Common Spine and Spinal Cord Syndromes Gabriel C. Tender, MD
Common Spine and Spinal Cord Syndromes Gabriel C. Tender, MD Assistant Professor of Clinical Neurosurgery, Louisiana State University in New Orleans Staff Neurosurgeon, Touro Infirmary Chronic Syndromes Lumbar • Cauda equina compression • Lumbar radiculopathy • Low back pain Cervical • Myelopathy (from cord compression) • Cervical radiculopathy • Axial neck pain Upper vs. Lower Motor Neuron Paralysis (cauda equina vs. myelopathy) Most Common Problems • Disc herniation – leads to leg (or arm) pain • Disc degeneration – leads to low back (or neck) pain Disc Herniation – Physiology • Tears in the annulus • Herniation of nucleus pulposus Disc Herniation – Physiology • Compression of the nerve root in the foramen leads to pain Disc Herniation – Physiology • Leg pain goes down to the toes (L5 or S1) • Arm pain can go in the shoulder (C5), thumb (C6), middle finger (C7), or little finger (C8) Disc Herniation – MRI Lumbar Disc Herniation – Treatment Conservative Tx. • • • • Moderate bed rest Spinal manipulation Physical therapy Medication • NSAIDs • Muscle relaxants • Rarely narcotics Surgical Tx. • “Microdiscectomy” • Less than half of an inch incision • Go home the same or next day • Good results in up to 90% of cases Lumbar Disc Herniation – Surgical Tx. Real Life Case (Lumbar Disc Herniation – Surgical Tx.) Results of Surgical Treatment • Good outcome in 80-90% of cases • Residual pain may last up to 6 months postop • Results are worse if pain was present for over 8 months before the operation (permanent nerve damage?) Low Back Pain • Second most common cause of missed work days • Leading cause of disability between ages of 19-45 • Number one impairment in occupational injuries Low Back Pain • Most episodes of LBP are self limited • These episodes become more frequent with age • LBP is usually due to repeated stress on the lumbar spine over many years (“degeneration”), although an acute injury may cause the initiation of pain Normal Anatomy Disc Degeneration – Physiology • With age and repeated efforts, the lower lumbar discs lose their height and water content (“bone on bone”) • Abnormal motion between the bones leads to pain Disc Degeneration – MRI Disc Degeneration – Treatment Conservative Tx. • • • • Moderate bed rest Spinal manipulation Physical therapy Medication • NSAIDs • Muscle relaxants • Rarely narcotics Surgical Tx. • Lumbar fusion OR • Replacement with artificial disc Lumbar Fusion • Decreases pain by stopping abnormal motion at the diseased level • Minimally invasive lumbar fusion can be done through 2 small incisions (less than an inch) Real Life Case (Minimally Invasive) Real Life Case (Open) Replacement with Artificial Disc • Decreases pain by reestablishing normal motion at the diseased level Fusion vs. Artificial Disc Fusion • Has been proven to work • The adjacent levels are more stressed and prone to degeneration • Can be done through a small incision Artificial Disc • Has not been proven to work yet • The adjacent levels are protected • Cannot be done through a small incision Indications for Surgical Treatment • • • • Low back pain for at least 2 years Incapacitating Resistant to physical therapy and medication Positive MRI findings (degenerative changes) at L4-5 and/or L5-S1 • For selected cases: • Concordant pain on discography • Psychological evaluation Results of Surgical Treatment • Fritzell et al., Spine 2001 Dec 1;26(23):2521-32 • Prospective randomized multicentric study (class I evidence) • In the surgical group, 63% of patients rated themselves as “much better” or “better”, compared to 29% in the nonsurgical group • Surgical treatment is superior to nonsurgical therapy in a well selected group of patients Osteoporosis and Vertebral Fractures Depressed endplate(s) Spine shorter, tilted forward Wedgeshaped Normal Fractured Osteoporosis and Vertebral Fractures Minimally Invasive Fracture Reduction Real Life Case Key Questions • What is worse, the leg or the back pain? (“both” is not acceptable; ask “if you had to chose, which one would you like me to cure?”) • What’s the intensity on a scale of 1 to 10? • On the average • At its’ worst • Is the pain interfering with your normal activities? Is it “incapacitating”? • What makes it better? (position, medication, leaning forward) or worse? • Did you try physical therapy for at least 3 months? • Are you involved in Workman’s comp or litigation? Neck and/or Arm Pain – Conservative Tx. • • • • Rarely bed rest Home cervical traction Physical therapy (if no weakness / myelopathy) Medication • NSAIDs • Muscle relaxants • Rarely narcotics Neck and/or Arm Pain – Surgical Tx. Anterior Approach • “Anterior cervical discectomy and fusion” • Small skin incision (about one inch) • The disc and bony spurs are removed • A small piece of bone is inserted in the disc space to achieve fusion • Alternatively, an artificial disc can be inserted Neck and/or Arm Pain – Surgical Tx. Posterior Approach • If there is an eccentric (lateral) disc herniation, the free fragment can be removed and the nerve root decompressed (the entire disc cannot be removed) • If there is canal stenosis at multiple levels, a decompressive laminectomy followed by a fusion can be performed THANK YOU!