Neurology_Adams

Neurology_Adams. information about the dural sleeves that surround the spinal roots, disclosing subtle truncations caused by laterally situated disc herniations and at times revealing surface abnormalities of the spinal cord, such as arteriovenous malformations. When metallic devices, such as a pacemaker, preclude the performance of MRI, CT, with or without myelography, remains very useful for diagnosis.


Neurology_Adams

Neurology_Adams. Nerve conduction studies and electromyography (EMG) are also helpful in suspected root and nerve diseases as indicated further on in the discussion of lumbar disc disease. However, all the aforementioned tests must be interpreted in the context of the history and clinical examination; otherwise they are subject to overuse and overinterpretation. Conditions Giving Rise to Pain in the Lower Back


Neurology_Adams

Neurology_Adams. Peptic ulcer disease and carcinoma of the stomach and pancreas most typically induce pain in the epigastric region. However, if the posterior stomach wall is involved, particularly if there is retroperitoneal extension, the pain may be felt in the thoracic spine, centrally or to one or both sides. If intense, it may seem to encircle the body. The back pain tends to reflect the temporal characteristics of the pain from the affected organ; for example, if caused by peptic ulceration, it appears about 2 h after a meal and is relieved by food and antacids. Diseases of the pancreas are apt to cause pain in the back, being more to the right of the spine if the head of the pancreas is involved and to the left if the body and tail are implicated. Retroperitoneal neoplasms—for example, lymphomas, renal cell tumors, sarcomas, and other malignancies—may evoke pain in the lower thoracic or lumbar spine with a tendency to radiate to the lower part of the abdomen, groins, anterior thighs, or flank.


Neurology_Adams

Neurology_Adams. cell tumors, sarcomas, and other malignancies—may evoke pain in the lower thoracic or lumbar spine with a tendency to radiate to the lower part of the abdomen, groins, anterior thighs, or flank. A tumor in the iliopsoas region often produces a unilateral lumbar ache with radiation toward the groin and labia or testicle; there may also be signs of involvement of the upper lumbar spinal roots. An aneurysm of the abdominal aorta may induce pain localized to an analogous region of the spine. The sudden appearance of lumbar pain in a patient receiving anticoagulants should arouse suspicion of retroperitoneal bleeding; this pain may also be referred to the groin. Retroperitoneal appendicitis may have an odd referral of pain to the low flank and back.


Neurology_Adams

Neurology_Adams. Gynecologic disorders may manifest themselves by back pain, and their diagnosis may prove difficult. Thorough abdominal palpation, as well as vaginal and rectal examination by an experienced physician, supplemented by ultrasonography and CT scanning or MRI, usually discloses the source of pain. The uterosacral ligaments are the most important pelvic source of chronic back pain. Endometriosis or carcinoma of the uterus (body or cervix) may invade these structures, causing pain localized to the sacrum either centrally or more to one side. In endometriosis, the pain begins premenstrually and often merges with menstrual pain, which also may be felt in the sacral region. Rarely, cyclic engorgement of ectopic endometrial tissue may give rise to sciatica and other radicular pain. Changes in posture may also evoke pain here when a fibroma of the uterus pulls on the uterosacral ligaments. Low back pain with radiation into one or both thighs is a common phenomenon during the last weeks of


Neurology_Adams

Neurology_Adams. posture may also evoke pain here when a fibroma of the uterus pulls on the uterosacral ligaments. Low back pain with radiation into one or both thighs is a common phenomenon during the last weeks of pregnancy.


Neurology_Adams

Neurology_Adams. Pain from neoplastic infiltration of pelvic nerve plexuses may be projected to the low back and is continuous, becoming progressively more severe; it tends to be more intense at night and may have a burning quality. The primary lesion can be inconspicuous and may be inevident on pelvic examination. Traumatic Disorders of the Low Back


Neurology_Adams

Neurology_Adams. Traumatic Disorders of the Low Back In severe acute lumbar injuries from direct impact the examiner must be careful to avoid further damage and movements should be kept to a minimum until an approximate diagnosis has been made. If the patient complains of pain in the back immediately after impact and cannot move the legs, the spine may have been fractured and the cord or cauda equina compressed or crushed. The neck should not be manipulated, and the patient should not be allowed to sit up. (See Chap. 42 for further discussion of spinal cord injury.) Lesser degrees of injury, such as sprains and strains, are ubiquitous and can be handled with less caution because they do not involve compression of neural structures.


Neurology_Adams

Neurology_Adams. Acute sprains and strains The terms lumbosacral strain, sprain, and derangement are used loosely and it is difficult to differentiate them. Furthermore, what was formerly referred to as “sacroiliac strain” or “sprain” is now known to be caused in some instances, by disc disease. The term acute low back strain may be preferable for minor, self-limiting injuries that are usually associated with lifting heavy loads when the back is in a mechanically disadvantaged position, or there may have been a fall, prolonged uncomfortable postures such as air travel or car rides, or sudden unexpected motion, as may occur in an auto accident.


Neurology_Adams

Neurology_Adams. Nonetheless, the discomfort of acute low back strain can be severe, and the patient may assume unusual postures related to spasm of the lower lumbar and sacrospinalis muscles. The pain is usually confined to the lower part of the back, in the midline, across the posterior waist, or just to one side of the spine. The diagnosis of lumbosacral strain is dependent on the biomechanics of the injury or activity that precipitated the pain. The injured structures are identified by the localized tenderness, augmentation of pain by postural changes—for example, bending forward, twisting, or standing up from a sitting position, and by the absence of signs of radicular involvement. In more than 80 percent of cases of acute low back strain of this type, the pain resolves in a matter of several days or a week, even with no specific treatment.


