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الكلية كلية الطب
القسم الجراحة
المرحلة 5
أستاذ المادة جميل تحسين محسن كاظم
5/18/2011 8:20:51 PM
? Acute disc rupture (prolapse)
The disc consists of an outer layer called annulus fibrosus & an inner nucleus bulbosus, the nucleus has hydrophilic properties & present under pressure especially in young patient but the hydrophilic properties of the nucleus change with aging & the disc become drier as the patient get older.
Causes;
The disc prolapse result from changes in the hydrophilic properties of the disc which become more hydrophilic leading to retention of the fluid & increase of the pressure, add to that a physical stress (a combination of flexion & compression as in lifting a heavy object). This lead to rupture of the annulus with extrusion of the nucleus to one side of the posterior longitudinal ligament. The most common site of prolapse is L4/L5 & L5/S1, where the maximum load & pressure of the disc.
The prolapse is either posterolateral, lateral or posterior, in lumbar spine the nerve root exit below the corresponding vertebra therefore the L4 root exit below the L4 vertebra, in case of posterolateral prolapse the disc will press on the nerve root
proximal to its exit therefore posterolateral prolapse of L4/L5 will press on the L5 nerve root while in case of lateral disc prolapse the disc will press on the nerve root at the same level, therefore disc prolapse at L4/L5 will press the L4 nerve root. Posterior (central) disc prolapse will press on the cauda equina.
Pathology; after rupture of the annulus the disc material will bulge & press on dural cover of the nerve root leading to pain in the back, buttock &posterior thigh this referred pain called sciatica (this pain is nonspecific & can occur in any pathology of the spine other than disc prolapse). But if the disc material press on the nerve root the patient complains from neurological symptoms like numbness, parasthesia, muscle weakness & depress reflexes this called radiculopathy which is more specific for disc prolapse than sciatica.
Clinical features; typically the patient is 20-45 years, who while lifting a heavy object develop severe backache & unable to get up, 1-2 days the patient develop pain in the buttock & thigh (sciatica), both backache & sciatica are increased by coughing( from increase intraspinal pressure). Later the patient develops numbness & muscle weakness in the leg (radiculopathy), rarely from central disc prolapse the patient develop cauda equina syndrome (bilateral lower limb weakness, urinary retention).
On examination, there is sciatic scoliosis, painful limitation of back movements, midline tenderness, muscle spasm, positive straight leg rising test, neurological examination show: if L5 root compressed there will be sensory loss on the outer aspect of the leg, dorsum of the foot & weakness of big toe extension, if S1 root compressed there will be sensory loss on the side of the foot, weakness of ankle planter flexion & eversion & depression of ankle jerk.
Imaging; X-ray to exclude other pathology, myelography will show the level of the prolapse, the most important imaging study in the diagnosis are the MRI & CT myelography.
Treatment; by 3R (Rest, Reduce, Remove)
? Rest: by bed rest, analgesia, heat, traction (to keep the patient in bed), when pain subside then exercise to increase the strength of back muscle.
? Reduce: by traction for about 2 weeks, if pain persists for more than 2 weeks then we can use epidural steroid injection.
? Remove: by surgical removal of the prolapsed disc;
Indications of surgery: (1) cauda equina syndrome, it is an emergency & should be carried within 6 hours. (2) Neurological deterioration while under conservative treatment (3) persistent pain & signs of sciatica after 3 weeks of conservative treatment. (4) Absolute neurological deficient.
Types of operations: (1) partial laminectomy & discectomy (2) microdiscectomy (3) percutaneous discectomy.
? Spondylolisthesis
It is a foreword shift of the vertebra over the one below usually the L4 over L5 or the L5 over the S1, this occur if the locking mechanisms fail these are the lamina & the facets joint.
Classification:
1. Dysplastic; it is a congenital defect of the superior articular facet of the vertebra below usually of the first sacral vertebra.
2. Lytic or isthmic; this account for 50% of the spondylolisthesis, either there is a defect in the pars interarticularis (spondylolysis) or the pars become elongated. These 2 lesions present in the children but the slipping occurs several years later due to stress & exercise.
