Common Spine and Spinal Cord Syndromes

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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

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Chronic Syndromes

• Lumbar
• Cauda equina compression
• Lumbar radiculopathy
• Low back pain

• Cervical
• Myelopathy (from cord compression)
• Cervical radiculopathy
• Axial neck pain

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Upper vs. Lower Motor Neuron Paralysis(cauda
equina vs. myelopathy)
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Most Common Problems

• Disc herniation leads to leg (or arm) pain
• Disc degeneration leads to low back (or neck)
  pain

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Disc Herniation Physiology

• Tears in the annulus
• Herniation of nucleus pulposus

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Disc Herniation Physiology

• Compression of the nerve root in the foramen
  leads to pain

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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)

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Disc Herniation MRI
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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

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Lumbar Disc Herniation Surgical Tx.
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Real Life Case (Lumbar Disc Herniation
Surgical Tx.)
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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?)

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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

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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

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Normal Anatomy
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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

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Disc Degeneration MRI
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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

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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)

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Real Life Case (Minimally Invasive)
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Real Life Case (Open)
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Replacement with Artificial Disc

• Decreases pain by reestablishing normal motion at
  the diseased level

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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

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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

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Results of Surgical Treatment

• Fritzell et al., Spine 2001 Dec 126(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

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Osteoporosis and Vertebral Fractures
Depressed endplate(s)
Spine shorter, tilted forward
Wedge- shaped
Normal
Fractured
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Osteoporosis and Vertebral Fractures
Minimally Invasive Fracture Reduction
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Real Life Case
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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?)
• Whats 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 Workmans comp or litigation?

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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

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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

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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

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