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Degenerative disease of the spine
Pathophysiology: With increasing age the water content of the nucleus pulposus falls and splits appear in the
surrounding annulus fibrosus. If the split is located
posteriorly, elements of the nucleus pulposus can then
herniate through the split into the spinal canal.
Spinal cord lesion
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A congenital weakness of the annulus may predispose
to these changes. At the same time, degenerative
changes, including the appearance of osteophytes,develop on the apophyseal joints.
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The symptoms associated with degenerative disease of
the spine are therefore the consequence either of
protrusion of the annulus or the disc, or narrowing
either of an intervertebral foramen or the spinal canal
by osteophyte formation.
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Posterior protrusion of the annulus fibrosus or a
herniated nucleus pulposus results in cord compression
at the cervical level, but compression of the cauda
equina in the lumbar region. Posterolateral protrusion of the annulus or a noncalcified (soft) disc, or
osteophytosis or vertebral body, can all produce
compression of the nerve root within the intervertebral
foramen, more commonly in the cervical than in the
lumbar region.
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Cervical spondylosis
Degenerative disease in the cervical spine occurs most
often at the C5/6 and C6/7 levels.
Cervical radiculopathy
Typically, patients give a history of neck pain
accompanied by pain radiating to the scapula, the shoulder
or the arm itself. Sensory symptoms, whetherparaesthesiae or numbness, serve to localise the affected
nerve root. Clinical examination reveals restricted neck
movement.
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Localization of the
involved root
Sensory symptoms
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The distribution of muscle
weakness follows the
pattern of innervation of the affected root.
Localization of the root
involved is aided by
examination of thereflexes.
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C5-6 disc protrusion
C6-7 disc protrusion
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Cervical myelopathy
Cervical spondylomyelopathy is most often the result
of a disease process at the C5/6 or C6/7 disc space,though multiple level compression is common.
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The clinical features are dependent on the level of
compression. Above C5 there will be a spastic
tetraparesis, below this level a combination of
radicular features (weakness, atrophy, pain andnumbness) in the upper limbs with pyramidal signs
(spasticity and exaggerated reflexes) in the lower
limbs, accompanied in some instances by long tract
sensory signs. Bladder function remains relatively
spared.
I i i
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Oblique views of the cervical spine are essential to
demonstrate protrusion into the intervertebral foramen of
osteophytes.
Investigation
Plain X-rays
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The evaluation of cervical myelopathy in CT myelography can demonstrate the degree of cord deformity.
Neuro-imaging
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MRI is the best technique
for evaluating spondylotic
myelopathy, provides an
accurate display of the
relationship between
vertebral body, disc and
spinal cord.
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Electrophysiological investigation can provide
confirmatory evidence of either root or cord
involvement.
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Management
Most cervical root syndromes are managed by acombination of cervical immobilization, using an
appropriately fitting firm collar together with
analgesics. Occasionally, surgical decompression of
the affected root is necessary, and is usually successfulin producing pain relief. In the presence of a
progressive myelopathy, surgery is generally
recommended.
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Thoracic disc disease
Thoracic disc disease is rare and often confused with
benign tumours. It predominates in the lower thoracic
region and is more likely to affect males than females.
The condition may simply present as a slowly progressive
spastic paraplegia but many patients complain of exercise
induced symptoms, either sensory, motor or both.
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Disc calcification is found in perhaps half the cases. The
disc protrusion and calcification are best identified using CT
myelography or MRI.
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Treatment is surgical, though the complication rate is
relatively high.
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Lumbosacral disc disease
Degenerative disease of the lumbar spine involves the
lower two levels in over 90 per cent of cases.Posterolateral, lateral and central patterns of protrusion
are described. Pain is a prominent feature.
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Posterolateral disc protrusion
Pain is a prominent feature in lumbar disc disease and
can be referred to the buttock and upper thigh in theabsence of root involvement. Areas commonly
affected by pain include the lower lumbar spine, in or
around the midline and the medial aspect of the
buttock. There may be local tenderness in these areas.
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Radicular pain may be accompanied by back pain or can
appear, at least initially, in isolation. Typically,
radicular pain is exacerbated by straining. Pain
extending from the back to the anterior thigh suggests
involvement of an upper lumbar root. Medial calf pain
suggest L5 and lateral calf pain suggest S1, root
compression. Sensory symptoms are common andgenerally segmental.
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Examination includes an assessment of the spine, a
search for signs indicating nerve root irritation and
finally an evaluation of any motor, sensory or reflex change relevant to the particular root. The back is
examined for areas of local tenderness and any
alteration of the normal lumbar lordosis or paravertebral
spasm.
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Stretch tests
Straight-leg raising is performed by gently elevatingthe outstretched leg from the horizontal with the
patient lying supine. It indicates an irritation of a root
at or below L5 level
The femoral stretch test is performed by extending the
hip with the patient lying on one side. A positive test
suggests an irritation of the roots of L2,3 or 4.
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Focal signs
Focal signs are
dependent on thedistribution of the
affected nerve root.
With L4 compression
there is weakness of
quadriceps and tibialis
anterior, with sensory
change over the medialaspect of the shin and
depression of the knee
jerk
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Central disc protrusion
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Central disc protrusion Following a central disc protrusion, which can occur without
an antecedent history of back pain, cauda equina compression
occurs, often in an abrupt fashion.Severe pain results, with
paravertebral localization or
with radiation into both lower limbs..
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Typically, there is severe distal
lower limb weakness with foot
drop, depression of the ankle
reflexes and impaired sphincter
function. Saddle anaesthesia is
common.