3. Degenerative; osteoarthritis of the facet joint & disc degeneration cause vertebral slipping.
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4. Posttraumatic; fractures of the facet & pars may lead to spondylolisthesis.
5. Pathological; bone destruction secondary to tumor, infection or T.B may destroy the pars or the facets causing spondylolisthesis.
6. Postoperative; wide laminectomy mat cause instability & progressive slipping.
Pathology:
in the lytic type the gap in the pars (between the pedicle & the lamina) is filled with fibrous tissue, with stress there will be stretching of the fibrous tissue & the gap increases, so the vertebra become 2 parts: an anterior (vertebral body, pedicles, transverse process & superior articular facet) will slip foreword leaving the posterior part (lamina, inferior articular facet & spinous process) behind.
Secondary to slipping there may be neurological deficient from pressure or stretching of the nerve roots or cauda equina.
Grads of the slipping; the spondylolisthesis divided into 4 grads according to the degree of slipping:
? Grad I, slipping of less than 25% of the width of the vertebral body.
? Grad II, slipping of 25-50 %.
? Grad III, slipping of 50-75 %.
? Grad IV, slipping of more than 75% of the width of the vertebral body.
Clinical features; in children the condition usually asymptomatic but there may be abdominal protuberance from increase lumbar lordosis.
In the adult there is backache, sciatica usually after exercise & in patient over 50 years with degenerative spondylolisthesis there may be symptoms of spinal stenosis.
Imaging; X-ray by doing anteroposterior, lateral & oblique views. CT & MRI, Myelography.
Treatment;
? Conservative treatment; by using brace, analgesia, exercise, modifying activities & job & local injection of the steroid.
? Operative treatment; by anterior or posterior spinal fusion with neurological decompression if there are neurological symptoms.
Indications of operation: (1) disabling symptoms (2) if the slipping is more than 50% & is progressing (3) significant neurological compression
Prognosis: congenital ( dysplastic) type occur early & may become severe with neurological deficient, lytic type if the slip more than 50% cause backache later, degenerative type progress slowly.
? Spinal stenosis
It is an abnormal narrowing of the central canal, lateral recess or the intervertebral foramina to the degree that there is compromise of the nerve roots & the patient develop neurological symptoms & sign in the lower limbs.
Causes;
1. Congenital vertebral dysplasia as achondroplasia.
2. Chronic disc protrusion & peri-discal fibrosis or ossification.
3. Hypertrophy or osteoarthritis of the facet joints.
4. Hypertrophy or ossification of the ligamentum flavum.
5. Bone thickening due to Paget’s disease.
6. Spondylolisthesis.
Clinical features; the patient usually a man over 50 years, complains of aching, heaviness, numbness, & parasthesia in the thigh & legs after standing & walking for 5-10 minutes, the symptoms relieved by sitting, squatting & leaning against a wall to flex the spine (because flexing the spine will increase the anteroposterior diameter of the spinal canal) therefore these symptoms called spinal claudication, the patient also prefer walking uphill (which flex the spine ) to walking downhill (which extend the spine). In unilateral root canal stenosis these symptoms are unilateral.
On examination, there is limitation of extension of the lumbar spine, symmetrical diminished reflexes.
Imaging; plane X-ray may show spondylolisthesis, disc degeneration & osteoarthritis, measurement of the spinal canal anteroposterior diameter can be made using the x-ray (should be more than 15 mm) or by using CT scan (more than 11 mm).
Treatment; conservative measures in form of postural training to avoid the aggravating posture, spinal exercise & epidural spinal injection. If these measures fails then operative decompression by doing wide laminectomy.
? Pyogenic osteomyelitis & discitis
It is an acute pyogenic infection of the spine, it is uncommon & account for 2-7% of all osteopmyelitis in the body.
Pathology;
? The causative microorganism usually staphylococcus aureus (50-60%) other microorganisms are gram negative (pseudomonas, E-coli, proteus).
