Spinal disorders Notes

NOTES NOTES SPINAL DISORDERS GENERALLY, WHAT ARE THEY? PATHOLOGY & CAUSES ▪ Disorders affecting spinal column ▫ Includes vertebrae, intervertebral discs, surrounding structures RISK FACTORS ▪ Obesity, extreme exercise/any factor that ↑ spinal column pressure COMPLICATIONS DIAGNOSIS DIAGNOSTIC IMAGING MRI ▪ Detects soft tissue involvement ▫ Intervertebral discs, ligaments, nerves X-ray ▪ May show osteoarthritis signs ▫ Joint pain narrowing, bony spurs ▪ Nerve compression, arthritis, progressive degenerative disease SIGNS & SYMPTOMS ▪ Localized pain, stiffness, limited range of motion ▪ Spine shape irregularities ▪ Compression → pulmonary, cardiac, gastrointestinal disorders ▪ Neurologic signs ▫ Numbness, paresthesia, weakness, tingling (if nerves affected) 696 OSMOSIS.ORG TREATMENT SURGERY ▪ If cause irreversible, condition advanced OTHER INTERVENTIONS ▪ Malformation ▫ Bracing ▪ Physical rehabilitation, analgesia

Chapter 119 Spinal Disorders DEGENERATIVE DISC DISEASE osms.it/degenerative-disc-disease PATHOLOGY & CAUSES ▪ Progressive intervertebral disc breakdown ▪ Most common back-pain source ▪ Accrual of factors → intervertebral disc’s nucleus pulposus (mostly water) dehydration → ↓ proteoglycan, collagen → ↓ padding between vertebrae → unable to absorb shock → disc collapse → annular tears, herniation of disc contents into spinal canal → nerve root irritation → nerve impingement → pain DIAGNOSIS DIAGNOSTIC IMAGING MRI ▪ Evaluates spinal canal, visualizes space available for neural structures ▪ ↑ signal on T2-weighted images indicate disc dehydration ▪ Detects annular tears X-ray ▪ Detects fracture CAUSES ▪ Multifactorial ▫ Accumulation of natural stress, minor injury throughout life ▫ Genetic predisposition RISK FACTORS ▪ Genetic predisposition, advanced age, menopause, repeated spinal trauma COMPLICATIONS ▪ Spine collapse, disc herniation, compression fracture, bony spur growth, neurologic deficit, myelopathy, vertebral artery compression SIGNS & SYMPTOMS ▪ Back pain (not correlating to damage’s extent), ↓ range of motion ▪ Pain may radiate ▪ Tingling, paresthesia, numbness ▪ Muscle weakness/atrophy ▪ ↓ deep tendon reflexes ▪ Headache, dizziness, vertigo Figure 119.1 An MRI scan of the spine. TREATMENT MEDICATIONS ▪ Pain management ▫ Non steroidal anti-inflammatory drugs (NSAIDs), local/epidural corticosteroids OSMOSIS.ORG 697

SURGERY ▪ Corpectomy ▫ Vertebral portion removal → enlarge intervertebral space ▪ Discectomy ▫ Herniated disc portion removed ▪ Nerve root injection ▪ Intervertebral disc arthroplasty ▫ Degenerated discs replaced with artificial discs ▪ Laminotomy ▫ Lamina removal → relieve nerve root pressure KYPHOSIS osms.it/kyphosis PATHOLOGY & CAUSES ▪ Exaggerated cervical, thoracic, sacral spinal convex curvature ▪ Greek κυφός kyphos, meaning “hump” ▪ Cobb angle: used to measure extent of curvature ▫ Angle > 45° classified as kyphosis ▪ Damage to vertebrae, intervertebral discs/ supporting ligaments/muscles → weightbearing forces asymmetry → further damage to high-pressure area structures → “wedge-shaped” vertebra → spinal curving TYPES ▪ May also be caused by trauma/iatrogenic causes (surgery) Postural ▪ Most common, occurs all ages Structural ▪ Osteoporosis, tumors, tuberculosis (Gibbus malformation), ankylosing spondylitis, fractures, arthritis Congenital ▪ Vertebral malformation/in utero fusion Scheuermann’s kyphosis ▪ Adolescent onset, type of osteochondrosis (disordered cartilage ossification) ▪ Vertebral disc intrudes into end plates in anterior ossification areas (Schmorl’s nodes on X-ray) 698 OSMOSIS.ORG RISK FACTORS ▪ Poor posture, weak back muscles, older age, vertebral fracture, osteoporosis, degenerative disc disease, arthritis ▪ Genetic disease affecting bone, ligaments ▫ Osteogenesis imperfecta, Marfan syndrome, Ehler–Danlos syndrome, mucopolysaccharidosis, glycogen storage disease COMPLICATIONS Sternal/vertebral fracture Cardiac disease Imbalance → fall, fracture risk Neurologic ▫ Nerve compressions ▪ Respiratory ▫ ↓ pulmonary function ▪ Gastrointestinal dysfunction ▫ Dysphagia, reflux, hernias ▪ ▪ ▪ ▪ SIGNS & SYMPTOMS ▪ Anterior thoracic pain, dyspnea, limited mobility ▪ Convex spinal curvature ▪ Dysphagia, reflux DIAGNOSIS ▪ Clinical diagnosis ▫ Curvature measurement using flexicurve ruler

