Vertebrogenic diseases

Transkript

1 Vertebrogenic diseases Department of Neurology 1st Faculty of Medicine and General Teaching Hospital J. Böhm M. Hoskovcová

2 Vertebrogenic diseases (statistics from the USA) Medical problem: rated as - the 2nd most common reason to visit a doctor - the 5th most common reason for hospitalisation - the 4th most common reason for surgical procedure Social problem: - the most common cause of work incapacity in people younger than 45 years - one-year costs for work incapacity: 50 billion USD Diagnostic problem?? Ca. 85% of people experience backache during their lives!

3 Classification of vertebrogenic syndrome 1. Vertebrogenic syndrome at specific organic diseases of spine, including the other systems (tumors, developmental and inflammatory diseases, injury etc.) 2. Vertebrogenic syndrome with organic impairtment of the spine and articulations of degenerativ origin (spondylosis, osteochondrosis, disc herniation,. coxarthrosis ) 3. Vertebrogenic syndrome without clear organic cause (so called functional vertebrogenic malfunction); (degenerativ changes have there uncertain and questionable role functional failure is main symptom)

4 Basic tasks of a clinician dealing with vertebrogenic pain syndrome proper diagnosis (fundamental anatomical and neurological knowledge) differentiate between simple VPS and syndrome with affected neural structures knowing red-flag symptoms algorithm of auxiliary examination methods knowing therapeutic algorithms

5 Causes of radicular and spinal cord compression Degenerative changes Cervical spinal cord o s t e o p h y t prolapse C5/6-20% C6/7-70% cervical stenosis Lumbar cauda p r o l a p s e osteophyt L4/5-45% L5/S1-45% lumbar stenosis

6 Cervical spine compression of spinal cord and neural roots by osteophyts Medial osteophyts deg. disc Spinal process lateral osteophyt vertebral a. C6 C7 Root C6 under the arc of C6 Root C7 under the arc C7

7 Medial prolapse Lateral prolapse Subarachnoidal space Dural sac L5 L4 L5 L4 L5 L5 Disc L4/5 - L4 Disc L5/S1 - L5 Root L5 under the arc of L5 Root S1 under the arc S1

8 Clinical presentation of radicular compression appearance: hypotrophy - atrophy mobility: limited - Lasségue muscle tone: reduced strength: reduced - paresis reflex: reduced - 0 pain: autodermography sensory dysf.: dermatomes

9 Irritative and destructive signs Irritative (positive) paresthesias dysesthesias hyperesthesias pain fasciculations Destructive (negative) hypotrophy, atrophy sensory deficit hypesthesia / anesthesia motor deficit - paresis reduced or absence reflexes

10 Lumbar spine anatomical relations I Th12 Spinal conus: Th12 - L1 Lumbar puncture Spastic paraparesis L1 L2 L3 Dural sac N. root passes under the arc (pedicle) of its vertebra Prolapse of disc L4/5 (disc L4) compresses the root L5 Prolapse of disc L5/S1(disc L5) compresses the root S1 L4 L5 sheath+root L 4 S1 root L5 root S1 Subarachnoidal space: dural sac + root sheaths Perimyelography - PMG Extradural fat

11 Lumbar spine anatomical relations II Th12 Th12 L1 L2 Spinal conus Dural sac + roots L1 L2 L3 Roots L4,L5,S1 Dura m.+sac roots L3 L4 L5 Intervertebral foramen L4 L5 Root sheaths S1 S1 Sheath + root L4 Sheath +root L5 Sheath + root S1 Extradural fat

12 Cervical spine anatomical relations Vertebral arteries Dens axis C2 medial osteophyts deform and dislocate spinal cord C4 C6 Lateral osteophyts in the foramen C4/5 Root C5 is under the arc of C5 Articulation of the 1st rib

13 Sensation radicular areas indicators Dermatomes Motor f. sp. cord level segment Diaphragm C3 Elbow flexion C5 Wrist extension C8 Elbow extensionc6 Thenar muscles C8 Hip adduction L2 Knee extension L3 Ankle extension L4 Toe extension L5 Plantar flexion S1 Anal sphincter S2

14 Cervical radicular syndromes C2 between C1/2 suboccippital pain C3 and C4 - toward trapezius and AO articulation C5 - shoulder, deltoideus, biceps, rotators C6 - thumb+index finger, elbow flexion, wrist extension C7 - middle finger+ring finger, triceps C8 - ring finger+little finger, flexor digitorum, interossei Th1 - interossei, Horner s sy 5% Pancoast s tu

