Compressive spine disease


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Compressive spine disease

  1. 1. Spinal cord Diseases Compressive Myelopathy Prof Nabil Khalil Suez canal university Ismailia EGYPT
  2. 2. Compressive Myelopathy Intra medullary Intradural extramedullary Extradural exrtamedullary
  3. 3. Extramedullary Intramedullary a)UMNL signs Common Late b)LMNL signs 1or2segments at the site of wide (Ant horn cell) root compression Motor Sensory a) Pain Root pain dythesia pain b) Dissociated sensory loss(loss of pain& temperature but preseved touch) Absent present c) Sacral sensation Lost Preserved d) Joint sensation Lost Late involvement e) Lhermitte`s sign present absent Autonamic involvement – Bowel and Bladder Late Early Intradural Extradural Mode of onset Asymmetrical , acute,rapid malignant Symmetrical,slow, progressive Benign Vertebral No Pain and gibbus Pain and Gibbus
  4. 4. COMPRESSIVE MYELOPATHY – CAUSES (mode compression based) Degenerative,CONGENITAL,trauma,tumours,vuscular,infections Extradural Intradural Intramedullary Spondylosis Disc prolapse Trauma Tumor-Metastasis,multiple myeloma C V J anomalies TB spine Epidural abscess Epidural haematoma Tumor-NF,meningoma, lipoma,sarcoma metastasis Arachonoiditis Sarcoidosis Cervical menigitis AVM Leukemic infiltration Arachonoid cyst Syrinx Tumor – ependymoma astrocytoma Haemagioblastoma Haematomyelia
  5. 5. COMPRESSIVE MYELOPATHY – CAUSES 1-Degenerative 2-CONGENITAL 3-infections 4-vuscular 5-Tumours 6-trauma
  6. 6. Spondylosis 1-Degenerative • spondylosis is a general term encompassing a number of degenerative conditions – – – – – Degenerative disc disease (DDD) Spinal stenosis With or without degenerative facet joints With or without the formation of osteophytes With or without a herniated disc • One single component as a diagnosis is rare, Usually multiple signs.
  7. 7. DISC DISEASE Disc degeneration Annulus Fibrosis Dehydration of disc Loss shock absorbing capacity Articular Facet Hypertrophy Load to Posterior elements of vertebra Prolapse of annulus Rupture of annulus Herniation of Nucleous pulposus Intraforaminal hermiations Posterolateral herniations Central disk herniations
  8. 8. Advaced cervical spondylosis narrow canal decreased disk height posterior osteophytes disk protrusions buckled posterior longitudinal ligamentand ligamentum flavum posterior subluxation
  9. 9. Clinical Aspects of Spondylosis: Cervical Spondylosis: common cause of progressive myelopathy commonly affects at cervical level;C5-C6 disc commonly involved >40yrs; M>F Neck pain,Root pain and LMN signs corresponding to compressed root UMN signs and Post colmn involvement below the compression level Lhermitte's Sign (Barber Chair phenomenon) Axial compression test Finger Escape sign Neck movement test Shoulder abduction relief sign
  10. 10. Cervical Spine - AP, lateral, and oblique disk space height Facet status Osteophyte formation Spinal alignment MRI SPINE low signal intensity – degenerated disc focal extension of disc material – herniation Herniated disc may extend above and below Ligaments calcification and changing contour Occlude the canal Compress the spinal cord Mid cervical region -common
  11. 11. MANAGEMENT: Conservative: Nonsteroidal anti-inflammatory Tricyclic antidepressants for chronic case short courses of collar stretching (traction),dynamic, isometric, strengthening exercises, aerobic exercise Lifestyle modification- low high pillows SURGERY Indications: Moderate to severe myelopathy progressive motor/gait impairment Static deficits with significant pain Anterior Cervical Diskectomy With Fusion or not Posterior Multiple – Level Laminectomy
  12. 12. LUMBAR DISC PROLAPSE Age 20-40 yrs; L4-L5 common site Acute or chronic Back ache Sciatic pain – S1 root compPostero lateral calf and heel L5 root companterolateral aspect of leg and ankle Femoral pain-L2-L3 rootsRadiate to front of thigh Foot dorsiflexion test lasegue test SLR test Most of the time it may need Surgery : – Fenestration, Laminotomy,Hemilaminectomy,Laminectomy Medical Management similar to Cervical spondylosis