Neurology_Adams

Neurology_Adams. Sacroiliac joint and ligamentous strain is the most likely diagnosis when there is tenderness over the sacroiliac joint and pain radiating to the buttock and posterior thigh, but this needs to be distinguished from the sciatica of a ruptured intervertebral disc (see further on). Strain is characteristically worsened by abduction of the thigh against resistance and may produce pain that is also felt in the symphysis pubis or groin. It, too, responds within days or a week or two to conservative management.


Neurology_Adams

Neurology_Adams. Treatment of acute low back strain The pain of muscular and ligamentous strains is usually self-limiting, responding to simple measures in a relatively short period of time. The basic principle of therapy in both disorders is to avoid reinjury and reduce the discomfort of painful muscles. As a result of several studies that have failed to demonstrate a benefit of bed rest, the recent practice has been to allow activity if the patient is able and to prescribe exercises designed to stretch and strengthen trunk (especially abdominal) muscles, overcome faulty posture, and increase the mobility of the spinal joints (Hagen). Despite this modern approach, the authors can affirm from personal experience that some injuries produce such discomfort that arising from a bed or chair is simply not initially possible (see Vroomen et al). Lying on the side with knees and hips flexed or supine with a pillow under the knees favor relief of pain. With strains of the sacrospinalis muscles and sacroiliac


Neurology_Adams

Neurology_Adams. possible (see Vroomen et al). Lying on the side with knees and hips flexed or supine with a pillow under the knees favor relief of pain. With strains of the sacrospinalis muscles and sacroiliac ligaments, the optimal position is mild hyperextension, which is effected by having the patient lie with a small pillow under the lumbar portion of the spine or by lying prone. Local physical measures—such as application of ice in the acute phase and, later, heat and massage—may relieve pain temporarily. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be given liberally during the first few days. It should be emphasized, however, the use of NSAIDs or narcotic analgesics for many months is hazardous and should also be avoided. Muscle relaxants (e.g., cyclobenzaprine, carisoprodol, metaxalone, and the diazepams) serve mainly to make bed rest more tolerable. Traction, formerly a popular treatment, is no longer used. When weight bearing is resumed, discomfort may be diminished by a light


Neurology_Adams

Neurology_Adams. and the diazepams) serve mainly to make bed rest more tolerable. Traction, formerly a popular treatment, is no longer used. When weight bearing is resumed, discomfort may be diminished by a light lumbosacral support, but many orthopedists refrain from prescribing this aid.


Neurology_Adams

Neurology_Adams. The use of spinal manipulation—practiced by chiropractors, osteopaths, and others—has always been a contentious matter partly because of unrealistic therapeutic claims relating to spinal alignment and adjustment made in treating diseases other than low back derangements. A type of slow muscle stretching and joint distraction (axial traction on a joint) administered by physiatrists and physical therapists is quite similar. It must be recognized that many patients seek chiropractic manipulation on their own for back complaints, often before seeing a physician and may not disclose this information to the physician. When the supporting elements of the spine (pedicles, facets, and ligaments) are not disrupted, chiropractic manipulation of the lumbar spine has undoubtedly provided acute relief to a number of our patients with low back strain or facet pain. At issue is the durability of the effect, particularly the need for repeated spinal adjustments. One randomized British trial has shown


Neurology_Adams

Neurology_Adams. to a number of our patients with low back strain or facet pain. At issue is the durability of the effect, particularly the need for repeated spinal adjustments. One randomized British trial has shown manipulation to be superior to analgesics and bed rest in returning patients to work after minor back injury (Meade et al). Some other trials have corroborated this finding (Hadler et al), whereas others have not, or, often, the results have been ambiguous. In the study by Cherkin and colleagues comparing chiropractic, physical therapy (McKenzie method), and simple instruction to the patient from a booklet, manipulation yielded a slightly better outcome at the end of a month.


Neurology_Adams

Neurology_Adams. Despite hypotheses offered by practitioners of spinal manipulation, the mechanism of pain relief is not known. The popping sound created by rapid and forceful distraction of the facet joints (and attributed to nitrogen coming out of solution in the joint fluid) seems not to be necessary for pain relief. It seems unlikely that mundane low back pain represents minor subluxation, as claimed by chiropractors. In the authors’ clinical experience, chronic low back pain, discussed below, has been less successfully treated by manipulative procedures, but there are some patients who testify to improvement in their clinical state and admittedly the medical profession has little to offer in most cases and the rate of spontaneous improvement is high. The results for acute and chronic back pain with another popular approach, acupuncture, have been even less beneficial, most studies showing it to be no more effective than sham needle treatment (Tudler et al).


Neurology_Adams

Neurology_Adams. Chronic and recurrent low back syndrome Often the symptoms of low back strain are recurrent and more chronic in nature, being regularly exacerbated by bending or lifting, suggesting that postural, muscular, and arthritic factors play a role. This is the most common syndrome seen in spine clinics, more often in men than in women.


