Vertebrogenic diseases

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Vertebrogenic diseases Department of Neurology 1st Faculty of Medicine and General Teaching Hospital

J. Böhm M. Hoskovcová Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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! Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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

Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Causes of radicular and spinal cord compression Degenerative changes

• Cervical – spinal cord • osteophyt • prolapse • C5/6 - 20% • C6/7 - 70% • cervical stenosis

• Lumbar – cauda • • • • •

prolapse osteophyt L4/5 - 45% L5/S1 - 45% lumbar stenosis Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Cervical spine – compression of spinal cord and neural roots by osteophyts Medial osteophyts

Spinal process

deg. disc

lateral osteophyt

C6

Root C6 under the arc of C6

vertebral a.

C7

Root C7 under the arc C7 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Medial prolapse

Lateral prolapse

Subarachnoidal space

Dural sac L4

L5

L4

L5 L5

Disc L4/5 - L4 Disc L5/S1 - L5

L5

Root L5 under the arc of L5 Root S1 under the arc S1



Clinical presentation of radicular compression • • • • • • •

appearance: mobility: muscle tone: strength: reflex: pain: sensory dysf.:

hypotrophy - atrophy limited - Lasségue reduced reduced - paresis reduced - 0 autodermography dermatomes Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Lumbar spine – anatomical relations I Th12

Spinal conus: Th12 - L1

Lumbar puncture Spastic paraparesis

L1

Dural sac N. root passes under the arc (pedicle) of its vertebra Prolapse of disc L4/5 (disc L4) compresses the root L5

L2

Prolapse of disc L5/S1(disc L5) compresses the root S1

L3

L4

L5

Subarachnoidal space: dural sac + root sheaths Perimyelography - PMG

sheath+root L4

S1 root L5 root S1

Extradural fat



Lumbar spine – anatomical relations II Th12 Th12

Spinal conus

L1

Roots L4,L5,S1

L2

Dura m.+sac roots

L1

Dural sac + roots L2

L3 Intervertebral foramen

L3

L4

Root sheaths

L4

L5

L5

S1 Sheath + root L4 S1 Sheath +root L5 Sheath + root S1

Extradural fat



Cervical spine – anatomical relations Vertebral arteries Dens axis C2

C4

medial osteophyts deform and dislocate spinal cord

Lateral osteophyts in the foramen C4/5 Root C5 is under the arc of C5

C6

Articulation of the 1st rib Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277

Sensation – radicular areas Dermatomes indicators

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



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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277

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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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277

Clinical presentation of herniation of lumbar prolapse Herniation level


Pain

Sensory f.

Motor f.

Trophic level

Reflexes

L4/5

L5/S1



Lateral

Medial L4

L4

L4

L4 L4

L4 L5

L5

L5 L5

S1 S2

S3

S1 S4 S2

S5


Morphologic methods in vertebrogenic pain syndrome


• • • •

X-ray CT MRI PMG

X-ray

(perimyelography)

• Scintigraphy

CT

algorithm ????? Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Medial prolapse of disc L5/S1

L SAG T2W/TSE

TRA T1W/SE Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


SAG

Osteophyt C5/6 – cervicobrachial syndrome C5 on the left

SAG

SAG

TRA T1W/SE

L TRA


20641/II


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.. Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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



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 B. Adamová, S. Voháňka, J.Bednařík, semiflexion of knees. Neurologická klinika FN Brno Reforma pregraduální výuky neurologie na 1.LF24 UK v Praze CZ.2.17/3.1.00/33277

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TRA

Segmental lumbar stenosis

TSE T2W

L

L4 L5

SAG T2W TSE Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Interspinos dekompression and X Stop

Reforma pregraduální výuky neurologie na 1.LF26 UK v Praze CZ.2.17/3.1.00/33277


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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Cervical myelopathy in cervical spondylosis

Paresthesia of UL Loss of vibration sens. f Clonus of foot

Spastic paraparesis of LL Circumduction while walking

Babinski +



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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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 * Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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…) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277

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• 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) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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… Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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..) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277




Postoperative scar L4/5 on the right

T1WSE+Gd

T1WSE+Gd

L T2WTSE

T1WSE

6166/5



The most common neuropathies for the 5th grade students 1st Faculty of Medicine of Charles University

J. Böhm M. Hoskovcová



Anatomy of peripheral nerve



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

– Waller´s degeneration) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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) Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Brachial plexus



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 Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


SCT



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



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.….. Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


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


Ulnar nerve lesion in elbow area




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. Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Mononeuropathy of ulnar nerve (EMG)

Partial block of n. conduction velocity over elbow



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



Radial nerve ( C5-8, Th1) • Axilla (high crutches) • Arms (paresis of lovers or drunkards)) • Elbow and forearm

dropping hand and fingers, Fallhand, „swan neck“



Radial nerve – motor innervation

• m. triceps brachii • ramus profundus: radial and dorsal muscles of the forearm

• Paresis: picture of the „swan neck“ resulting from paresis of extensor muscles



Radial nerve – sensory innervation



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



Peroneal (fibular) nerve



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“ Reforma pregraduální výuky neurologie na 1.LF UK v Praze CZ.2.17/3.1.00/33277


Peroneal paresis



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



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



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


Femoral nerve examination of flexion in the hip joint





Vertebrogenic diseases

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