  13. 13. LUMBAR CANAL STENOSIS Congenital narrowing of lumbar canal L4-L5 commonly affected Cauda equina lesion M>F;40-50 yrs Neurogenic claudication Claudicating distance positive Usually surgery needed- laminectomy
  14. 14. 2-CONGENITAL MALFORMATIONS CRANIOVERTEBRAL JUNCTION ANOMALIES  Malformations of occipital boneBasilar invagination, Remnants around foramen magnum,Clivus segmentations)  Malformations of atlasFailure of atlas segmentation from occiput, Atlantoaxial fusion Malformations of axis Atlantoaxial segmentation failure Segmentation failure of C2-C3 Dens dysplasias – os odontoideum, odontoid hypoplasia/apla ossiculum terminale persistens
  15. 15. 2. DEVELOPMENTAL AND ACQUIRED ABNORMALITIES Foramen magnum abnormalities -Foraminal stenosis ATLANTOAXIAL INSTABILITY -Traumatic (eg.achondropl atlantoaxial / asia ,MPS ) occipitoatlantal -Secondary basilar dislocation invagination -Degenerative eg. Paget’disease, (ligamentous osteomalacia, disruption at CV hyperparathyroi junction) dism -Inflammatory (RA, ankylosing spondylitis) -Tumours ( chordoma, syringomyelia, NF ) -Down’s syndrome SKELETAL ANOMALIES NEURAXIAL ANOMALIES -Platybasia -Basilar invagination ( 10 / 20) -Klippel-feil anomaly -Occipitalisation of atlas -Atlanto-axial dislocation -Arnold Chiari malformation -Dandy Walker syndrome -Occipito cervical myelomeningiocoel e -Posterior fossa cysts
  16. 16. CV junction malformation Vs Neurological symptoms Mechanisms: – Bone and soft tissues compress directly on medulla or upper cervical cord – Associated CNS developmental anomalies – Raised ICT due to impaired CSF flow  Around 20-25 yrs; both sexes  Painful or restricted cervical movements  Pyramidal signs with varying motor disabilities in one or mostly all limbs. Muscle wasting in UL;progressive over 5yrs  Cerebellar signs usually;sensory symptoms(lat and Pos)  Neuro vascular symptoms rare. transient reversible weakness may present
  17. 17. CHAMBERLAIN’S LINE -joins posterior tip of hard palate to posterior rim of foramen magnum dense 3.6mm below it -Basillar invagination McRae’s LINE Joins anterior and posterior edges of foramen magnum: sagittal diameter of foramen magnum. (Avg – 35mm);dense below the line foramen stenosis MCGREGOR’S LINE (Basal line)Joins hard palate to lowest point of occipital bone Tip of dens should not exceed 5 mm above this line FISHGOLD’S DIGASTRIC LINE – paramedian abnormality HEIGHT INDEX OF KLAUS – dense to tuberculam line < 30 basillar invagination
  18. 18. KLIPPEL FEIL SYNDROME • • • • Congenital fusion of cervical vertebrae Failure of normal segmentation of the cervical vertebrae/somite between 3rd and 8th weeks of fetal development (rather than a secondary fusion) Incidence – 1 in 42,000 births ;more in females Autosomal dominant inheritance – C2-C3 fusion. Autosomal recessive – C5- C6 fusion FEIL’S TRIAD : 1. Low posterior hair line(<L4) 2. Short neck 3. Limitation of head and neck movements / decreased range of motion in cervical spine
  19. 19. KLIPPEL FEIL SYNDROME cont. upper cervical spine  earlier age Rotational loss and lateral bending is usually more pronounced than loss of flexion and extension Scoliosis, Sprengel deformity/ high scapula pterygium colli - Webbing of soft tissues on each side of the neck ; Assocd torticollis Facial asymmetry Cardiovascular- VSD, PDA Urinary tract abnormalities – agenesis of kidney, horseshoe kidney, hydronephrosis, Deafness (absence of auditory canal and microtia) Neurologic deficit- facial nerve Palsy, rectus muscle palsy, ptosis of eye, cleft palate, etc Cervical spine routine x-ray followed by flexion/extension lateral X-rays. flattening and widening of vertebrae, hemivertebrae or block vertebrae, instability. MRI with head flexed and extended - subluxation and cord compression cord anomalies.