Neurology_Adams

Neurology_Adams. Insidiously, or after some unusual activity, raising the question of trauma, especially if it happens in the work-place, the patient develops aching pain in the low back, increased by certain movements and attended by stiffness. The pain may additionally have a restricted radiation into the buttocks and posterior thigh, thereby simulating root compression. There are no motor, sensory, or reflex abnormalities. Imaging usually reveals some combination of osteoarthropathy, changes in vertebral discs, osteoarthritic changes in apophyseal joints, and sometimes osteoporosis or slight spondylosis, or they may be entirely normal. Treatment with short-duration bed rest, analgesics, and physiotherapy, as outlined for acute strains, helps to relieve the symptoms, and the majority of patients recover within a few weeks, only to have a recurrence of similar pains in the future.


Neurology_Adams

Neurology_Adams. Recurrent attacks are typical of degenerative spine disease that affects the vertebrae and facet joints. Chiropractic manipulation has the same uncertain effect as for acute low back symptoms. Usually the origin of the pain cannot be assigned with certainty to spinal, joint, or muscular injury, but direct percussion tenderness of one vertebral segment always raises concern of metastatic disease as noted above. Quite often, changing the firmness of the mattress (in either direction) is helpful. Compensation relating to injuries at work or to an accident and related legal matters often prolong and intensify the reported disability, but there are, of course, many legitimate injuries that occur in these circumstances.


Neurology_Adams

Neurology_Adams. Vertebral fractures Fractures of lumbar vertebral bodies are usually the result of flexion injuries. Such trauma may occur in a fall or jump from a height (if the patient lands on his feet, the calcanei may also be fractured) or as a result of an auto accident or other violent impact. If the injury is severe, it may cause a fracture dislocation, a “burst” fracture of one or more vertebral bodies, or an asymmetrical fracture of a pedicle, lamina, or spinous process; most often, however, there is asymmetrical loss of height of a vertebral body (compression fracture), which may be extremely painful at the onset. When compression or other fractures occur with minimal trauma (or spontaneously), the bone has presumably been weakened by some pathologic process. Most of the time, particularly in older individuals, osteoporosis is the cause of such an event, but there are many other causes, including osteomalacia, hyperparathyroidism, prolonged use of corticosteroids, myeloma, metastatic


Neurology_Adams

Neurology_Adams. in older individuals, osteoporosis is the cause of such an event, but there are many other causes, including osteomalacia, hyperparathyroidism, prolonged use of corticosteroids, myeloma, metastatic carcinoma, and a number of other conditions that are destructive of bone. Spasm of the lower lumbar muscles, limitation of all movements of the lumbar section of the spine, and the radiographic appearance of the damaged lumbar portion (with or without neurologic abnormalities) are the basis of clinical diagnosis. The pain is usually immediate, although occasionally it may be delayed for hours or exceptionally, days after injury.


Neurology_Adams

Neurology_Adams. A fractured transverse process, which is almost always the result of high-impact rotary injury of the spine, causes tearing of the paravertebral muscles and a local hematoma, producing deep tenderness at the site of the injury and limitation of all movements that stretch the lumbar muscles. The imaging findings, particularly MRI, confirm the diagnosis. In some circumstances, tears of the paravertebral musculature may be associated with extensive bleeding into the retroperitoneal space; this produces paraspinal or groin pain and proximal leg weakness with loss of the patellar reflex on the affected side. There may be a delayed subcutaneous hematoma in the flanks due to seepage of blood from the retroperitoneal space (Grey-Turner sign).


Neurology_Adams

Neurology_Adams. For the mundane thoracic and lumbar fracture associated with osteoporosis, bed rest, and analgesics are usually adequate. In the past two decades several mechanical approaches to reducing pain have been investigated. The injection of various materials directly into the fracture site within the vertebral body (vertebroplasty) attained popularity because of reports of marked pain relief. Several large trials have addressed the use of vertebroplasty and given conflicting results. The best conducted of these, with a placebo control group (see Buchbinder et al and Kallmes et al) concluded that there was no durable benefit; however, these two studies included patients with fractures up to a year old and the studies apply specifically to osteoporotic fractures. Having witnessed a few patients with almost immediate and remarkable relief of severe pain, we are uncertain of the best course but acknowledge that this is probably not an effective treatment for the majority of patients. Further


Neurology_Adams

Neurology_Adams. with almost immediate and remarkable relief of severe pain, we are uncertain of the best course but acknowledge that this is probably not an effective treatment for the majority of patients. Further discussion can be found in the review by Ensrud and Schousboe.


Neurology_Adams

Neurology_Adams. Herniation of Lumbar Intervertebral Discs (Table 10-1) This condition is a major cause of severe and chronic or recurrent low back and leg pain. It occurs mainly during the third and fourth decades of life when the nucleus pulposus is still gelatinous. The disc between the fifth lumbar or first sacral vertebrae (L5-S1) is most often involved, and, with decreasing frequency, that between the fourth and fifth (L4-L5), third and fourth (L3-L4), second and third (L2-L3), and—quite infrequently—the first and second (L1-L2) lumbar vertebrae. Disc disease is relatively rare but well described in the thoracic portion of the spine. It is frequent in the cervical spine, especially at the fifth and sixth and the sixth and seventh cervical vertebrae (see further on).