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? The organisms reach the spine either directly during the invasive spinal procedure (spinal injection or disc operation) OR indirect haematogenous spread from infection at remote sites.
? The infection starts in the intervertebral disc & spread to the adjacent vertebral body or starts in the vertebrae & spread to disc. Later on the infection may spread to the soft tissue forming an abscess in the paraspinal muscles.
Clinical features; there is sharp intense pain with muscle spasm & restricted movement, examination reveals a localized tenderness, fever & tachycardia are mild.
Investigation; WBC & ESR are usually elevated but not markedly, antistaphylococcal antibodies are elevated to high titer.
Imaging; X-ray in the first weeks looks normal later on it will show loss of disc height, irregularities of disc space, erosion of the vertebral end plate & reactive new bone formation. MRI is the definitive diagnostic tool showing the characteristic changes in the vertebral end plate, disc & paravertebral soft tissue.
Treatment;
? Conservative treatment by bed rest, analgesia & intravenous antibiotics for 4-6 weeks then oral antibiotics for another 6-8 weeks.
? Operative treatment is indicated in the following situations: (1) failure to respond to conservative treatment, (2) neurological deficient & (3) the need to drain an abscess.
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? Tuberculosis of the spine (T.B)
The spine is the most common site of the skeletal T.B & the most dangerous.
Pathology; the infection reach the spine via blood stream & settle in the vertebral body adjacent to intervertebral disc causing bone destruction & caseation, the infection spread to intervertebral disc & adjacent vertebrae as the vertebral bodies collapse into each other a sharp angulation (kyphos) develop. The caseation & cold abscess may extend into neighbouring vertebrae or extend into soft tissue or extend posteriorly into the spinal cord. Spinal cord damage may results from (1) pressure by cold abscess or caseation, (2) pressure by displaced bone fragments, (3) ischemia from spinal artery thrombosis. On healing the vertebrae recalcify & bony fusion occurs between them.
Clinical features; there is a long history of ill health, fever, night sweating & deformity ( kyphos),backache & stiffness, the patient may complains from parasthesia & weakness in the lower limbs. Examination reveals deformity, groin or loin abscess, neurological examination may show motor &/or sensory changes in the lower limbs.
Pott’s paraplegia; paraplegia is the most serious complication of the spinal T.B. it is of 2 types:
? Early-onset paresis is due to cord pressure by an abscess, caseous material or a bony sequestrum, the patient present with sign & symptoms of upper motor neuron lesion in the lower limb.
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? Late-onset paresis, due to increasing deformity or reactivation of the disease.
Imaging; X-ray: early on will show local osteoporosis of the adjacent vertebra followed by narrowing of the disc & fuzziness of vertebral end-plate, later on there is more bone destruction & collapse of the vertebrae there may be a shadow of paravertebral abscess, in the healing stage there is fusion of the involved vertebrae.
MRI & CT scan are used if there is sign of cord damage.
Investigation; there is increased ESR, positive tuberculin test, definitive diagnosis can be done by biopsy both for histopathology (show the granuloma) & for bacteriology to show the (bacteria).
Differential diagnosis;
1. Pyogenic spondylosis, the condition is acute, the patient is more toxic.
2. Scheuermann’s disease.
3. Secondary deposit, there is vertebral collapse but the vertebral bodies intact.
4. Trauma, there is history of trauma, the vertebral body collapse but the disc intact.
5. Other causes of paraplegia, disc prolapse, spinal cord tumor.
Treatments;
? The aims of the treatment (1) eradicate or arrest the disease,(2) prevent or correct the deformity.(3) prevent or treat the paraplegia.
? Conservative treatment, either ambulant chemotherapy (keeping the patient ambulatory) for 6-12 months used for patient with early limited disease with no
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abscess OR continuous bed rest & chemotherapy for patient with more severe disease with no abscess.
? Operative treatment. It is indicated in the following situations (1) when there is abscess (2) advanced disease with severe kyphosis, (3) when there is paraparesis.
The aims of the surgery are to remove the diseased vertebral body, decompress the spinal cord, filling the defect by bone graft & posterior spinal fusion for additional stability.
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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