Dr.Farzad Ravari
M.D
Specialist Orthopedic Surgeon
Cedars J.A Int.Hospital
ANATOMY OF SPINE
Intervertebral Disc
 The intervertebral disc absorbs shock, accommodates
movement, provides support, and separates vertebral
bodies to lend height to intervertebral foramina. The
disc consists of an eccentrically located nucleus
pulpous and a surrounding annulus fibrosis separating
each segmental level between the C2-T1 vertebrae. No
disc exists between C1 and C2, and only ligaments and
joint capsules resist excessive motion
DISC HERNIATION
Pathophysiology of acute discopathy
 Acute disc herniation causes radicular pain through
chemical radiculitis in which proteoglycans and
phospholipases released from the nucleus pulposus
mediate chemical inflammation and/or direct nerve
root compression. Interleukin 6 and nitric oxide are
also released from the disc and play a role in the
inflammatory cascade. The chemical radiculitis is a
key element in the pain caused by HNP as nerve root
compression alone is not always painful unless the
dorsal root ganglion is also involved. Herniation may
induce nerve demyelination with resulting neurologic
symptoms
Pathophysiology of acute discopathy
 Acute Disc Herniation
Release of PG,Interlukin 6,nitrous oxide
From NUC.PUL.
Nerve root compression
Chemical inflamation
Chemical radiculitis
PAIN
CERVICAL DISCOPATHY
HNP
DDD
 M=F
 M=F
 <40 yo
 >40 yo
 Etiology:
 Etiology
 repetitive cervical stress
 is part of natural aging
 a single traumatic incident
 poor nutrition
 vibrational stress, heavy
 Smoking
lifting
 , prolonged sedentary
position
 whiplash accidents
 Atherosclerosis
 job-related activities
 genetics.
Clinical manifestation
 Discogenic pain without nerve root involvement typically is vague,
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diffuse, and distributed axially
Pain increase after lifting &Valsalva maneuver & Vibrational stress
from driving
Pain decrease after lying supine
radicular pain is deep, dull, and achy or sharp, burning, and electric.
most commonly radiates to the interscapular region & to the occiput,
shoulder, or arm
Neck pain does not necessarily accompany radiculopathy and
frequently is absent
distal limb numbness and proximal weakness & Atrophy
Dermatomes
Physical Exam.
 displays decreased cervical range of motion (ROM).
 Pain is exacerbated by neck extension and rotation or by
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Spurling maneuver (patient's neck is extended, laterally
bent, and held down)
Pain improves with neck flexion or with abduction of the
symptomatic upper limb over the top of the head
(abduction sign).
Decreased sensation to pain, light touch, or vibration
Diminished or absent reflexes
Increased upper and lower limb reflexes or other upper
motor neuron signs suggest myelopathy
Myofascial tender or trigger points
Differential diagnosis
 Brachial Neuritis
 Paget Disease
 Cancer and Rehabilitation
 Psoriatic Arthritis
 Cervical Myofascial Pain
 Radiation-Induced Brachial
 Cervical Spondylosis
 Cervical Sprain and Strain
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 Complex Regional Pain
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Syndromes
Fibromyalgia
Neoplastic Brachial Plexopathy
Osteoarthritis
Osteoporosis
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Plexopathy
Rheumatoid Arthritis
Rotator Cuff Disease
Scheuermann Disease
Thoracic Outlet Syndrome
Traumatic Brachial Plexopathy
Diagnosis & work up
 LAB:
 Rheumatoid factor (R.A)
 HLA-B27 (A.S)
 ESR( polymyalgia rheumatica)
 infection workup to evaluate for possible
discitis, epidural abscess, and vertebral
osteomyelitis, including the following
tests:
 W.BC count with differential
(elevated with a left shift in bacterial
infection)
 Blood cultures (positive for the
infecting organism)
 ESR(elevated in infection, but may
be a nonspecific finding
 Plain radiographs
 Cervical spine trauma films use
7 views
Flex/ext views: sublux,
instability.
 Open-mouth views:the
odontoid process and C1-C2
stability.
 AP views: tumors,
osteophytes, and fractures.
 Lateral views:stability and
spondylosis (ie, spurring, disc
space narrowing).
 Oblique views reveal DDD, as well
as foraminal encroachment by
uncovertebral or Z-joint osteophytes
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CT scan:cervical spine fracture
CT myelography
MRI
 evaluates the spinal canal, the
 of choice to evaluate cervical
spinal cord, and nerve root
impingement from disc, spur, or
foraminal encroachment
 superior to MRI in detecting
lateral and foraminal
encroachment
HNP
 depict pathology larger than
actual size
 Contraindications to MRI
include patients with embedded
metallic objects, such
as pacemaker, surgical clips,
spinal cord stimulators, or
prosthetic heart valves that may
be dislodged by MRI magnets.
