Back And Spinal Cord Disease

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Ddx of back pain

• Musculoskeletal strain (experienced by up to 80% of the population at some time) osteoarthritis, vertebral compression fracture, ankylosing spondylitis

• Disk herniation syndromes (see below)

• Metastatic: lung, breast, prostate, multiple myeloma, lymphoma

• Infectious: vertebral osteomyelitis or epidural abscess (see ID section)

• Visceral disease with referred pain

PUD. cholelithiasis pancreatitis, pancreatic cancer pyelonephritis, nephrolithiasis uterine or ovarian cancer, salpingitis leaking aortic aneurysm

Initial evaluation

• History: location, radiation, neurologic symptoms, infection, malignancy

• General physical examination: local tenderness. ROM. signs of infection or malignancy.

Spurling sign (cervical radicular pain w neck extension & lateral rotation toward affected side) Straight leg raise (© radicular pain at <60°). ipsilateral: 95% Se. 40% Sp: crossed (contralateral): 25% Se. 90% Sp

• Neurologic examination: full motor (including sphincter tone), sensory (including perineal region), and reflexes including anal (S4) and cremasteric (L2)

• Laboratory (depending on suspicions): CBC. ESR. Ca. PO.».

• Neuroimaging (depending on suspicions): x-rays. CT or CT myelography. MRI, bone scan

• EMG NCS may be useful to distinguish root plexopathies from peripheral neuropathies

Disc Herniation Syndromes Clinical manifestations

• Back pain aggravated by activity (esp. bending, straining, and coughing), relieved by resting on unaffected side with affected leg in flexed posture

• "Sciatica" = aching pain that radiates from the buttocks down the lateral aspect of the leg, often to the knee or lateral calf : numbness and paresthesias radiating to lateral foot

Cervical and Lumbar Disk Herniation Patterns

Disc

Root

Pain / Paresthesias

Sensory loss

Motor loss

Reflex loss

C4-C5

C5

Neck, shoulder upper arm

Shoulder

Deltoid, biceps, infraspinatus

Biceps

C5-C6

C6

Neck, shoulder, lat. arm. radial forearm, thumb & index finger

Lat- arm. radial forearm, thumb & index finger

Biceps, brachioradialis

Biceps, brachioradialis. supinator

C6-C7

C7

Neck, lat arm, ring & index fingers

Radial forearm, index & middle fingers

Triceps, extensor carpi ulnaris

Triceps, supinator

C7-T1

C8

Ulnar forearm

Ulnar half of ring

Intrinsic hand

Finger

and hand

finger, little finger

muscles, wrist extensors, flexor dig profundus

flexion

L3-L4

L4

Anterior thigh. Inner shin

Anieromedial thigh and shin, inner foot

Quadriceps

Patella

L4-L5

LS

Lat thigh and calf, dorsum of foot, great toe

Lat. calf and great toe

Extensor halllcus longus, * foot dorsiflexion, invers. & evers.

None

L5-S1

SI

Back of thigh, lateral posterior calf, lat. foot

Posterolat. calf, lat and sole of foot, smaller toes

Gastrocnemius • foot eversion

Achilles

(Nb. lumbar disk protrusion tends to compress the root corresponding to the level of the vertebra below it)

(Nb. lumbar disk protrusion tends to compress the root corresponding to the level of the vertebra below it)

Treatment

• Conservative: avoid bending lifting; NSAIDs

• Spinal epidural steroid injections: radicular pain refractory to medical management

• Surgery: cord compression or cauda equina syndrome (see below); progressive loss of motor function; bowel or bladder dysfunction; failure to respond to conservative therapy (NQM 2007:356:2245)

Cord Compression

Clinical manifestations

• Flaccid paraparesis and absent reflexes if acute

• Spastic paraparesis and hyperactive reflexes if subacute to chronic

• Posterior column dysfunction in legs (loss of vibratory sense or proprioception)

• Bilateral Babinski responses

• Conus medullars syndrome: symmetric saddle anesthesia, bladder & bowel dysfunction

(urinary retention. I anal tone), absent bulbocavernosus and anal reflexes

• Cauda equina syndrome: severe back pain, leg weakness and or sensory loss, r i reflexes in lower extremities, relative sparing of bowel & bladder function (but occurs)

Evaluation and treatment

• STAT MRI and neurology consultation

• Empiric dexamethasone 10 mg IV or methylprednisolone 30 mg kg IVB over 15 min

— 5.4 mg kg h starting 45 min after bolus and continuing for 23 h

• Emergent radiation therapy ; surgery for compression due to metastatic disease

• Emergent neurosurgical consultation

Spinal Stenosis

Clinical manifestations

• Neurogenic claudication back or buttocks pain induced by walking or prolonged standing, relieved by bending forwards and by rest

• ± Focal weakness, sensory loss, diminished reflexes

• Unlike claudication: max discomfort in anterior thighs, preserved lower extremity pulses

• Unlike disk herniation: pain relieved by sitting

Evaluation

Treatment

• Conservative: avoid bending lifting; NSAIDs

• Surgical decompression if failure to respond to conservative therapy (NEJM 2007J56:2257)

NOTES

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