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Investigation of lumbosacral disc disease
Plain X-rays
Plain X-rays are of very limited value in the investigationof a lumbar radiculopathy.
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Plain CT
High-resolution CT,
without contrast, hadbeen previously
recommended as the
initial investigationfor the evaluation of
lumbar disc disease &
lumbar canal stenosis.
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CT myelography
CT myelography
achieves a 60-80 per cent
accuracy in the diagnosis
of herniated lumbar disc.
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MRI
MRI is now the
screening technique of choice for the accurate
definition of lumbar disc
herniation.
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Spinal stenosis
Though in many
patients spinal stenosis
is congenital, in others
it is secondary to
hypertrophy of the bony
elements of the lumbar
canal, ligamental
hypertrophy or disc
degeneration.
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Canal stenosis usually affects middle-aged men.
Typically, (Intermittent neurogenic claudication)
paroxysmal numbness or paraesthesiae, rather than pain,
appear in the lower limbs during walking and
sometimes in certain standing postures. The symptoms
often march from the distal parts of the extremities to
the proximal.
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High-resolution CT is the
investigation of choice,
allowing definition both of the central canal and of the
lateral recess.
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Spinal or foraminal stenosis is managed surgically
if the symptoms are disabling. Lumbar disc
prolapse, if central, is managed by immediatesurgery. Posterolateral disc prolapse is managed
conservatively initially but by surgery if symptoms
fail to resolve with rest.
S i l d i f i
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Spinal cord infections
Spinal epidural abscess
Haematogenous spread of infection is the usual
source of an epidural abscess, but in some cases the
condition is triggered by a spinal procedure which
can include epidural injection as well as opensurgery.
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Typically, the infective process, which is
usually due to Staphylococcus aureus, beginsin the vertebral body before spreading to the
epidural space. The abscesses occur most
often in the lumbosacral region.
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Clinical features
Back pain with evidence of a febrile illness thenRadicular pain followed by neurological deficit
include motor, sensory and sphincter disturbance.
An elevated ESR is usual.
CSF findings: an elevated white cell count
(polymorphonuclear leucocytes or lymphocytes) and
protein concentration but with a normal glucose
level.
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Investigation
Plain radiographs mayestablish the presence of a
vertebral destructive
process but can be normal.
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CT Myelography,
characteristicallyreveals a total or partial
block of the
subarachnoid space,
associated with cord
compression. Rarely,
MRI has been reported
as normal in thiscondition. .
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Tuberculous disease of the spine
Tuberculous disease of the spine is usually secondary to
tuberculosis elsewhere in the body and concentrates in the
thoracolumbar region. Multiple vertebral involvement is the
rule. The disease usually commences in the vertebral body.
The vertebral interspace is relatively spared but becomesinvolved when the disease is extensive.
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Eventually, passage
through or round the
anterior or posterior
longitudinal ligamentsleads to paraspinal
abscess formation.
Vertebral collapse with
kyphosis is an
additional mechanism
sometimes responsible
for spinal cord damage.
Clinical features
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Clinical features
Initial features of the illness include fever, malaise
and weight loss. Subsequently, pain emerges,
associated with focal tenderness. A radicular element
to the pain is often prominent.
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Tracking of the
abscess in the cervical
region can lead to a
neck swelling, while
from the
thoracolumbar region,
tracking along thepsoas sheath results
eventually in a mass in
the iliac fossa, pelvis
or groin.
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Investigation
Blood tests are of limited value in diagnosis.
Plain X-rays are usually but not inevitably abnormal.
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Typically, there is
erosion of the vertebral
bodies with disc spacenarrowing and, in the
later stages, shadowing
secondary to
paravertebral abscessformation.
L f k b d i i h b l ll
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Later more frank bone destruction with vertebral collapse or
deformity become evident.
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Plain CT is highly accurate in establishing the
diagnosis. With contrast, rim enhancement is seen in
any paravertebral collection.
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The MRI revealed a
multiple vertebral
involvement withrelative preservation of
the intervening discs, a
picture liable to cause
confusion withmetastatic disease.
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Treatment is with standard anti-tuberculous
therapy, combined, where there is neurological
involvement, with surgery. Laminectomy isrequired if the disease is affecting the posterior
neural arch. For anterior paravertebral masses an
anterior approach is usually undertaken.
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Brucellosis
Brucella spondylitis
most frequentlyinvolves the lumbar
spine at the L4 level.
CT demonstrates
rounded defects inthe vertebral end
plates though
vertebral collapse is
rare.
Incidence is more common in veterinarians and those
who are in contact with milk products.
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Brucella myelitis can occur in isolation or as part of a
meningo-encephalitic syndrome. In addition, cord
involvement may follow primary vertebral disease withor without extradural granuloma formation. Most
patients have evidence of systemic brucellosis. Back
pain is common, associated with a spastic paraparesis
or quadriparesis with sphincter involvement in some
cases. The sensory deficit is less conspicuous.
Pl i X f th
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Plain X-rays of the
spine are often
normal. The
vertebral andextradural
manifestations are
more successfully
demonstrated by
MRI than CT.
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Schistosomiasis
Spinal cord disease in patients with schistosomiasis is
usually due to infection by S. mansoni.
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Granuloma formation most frequently involves conus
medullaris. Granuloma formation both within andoutside the cord have been described.
Expanded conus
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The cauda equina can also be affected. Typically, a
transverse myelitis appears, sometimes acutely. The
CSF shows a raised protein concentration, alymphocytic pleocytosis and elevated antibody
levels. Treatment combines steroids with
antischistosomal drugs with surgery in some cases.