Neurology_Adams

Neurology_Adams. The likely cause of a herniated lumbar disc is a flexion injury, but a considerable proportion of patients do not recall a traumatic episode. Degeneration of the nucleus pulposus, the posterior longitudinal ligaments, and the annulus fibrosus may have taken place silently or have been manifest by mild, recurrent lumbar ache. A sneeze, lurch, or other trivial movement may then cause the nucleus pulposus to prolapse, pushing the frayed and weakened annulus posteriorly. A fragment of the nucleus protrudes through a tear in the annulus, usually to one side or the other (sometimes in the midline), where it impinges on a root or roots and cause the characteristic sciatic or other radicular pain and neurologic signs. In more severe cases of disc rupture, a small piece of the nucleus becomes entirely extruded as a “free fragment” and is mobile enough to affect a root at an adjacent level or to give rise to unusual positional features of radicular pain. Large protrusions cause pain by


Neurology_Adams

Neurology_Adams. entirely extruded as a “free fragment” and is mobile enough to affect a root at an adjacent level or to give rise to unusual positional features of radicular pain. Large protrusions cause pain by compressing the adjacent root against the articular apophysis or lamina. The protruded material may shrink, presumably from desiccation, but often there is continued chronic irritation of the root or later posterior osteophyte formation.


Neurology_Adams

Neurology_Adams. Clinical syndrome of lumbar disc herniation The fully developed syndrome of the common herniated (the terms ruptured and prolapsed are used equivalently) intervertebral lower lumbar disc consists of (1) pain in the sacroiliac region, radiating into the buttock, thigh, and the calf, a symptom termed sciatica; (2) a stiff or unnatural spinal posture; and often (3) some combination of paresthesia, weakness, and reflex impairment.


Neurology_Adams

Neurology_Adams. The pain of herniated intervertebral disc varies in severity from a mild aching discomfort to severe knife-like stabs that radiate the length of the leg and are superimposed on a constant intense ache. Sciatic pain is perceived by the patient as originating deep in the buttock and radiating to the posterolateral thigh; it may progress to the calf and ankle—to the medial malleolus (L4), lateral malleolus (L5), or heel (S1). Distal radiation to the foot is infrequent and should raise concern of an alternative process. Abortive forms of sciatica may produce aching discomfort only in the lower buttock or proximal thigh and occasionally only in the lower hamstring or upper calf. With the most severe pain, the patient is forced to stay in bed, avoiding the slightest movement; a cough, sneeze, or strain is intolerable. The most comfortable position is lying on the back with legs flexed at the knees and hips and the shoulders raised on pillows to obliterate the lumbar lordosis. For some


Neurology_Adams

Neurology_Adams. or strain is intolerable. The most comfortable position is lying on the back with legs flexed at the knees and hips and the shoulders raised on pillows to obliterate the lumbar lordosis. For some patients, a lateral decubitus position is more comfortable. Free fragments of disc that find their way to a lateral and posterior position in the spinal canal may produce the opposite situation, one whereby the patient is unable to extend the spine and lie supine. Sitting and standing up from a sitting position are particularly painful. It is surprising to patients that a lumbar disc protrusion may cause little or no back pain. As a corollary, the presence of lumbar disc disease, even frank rupture, bears an inconsistent relationship to low back pain, as already emphasized.


Neurology_Adams

Neurology_Adams. In cases of root compression, pain is also characteristically provoked by pressure along the course of the sciatic nerve at the classic points of Valleix (sciatic notch, retrotrochanteric gutter, posterior surface of thigh, and head of fibula). Pressure at one point may cause radiation of pain and tingling down the leg.


Neurology_Adams

Neurology_Adams. Elongation of the nerve root by straight-leg raising or by flexing the leg at the hip and extending it at the knee (Lasègue maneuver discussed earlier) is the most consistent of all pain-provoking signs. During straight-leg raising, the patient can distinguish between the discomfort of ordinary tautness of the hamstring and the sharper, less-familiar root pain, particularly when asked to compare the experience with that on the normal side. Many variations of the Lasègue maneuver have been described (with numerous eponyms), the most useful of which is accentuation of the pain by dorsiflexion of the foot (Bragard sign) or of the great toe (Sicard sign). The Lasègue maneuver with the healthy leg may evoke sciatic pain on the contralateral side), but usually of lesser degree (Fajersztajn sign). However, the presence of the “crossed straight-leg-raising sign” is highly indicative of a ruptured disc as the cause of sciatica (Hudgkins). With the patient standing, forward bending of the trunk


Neurology_Adams

Neurology_Adams. However, the presence of the “crossed straight-leg-raising sign” is highly indicative of a ruptured disc as the cause of sciatica (Hudgkins). With the patient standing, forward bending of the trunk will cause flexion of the knee on the affected side (Neri sign). Sciatica may be provoked by forced flexion of the head and neck, coughing, or pressure on both jugular veins, all of which increase the intraspinal pressure (Naffziger sign). Marked inconsistencies in response to these tests raise the suspicion of psychologic factors or of referred muscular pain.


Neurology_Adams

Neurology_Adams. An antalgic posture, referred to as sciatic scoliosis, is maintained by reflex contraction of the paraspinal muscles, which can be both seen and palpated. In walking, the knee is slightly flexed, and weight bearing on the painful leg is brief and cautious on the ball of the foot, giving a limp. It is particularly painful for the patient to go up and down stairs. The signs of more severe spinal root compression are impairment of sensation, loss or diminution of tendon reflexes, and muscle weakness, as summarized in Table 10-1.


