common cervico/lumbar pathologies beyond the herniated disc
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Common cervico/lumbar pathologies beyond the
herniated discKatie Krause MD, PhD
Virginia Mason Neurosurgery
Cervical
• Cervical spondylotic myelopathy
• Ossification of the Posterior Longitudinal Ligament (OPLL)
• Diffuse idiopathic skeletal hyperostosis (DISH)
• Rheumatoid arthritis pannus
Cervical spondyloticmyelopathy (CSM)
• Spondylosis: general term referring to the degeneration of intervertebral discs, vertebral bodies, and ligamentous structures
• A process associated with aging
• Rare before the age of 50
• CSM likely multifactorial
• Dynamic forces: increased motion
• Static forces: ischemic changes
Davies et al BMJ 2018;360:k186
• Normal anterior-posterior canal diameter 13-17 mm
∙<13 mm considered stenotic
Cervical spondyloticmyelopathy (CSM)
• Presentation• Vague complaint of axial neck pain/stiffness, dull
arm pain• Numbness• Clumsiness• Weakness• Difficulty with gait• Loss of bladder/bowel control
• Exam: • True pyramidal weakness, upper limb > lower• Sensory loss• Hoffman’s• Clonus• Hyperreflexia• Gait disturbance
Cervical spondyloticmyelopathy (CSM)
• Treatment
• Conservative therapies with rare success
• Mostly a surgical disease
• Depending on the severity of the disease, the goal is to halt progression, with secondary goal to reverse injury
Anterior cervical discectomy and fusion (ACDF)
• Offers direct decompression of the spinal cord when the offending cause is a protruding disc or osteophyte
• Offers indirect decompression when a graft is placed within the disc space, widening the foramen
• Can help restore any loss of lordosis
Anterior cervical discectomy and fusion (ACDF)
• Complications:
• Dysphagia
• Dysphonia
• Esophageal perforation
• Vertebral artery damage
• Horner’s syndrome (ptosis, miosis, and anhidrosis)
• Post-operative neck hematoma leading to airway compromise
Ossification of the Posterior Longitudinal Ligament (OPLL)
• Hyperostosis and calcification of the PLL
• Twice as common in men > women
• More common in the Asian population (2-4%), but can be found in all
• Pathogenesis generally unknown, although associated with increased BMP-2, and often inherited
Ossification of the Posterior Longitudinal Ligament (OPLL)
• If symptomatic, commonly presents in the 5th- 6th
decade
• 25% of patients with myelopathy have evidence of OPLL
• Decreases the space available for the spinal cord
• Can be worse in the setting of congenitally narrowed canal or hyper-extension injury
• Treatment
• None if asymptomatic
• Surgery if myelopathic
• Abiola et al Global Spine J. 2016 Mar; 6(2): 195–204
Laminoplasty
• Expansion of the posterior arch providing direct decompression
• Allows the spinal cord to drift backward, providing indirect decompression
• Non-fusion alternative
• May decrease accelerated adjacent segment disease
• No risk of pseudarthrosis associated with fusion procedures
• May prevent/lessen post-laminectomy kyphosis
• Weinberg et al J Spine Surg. 2020 Mar; 6(1): 290–301
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
• Characterized by the ossification of ligaments, most often affecting the spine
• Bulky ossification Anterior Longitudinal Ligament• 4 contiguous vertebrae
• Preserved disk height
• Absence of ankylosis of facet joints
• Often described as “candle wax dripping down the spine”
• Seems to be age-related, rather than a disease process
• Thought to affect 25% of older adults
• Twice as common in men > women
• Associated with DM2 and obesity• Suggested to be phenotypic expression of
metabolic syndrome
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
• Presentation• Can be asymptomatic
• Axial neck/back pain
• Stiffness
• Dysphagia
• Generally no loss of range-of-motion
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
• Predisposes to major fracture from minor trauma
• 4-8 fold risk of fracture from low-impact trauma
• Especially prone to fracture in hyper-extension injuries
• High risk of unstable fracture pattern and neurological injury
• Treatment
• Generally empiric, conservative management
• Surgery often for fracture or dysphagia
Rheumatoid Arthritis (RA)
• Chronic systemic autoimmune inflammatory polyarthropathy that mostly involves the hand and feet, although any joint lined by synovial membrane may be involved
• Female: male = 3:1
• White more affected than non-whites
• Onset 35- 50 years
• Autoimmune response that stimulates proliferating inflammatory cells, resulting in a build-up of granulation tissue
• Destroys cartilage, ligaments, tendons, bone
Rheumatoid Arthritis (RA)
• Does not typically affect the axial spine
• Atlantoaxial joint is synovial-lined and thus susceptible to proliferative synovitis and pannus formation
• 3rd most common joint involved
