Spinal nerve root entrapmentand spinal cord compression

1. Spinal nerve root entrapment
and spinal cord compression
Dr. RUTAYISIRE François Xavier
PGY1
Common surgical conditions module
University of Rwanda
Lecturer: Dr Allen JC Ingabire

2. Anatomy
Spinal cord is part of the
CNS (UMN)
It lies in the upper 2/3 of the
spinal canal.
Extends from the foramen
magnum to the space
between L1-L2 vertebrae.

3. Anatomy cont.…
• At each vertebral level, 2
roots emerge laterally.

4. Spinal cord compression
• Mechanical force which result in compression of the spinal cord
causing neurological symptoms.
• Spinal cord compression can result from a myriad of both atraumatic
and traumatic causes.
• The spinal column is vulnerable to a variety of compressive
phenomena, such as the expansion of blood products, neoplastic
disease, infectious collections, or protrusion of bone or intervertebral
disc within the limited area of the fat-filled spinal epidural space and
meninges.

5. Pathology:
The spinal cord can be compressed
by lesions situated:
i. Extradural 80%.
ii. Intradural, extramedullary 15%.
iii. Intradural, Intramedullary 5%.

6. A) Congenital (developmental):- arachnoid cyst
- syrinx
B) Acquired:
1. Traumatic: - Fracture spine, hematoma, Traumatic disc
2. Inflammatory - specific (spinal tuberculosis)
- non specific (abscess)
3. Neoplastic - primary
- metastatic
4. Degenerative - disc prolapse
- osteoporosis
- spondylosis, spondylolisthesis
5. Vascular - AV malformation
Causes of Spinal Cord Compression

7. Presenting features:
1. Pain
2. Neurological deficit:
a- Progressive motor weakness
b- Sensory disturbance
c- Sphincteric disturbance
The first and most common
complaint and often precedes
the onset of any neurological
disturbance .
Pain is due to:
- Involvement of pain sensitive
structures such as the bone.
- Radicular pain due to spinal
root compression.
- Central pain due to Spinal cord
compression results in
unpleasant diffuse dull ache.
1. Pain
Symptoms

8. • 2. Neurological deficit:
- Depends on:
a- the level of compression
b- site of compression
c- involvement of adjacent nerve
roots
d- speed of compression
e- the pathological nature of the
compressing lesion
• a. Progressive motor
weakness
Paraperesis or quadriparesis
according to the level of
compression.
The pattern of weakness is also
affected by the position of the
compressing lesion.
Conus medullaris lesions give a
mixture of UMN and LMN features.
Cauda equina compression
produces LMN signs.
Cervical or dorsal compression till L1 : UMNL.
Lumbar or sacral compression till S2 : LMNL.

9. b. Sensory disturbance
It is either due to affection
of long tracts
(spinothalamic), or nerve
roots.
Sensory level is the main
sign of spinal cord
compression.
Thoracic region leads to
sensory level on the trunk.

10. Occurs following:
a. Compression of the cord.
b. Compression of the conus.
c. Compression of the cauda
equina.
The first symptom is difficulty in
initiating micturation leading to
urinary retention.
In addition to constipation and
Feacal incontinence.
c. Sphincteric disturbance:
Urinary
bladder
Bowel Sexual
Incontinence Chronic
constipation
Impotence
Retention Faecal
incontinence
Its signs include:
a. Enlarged urinary bladder.
b. Saddle shape hypoesthesia.
c. Decreased anal tone.

11. Spinal Cord Compression
Radiological investigations:
1. Plain x ray:
i. Bony destruction
ii. Thinning of the pedicle and widening
of the interpedicular distance.
iii. Scalloping of the posterior surface of
vertebral bodies.
iv. Neurofibroma: widening of the
intervertebral foramen.
v. Destruction of the disc space
suggestive of infection.

12. Radiological investigations:
2. CT scan
3. MRI
4. Myelography
5. Radioactive bone scanning
6. Metastatic work up

13. Treatment:
 Spinal cord compression is a neurosurgical
emergency.
 The standard treatment of spinal compression
is urgent surgery except in some cases due to
malignant tumors where corticosteroids and
radiotherapy are given.

14. Spinal Nerve root entrapment
• Spinal nerve root entrapment, also known as Radiculopathy, is a
condition that results when a nerve root is pinched or irritated as it
exits the spine.

15. Spinal Nerve Root Disorders
• Most common: monoradiculopathy (cervical or lumbosacral)
• Radiating pain, +/- weakness, +/- sensory loss. Reduced reflex for that
root level
• Commonest causes: disk herniation, minor trauma, degenerative
change
• Usually self-limited
• Image if severe, worsening, or concern for cancer, infection
15

16. Aetiology
25%
75%

17. Soft Disc
• Single level
• Inflammation:
• Interleukins &
Prostaglandin
• Majority
spontaneously resolve
(weeks – months)
Spondylosis
• Uncovertebral joint
degeneration
• Multiple levels
common
75%
25%

18. Natural History
• 88% of patients show improvement within 4/52
Alentado et al 2014
• 90% have no or mild symptoms after 4-5yrs
• 20% did not improve  surgery Radhakrishan et al 1994
• Recurrence – 12.5% in 1-2yrs Honet & Puri 1976
Limited studies supporting any optimal duration of conservative treatment
prior to surgery  evidence-based conclusions cannot be made
Alentado et al 2014
Traditional failure of 6/52 conservative management
 escalation

19. Diagnostic Test
• Valsalva
• Cough, laughter, voluntary contraction of
abdominal wall muscles, when straining,
make radicular pain worse
• Stretching the involved nerve root —L5S1—sitting
worsens, C5C6—abduct arm over head relieves.
• Straight leg raising test.—L5S1 worsens.
• Crossed straight-leg raising test.
specificity over 90% for lumbosacral nerve root
compression.
• Percussion of the spine.
May indicate metastatic disease ,epidural
abscess,osteomyelitis,or other disorders of the
vertebral bones, although this sign is often absent
in these conditions.

20. Imaging: Modalities
• X-rays: most useful in trauma to exclude fracture, not sensitive for nerve root or spinal cord pathology.
• CT: most useful study for bony anatomy.
• MRI: most useful study for imaging disk, nerve root and spinal cord pathology.
• Contrast is used if patient has had prior spine surgery in the affected area b/c can light up scar tissue, or if tumor, infection, or other
inflammatory etiology is suspected.
• CT myelogram, CT/w dye injected into spine: in patients who cannot obtain MRI, often the best study for imaging the
nerve roots of a selected area.
• Other diagnostic modalites:
EMG and NCS
• In patients with acute radiculopathy, EMG studies will not be of value until at least 3 weeks .
• EMG studies can help the decision making process by identifying the distribution and extent of
spinal nerve root damage, the degree of acute axon loss, and the likelihood of conduction block.

21. Treatment of Radiculopathy:
• Natural history of lumbosacral and cervical
radiculopathy:
• Up to 75% spontaneously improve
• Length of time required for improvement may be
several weeks or up to years!
• If there is a progressive neurologic deficit or
intractable pain, surgery may be considered.
• Procedures such as laminotomy, or discectomy may
be considered by neurosurgeons and orthopedic
surgeons.

22. Empiric Treatment of Radiculopathy:
• Medications:
• Pain control with NSAIDS and narcotic medications as necessary
• Short course of corticosteroids in selected patients; justification is to
decrease inflammation around the nerve root.
• Gentle physical therapy (mobilization and stretching)
• Bed rest
• Traction for the cervical spine
• Epidural steroid injections for the LS spine
• Transforaminal steroid injections for the LS spine

23. Murakoze