backache, disc lesions and cauda equina syndrome

8/6/2019 Backache, Disc Lesions and Cauda Equina Syndrome

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BACKACHE, DISC

LESIONS AND CAUDAEQUINA SYNDROMELt Col Syed Atif Mahmood Kazmi,

Neurosurgeon


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Classification of Back Problems

Potential Serious Spinal ConditionsSpinal tumors, infections, Fractures or Cauda

Equina Syndrome.

SciaticaPain along the course of the sciatic nerve,

usually caused by the compression of nerve.

Non-Specific Back Syndrome

Symptoms occuring in the back that suggestneither nerve root compression, nor a seriousunderlying condition.


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Low Back Pain

Extremely common.

Most common cause of disability in persons


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Differential Diagnosis

Acute Low Back Pain

1. Non-specific(e.g., L.S.Sprain)

2. Trauma.

3. Spinal Tumors.

4. Infections: Discitis

Epidural Abscess.

Vertebral Osteomyelitis.

5. Inflammatory Ankylosing spondylitis.

6. Cauda Equina Syndrome may be caused by:

Spinal Epidural Abscess.

Spinal Epidural Haematoma.

Spinal Tumor (I/D , E/D).Massive Central Disc Herniation.


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7. Pathological Fractures

Osteoporosis

Chronic Steroid use, e.g., Rh. Arthritis

8. Coccydynia.

9. Tears in Annulus Fibrosus.

10. Sub-arachnoid Haemorrhage.


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Subacute Low Back Pain

10% have LBP that persists> 06 weeks.

Includes causes of Ac. LBP and also

1. Continued pain at rest should prompt evaluation for spinalostemyelitis or neoplasm.

2. Plain Spine X-rays may show possible causativecondition.

Sponylolisthesis

Spinal osteophytes (Spondylosis)Lumbar Stenosis

Shmorls Node- disc herniation through cartilaginous end plateinto vertebral body.


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Chronic Low Back Pain

5% of patients will continue to have persistent symptoms.

Differential diagosis includes causes of acute and sub-acute Low back pain.as wellas:

1. Degenerative conditions-

Degenerative spinal listhesis.

Spinal stenosis.

Lat recess syndrome.

2. Spondyloarthropathies-

Ankylosing spondylitis.

changes into sacroiliac joints and positive HLA B-27.

3. Psychological overlay-

Including secondary gain ( financial- emotional).


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Red Flags inthe history of low back problems.

Cancer or Infection- Age > 50 or 60 years.

H/O cancer.Unexpected weight loss

Immunosuppression.

I/V Drug abuse, UTI, Fever,

Chills.Spinal Infection- Back pain at rest.

H/O significant Trauma.

Prolonged use of steroids.

C E Syndrome and- Acute onset of urinary retention orsevere nerve overflow .

Compression Fecal incontinence.

Saddle Anaesthesia.

Weakness of lower extremities.


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I/V Disc Herniation

The function of inter-vertebral disc is to permitstable motion of the spine while supporting anddistributing the loads under movement. Thenucleus of the disc undergoes a decrease inproteoglycan content with aging and dessication(loss of hydration) occurs. Mucoid degenerationand ingrowth of fibrous tissue occurs. There is aloss of disc space height and increasedsusceptibility to injury. Annular tears and herniationof nucleus may occur from increased nuclearpressure under mechanical loads.


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Lumbar Disc HerniationClick to edit Master text styles

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Lumbar Disc Herniation

Sciatica is a set of symptoms including painthat may be caused by compression or irritation ofthe sciatic nerve or nerves. The pain is felt in thelower back, buttock, and /or various parts of theleg and foot.In addition to pain , there may benumbness, muscular weakness, tingling anddifficulty in walking, maybe unilateral or bilateral.

Pain is relieved upon flexing the knee and thigh.

The pain is increased on coughing, sneezing andstraining.


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Physical Findings.

l Motor weakness.

l

Dermatomal sensory changes.l Reflex changes.

l Positive nerve root tension signs.

Lasegues sign(SLR).Femoral stretch test.


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Lumbar Disc Syndromes

L3 L4 Depressed knee jerk

Weakened knee extension

Decreased sensations overmedial malleolus and medial foot

Pain along anterior thigh


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L4-L5 Weakened EHL and anterio

tibialis muscle

Decreased sensations over 1stweb and dorsum of foot

Pain along posterolateral leg

L5-S1 Diminshed ankle jerkWeakened calf muscles

Decreased sensations over

lateral malleolus and lateral footPain along posterior lower

extremity even upto ankle


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Radiological evaluationIn the absence of Red Flags , imaging studies are not recommended inthe first month of symptoms.

Plain X-rays- Useful to diaganose trauma,

spondylosis,spondylolisthesis

infections,bony tumors etc.

MRI - Investigation of choice in

sciatica.

Non invasive

No ionizing radiation involved

Provides information in sagittal

plane.Provides information about tissues outside

spinal canal.


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Lumbo-sacral - For HLD it is less sensitive than

CAT Scanning MRI.

May miss some large discs.

Does not evaluate sagittal

plane.

Evaluates limited levels.

Faster, less expensive and lessclaustrophobic than MRI.

T t t


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TreatmentConservative treatment

1. Bed rest -- upto 2-4 days.Prolonged bed rest notrecommended.

2. Activity modificatione.g. care of posture and changeof the nature of job.

3. Exercises-- may include walking, swimming and

bicycling in the 1st two weeks with no stress on theback.

Later conditioning exercises for the back muscles andabdominals may be done.

4. Analgesics NSAIDS and paracetamol are sufficient.

For severe pain opioids may be used for 2-3 weeks.5. Patient education Includes reassurance and guidance

regarding proper sitting, sleeping and liftingtechniques.


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6.Epidural steroid injection Given for short

term relief in radiculopathy, if response toanalgesics is inadequate and the patient isnot a surgical candidate.

7. Physiotherapy


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Surgical Treatment

Upto 85% of patients improve in six weeks withconservative methods . Hence we usually wait for 5-8weeks.

Indications for Disectomy

Patients with less than 4-8 weeks duration of symptoms

1. Patients with Red Flags leading to urgent surgerye.g. C.E syndrome, a progressive neurological deficit.

2. Severe pain, unresponsive to analgesics.

Patients with more than 4-8 weeks of symptoms of Sciaticawhich are severe and disabling and are not improvingwith time with a radiographically identified abnormalitythat correlates with finding on history and physicalexamination.


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Cauda Equina Syndrome

May be due to compression from massive ruptured discusually in the midline .

Other conditions whichmay cause CES include tumors,trauma, spinal epidural haematoma or abscess.

Possible findings include

1. Sphincter disturbance.

2. Saddle anaesthesia.

3. Significant motor weakness/paraplegia.

4.

Low back pain and/or.5. Bilaterally absent ankle jerk.

Treatment is urgent surgery within 24-48 hours.

backache, disc lesions and cauda equina syndrome

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