15 Poruchy čití Praha & EU: Investujeme do vaší budoucnosti

16 Lumbar radicular syndromes L1, L2, L3 thigh from the ventral side distally from inguinal region, iliopsoas m., cremaster r. L4 thigh from ventral side, crus from the inner side, ant. tibial m.+quadriceps, r.l2-4 L5 - lampas, dorsal surface of foot and of toe, extensor hallucis longus, rr. norm., not present along the heel S1- through the back of hip+thigh+calf+little finger of foot, hypotonia of max. gluteal m., r. L5-S2 not along the tip

17 Clinical presentation of herniation of lumbar prolapse Herniation level Pain Sensory f. Motor f. Trophic level Reflexes Praha & EU: Investujeme do vaší budoucnosti L4/5 L5/S1

18 Lateral Medial L4 L4 L4 L4 L4 L4 L5 L5 L5 L5 S1 S2 S1 S3 S4 S2 S5

19 Morphologic methods in vertebrogenic pain syndrome X-ray CT MRI PMG (perimyelography) Scintigraphy CT X-ray algorithm?????

20 Medial prolapse of disc L5/S1 SAG T2W/TSE TRA T1W/SE L

21 20641/II Praha & EU: Investujeme do vaší budoucnosti SAG SAG Osteophyt C5/6 cervicobrachial syndrome C5 on the left SAG TRA T1W/SE L TRA

22 Spinal stenosis Segmental or generalized narrowing of spinal canal: Congenital (idiopathic) Acquired (degenerative) aging process Cervical even up to level of cervical myelopathy Lumbar even up to the level of lumbar stenosis: neurogenic claudications, radiculopathy, chronic cauda sy Central x lateral spinal stenosis achondroplasia, Paget, diffuse idiopat. spinal hyperostosis etc..

23 Lumbar stenosis Flexion posture C, Th, L, hips and knees Superior art. process Inferior art. process Lateral recessus Normal size of foramen physiological disc Small foramen+deformation for decline of dics CT image

24 Neurogenic claudications Neurogenic claudications are characterized by the fact that certain duration of standing or walking in upright position leads to pain, paresthesia and subsequent weakness of the lower limbs that may lead to falls. Condition is deteriorated by backward bend. On the contrary, forward bend, lying and sitting position brings relief and continual fade-away of difficulties up to several minutes. Greater difficulties result from walking downwards (accompanied by retroflexion and further narrowing of spinal canal) than from walking upwards. Riding the bike doesn t lead to difficulties. Some patients hold special relief posture in forward bend position with semiflexion of knees. B. Adamová, S. Voháňka, J.Bednařík, Neurologická klinika FN Brno 24

25 Segmental lumbar stenosis TRA TSE T2W L L4 L5 SAG T2W TSE

26 Interspinos dekompression and X Stop 26

27 Cervical myelopathy Symptoms from radicular and spinal cord compression Upper limbs: dysesthesia, weakness, clumsiness, radicular pain, rarely fasciculations, even atrophy limited movement: clenching hand to fist Lower limbs: spasticity (gait as well), ataxia, py irrit.+, sphincters Congenitally narrow canal+degenerative changes, sneak onset, more levels Large medial cervical prolapse - sudden, 1 level (etage), youth

28 Cervical myelopathy in cervical spondylosis Paresthesia of UL Loss of vibration sens. f Clonus of foot Babinski + Spastic paraparesis of LL Circumduction while walking

29 Cervical myelopathy Quickness of progression of degenerative changes Restricted vascular supply to compressed spinal cord Morphology - CT, MR Function - EMG, SEP and MEP Differential diagnosis: MS plaques, SC tomor, syringomyelia, hydrocephalus, ALS, funicular myelosis, reumathoid arthritis, dystonia, sarcoidosis

30 Cervical spine and spinal cord Flexion Extension 15-20mm 13mm 9mm Draping of ligg.flava denticulata Elongation of canal and spinal cord Shortening of canal and sp. cord

31 System of,,red flags Warning signs relevant do differentiate more serious pathologies in vertebrogenic pain syndrome Schematic model applicable to medical history Tumors, infections, traumatic injuries, serious neurolog. condition

32 Red flags tumors Positive oncology medical history Pain persists in lying position (including nocturnal pains) Duration of pain more than 4 weeks Marked local sensitivity to palpation* Unexplainable weight loss* Age higher than 50 years or lower than 20 years Elevated erythrocyte sedimentation rate (Bigos et al. 1994)