Chapter 119 Spinal Disorders DIAGNOSTIC IMAGING X-ray ▪ Sagittal plane: > 45° Cobb angle ▫ Lines drawn above first, last deviating vertebra → draw perpendicular lines to those → angle where they close is Cobb angle TREATMENT SURGERY ▪ Reserved for significant pulmonary/ neurologic impairment cases OTHER INTERVENTIONS ▪ Milwaukee brace ▫ Improves proprioception, helps support back muscles ▪ Physical therapy strengthens back muscles ▪ Pain management Figure 119.2 A lateral X-ray image of the spine demonstrating marked thoracic kyphosis secondary to Scheuermann’s disease. LORDOSIS osms.it/lordosis PATHOLOGY & CAUSES ▪ Exaggerated inward curvature of lumbar, cervical spine ▪ Greek lordōsis, from lordos, meaning “bent backward” ▪ Bone/neuromuscular imbalance → weightbearing force asymmetry → further damage to high-pressure area structures/ compensatory muscle spasms → spinal curving CAUSES ▪ High spine flexibility, lower limb imbalance ▪ Hip imbalance; improper lifting, squatting ▪ Muscle strength imbalance (e.g. weak hamstrings; tight hip flexors) ▪ Obesity ▪ Osteoporosis ▪ Spondylolisthesis, discitis ▪ Temporary lordosis during pregnancy RISK FACTORS ▪ Poor posture, muscle strength imbalance ▪ Musculoskeletal ▫ Osteoporosis, spondylolisthesis ▪ Genetic ▫ Achondroplasia, Ehler–Danlos syndrome OSMOSIS.ORG 699

COMPLICATIONS ▪ Degenerative disc disease, nerve compression SIGNS & SYMPTOMS ▪ Lower-back pain ▪ Apparent ↑ lower-back curvature DIAGNOSIS ▪ Physical examination reveals ↑ degree of lower-back curvature, muscle tightness DIAGNOSTIC IMAGING MRI ▪ Detects nerve compression X-ray ▪ Confirms curvature degree ▪ Lamina, neural arch of vertebrae may form divert ‘V’ on anteroposterior lumbar spine radiograph TREATMENT OTHER INTERVENTIONS ▪ Boston brace ▫ ↓ disc stress, muscle strengthening ▪ Physical therapy to strengthen, balance back muscles ▪ Pain management 700 OSMOSIS.ORG Figure 119.3 A lateral X-ray image of the spine in an individual with hyperlordosis of the lumbar spine.

Chapter 119 Spinal Disorders SCOLIOSIS osms.it/scoliosis PATHOLOGY & CAUSES ▪ Lateral spinal curvature in coronal plane, commonly coexists with rotational curvature ▪ Bone/neuromuscular imbalance in vertebral/ paravertebral area → weight-bearing force asymmetry → further damage to highpressure area structures → spinal curving ▪ Sometimes associated with kyphosis, lordosis Classification according to etiology ▪ Structural (intrinsic) ▪ Postural (compensatory) ▪ Bone tumors, neuromuscular/neural disorders (e.g. Duchenne muscular dystrophy) ▪ Advanced bone maturity at presentation, biologically-female individuals ▫ More severe progression COMPLICATIONS ▪ Chest wall abnormalities → respiratory compromise, cardiac complications ▪ Low self-esteem, depression ▪ Spinal nerve damage, hemiplegia Classification according to shape ▪ C/S shaped ▪ Direction ▫ Projection of curvature apex defined with segment involved (most common right-thoracic with left-lumbar presentation) CAUSES ▪ Congenital ▪ Idiopathic ▫ Most common; infantile, juvenile, adolescent/early–late onset ▫ Multifactorial (environmental, genetic factors) ▪ Secondary ▫ Osteopathic (Marfan syndrome), neuromuscular, neuropathic (neural palsy), myopathic, neurofibromatosis RISK FACTORS ▪ Family history ▪ Obesity ▪ Lower limb fracture → limb length difference → compensatory scoliosis ▪ Sudden growth Figure 119.4 An individual with thoracic and lumbar scoliosis. The uneven position of the scapulae is clearly visible. OSMOSIS.ORG 701