Nerve conduction studies (NCSs) or nerve conduction
velocity(NCV)and electromyography (EMG)
NCS(NCV)/EMG
 differentiating cervical
radiculopathy from neuropathic
conditions (eg, ulnar nerve
entrapment, carpal tunnel
syndrome, peripheral
neuropathy, plexopathy).
 routine motor NCSs do not
evaluate the C6 and C7 nerve
roots, which are most commonly
involved, or the levels above
Somatosensory evoked
potentials (SEPs)
 evaluate sensory conduction
peripherally and centrally
 Lower limb SEPs involving tibial
and peroneal nerves, which
assess spinal cord conduction,
are more sensitive in diagnosing
myelopathy than are upper limb
median and ulnar SEPs.
TREATMENT
 The McKenzie system:3 mechanical syndromes that cause
pain and compromise function:
 1-The postural syndrome :pain when normal soft tissues are
loaded statically at end ROM; pathology need not be
present. Treatment aims to correct posture.
 2-The dysfunction syndrome :pain when the patient, upon
attempting full movement, mechanically deforms
contracted scarred soft tissue. Consequently, therapy
involves stretching and remodeling of such contracted
tissue.
 3-The derangement syndrome :intermittent pain when
certain movements or postures occur. pain may become
centralized or peripheralized because of discopathy.
Therapy attempts to correct derangement .
Conservative treatment
 Physiotherapy:
 Superficial heat >> relax muscle ,soft-tissue pain
 deep-heating modalities (eg, ultrasonography) should
be avoided in acute cervical radiculopathy, because
they augment inflammation and, consequently,
exacerbate radicular pain and nerve root injury.
 Cervical traction may relieve radicular pain from nerve
root compression. Traction does not improve softtissue injury pain. Hot packs, massage, and/or
electrical stimulation should be applied prior to
traction to relieve pain and relax muscles
traction
 Traction include heavy weight-intermittent or light weight-continuous. The
neck is flexed 15-20 º (ie, not extended) during traction. In the cervical spine,
approximately 10 lb of force is necessary to counter gravity and 25 lb of force is
necessary to achieve separation of the posterior vertebral segments.
 Light weight-continuous home traction is cost effective and provides the
patient with more autonomy.
 Pneumatic traction devices afford greater patient comfort and, consequently,
increased compliance.
 A soft cervical collar is recommended only for acute soft-tissue neck injuries
and for short periods of time (ie, not to exceed 3-4 days' continuous use). Risks
include limiting cervical ROM and losing neck strength if the collar is worn
continuously for longer periods.
 When worn for radiculopathy caused by foraminal stenosis, the wide part of
the collar is placed posteriorly and the thin part is placed anteriorly to promote
neck flexion, discourage extension, and open the intervertebral foramina.
 Collars can be worn during certain activities, such as sleeping or driving, for
longer periods.
 Although not commonly used, a Philadelphia collar can be worn at night to
position the neck rigidly in flexion, thereby maintaining open foramina
Manipulation , mobilization
 Spinal manipulation and mobilization may restore normal ROM and
decrease pain, joint adjustment improves afferent signals from
mechanoreceptors to peripheral and central nervous systems.
 Normalization of afferent impulses improves muscle tone, decreases
muscle guarding, and promotes more effective local tissue metabolism.
These physiologic modifications subsequently improve ROM and pain
reduction.
 Studies document short-term improvement in the acutely injured
patient and in those with cervicogenic headache and radiculopathy
secondary to disc herniation.
 No evidence exists that manipulation confers long-term benefit,
improves chronic conditions, or alters the natural course of the
disorder.
MEDICINE
 NSAIDs are first-line
 muscle relaxants to potentiate the NSAID analgesic effect
 Oral corticosteroids, No AVN when the total prednisone dose stayed
under 550 mg.
 Tricyclic antidepressants (TCAs) decrease pain and reduce
nonrestorative sleep, Side effects include dry mouth, constipation, and
weight gain
 membrane-stabilizing agents (eg, gabapentin, carbamazepine).
Gabapentin in treating diabetic peripheral neuropathic pain
 Other analgesics (acetaminophen, tramadol) provide pain relief
without inflammation control.
Injection:
 the epidural space (interlaminar) or along the nerve root
(transforaminal) after precise radiologic, contrast-enhanced
fluoroscopic localization.
 Adverse effects include :
 epidural hematoma, seizure, vertebral artery spasm,
infection, temporary quadriparesis from anesthetic,
and respiratory arrest
 serious CNS complications, including spinal cord
injuries and strokes, due to occlusion of a vessel
SURGERY
 1- neurogenic bowel or bladder dysfunction,
 2-deteriorating neurologic function,
 3- intractable radicular or discogenic neck pain exists
THORASIC DISCOPATHY
 Frequency: 1 in 1 million persons / year, =0.25-0.75% of all disc
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herniations
Pathophysiology:
The thoracic discs are stable due to the surrounding rib cage, with the
stabilizing effect of the rib articulations. the blood supply at the T4-T9
watershed area, which is more prone to ischemic injury.
The facet orientation in the thoracic spine is vertical, with a slight
medial angulations. >>>>easier lateral bending and rotation versus
pure bending,>>>> the thoracic spine discs are at a decreased risk of
injury because of the decreased bending potential in this segment of
the spine.