  20. 20. Occipitalization of Atlas Atlando Axial Dislocation Diagnosis- Atlas-Dens interval of more than 5 mm in children and more than 3 mm in adults is diagnostic Platybasia >135
  21. 21. Arnold-Chiari Malformation 1) Extension of a tongue of cerebellar tissue, posterior to the medulla and spinal cord, into the cervical canal 2) displacement of the medulla into the cervical canal, along with the inferior part of the fourth ventricle 1) Increased ICTheadache, 2) progressive cerebellar ataxia, 3) progressive spastic quadriparesis, 4) downbeating nystagmus 5) cervical syringomyelia 6)lower cranial nerves palsies hydrocephalus, Type I – Cerbellar tonsilar herniation – adult onset,syrinx Type II-Part of Vermis, Medulla & 4th Ventricle herniating upto mid cervical region – early ages;ass with mengiomyelocele Treatment to do nothing Progessive symptomaticupper cervical laminectomy and enlargement of the foramen magnum
  22. 22. Syringomyelia (syrinx, “pipe” or “tube”) A chronic progressive degenerative or developmental disorder of the spinal cord, characterized by cavitation of the central part of Cervical Canal Associated with Vertebral and Base of Skull Anomalies 90% syrinx ass with Type-I chairy malformation 20-40yrs initial ;M=F Insidious onset ,irregular progressive over 5-10yrs Pt cant say when disease began Disease depends on1.cross sectional extent 2.longitu extent. Classic elements: a) segmental weakness and atrophy of the hands and arms b) loss of some or all tendon reflexes in the arms c)segmental anesthesia of a dissociated type (loss of pain and thermal preservation of touch)over the neck,shoulders,and arms(cape sensation) Pyramidal tract: UL : Reflexes preserved or brisk amyotrophy of shoulders and hands spastic LL: Spastic type Post column,spinothalamic tract involvement later Horner syndrome can occur Usually have tropic ulcers; vague pain may be presenting feature
  23. 23. BARNETT`s Classification Syringobulbia : affect the brainstem(medulla ,pons) 1. Vestibular nuclei  Vertigo & nystagmus 2. Nucleus ambiguus dysphagia & hoarseness of voice 3. Spinal trigeminal nucleus  Analgesia & thermal anesthesia on ipsilateral face (Onion skin pattern ) 4. hypoglossal nucleus Weakness of lingual muscles & dysarthria
  24. 24. Investigations: MRI with contrast – slow filling cavity ; look other skeleatl manifestations CT Myelogram; X ray of cervical spine and skull DD for Dissociated sensory loss: Pseudosyringomyelia-; DM,, ant Spinal artery thrombosis PICA ischaemia Treatment Type I-surgical decompression of foramen magnum and upper cervical canal(relieve headache, pain,mildy improve motor sym;ataxia&nystagmus persist Syringostomy or Shunting by T tube by syringotomy in Type I and some II Other types – surgery not useful
  25. 25. 3-INFECTIVE EPIDURAL ABSCESS : Triad – Fever;Midline dorsal pain over spine;progressive limb weakness 2/3 – hematogenous spread 1/3 – extension of a local infection Lesion mainly – compress venous plexus leads to oedema or direct compression of neural tissue Staph. Aureus is common Strepto,gram neg bacilli Inc ESR/CRP MRI; CSF analysis Bacterial culture positive <25% Rx: Decompressive laminectomy /drainage + long term parentral(6-8wk) antibiotic weakness several days – not improve with surgery immediately In Cauda equina – antibiotics is may be enough mostly Empiric Abx: Nafcillin plus metronidazole plus either cefotaxime or ceftazidime Vancomycin (1 g every 12 hours) can be substituted for nafcillin
  26. 26. ARACHNOIDITIS Syndrome of painful root and spinal cord symptoms;patchy motor symptoms adhesions between the arachnoid and dura Causes;TB,syphilis,viral & bacterial meningitis,anesthesia,LP acute or delayed for weeks, months, or even years Lumbo-Sacral(cauda equina) commonly involved Root pain one side next sidereflex changes motor weaknessspastic ataxia&sphincter disturbance CSF: moderate lymphocytosis,elev protein – acute stage sometimes normal due to complte block MRI:loss of normal ring of CSF,loculations CT myelogram: candle gutter appearance Management Steroids can be tried Surgery if cyst formed Pain relieving medications and surgeries