SIGNS & SYMPTOMS ▪ Visible spinal curvature, fanning of ribs on one side, uneven musculature ▪ Back pain ▪ Difficulty breathing ▪ Intestinal compression → gastrointestinal difficulty DIAGNOSIS DIAGNOSTIC IMAGING X-ray ▪ Cobb angle ▫ Lines drawn above first, last deviating vertebra → draw perpendicular lines to those → Cobb angle > 10° OTHER DIAGNOSTICS Physical examination ▪ Adams Forward Bend Test ▫ Shows torsion, shoulder, pelvis misalignment, unparallel scapulae TREATMENT SURGERY ▪ Cobb angle > 45° ▫ Vertebral fusion surgery OTHER INTERVENTIONS ▪ Cobb angle < 30° ▫ Watchful waiting (frequent check ups estimating curve angle, physical therapy) ▪ Cobb angle > 30° ▫ Boston brace 702 OSMOSIS.ORG Figure 119.5 A plain chest radiograph demonstrating spinal scoliosis.

Chapter 119 Spinal Disorders SPINAL DISC HERNIATION osms.it/spinal-disc-herniation PATHOLOGY & CAUSES ▪ Middle portion of intervertebral disc (anulus pulposus) herniates through tear in outer portion (anulus fibrosus) of disc ▫ AKA slipped disc ▪ Weakening of intervertebral disc’s outer circle → outer ring tear → inner ring bulging out of spinal column → local nerve compression ▪ Disc protrusion ▫ Outer ring intact but middle portion of disc bulges ▫ May → herniation RISK FACTORS ▪ Obesity, advanced age, heavy lifting, degenerative disc disease, trauma DIAGNOSIS DIAGNOSTIC IMAGING MRI ▪ Confirm diagnosis OTHER DIAGNOSTICS History ▪ History of heavy lifting, bone degenerative disease Clinical exam ▪ Straight leg raise test ▫ Individual lies supine, clinician passively raises leg → pain indicates disc herniation COMPLICATIONS ▪ Nerve impingement ▪ Sciatica ▪ Cauda equina syndrome (compression of nerve roots controlling bowel, bladder, legs) SIGNS & SYMPTOMS ▪ Continuous pain in certain position, level dependent on injury extent, often unilateral (may present bilaterally) ▪ Sciatica ▫ Lumbar/sacral nerve root compression → pain radiating down legs ▪ Other symptoms ▫ Sensory: numbness, paresthesia ▫ Motor: chronic atrophy, weakness Figure 119.6 An MRI scan of the spine in the sagittal plane demonstrating protrusion of the L4/L5 and L5/S1 intervetebral discs. OSMOSIS.ORG 703

TREATMENT MEDICATIONS ▪ Pain, inflammation control ▫ NSAIDs, local corticosteroids SURGERY ▪ Repair ▫ In neurologic signs, nerve compression cases OTHER INTERVENTIONS ▪ Physical rehabilitation, weight loss SPINAL STENOSIS osms.it/spinal-stenosis PATHOLOGY & CAUSES ▪ Common chronic condition characterized by narrowing of spinal canal/intervertebral foramina ▫ More common in cervical, lumbar regions CAUSES ▪ Aging ▫ Bone spurs grow into canal, ligaments thicken, slipped discs ▪ Skeletal disease (e.g. rheumatoid arthritis, osteoarthritis, Paget disease, ankylosing spondylitis, spondylosis, degenerative disc disease) ▪ Congenital (e.g. achondroplasia, spinal dysraphism) ▪ Other causes ▫ Trauma, fracture, neoplasm, idiopathic RISK FACTORS ▪ Obesity, advanced age, family history COMPLICATIONS ▪ Cauda equina syndrome 704 OSMOSIS.ORG ▫ Bilateral leg weakness, urinary incontinence ▫ Spinal cord narrowing → nerve root compression (L3–S4) → bowel incontinence/sexual dysfunction ▫ Neurologic emergency (requires immediate surgical decompression) SIGNS & SYMPTOMS ▪ Canal diameter < 10mm ▪ Neurogenic claudication ▫ Discomfort, sensory loss/leg weakness (buttocks, calves) ▫ Symptomatic when active (e.g. walking, standing); with lumbar extension ▫ Relieved by rest, lying down, waist flexion (squatting, leaning forward) ▫ Back pain may coexist ▪ Radicular pain ▫ Pain radiates along dermatome ▪ Neurologic symptoms ▫ Typically bilateral if nerve compression is involved ▫ Numbness, weakness, paresthesia, limb pain, urinary/bowel incontinence, sexual dysfunction