Neurology_Adams

Neurology_Adams. Table 10-1. Generally, disc herniation compresses the root of the level just below the herniation (see below). Hypotonia may be evident on inspection and palpation of the buttock and calf. In only a few patients is a foot drop (L5 root) or weakness of plantar flexion (S1 root) the main feature of disc protrusion, but it is notable that some patients have little pain with disc rupture. The reflex changes noted below have little relationship to the severity of the pain or sensory loss. Furthermore, compression of the fourth, or sometimes fifth, lumbar root may occur without any change in the tendon reflexes. Bilaterality of symptoms and signs is rare, as is sphincteric paralysis, but they occur with large central protrusions that compress the cauda equina. The cerebrospinal fluid (CSF) protein is then slightly elevated, usually in the range of 55 to 85 mg/dL, sometimes higher.


Neurology_Adams

Neurology_Adams. As emphasized earlier, herniations of the intervertebral lumbar discs occur most often between the fifth lumbar and first sacral vertebrae (compressing the S1 root;


Neurology_Adams

Neurology_Adams. Fig. 10-3) and between the fourth and fifth lumbar vertebrae (compressing the L5 root). Lesions of the fifth lumbar root (L5) produce pain in the region of the hip and posterolateral thigh (i.e., sciatica) and, in more than half such cases, lateral calf (to the lateral malleolus), and less often, the dorsal surface of the foot and the first or second and third toes. Pain is elicited by the straight-leg raising test or one of its variants, and protective nocifensive reflexes come into play, limiting further elevation of the leg. Paresthesia may be felt in the entire territory or only in its distal parts. The tenderness is in the lateral gluteal region and near the head of the femur. Weakness, if present, involves the extensors of the big toe and foot and the foot invertors (a distinguishing feature of foot drop originating from peroneal nerve damage, which spares inversion because it is a tibial nerve function). The ankle jerk may be diminished (more often it is normal), but the knee


Neurology_Adams

Neurology_Adams. feature of foot drop originating from peroneal nerve damage, which spares inversion because it is a tibial nerve function). The ankle jerk may be diminished (more often it is normal), but the knee jerk is hardly ever altered.


Neurology_Adams

Neurology_Adams. With lesions of the first sacral root (S1), the pain is felt in the midgluteal region, mid-posterior part of the thigh, posterior region of the calf to the heel, outer plantar surface of the foot, and fourth and fifth toes. Tenderness is most pronounced over the midgluteal region. Paresthesia and sensory loss are mainly in the lower part of the leg and outer toes, and weakness, if present, involves the plantar flexor muscles of the foot and toes, abductors of the toes, and hamstring muscles. The Achilles reflex is diminished or absent in the majority of cases. In fact, loss of the Achilles reflex may be the only objective sign. Walking on the toes is more difficult and uncomfortable than walking on the heels because of weakness of the plantar flexors.


Neurology_Adams

Neurology_Adams. The less-frequent lesions of the third (L3) and fourth (L4) lumbar roots give rise to pain in the anterior part of the thigh and knee and anteromedial part of the leg (fourth lumbar), with corresponding sensory impairment in these dermatomal distributions. The knee jerk is diminished or abolished. Third lumbar (L3) motor root lesions may weaken the quadriceps, thigh adductor, and iliopsoas and reduce the knee jerk; L4 root lesions weaken the anterior tibial innervated muscles, sometimes with a mild foot drop and variably affect the knee jerk. First lumbar (L1) root pain is projected to the groin, and L2, to the lateral hip.


Neurology_Adams

Neurology_Adams. Much has been made of a distinctive syndrome associated with extreme lateral disc protrusions, particularly those situated within the proximal portion of the intervertebral spinal foramina. Unremitting radicular pain without back pain and a tendency to worsen with extension of the back and torsion toward the side of the herniation are characteristic. Also, in rare instances of lumbar intradural disc rupture, there may not be sciatic pain because the free fragment in the subarachnoid space does not impinge on the roots of the cauda equina. Both of these configurations may confound clinical and radiologic diagnosis and make surgery more difficult.


Neurology_Adams

Neurology_Adams. Rarer still, and often clinically obscure, are protrusions of thoracic intervertebral discs (0.5 percent of all surgically verified disc protrusions, according to Love and Schorn). The four lowermost thoracic interspaces are the most frequently involved. Trauma, particularly hard falls on the heels or buttocks, is an important causative factor. Deep boring spine pain; root pain circling the body or projected to the abdomen or thorax (sometimes simulating visceral disease); paresthesia below the level of the lesion; loss of sensation; both deep and superficial; and paraparesis or paraplegia are the usual clinical manifestations.


Neurology_Adams

Neurology_Adams. A herniated lumbar disc at one interspace may compress more than one root (see Fig. 10-3), and it follows that the symptoms reflect this. Furthermore, the above descriptions of single root compression refer mainly to signs and symptoms of typical posterolateral disc protrusion. Very large central disc protrusions may compress the entire cauda equina with a dramatic syndrome that includes intense low back and bilateral sciatic pain, incomplete paraparesis, loss of both ankle jerks, and, most characteristic, varying degrees of urinary retention and incontinence. This circumstance usually demands surgical attention. Anomalies of the lumbosacral roots may lead to errors in localization (see descriptions by Postacchini et al). The combined rupture of two or more discs occurs occasionally and complicates the clinical picture. When both the L5 and S1 roots are compressed by a large herniated disc, the signs of the S1 lesion usually predominate.


