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!