Chapter 119 Spinal Disorders DIAGNOSIS DIAGNOSTIC IMAGING CT myelogram ▪ Shows detailed spinal canal contours (if MRI contraindicated) MRI ▪ Spinal canal narrowing, nerve compression TREATMENT MEDICATIONS ▪ Pain medications (NSAIDs), epidural steroid injections SURGERY ▪ Decompression (advanced disease, complications) Figure 119.7 An MRI scan of the cervical spine demonstrating spinal stenosis from C3 to C6 resulting in cord compression. OTHER INTERVENTIONS ▪ Physical therapy, weight loss SPONDYLITIS osms.it/spondylitis PATHOLOGY & CAUSES ▪ Chronic vertebrae, vertebral joint inflammation ▪ AKA spondyloarthritis ▪ Autoimmune/infectious agent attacks vertebra → inflammatory cells invade site → inflammation, damage to bone, cartilage; thick paravertebral ossification formation ▪ Spondylodiscitis ▫ Vertebrae, intervertebral disc inflammation CAUSES ▪ Infectious ▪ E.g. Pott’s disease (osteoarticular tuberculosis); Staphylococcus aureus ▪ Autoimmune ▪ Ankylosing spondylitis, rheumatoid arthritis RISK FACTORS ▪ Family history ▪ Immunocompromised state ▪ Spinal surgery/invasive intervention history COMPLICATIONS ▪ ▪ ▪ ▪ Osteoporosis, osteopenia Fractures Neurologic Spinal cord compression, cauda equina syndrome OSMOSIS.ORG 705

SIGNS & SYMPTOMS ▪ Localized pain ▫ Segment-dependent ▪ Gradual symptom onset ▫ Autoimmune disease ▪ Limited movement ▪ Spinal stiffness ▪ Symptoms worse in morning, improve with exercise DIAGNOSIS DIAGNOSTIC IMAGING MRI ▪ Shows calcifications in column; may reveal erosive disease X-ray ▪ Asymmetric parasyndesmophytes visualization (paravertebral soft-tissue calcifications) OTHER DIAGNOSTICS ▪ History of joint pain ▪ Positive autoimmune disease/exposure history TREATMENT MEDICATIONS ▪ Infectious cause ▫ Antibiotics ▪ Autoimmune disease ▫ Disease modifying rheumatoid medications (sulfasalazine, local corticosteroids) ▪ Pain management (NSAIDS, opioids); severity-dependent SURGERY ▪ Severe cases OTHER INTERVENTIONS ▪ Physical therapy to strengthen back muscles LAB RESULTS ▪ Blood tests ▫ Infectious cause ▪ Genetic testing ▫ Autoimmune cause SPONDYLOLISTHESIS osms.it/spondylolisthesis PATHOLOGY & CAUSES ▪ Spontaneous anterior/posterior vertebral body slippage over one below it ▫ Most commonly affects lumbosacral articulation ▪ Vertebral joint dysfunction → joint instability → vertebral body slipping from original position 706 OSMOSIS.ORG CAUSES ▪ Lytic/isthmic ▫ Most common ▫ Multiple pars interarticularis microfractures; usually affects athletes ▪ Degenerative ▫ Pseudospondylolisthesis, arthritis, osteoporosis ▪ Dysplastic ▫ Congenital posterior spinal dysplasia elements; usually presents with adolescent growth spurt