33 Red flags infection Febrile condition, elevated level of CRP* Imunosuppression (corticosteroids, cytostatic medic., HIV, DM) Intravenous addiction Medical history of : - pyogenic infections (urological, dermal and pulmon.) - spinal operation or another invasive procedure (LP, PMG, diskography..) Pain : - persisting in lying position (including nocturnal pains) - marked local sensitivity to palpation *

34 Red flags traumatic injuries Traumatic event in medical history Presence of osteoporosis Prolonged treatment by corticosteroids Age over 70 years (or even over 50 years in moderate traumatic injuries non specified)

35 Red flags serious neurological condition Syndrome of cauda Compression of the upper part of cauda, usually medial or paramedial dics herniation L3-4 (or stenosis, tumor, abces..) Iradiation severe pain into the both legs, often asymmetrical Peripheral paresis or plegia of the both feets (distal) Perigenital hypesthesia (saddle typ) Sfincter disturbance (urinary and stool retention), incontinency is possible (paresis of detrussor muscle) Absence of reflexes: anal, cremaster Fast progressing neurological deficit (sudden onset of mono- / pluri-radicular motor weakness)

36 Therapeutical guidelines I. Acute stage: REST + analgesics + myorelaxant In time and energetic treatment of pain maximally shortenig of pain period prevention of long lasting inactivity and restriction in activities of daily living (ADL) prevention of stress and psychological suffering Danger of pathological movement pattern fixation and fixation of the central pain Movement restriction only for necessarely time strictly individual approuch (cont )

37 continuation. Praha & EU: Investujeme do vaší budoucnosti During acute attack STABILIZATION Suitable only short lasting time of stabilization by the neck collar or lumbar belt : During day, but over the night primarily (invid. approuch!!) subj. worsening of pain during sleeping relaxation of the muscles, partially stabilized unstabale segment, leading to increasing pain due to joint segment dislocation stabilization over night especially at the group of FBSS (subjective tolerance)

38 Therapeutical guidelines II. Subacute stage Physical therapy (only supporting therapy 5%) Efect analgesic, myorelaxant agent Basic starting physiotherapy and asking patient for active collaboration!! Provide maximal physiological and good stabilization of the spinal segments by the activation of the stabilizer of spinal muscular system As soon as possible back to the work (prevention of fixation for the disease, hypomobility and worsening muscular dysbalance)

39 Therapeutical guidelines III. Physiotherapy 1. Adjustment of muscular dysbalance relaxation muscles in spasm stretching shortened musles strengthen weakens muscles Any kind of excercise without improvement of muscular dysbalance leads to: worsening muscular dysbalance and deterioration of condition contin

40 Therapeutical guidelines III. Physiotherapy 2. Isometric excercise minimal movement strain of unstable segment (disc herniation) and maximum of muscular activity for its fixation 3. Improvement of breathing stereotype 4. Concept of McKenzi 5. Activation of all the muscles of the spine, making its stabilization, without overloading of degenerative parts sensimotor stimulation reflective lokomotion of Vojta 6. Adequate movement aerobic strain

41 Conservative treatment Antiinflammatory maximal daily dosage 7-10 days Myorelaxant agent (?!!!!) particulary for the night, may lead to muscle weakness anf fatigue during the day Analgesic in severe pain, potentiation of effect is favourable Local injection peripheral (intradermal) and radicular under CT control Corticosteroids

42 Prevention Restriction one-sided static strain and stereotype Restriction of dynamic overloading from time to time Not catch cold Maintain ergonomic of work including right posture of the body Right stereotype of common daily activities (school of the spine) Regular movement activity Exluding inaproppriate type of sport at those man with disc herniation

43 Surgical treatment indication Absolute indications 1. Syndrome of cauda pain, positive abdominal pressure, peripheral flaccid pareses of radicular type on both lower limbs, sphincter disturbancy.. 2. Fast development of paresis Relative indications increasing negativ neurological symptomatology transition of negativ abdominal pressure to positive development of peripheral paresis pain, long duration of difficulties, individual urgency, inefficacy of conservativ treatment

44 Surgical treatment - type Microdiscektomy (microlumbal discectomy, MLD) : Open (microscope and assisted endoskopy) Closed (percutaneous) Decompression (and event. stabilization) Stabilization of unstable segment Replacement of disc arthroplastic Failed Back Surgery Syndrom (FBSS): Progression or persistance difficulty after surgary (failure by indication of surgery, failure of surgury, epidural postoperative scares, etc..)