Neurology_Adams

Neurology_Adams. Herniation may occur directly into the adjacent vertebral body, giving rise to a Schmorl nodule. In such cases there are no signs of nerve root involvement although back pain may be present, sometimes recurrent and referred to the thigh. Most often, these circular radiographic densities adjacent to the endplate of the vertebral body are found incidentally on CT or MRI.


Neurology_Adams

Neurology_Adams. Diagnosis When all components of the lumbar disc syndrome are present, diagnosis is virtually assured. With persistent symptoms, many neurologists prefer to corroborate their clinical impression with MRI of the spine from L3 to S1 (Fig. 10-4). This, of course, is not necessary if the pain is manageable and surgery is not contemplated (see further on). MRI is favored over CT because of the advantages of the sagittal image and the clarity of the anatomic relationships between discs and nerve roots (Epstein). MRI also excludes herniations at other sites or an unsuspected tumor. As indicated earlier, in cases in which MRI is not possible or it has been unrevealing, we often turn to CT with myelography for a refined definition of the root sleeves and use the EMG to corroborate subtle findings. At the lumbosacral junction there is a wide gap between the posterior margins of the vertebrae and the dural sac, so that a lateral or central protrusion of the L5-S1 disc may fail to distort the


Neurology_Adams

Neurology_Adams. At the lumbosacral junction there is a wide gap between the posterior margins of the vertebrae and the dural sac, so that a lateral or central protrusion of the L5-S1 disc may fail to distort the dural margin and remain undetected on myelography.


Neurology_Adams

Neurology_Adams. The needle EMG study is abnormal, showing fibrillation potentials in denervated muscles after 1 or 2 weeks of symptoms in more than 90 percent of cases according to Leyshon and colleagues but less frequently in other studies. Loss or marked asymmetry of the H reflex is another useful indication of S1 radiculopathy, but this finding simply corroborates the loss of an Achilles reflex. The finding of denervation potentials in the paraspinal muscles (indicating root rather than peripheral nerve lesions) and in muscles that conform to a root distribution is also helpful, but at least 2 or 3 weeks must have elapsed from the onset of root pain for these findings to be present. We emphasize that, while useful information is gained from EMG, it is not routinely required and often provides mainly corroborating data.


Neurology_Adams

Neurology_Adams. Many disc abnormalities observed on MRI and loosely referred to as “herniation” are actually disc bulges and can be considered incidental findings, unrelated to the patient’s symptoms. Jensen and colleagues, in an MRI study of the lumbar spine in 98 asymptomatic adults, found that in more than half there was a symmetrical extension of a disc (or discs) beyond the margins of the interspace (bulging). In 27 percent, there was a focal or asymmetrical extension of the disc beyond the margin of the interspace (protrusion), and in only 1 percent was there more extreme extension of the disc (extrusion). These findings emphasize the importance of using precise terms in describing the imaging abnormalities and evaluating them strictly in the context of the patient’s symptoms. Treatment of Ruptured Lumbar Disc


Neurology_Adams

Neurology_Adams. Treatment of Ruptured Lumbar Disc In the treatment of an acute or chronic rupture of a lumbar disc, it seems reasonable to advise avoidance of physical activities and positions that cause pain, and suggested bed rest if it appears to be helpful to the patient. But even this time-honored tenet has been strongly questioned by the results of several studies (Vroomen et al). It would appear that the main benefit is simply that time has passed and the expected resolution of pain has taken its course in many patients. The patient may suffer minor recurrence of pain but should be able to continue some of his usual activities. The results of several surveys give guidance that is conservative in the treatment of sciatica in so far as sciatica resolves without treatment in one-third of patients within 2 weeks and in 3 quarters of patients within 3 months (see Vroomen et al 2002).


Neurology_Adams

Neurology_Adams. Analgesic medications, either NSAIDs or opioids, may be required for a few days. In a few patients with severe sciatica we have been impressed with the temporary relief afforded by administration of oral dexamethasone (4 mg every 8 h) for several days, although this approach has uncertain effects according to several systematic surveys summarized by Ropper and Zafonte. The treatment of nerve root compression with repeated epidural injections of corticosteroids has enjoyed periods of popularity, but controlled studies have failed to confirm a sustained efficacy (White et al; Cuckler et al), and it is not without complications. As with many similar studies, Carette and colleagues (1997) found short-term improvement with epidural steroid injection and the ultimate need for surgery was not altered. Nevertheless, we and many other neurologists and pain clinics have not discarded this form of treatment in view of notable success in selected patients, even if short-lived and only aiding in


Neurology_Adams

Neurology_Adams. Nevertheless, we and many other neurologists and pain clinics have not discarded this form of treatment in view of notable success in selected patients, even if short-lived and only aiding in mobilizing the patient and relieving discomfort.


Neurology_Adams

Neurology_Adams. Surgical relief of lumbar disc disease Urgent surgery is generally required for an acute compression of the cauda equina by massive disc extrusion, causing bilateral sensorimotor loss and sphincteric paralysis. Although not the recommended course, it should be pointed out that there are infrequent instances where even a dramatic syndrome of cauda equina compression has resolved after several weeks of bed rest.