Chapter 119 Spinal Disorders ▪ Pathologic ▫ Vertebral lesions; neoplastic/infectious infiltration ▪ Traumatic ▫ Facet(s)/pars interarticularis fracture; post-surgical complication RISK FACTORS Genetic predisposition Competitive sports (dancing, gymnastics) Extreme growth spurt, muscle weakness Spinal malformation (Scheuermann’s kyphosis) ▪ Biologically-female individuals ▪ ▪ ▪ ▪ COMPLICATIONS ▪ Intervertebral disc degeneration ▪ Spinal stenosis SIGNS & SYMPTOMS ▪ Chronic back pain/stiffness, posterior leg compartment tightness ▫ Pain ↑ with activity, ↓ with rest ▪ Limited range of motion ▪ Change in gait (often waddling) ▪ Forward flexion with development of transverse abdominal crease ▪ Hip, knee flexion malformations ▪ Sciatic nerve involvement signs (radiating pain down legs) DIAGNOSIS DIAGNOSTIC IMAGING X-ray or CT scan ▪ Shows altered vertebral body alignment TREATMENT MEDICATIONS ▪ Pain management (e.g. NSAIDs) SURGERY ▪ Repair ▫ If persistent pain/neurologic symptoms, vertebral sliding is > 50% OTHER INTERVENTIONS ▪ Orthoses (lumbar corset) ▫ May help reestablish proprioception, strengthen muscles ▪ Physical therapy to strengthen back muscles Figure 119.8 A lateral X-ray image of the spine demonstrating spondylolisthesis at L5/ S1. OSMOSIS.ORG 707

Figure 119.9 A CT scan of the spine in the sagittal plane demonstrating spondylolisthesis of the L5/S1 intervertebral joint. SPONDYLOLYSIS osms.it/spondylolysis PATHOLOGY & CAUSES SIGNS & SYMPTOMS ▪ Pars interarticularis vertebral defect, mostly lumbar area ▫ May be unilateral/bilateral ▪ Extreme lumbar spine stress → spinal overextension with rotation → vertebral arch fracture/separation ▪ Pain, lumbar spine pressure sensation, focal tenderness ▪ Unilateral pain radiates into corresponding side’s leg ▪ Painful lumbar spine extension ▪ Antalgic gait ▫ Stance phase of gait shorter than swing phase as means of avoiding pain ▪ ↑ lumbar lordosis ▪ Hamstring tightness CAUSES ▪ Unknown, occasionally appears asymptomatically RISK FACTORS ▪ Extreme sports during adolescence COMPLICATIONS ▪ Sciatica, spondylolisthesis, spinal malformations 708 OSMOSIS.ORG

Chapter 119 Spinal Disorders DIAGNOSIS DIAGNOSTIC IMAGING MRI ▪ Used if neurological findings; visualizes soft tissue, neural structures X-ray/CT scan ▪ Lucency in region of pars interarticularis ▪ Description ▫ Collar/“broken neck on the Scotty dog” in lateral oblique view OTHER DIAGNOSTICS Figure 119.10 A CT scan of the spine in the sagittal plane demonstrating spondylolisthesis of the L5/S1 intervertebral joint. ▪ Clinical exam ▫ Stork test (ask to stand on one leg, lift the other hip), tenderness on palpation in fracture area TREATMENT MEDICATIONS ▪ Pain management OTHER INTERVENTIONS ▪ Boston brace ▪ Physical therapy to strengthen back muscles Figure 119.11 A plain radiograph of the spine shows the “scotty dog sign” in a case of spondylolysis. OSMOSIS.ORG 709

SPONDYLOSIS osms.it/spondylosis PATHOLOGY & CAUSES ▪ Spinal column degeneration, compression ▪ Spinal osteoarthritis → degeneration of vertebral bodies, joints, foramina → intervertebral space narrowing → compression, damage to nerve roots CAUSES ▪ Osteoartritis, trauma, postural RISK FACTORS ▪ Obesity, older age, hyperkyphosis/ hyperlordosis COMPLICATIONS ▪ Nerve compression, vertebrobasilar insufficiency, spinal disc protrusion, myelopathy SIGNS & SYMPTOMS ▪ Progressive pain in affected spinal region, ↓ range of motion ▪ If nerves involved ▫ Paresthesia, radiating pain, numbness DIAGNOSIS DIAGNOSTIC IMAGING MRI ▪ Shows nerve impingement and disc abnormalities OTHER DIANOSTICS ▪ Clinical exam ▫ Cervical compression test: lateral flexion of head causes pain in neck, shoulder on same side 710 OSMOSIS.ORG TREATMENT MEDICATIONS ▪ Pain management SURGERY ▪ Alleviate neural impingement OTHER INTERVENTIONS ▪ Braces ▪ Physical therapy to strengthen back muscles