  27. 27. POTT`S DISEASE TB skeletal TB  spinal is common Common in paediatric and adolscence group Dorsal 42% >Lumbar>Dorsolumbar , Cervical Lesion could be Florid - invasive and destructive lesion Non destructive - lesion suspected clinically but identifiable by investigations Carries sicca Hypertrophied Periosteal lesion. Anatomically the lesion could be : Paradiscal - destruction of adjacent end plates Appendeceal (Posterior) - involvement of pedicles, laminae, spinous process Central - Cystic or lytic, concertina collapse Anterior –longitudinal lig Synovitis in post facet
  28. 28. Pathophysiology: xtraspinal source of infection osteomyelitis and arthritis (anterior aspect of the vertebral body adjacent to the subchondral plate) spread to adjacent intervertebral disks Child may de direct invasion bone destruction Kyphotic deformity vertebral collapse and kyphosis(throcic>lumbar>cervical) abscesses, granulation tissue, or direct dural invasion Paravertebral abscess anterior longitudinal lig Healing by fibrous tissue bony ankylosis vertebrae. spinal cord compression and neurologic deficits Groin abscess Thoracic abscess
  29. 29. Clinical Features: Back pain is the earliest and most common symptom Duration of symptoms at the time of diagnosis is 3-4 months fever and weight loss Pain can be spinal or radicular Neurologic abnormalities - 50% spinal cord compression with paraplegia paresis, impaired sensation, nerve root pain, cauda equina syndrome Investigations Tubercline Test -Mantoux;IFN PCR, sputum ,AFB XR;Xray Thracolumbar spine; CT spine MRI
  30. 30. X Ray appearances Lytic destruction of anterior portion of vertebral body anterior wedging Collapse of vertebral body Reactive sclerosis Intervertebral disks shrunk or destroyed Vertebral bodies may show destruction Enlarged psoas shadow with or without calcification Fusiform paravertebral shadows MRI
  31. 31. T B spine with PARAPLEGIA INCIDENCE 10-30% Dorsal spine (MC) Motor functions affected before /greater than sensory Sense of position & vibration last to disappear Patho of Tuberculoses Paraplegia 1. 2. 3. 4. Inflammatory Edema –vascular stasis,toxin Extradural Mass – Tuberculous ostetis,abscess Bony Disorder – Sequestra, Internal Gibbus Meningeal changes – ‘dura as rule not involved’ Extradural granulation –contractcicatrizationperidural fibrosis paraplegia 5. Infarction of spinal cord - Ant spinal artery Endarteritis, Periarteritis, Thrombosis 6. Changes in Spinal cord- Myelomalacic,Syringomyelic change
  32. 32. Seddon’s Classification: GROUP A_-Early onset - in active stage of the disease within first 2 years (active disease - Caseous material, debris, sequestrated disc or bone, internal gibbus, stenosis and deformity can cause compression) GROUP B -Late onset- Usually after 2 years of onset of the disease (Healed disease - Usually internal gibbus and acute kyphotic deformity) Kumar’s classification(paraplegia) 1 Negligible :Unaware of neural deficit, Plantar extensor/ Ankle clonus 2 Mild :Walk with support 3 Moderate :Nonambulatory, Paralysis in extention,sensory loss <50% 4 Severe :3+ paralysis in flexion/sensory loss>50%/ Sphinters involved MANAGEMENT: ATT – prolonged R and surgery may be
  33. 33. Surgical indications: 1. No sign of Neurological recovery after trial of 3-4 weeks therapy 2. Neurological complication during treatment 3. Neuro deficit becoming worse 4. Recurrence of neuro complication 5. Prevertebral cervical abscesses,neurological signs 6. Advanced cases- Sphincter involvement, flaccid paralysis, Severe flexor spasms 7.severe neuro deficcit Surgical techniques: 1. Decompression -Failed response 2 .Debridement+/- Failed response after 3-6 fusion months, 3 .Debridement +/- Recrudescence of disease DECOMP+/- fusion 4 Debridement+/Prevent severe Kyphosis fusion 5 .Anterior Severe Kyphosis +neural deficit- Transposition 6 .Laminectomy STS,secondary stenosis, posterior disease 7.screws fixation and bone graft 7. Costotransversectomy– in tense paravertebral abscess