The spinal cord-to-canal ratio is 40% in the thoracic spine versus 25%
in the cervical spine. The thoracic spine is also naturally kyphotic.
These 2 facts make the thoracic spine more sensitive to cord
compression from disc herniation
Clinical manifestation:
 Thoracic disc disease may emulate the symptoms of lumbar disc disease.
 Shooting pain down the legs implies nerve root irritation versus cord compression.
 Pain in the thoracic area signifies mechanical pain that is possibly secondary to fractures,
degenerative disc disease, tumors, or infections.
 Night pain that wakes the patient is suggestive of infection or an oncologic process.
 Cord compression is present with myelopathy, which requires immediate attention.
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Myelopathy is seen with the following:
The presence of clonus or a positive Babinski reflex
Bowel and bladder dysfunction (seen in up to 20% of symptomatic discs)
High thoracic (T2-T5) herniation mimics cervical disc disease
Patients can present with upper extremity involvement, including Horner syndrome.
If myelopathy is present, a negative result from the Hoffmann test makes cervical spine
involvement unlikely. A positive result from the Hoffmann test is seen when the middlefinger metacarpophalangeal joint and the proximal interphalangeal joints are kept
extended; a flexion reflex of the thumb is seen when the distal interphalangeal joint is
flicked or suddenly extended. This is known as the Hoffmann sign.
Radicular symptoms include pain/paresthesias or dysesthesias in a dermatomal
distribution. Dermatome T10 is usually involved.
physical exam:
 Palpation>>>>>.>Entire spine.Muscle spasms.
 ROM>>>>hips, knees, and ankles for radiculopathy vs hip , knee pathology
 Arthritis>> pain increase by extension
 Radiculopathy>>> pain increase by flex
 Bilateral SLR
 Motor examination L2-L4 (knee extension), L4 (inversion), L5
(dorsiflexion), and S1 (eversion and plantar flexion)
 Sensory examination
 nipple =T4; xiphoid= T7; umbilicus= T10; inguinal region= T12.
 Reflex testing: knee (L4) ankle (S1)
 The abdominal reflexes and cremasteric reflex (check for symmetry
and presence) for myelopathy and cord compression.
 Vascular examination of the dorsalis pedis artery, posterior tibial artery,
and femoral artery can rule out other causes of the patient's sym
Ethiology:
 Age
 Trauma
 Smoking
 Obesity
 Sedentary lifestyle
 Poor physical fitness
Diagnosis:
 Radiography
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 Should be the initial examination that is ordered
 Unable to distinguish actual disc herniation
 identify disc calcification
 infectious or oncologic causes for the patient's pain
 Magnetic resonance imaging (MRI)
 Both T1- and T2- imaging are needed
 Sensitive for identification of disc herniation
 T2-weighted images exaggerate findings.
 calcification by low signal in T1- and T2-images.
 bony inflammation with tumors/infection
 Computed (CT) myelogram
 Has improved bony visualization compared with MRI
 Not as sensitive for disc sequestration/migration
 Invasive relative to MRI
 Discogram
 Controversial
 Used for provocative testing for the level of
involvement before surgery
Treatment:
 1-Physical therapy
 2-Medicine
 3-surgery
 Surgical Intervention
 Surgical decompression is indicated in patients with
myelopathy (unless improving), progressive
neurologic symptoms, and worsening symptoms or
lack of improvement in the patient's symptoms by 4-6
weeks of conservative management
LUMBAR DISCOPATHY
FREQUENCY: male /female=2/1
 clinical manifestation:
 often as a shooting or stabbing pain
 L3,L4>>>radiate into the groin or
anterior thigh
 L5>>lateral and anterior thigh and
leg pain
 S1>>cause pain in the calf and
bottom of the foot
 pain usually improves in the supine
position with the legs slightly
elevated. Patients are more
comfortable when changing
positions. Short walks can bring
relief. Long walks or extended
sitting (especially driving) can
aggravate the pain.
Physical exam
 SLR +++VE less than 50’
 More than 50’>>>>> hamestring spasm
 CROSS SLR++ve >>> more diagnostic
 Scoliotic spine
 abnormal gait
 Weakness of muscle
 vvvvv DTR
X-RAY
MRI
TREATMENT
INDICATION OF SURGERY
 1-cauda equina syndrome
 2-progressive neurologic deficit during a period of
observation
 3-Persistent sciatic pain, for 6-12 weeks
NOT GOOD CANDIDATE FOR SURGERY
 A patient with unrelenting back pain
 A patient with an incomplete workup
 A patient not provided adequate conservative
treatment
COMPLICATION OF SURGERY
 The overall complication rate is 2-4% for the surgery.
 the wrong level>>>intraoperative radiographic confirmation
 Bleeding intraoperatively due to>Engorged venous epidural channels
& malposition
 the anterior annulus is violated and a retroperitoneal vessel is injured
 Infections, usually skin infections
 postoperative discitis :increasing sedimentation rate, fevers, severe
localized pain, and recurrent symptoms.
 Increased neurologic deficit is usually mild and is due to excessive
retraction of the root
 nerve root is mistaken for a disc herniation and is removed