Neurology_Adams

Neurology_Adams. If the pain and neurologic findings do not subside in response to conservative management or the patient suffers frequent disabling acute episodes, surgical treatment must be considered. Useful information regarding surgery and its timing can be ascertained from a recent randomized Dutch trial conducted by Peul and colleagues and from the Spine Patients Outcomes Research Trial (SPORT) conducted by Weinstein and coworkers (2006). In the first mentioned trial, a large proportion of patients assigned to treatment with physical therapy and pain medications nonetheless had enough pain that they required surgery after several months. Patients assigned initially to surgery by microdiscectomy also had considerably faster relief of back and sciatic pain, but at the end of a year, both groups had minimal disability and similar degrees of minor pain. The implications of this study are that avoiding surgery initially does not have adverse consequences but if rapid pain relief and mobilization is


Neurology_Adams

Neurology_Adams. disability and similar degrees of minor pain. The implications of this study are that avoiding surgery initially does not have adverse consequences but if rapid pain relief and mobilization is the aim, surgery is preferable. In the second cited study there was even greater crossover between conservative and surgically assigned groups but there was a slightly more favorable outcome in those who underwent early surgery.


Neurology_Adams

Neurology_Adams. The surgical procedure most often indicated for lumbar disc disease is one of the variants of a hemilaminectomy with excision of the disc fragment. Questions relating to the relative merits of limited (“microdisc”) excision of the lamina are often raised by patients but no clear answer can be given except that individual surgeons excel at one or another technique and a minimal procedure is currently favored but the short-term outcomes are similar for most approaches. Eighty-five to 90 percent of cases with sciatic pain because of L4-L5 or L5-S1 disc ruptures are relieved by operation, are home in days or less, and resume activities within weeks. Rerupture occurs in approximately 5 percent or fewer operated cases according to Shannon and Paul. Fusion of the involved segments may be indicated in cases in which there is substantial spondylolisthesis or instability. It is not known if delaying surgery in patients with foot or leg weakness from disc herniation risks irreversible damage.


Neurology_Adams

Neurology_Adams. in cases in which there is substantial spondylolisthesis or instability. It is not known if delaying surgery in patients with foot or leg weakness from disc herniation risks irreversible damage. Similar issues pertain to surgical to the more complex issue of decompression of lumbar stenosis, discussed in a later section. It is of interest that the findings on follow up at a year or so after laminectomy for disc removal do not correspond to the clinical outcomes according to Barzouhi and coworkers.


Neurology_Adams

Neurology_Adams. In our experience and that of our neurosurgical colleagues, the features that are predictive of better outcome from decompressive surgery are the presence of radicular leg pain, younger age, a clear precipitating event for the back and sciatic pain, clinical features that are restricted to compression of a single nerve root, and the absence of chronic or recurrent back pain. Psychological problems of various types and chronic smoking, because of poor bone structure, are risks for poorer outcomes. Congenital Anomalies of the Lumbar Spine


Neurology_Adams

Neurology_Adams. Congenital Anomalies of the Lumbar Spine Anatomic variations of the spine are frequent and, though infrequently themselves the source of pain and functional derangement, they predispose an individual to discogenic and spondylotic complications by virtue of altering the mechanics and alignment of the vertebrae, joints, or size of the spinal canal or by giving rise to traumatic fractures of the pedicles. Congenital scoliosis in particular is a complex matter in relation to secondary spinal disease and entire textbooks have been devoted to the analysis of this subject. It is not therefore discussed here except to point out that there is no obligatory relationship between mild degrees of scoliosis that carries over into adulthood and back derangements, and further that some instances of scoliosis occur in parallel with congenital anomalies of the spine and base of the brain such as Chiari malformation and syringomyelia.


Neurology_Adams

Neurology_Adams. A common anomaly is fusion of the fifth lumbar vertebral body to the sacrum (“sacralization”) or, conversely, separation of the first sacral segment, giving rise to 6, rather than the usual 5 lumbar vertebrae (“lumbarization”). However, neither of these is consistently associated with any type of back derangement. Another less-common finding is a lack of fusion of the laminae of one or several of the lumbar vertebrae or of the sacrum (spina bifida). Occasionally, a subcutaneous mass, hypertrichosis, or hyperpigmentation in the sacral area betrays the condition, but in most patients it remains occult until it is disclosed radiologically. The anomaly may be accompanied by malformation of vertebral joints and usually induces pain only when aggravated by injury. The neurologic aspects of defective fusion of the spine (dysraphism) are discussed in Chap. 37, with other developmental abnormalities of the nervous system.


Neurology_Adams

Neurology_Adams. Many other congenital anomalies affect the lower lumbar vertebrae: asymmetrical facet joints, abnormalities of the transverse processes, are seen occasionally in patients with low back symptoms, but apparently with no greater frequency than in asymptomatic individuals.


Neurology_Adams

Neurology_Adams. Spondylolysis consists of a congenital and probably genetic bony defect in the pars interarticularis (the segment at the junction of pedicle and lamina) of the lower lumbar vertebrae. It is remarkably common, affecting approximately 5 percent of the North American population and mainly a disease of children (peak incidence between 5 and 7 years of age). The defect assumes importance by predisposing to subtle fracture of the pars articularis, sometimes precipitated by slight trauma but often in the absence of an appreciated injury. In some young individuals it is unilateral and may cause unilateral lumbar aching back pain that is accentuated by hyperextension and twisting. In the usual bilateral form, small fractures at the pars interarticularis allow the vertebral body, pedicles and superior articular facets to move anteriorly, leaving the posterior elements behind. This leads to an anterior displacement of one vertebral body in relation to the adjacent one, namely spondylolisthesis.