  34. 34. 4-VASCULAR – Compressive myelopathy Epidural Haematoma: predisposing factors: Anticoagulation therapy,Trauma,Bleeding disorder,tumor Acute focal &/ radicular Pain Acute Spastic paraparesis or conus medularis syndrome Surgical decompression Haematomyelia: Haemorrhage into the substances of spinal cord Trauma,parenchymal vascular malformations,vasculitis,tumors ACUTE PAINFUL TRANSVERSE MYELOPATHY – INTRAMEDULLARY subarachnoid hge can occur MRI; Spinal Angiography Conservative management only surgery if AVM is the cause
  35. 35. AV Malformation of cord: Reversible cause of paraparesis located posteriorly along the surface of the cord or within the dura at or below the midthoracic level Clinical features: middle-aged man progressive myelopathy that worsens slowly or intermittently with periodic remissions incomplete sensory, motor, and bladder disturbances mixture of upper and restricted lower motor neuron signs Pain over the dorsal spine, dysesthesias, or radicular pain symptoms that change with posture, exertion such as singing, menses Foix-Alajouanine syndrome - progressive thoracic myelopathy with paraparesis Investigation:MRI contrast;CT myelogram;Selective spinal angiography Management: Endovascular embolization of feeding vessels surgical if ruptured
  36. 36. 5-TUMORS AND COMPRESSIVE MYELOPATHY METASTASIS: Metastasis is common tumor(high marrow) Epidural type of compression is common Throacic is common; Lumbar&Sacral – Prostate and ovarian Breast>Lung>Prostate>Kidney>Lymphoma>Plasmacell dyscrasia old age pt Vertebral pain with acute onset of neurological deficit MRI – hypodense in T1;doesnot cross the adjacent disc space Bone scan may be useful to detect the all other metastasis Management: -Glucocorticoid – upto 40mg/d Dexamethasone -RT – 3000cGy in 15 daily fractions -Surgery- laminectomy or vertebral resection (neuro signs worsen even with Radiotherapy) Prognosis: Ambulatory pt – good response with RT Fixed motor deficit-time of surgery <12hr good response >12hr chance to improve >48hr no improvement
  37. 37. Primary tumors of spinal cord common in cervical Intradural : Benign and slow growing ; progressive compression signs Meningioma,Neurofibroma,chordoma,lipoma dermoid,sarcoma MENINGIOMA: benign throcic cord level or near foramen magnum from arachonoid cells forms Psommama bodies Radiation therapy- Gammma Knife, proton beam treatment external beam NEUROFIBROMA: from schwwan cells arises near posterior root begins with radicular symptoms asymetric progressive spinal cord syndrome need surgical treatment INTRAMEDULLARY: uncommon cervical commonly central cord syndrome or hemicord syndrome Ependymoma,Haemangioblastoma,secondaries astrocytoma(lowgrade) Microsurgical debulking can be tried RT is not useful
  38. 38. 6-Spinal Cord Injuries; and spine Fractures
  39. 39. CAUSES OF SCI
  40. 40. SYMPTOMS The vertical location of the injury • In general, injuries that are higher in our spinal cord produce more paralysis. The severity of the injury.(T S section) • Spinal cord injuries are classified as partial or complete, dependin g on how much of the cord width is damaged.
  41. 41.           Classification of Injuries Simple Compression (1-2 column injury) Stable burst (2-3 column injury) Unstable burst (3 column injury) Flexion distraction (2 nonconjoined columns) Chance (3 column failure all in tension) Fracture dislocation (3 column injury) Pure Dislocation (rare) (3 column injury) Pathological (any and all) Insufficiency (any and all) Multiple contiguous fractures (nly 1-2 columns)
  42. 42. Unstable Burst  3 column involvement  Possible neuro involvement  Severe communition  Significant pedicle widening  Look for laminar fracture (asso. with root entrapment)
  43. 43. Treatment of Neurologic Injury • Methylprednisolone protocol (30 mg/kg loading and 5.4 mg/kg x 24 (or 48) hours • Only for central injuries- not peripheral nerve injuries (conus is central injury)
  44. 44. Time to healing • Most non-surgical fractures heal within 12 weeks • Back support with braces(types)on whenever patient upright • When healed- 4 weeks of PT for deconditioning • Residuals of barometric sensitive discomfort and occasionally problems with lifting • 10 % may need to go on to surgery from instability,NEUROLOGIC DEFICITS,Pain. • Surgery is reduction and fixation by pedicle screws or any suitable device
  45. 45. Thank You