - Lumbar disc prolapse occurs when soft nucleus pulposus herniates through tear in annulus (peripheral fibrous cartilage). - The majority of LDP occurs at L4-L5 and L5-S1 (95%). - Lumbar disc prolapse → cause of 90% of sciatica. - There is history of falling or lifting heavy weights preceding onset of symptoms. - Typical patient with acute lumbar disc prolapses is from 30-50 years of age in the most productive period of his life, and has complained of chronic low back pain for some time prior to the onset of acute disorder. ### 3.3) Clinical picture of lumbar disc prolapse: - Herniation occurs either centrally or lateral. - When laterally, it compresses adjacent nerve root (Radiculopathy). - When central, it compresses cauda equina → (Cauda equina syndrome). ### 3.4) 1) Symptoms: - Back pain. - Sciatica (Pain in the leg in the distribution of the affected root). - Coughing, sneezing aggravates leg pain, which is more severe than associated backache. - Patients avoid excessive movements. - Pain relief upon flexion of knee and thigh - Numbness or tingling occurs in the distribution of the affected root. - Motor weakness. - Bladder symptoms (urgency, frequency, retention). ### 3.5) 2) signs: #### 3.5.1) A. Back signs: - Restricted spinal movement. - Scoliosis. - Obliteration of lumbar lordosis. - Local tenderness. - Paravertebral muscle spasm. #### 3.5.2) B. Signs of radiculopathy: - Motor weakness. - Dermatomal sensory changes. - Reflex changes. - Depends upon the root compressed. ### 3.6) C. Clinical tests (nerve root tension signs): #### 3.6.1) 1) Straight leg raising test (SLRT): - Types of SLRT: - SLRT (Lasegue's sign) → Passive elevation of fully extended leg is considered positive if the patients feels sciatica at an angle <60°. - Crossed SLRT. - Augmented SLRT. #### 3.6.2) 2) Femoral stretch test (reverse SLRT): - With patient in prone position, extend hip joint. - Patient feels femoral pain. - +ve in higher disc prolapse (L2, L3 or L4 root irritation). ### 3.7) D. Cauda equina syndrome → Presentation: - Low back pain and bilateral sciatica - Motor: - Bilateral weakness of dorsi & plantar flexion of the foot. - Weakness of hip flexor and/or extensors. - Weakness of knee flexors and/or extensors may also occur. - Sensory: hyposthesia bilaterally according to spinal roots affected and saddle shaped hyposthesia. - Reflexes: ankle reflex is lost bilaterally and also may be the knee reflex. - Sexual dysfunction (impotence) Sphincteric disturbance (retention or incontinence of urine, chronic constipation or incontinence of stools, diminished anal tone). - Clinical test → SLRT positive bilaterally. ### 3.8) E. Neurogenic claudication → occurs in cases of lumbar canal stenosis. ### 3.9) Investigations: 1. Plain x ray: - AP and lateral views. - Dynamic study (neutral, fexion, extension). - Show: - Narrowing of the disc space. - Osteophytes. - Obliteration of lumbar lordosis. - Scoliosis. - Spondylolisthesis. - To exclude other pathologies as metastatic lesions. 2. CT scan: - More accurate than myelography. - Detects: - Lumbar canal stenosis. - Hypertrophied facet joint. - Narrow canal dimension. 3. MRI. 4. Myelography. 5. Nerve conduction velocity and EMG. 6. Motor Evoked Potential (MEP). 7. Somatosensory Evoked Potential (SSEP). ### 3.10) Treatment: #### 3.10.1) 1) Conservative treatment: - Bed rest for 2-4 days on hard board mattress. - Exercise. - Activity modification and avoid lifting heavy weights. - Analgesics. - Muscle relaxants. - Reduction of body weight. - Education. #### 3.10.2) 2) Surgical treatment: - Indication: - Failure of non-surgical treatment. - Patients who do not want to invest time in a trial of non-surgical treatment. - Urgent surgery: - Cauda equina syndrome. - Progressive motor deficit. - Severe, unremitting, leg pain which is not relieved by conservative measures. - Surgical treatment options: - Standard open laminectomy and discectomy. - Microdiscectomy. - Endoscopic discectomy. - Automated percutaneous lumbar discectomy (nucleotome). - Percutaneous endoscopic discectomy. - Laser disc decompression. - Chemonucleolysis. - Surgical techniques: - Hemilaminectomy and discectomy. - Endoscopic discectomy. - Percutaneous discectomy. ## 4) Lumbar Canal Stenosis - Clinically: - Root pain and sense of heaviness of both lower limbs develops after standing or walking. It is relieved by sitting or lying down (claudicating sciatica). - Negative straight leg raising test. - Neurological deficit, such as muscle weakness or sensory troubles are bilateral, predominantly at one side. - In many cases there is sphincteric function impairment. ## 5) Spondylolisthesis - Definition → Forward sliding of one vertebral body over other. - This usually occurs between L5-S1 & L4-L5. - Due to congenital defective facet articulation: - Fracture pars inter articularis (isthmic spondylolisthesis). - Prolonged degenerative process of spine (degenerative spondylolisthesis). - Narrowing of spinal canal may cause root compression. ### 5.1) Treatment - Conservative: - External spinal support. - Analgesics. - Weight reduction. - Surgical → Decompression and fusion of the involved levels i.e. bony fusion with or without rods and transpedicular screws. ## 6) Spine Fracture - Epidemiology: - Common in young age (working age). - In old age it is usually secondary to osteoporosis or metastatic lesions. - Incidence: 2-5/100 000 population. - 10% will result in paraplegia or quadriplegia. - Causes: - Road traffic accidents (most common). - Sport injuries: - Swimming "diving". - Horse riding. - Skiing. - Blunt trauma. - Falling from height. - Falling of heavy object over the head. ### 6.1) Type of fracture: | Fracture | Failure of | | :----------------- | :-------------------------------------------------------------------------------- | | Compression | Anterior column | | Burst Fracture | Anterior and middle columns | | Seat Belt | Middle and posterior columns | | Dislocation | Anterior, middle, posterior columns | ### 6.2) Stability of lesion: | | Stable Fracture | Unstable Fracture | | :------------------------------- | :---------------------------------------------------------------------- | :---------------------------------------------------------------------------------------------------------------------- | | occurs if damage is in | One column only. | More than 2 columns are disturbed. | | causes | Wedging of vertebra. | In burst fracture. | | more seen | With falling while sitting, exaggerated flexion injury. | NB: seen if torsion stress occurs. | ### 6.3) Investigations: 1. Plain x ray - AP and lateral views. - Dynamic study (neutral, fexion, extension). 2. CT scan → more accurate than X-ray and MRI for bony compression. 3. MRI → shows cord contusion injuries & presence of any cord insult 4. Myelography 5. Motor Evoked Potential (MEP) 6. Somatosensory Evoked Potential (SSEP) ### 6.4) Treatment: #### 6.4.1) At site of trauma: - Prevention of further injury: - We must assess the vital signs, conscious level, neurological status, and associated injuries. - During transfer spinal immobilization is a must: - Cervical neck collar if cervical fracture is suspected. - While drozitumab brace if there is lower spine fracture. - Careful attention to body temperature. - Nasogastric tube. - Urinary catheter. #### 6.4.2) Steroids → Methyl prednisolone 30 mg/kg infusion within the first 8 hours (optimum dose gives results within optimum time). ## 7) Spinal Tuberculosis - Usually affects the dorsal vertebrae. - Spinal tuberculosis affects first superior, inferior or anterior edge of vertebral body. ### 7.1) Treatment: - Antituberculous drugs. - Excision of granulation tissue, drainage of abscess; and diseased vertebral body may be excised by anterolateral approach. Fusion may be done. ## 8) Spinal Abscess - A rare condition. - Requires urgent surgery. - Thoracic or thoracolumbar region is most common area of affection, due to hematogenous spread or directly from adjacent vertebral infection. ### 8.1) Organism: - Staph. aureus, Streptococci, or pseudomonas. - Spinal cord compression is due to inflammatory swelling and pus collection. ### 8.2) Clinical picture: - Severe local spinal pain. - Rapid neurological signs. - Constitutional manifestation. ### 8.3) Treatment: - Urgent laminectomy and abscess evacuation. - Antibiotics (according to the sample culture and sensitivity). ## 9) Spinal Neoplasm - Spinal tumors are one of main causes of spinal compression. ### 9.1) Classified into: #### 9.1.1) Extradural Spinal Tumors - Osseous - Extra - osseous - Extradural meningioma. - Neurofibroma. - Lymphoma. - Extradural hemangioma. - Extradural lipoma. - NB: MC is metastatic tumor. - Intradural Spinal Tumors - Extramedullary - Meningioma “MC”. - Neurofibroma. - Sarcoma. - Intramedullary - Glioma “MC”. - Ependymoma. - Hemangioblastoma. #### 9.1.2) Extradural Spinal Tumors: - Aneurysmal bone cyst - Chordoma - Chondrosarcoma ### 9.2) Investigations: - Bone scan → sensitive test for neoplastic disease of the spine is 99m technetium bone scan. ### 9.3) Goals of treatment should be as follows: - Decompression of nervous structures. - Obtain definite diagnosis through biopsy or primary excision. - Preservation of neurological functions. - The maintenance of spinal cord stability. ### 9.4) Treatment: - Most of the extradural spinal tumors are metastatic. Operative decompression should be carried out. Radiation therapy may be given after surgery. - Intradural extra medullary neoplasms are usually benign and total excision is possible. - Total excision of intradural intra medullary tumors usually is not possible, so radiation therapy is indicated in malignant cases.