• Neck stiffness, headache
• Instability/subluxation due to rupture of the transverse ligament
• Myelopathy (Weakness => quadriparesis, sensory deficits, sphincter dysfunction, hyperreflexia)
• Occipital neuralgia due to compression of the C2 nerve
• TIA/cerebellar signs
• Vertebral artery impingement from subluxation
• Basilar artery impingement from upward displacement of dens
Rheumatoid Arthritis (RA)
• Treatment
• NSAIDs, steroids, disease-modifying anti-rheumatic drugs
• Surgery: most often C1-2 fusion
• Can achieve stability, which can lead to resorption of retrodental pannus
Lumbar
• Spondylolisthesis
• Synovial cysts
• Tavlov cyst
• Ankylosing spondylitis
Spondylolisthesis
• The forward slippage of one vertebral body with respect to the one below it
• Most commonly involves L5-S1, followed by L4-5
• 6 types:
• Congenital: agenesis of the superior articular facet
• Isthmic: defect/fracture of the pars
• Degenerative: degeneration of the articular processes
• Traumatic: trauma NOT involving the pars
• Pathologic: ie, malignancy
• Iatrogenic: post-surgical
Spondylolisthesis
• Isthmic: Associated with defects in the pars interarticularis
• May be congenitally defective
• Repeated micro-stress
• Gravity
• Posture
• High intensity maneuvers in childhood
• Results in microfractures of the isthmus, often resulting in fibrous non-union and elongation of the pars, causing listhesis
• Also associated with degenerative disk disease, herniated disc, facet arthropathy, foraminal stenosis
Spondylolisthesis
• Meyerding grading scale, based on the amount of vertebral subluxation in the sagittal plane
• I: <25% vertebral diameter
• II: 25-50%
• III: 50-75%
• IV: 75-100%
• Spondyloptosis: >100%
Spondylolisthesis
• Presents with low back pain and radiculopathy, often exacerbated by motion
• Most common intervention requires an instrumented fusion procedure
• Transforaminal interbody fusion (TLIF)
• Anterior lumbar interbody fusion (ALIF)
Synovial cysts
• Can be found anywhere in the body
• Within the spine, there is a Lumbar predominance• L4-5 most common level
• Benign expansive cysts attached to facet joint
• Epithelium-lined capsule enclosing synovial fluid
• Can encroach into the epidural space, causing compression of thecal sac and nerve
• If symptomatic, present with radiculopathy or neurogenic claudication
• Symptoms can wax/wane with activity as the fluid expands and remits
• Often associated with spondylolisthesis
Synovial cyst
• Well-circumscribed, smooth, extra-dural, adjacent to facet
• Can sometimes be confused with tumor
• Should have same characteristics of synvovialfluid
• Can sometimes contain hemorrhage or calcification
Synovial cyst
• Treatment when symptomatic
• Percutaneous puncture• Can often recur
• Simple decompression with cyst resection often effective
• Instrumented fusion sometimes necessary
Tarlov cyst
• CSF-filled dilations in the nerve root sheath, generally along the dorsal root ganglion
• Most commonly found at the sacral level
• 5-10% of the general population
• 87% female
• Almost always asymptomatic
• If large, can present with coccygodynia, low back pain, buttock pain, radicular pain, possible urinary dysfunction
Tarlov cyst
• Often require no treatment or further investigation
• Can perform EMG, or urodynamics if reassurance required
• Will have same characteristics of CSF on imaging
• May result in bony remodeling if large
• Thank you!
• Questions?
Ankylosing spondylitis
• Multi-system inflammatory disorder that involved mostly the SI joint and spine
• Strong association with HLF-B27 (92%)
• Male: female = 3:1
• More common in white than non-white
• Age of onset young adulthood
• Lesions start with subchondral granulation tissue that erodes the joint, that is gradually replaced by cartilage and ossification
• In the spine, this occurs at the junction of the vertebrae and anulus fibrosus, giving rise to “bamboo spine”
Ankylosing spondylitis
• Lesions start with subchondral granulation tissue that erodes the joint, that is gradually replaced by cartilage and ossification
• In the spine, this occurs at the junction of the vertebrae and anulus fibrosus, giving rise to “bamboo spine”
• Can give rise to spinal deformity and predispose to fracture
Ankylosing spondylitis
• Presents with dull back pain and SI area that flares and remits
• Generally worse in the morning or inactivity, improves with exercise
• Stiffness
• Decreased ROM
• Generalized fatigue, and other systemic manifestations
• Uveiitis: most common
• Enthesitis: inflammation of ligamentous insertion sites
• Peripheral joint involvement: hips, shoulders
• Treatment
• No proven disease-modifying agents, possible success with TNF-a inhibitors
• Surgery indicated for correction of deformity or fracture
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