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46 Postoperative scar L4/5 on the right T1WSE+Gd T1WSE+Gd L T2WTSE T1WSE 6166/5

47 The most common neuropathies for the 5th grade students 1st Faculty of Medicine of Charles University J. Böhm M. Hoskovcová

48 Anatomy of peripheral nerve

49 Lesion of peripheral nerve Neuroapraxia ( myelin : 4-9 weeks) Axonotmesis ( axon as well) Neurotmesis ( complete interruption of nerve Waller s degeneration)

50 Etiology Compression (gall pareses) x entrapment syndromes Iatrogenic Ischemic (occlusion of artery, embolism) Infectious (Lyme borreliosis, herpes zoster) Metabolic and endocrine (DM, thyreopathy) Autoimmune diseases (RA, SLE,..) Systemic diseases (multiplex mononeuropathy e.g. vasculitis)

51 Therapy Depends on the degree of nerve lesion and etiology Conservative aimed physiotherapy Surgical - acute - early (evident nerve interruption) delayed (ca. 6-8 months after lesion)

52 Brachial plexus

53 Median nerve (C5-8,Th1) Struthers entrapment syndrome Pronator entrapment syndrome Sy.n. inteosseus ant.(kiloh-nevin s) SCT (syndrome of carpal tunnel) = demyelinizační neuropatie

54 SCT

55 Sy of carpal tunnel motor innervation M. abductor.pollicis brevis M. opponens pollicis M. flexor pollicis brevis Lumbrical muscles for the 2nd and 3rd finger

56 Medical history and clinical presentation of carpal tunnel syndrome Paresthesias of fingers, often with nocturnal awakenings Relief maneuvres Sensation of swollen fingers and hand Frequent pains, sometimes even irradiating to elbow, arm and shoulder Reduced strength and atrophy with slow progression (lateral part of thenar, lumbrical muscles of the 2nd and 3rd finger) diminished opposition of thumb and slightly weakened abduction of thumb motor symptoms are mostly late and not observed by patients Phalen s symptom etc...

57 Ulnar nerve (C8,Th1) Lesion in sulcus n. uln. and cubital canal Lesion in Guyon s canal

58 Ulnar nerve Praha & EU: Investujeme do vaší budoucnosti lesion in elbow area

59 Ulnar nerve lesion in the elbow Innervation: m.flexor carpii uln., flexor digg. profundus IV.a V., muscles of hypothenar, m.palmaris brevis, dorsal and volar intersosseal muscles, lumbrical muscles for the 4th and 5th finger, m. adductor pollicis Paresthesias of the 4th and 5th finger Spontaneous pains in medial humeral epicondylus (in some cases) Pareses and atrophies incomplete hand grip - clutchy hand Froment s test, etc.

60 Mononeuropathy of ulnar nerve (EMG) Partial block of n. conduction velocity over elbow

61 Ulnar nerve Guyon s canal Disrupted sensation only on the palmar side of innervation zone of ulnar nerve

62 Radial nerve ( C5-8, Th1) Axilla (high crutches) Arms (paresis of lovers or drunkards)) Elbow and forearm dropping hand and fingers, Fallhand, swan neck

63 Radial nerve motor m. triceps brachii innervation ramus profundus: radial and dorsal muscles of the forearm Paresis: picture of the swan neck resulting from paresis of extensor muscles

64 Radial nerve sensory innervation

65 Fibular nerve (L4-5, S1) N. peroneus communis (common fibular nerve) N. peroneus profundus (deep fibular nerve) N. peroneus superficialis (superficial fibular nerve)

66 Peroneal (fibular) nerve

67 Paresis of common peroneal nerve in the area of fibular head Paresthesias of external surface of the shank, on the back of the foot, and less pronounced on fingers as well Onset of paresis is sudden ramus profundus: weakening of dorsal flexion of the foot ramus superficialis: disrupted foot eversion,,foot-drop : stumbling over the tip,steppage gait

68 Peroneal paresis

69 Femoral nerve (L2-L4) Inguinal canal M. illiopsoas M. sartorius M. quadriceps fem. N. saphenus

70 Femoral nerve sensory innervation Anteromedial side of the thigh Anteromedial side of the shank Inner ankle

71 Paresis of femoral nerve Sudden falls for unexpected drooping or recurvation of knee Disruption of knee-joint,,locking (especially when walking on the rough terrain, up to the stairs etc.). Paresthesia and disturbed sensation in the innervation zone

72 Femoral nerve examination of flexion in the hip joint

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