Term
| how many annular fibers are there in a disc? |
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Definition
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Term
| what is the purpose of the nucleus pulposus? |
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Definition
| this water and protein based substance is deformable - spreads out to distribute wt |
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Term
| what is the purpose of the annular fibers? |
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Definition
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Term
| what are 3 ways that spinal disc damage can occur? |
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Definition
| tear of the inner fibers (internal disc disruption), tear of the inner fibers w/the nucleus pushed out - but still contained, and fracture of all the annular rings to the point where some of the nucleus is outside the disc space. |
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Term
| where are the ligaments surrounding the annulus most weak? |
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Definition
| in the posterior - which is bad b/c this makes the disc more likely to herniate posteriorly into the spinal cord |
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Term
| what are the 3 things which cause symptoms of a herniated disc? |
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Definition
| *compression of the nerve root (neurological deficit), *inflammation of the nerve root (pain), and *immunologic (immune system reacts to "foreign" glycoprotein from inside the broken disc) |
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Term
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Definition
| radiating pain, either to the arm or leg due to nerve root *irritation |
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Term
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Definition
| pathology from a *compressed nerve root - can take the form of motor/sensory/reflex deficit |
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Term
| are radiculitis and radiculopathy treated the same? |
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Definition
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Term
| what will 90% of pts w/lumbar ruptured disc improve with? |
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Definition
| conservative therapy: bed rest, physical therapy, and muscle relaxants. |
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Term
| what describes most of the 10% of pts who do require sx for lumbar ruptured discs? |
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Definition
| pts who do not get better w/conservative therapy or pts who cannot wait around for symptoms to get better (6-8 wks). *however, bowel and bladder symptoms w/upper lumbar cauda equina syndrome = surgical emergency. |
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Term
| what is important about assessing disc herniation in the cervical area? |
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Definition
| there are not only nerve roots (radicular signs) but also the spinal cord (myelopathy) to take into account. therefore, when someone comes in with neck and arm pain you must also examine their lower extremities for long tract signs of myelopathy (hyperreflexia, clonus in upper extremities, pointing toes). |
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Term
| what are muscles to examine in pts w/radicular symptoms which will give meaningful information? |
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Definition
| examination of the deltoids, biceps, triceps, wrist flexors and extensors, digital muscles, intrinsic hand muscles - all of which are innervated by a single nerve root. (look for patterns of weakness and reflex changes in the arms and legs to localize where the patient’s problem is). |
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Term
| what characterizes isolated disc sx? |
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Definition
| the operation has to be tailored to the specific pt but 90-95% of patients will have an excellent recovery. if a pt needs disc sx, there is a good chance they will need another later on (a lot of it is genetically predetermined). |
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Term
| what are some problems w/isolated disc sx? |
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Definition
| scar tissue forms around the nerve root due to inflammation and may relay pain. |
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Term
| what are the 2 things vertebrae do not do well? |
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Definition
| axial loading and torsion |
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Term
| what are the 2 ways of treating cervical disc disease? |
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Definition
| *posterior approach: laminectomy - try to make room for affected nerve root, good for when there is pressure but not necessarily herniation. *anterior approach - remove disc from front, non-biologic spacer is put in -> more common approach (common complaint is a sore throat for a couple days and potential of long term hoarseness from recurrent laryngeal nerves in 1% of patients). |
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Term
| what is the difference between radiculopathy and myelopathy in the lumbar? |
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Definition
| radiculopathy: compressed nerve root. myelopathy: involvement of spinal cord, such as w/cauda equina syndrome: autonomic dysfunctions of the bowel and bladder and long w/back and leg pain |
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Term
| what is disc arthroplasty? |
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Definition
| artificial disc technology - which was developed to avoid disc fusion, but ultimately will not avoid fusion. currently the shift is moving away from artificial discs and toward fusion in the lumbar. in the cervical region, artificial discs are more common b/c the approach is usually the same for repair anyways. |
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Term
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Definition
| the disc dessicate w/age and lose their shock absorber quality - settling, narrowing and putting more pressure on the facets and ligaments surrounding the canal. this pushes the disc back, the ligamentum flavum gets thicker and the facets get thicker. |
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Term
| what does compression give? |
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Definition
| neurological symptomatology |
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Term
| what is the more common form of spinal disorder in the cervical region? |
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Definition
| myelopathy - pts will have discoordination, problems w/fine motor tasking and spastic gait. |
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Term
| what is neurogenic claudication? |
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Definition
| spinal stenosis causes pts to be no longer be able to walk as far as they used to w/o cramping pain in their buttocks and aching in the legs/ankles. most of the time, patients with neurogenic claudication from spinal stenosis are likely to have vascular insufficiency too (to differentiate, ask if pts get "rest pain" = vascular insufficiency). |
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Term
| what is management for pts w/mild-moderate spinal stenosis? |
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Definition
| pain medication, physical therapy and core exercises. if the pt has progressive myelopathy, to the point that they cannot use hands or cannot walk, sx is recommended. (most pts w/myelopathy do not make a complete recovery and if there is hand involvement, the prognosis is even worse). |
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Term
| what is the 3 column support model of spinal stability? how does this help determine need for sx? |
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Definition
| the spine is divided into anterior (front of vertebral column), middle (posterior edge of spinal cord), and posterior (spinal cord facets). if 2 contiguous columns are disturbed, the pt is then considered to be a surgical candidate (mechanically unstable). |
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Term
| what is a compression fracture? |
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Definition
| a collapse of the vertebral body, usually due to osteoporosis (also metastasis/trauma) |
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Term
| what is the success rate for compression fracture tx? what is typical tx? |
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Definition
| 99%+ virtually complication free w/instantaneous relief of pain. |
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Term
| what pt is kyphoplasty best for? (*know this*) |
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Definition
| those w/compression fractures not completely collapsed (do not have a vertebra plana) as well as metastatic fractures. |
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Term
| how does a kyphoplasty work? |
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Definition
| a needle is inserted through the pedicle into the vertebral body, balloons are inserted which expand the vertebral body height and then methyl methacrylate is injected which heats and hardens. (vertebroplasty is this w/o the balloon). the pain should go away even if height isn't necessarily restored b/c it is due to the microfractures abrading each other |
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Term
| what is the typical tx for an osteoporotic vertebral compression fracture? |
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Definition
| bed rest and bracing for 6-8 wks |
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Term
| what is the most common spine tumor? (*know this*) |
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Definition
| metastatic (by definition extra dural). most commonly from the lung, breast, prostate. |
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Term
| what characterizes intradural and extradural spinal cord tumors? |
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Definition
| the extramedullary (not spinal cord) tumors are all almost benign (meningiomas, schwannomas, neurofibromas). the intramedullary tumors (spinal cord) are almost always malignant (ependymomas, astrocytomas). |
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Term
| what kinds of infections are seen in the spine? tx? |
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Definition
| discitis (just disc) and osteomyelitis (may include disc). principles of management of these diseases include obtaining a bacterial diagnosis, localizing the spine where possible, treating with antibiotics and surgery if they do not recover. |
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Term
| what do the principles for tumor, trauma and infection management have in common? |
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Definition
| decompress neural elements, remove tissue that is no longer useful for the patient, reconstruct the spine as best you can, and stabilize the spine so the patient can heal and be able to function with relatively normal biomechanics. |
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Term
| what are the 3 roots which need to be considered in the lumbar? |
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Definition
a. L4 for L3,4 herniated disc
b. L5 for L4,5 herniated disc
c. S1 for L5, S1 herniated disc |
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