Neurology_Adams

Neurology_Adams. articular facets to move anteriorly, leaving the posterior elements behind. This leads to an anterior displacement of one vertebral body in relation to the adjacent one, namely spondylolisthesis. (The main cause of spondylolisthesis in older adults is degenerative arthritic disease of the spine as discussed further on.) Patients with progressive vertebral displacement and neurologic deficits require surgery. Reduction of displaced vertebral bodies before fusion and direct repair of pars defects are possible in special cases and back pain is usually reduced or relieved.


Neurology_Adams

Neurology_Adams. Other Causes of Sciatica and Low Back Pain An increasing experience with lumbar back pain and sciatica has impressed the authors with the large number of such cases that have no clear cause. At one time all these cases were classified as sciatic neuritis or “sacroiliac strain.” After Mixter and Barr popularized the concept of prolapsed disc, all sciatica and lumbar pains were ascribed to this condition. Operations became widely practiced, not only for frank disc protrusion but also for “hard discs” (unruptured) and related pathologies of the spine. In large referral centers the surgical results became decreasingly satisfactory until recently, as many patients were being seen with unrelieved postlaminectomy pain as with unoperated ruptured discs.


Neurology_Adams

Neurology_Adams. To explain these cases of chronic sciatic pain, a number of pathologic entities have been described. Entrapment of lumbar roots may be the consequence not only of disc rupture but also of spondylotic spurs with stenosis of the lateral recess, cysts of the synovium derived from degenerative disease of the facet joint, hypertrophy of facets, and, rarely, arachnoiditis. Lateral recess stenosis in particular may be a cause of sciatica not relieved by disc surgery (see later, under “Lumbar Stenosis”). Synovial cysts arising from a facet joint are not uncommon, and even very small ones may be situated in the proximal portion of the foramen, thereby causing sciatica. If pain is intractable, surgical removal of the cyst is indicated. Another surprising finding in the course of imaging the spinal canal is a cyst-like dilatation of the perineural sheath (Tarlov cysts). One or more sacral roots may be involved at points where they penetrate the dura and may be associated with radicular symptoms.


Neurology_Adams

Neurology_Adams. is a cyst-like dilatation of the perineural sheath (Tarlov cysts). One or more sacral roots may be involved at points where they penetrate the dura and may be associated with radicular symptoms. There are reports of relief from opening the cysts and freeing the roots, but the results seem more uncertain to us. Sciatica that is temporally linked to the premenstrual period is almost always a result of endometriosis involving the nerve at the sciatic notch (“catamenial sciatica”). We have also observed cases of sciatica that occurred with each pregnancy, presumably from uterine traction on the nerve.


Neurology_Adams

Neurology_Adams. Over the years the notion of a piriformis syndrome, so named by Kopell and Thompson, has arisen as a cause of otherwise unexplained buttock pain or vague sciatica. The muscle overlies or, in a small proportion, embeds the peroneal trunk of the sciatic nerve. Hypertrophy, spasm, or simply the anatomic variation in which the nerve is entrapped in the tendinous origin of the muscle, have all putatively caused local and some degree of sciatic pain. Pain in these cases is ostensibly elicited by stretching the muscle through flexion, adduction, and internal rotation of the hip. The validity of this syndrome is uncertain and it has been the subject of polemical discussions in the literature. EMG data are ambiguous but reportedly show distal denervation, sparing more proximally innervated muscles. Our practice would be to avoid surgery in such cases, but to endorse physical therapy, which may include injection of botulinum toxin or corticosteroids into the muscle.


Neurology_Adams

Neurology_Adams. Compression of the cauda equina by epidural tumor, as described further on, most often begins with back pain or sciatica, as a result of deposits of prostatic or breast cancer or myeloma. The sciatic nerve or the plexus from which it originates may be implicated in tumor growths (lymphoma, neurofibrosarcoma). Several inflammatory diseases of the cauda equina produce back pain and bilateral sciatica and may be mistaken for the more usual types of cauda equina compression; cytomegalovirus infection in AIDS patients, Lyme disease (Bannwarth syndrome), herpetic infection, and neoplastic meningitis at times behave in this fashion. In all of these, the CSF shows a pleocytosis. The Guillain-Barré syndrome may also produce misleading back and radicular pain before weakness is apparent. The caudal roots in these diseases usually enhance with gadolinium on MRI.


Neurology_Adams

Neurology_Adams. An unusual lumbosacral plexus neuritis (Wartenberg plexitis, see Evans et al) is a unilateral (occasionally bilateral) disorder akin to brachial neuritis, which may cause sciatica, as does occasionally nerve infarction or damage from diabetes, herpes zoster, or a retroperitoneal mass (see Chap. 43).


Neurology_Adams

Neurology_Adams. In the lumbar region, osteoarthritic and related degenerative changes, which together cause a spondylotic narrowing of the canal, lead to compression of one or more lumbar and sacral roots. The problem is more likely to occur if there is a congenitally narrow lumbar canal. The roots are typically compressed between the posterior surface of the vertebral body anteriorly, the facet joint laterally, and the ligamentum flavum posteriorly. Lateral recess stenosis, which is a common feature of spondylotic change (as mentioned above in relation to disc disease), also contributes to root compression and may be the main cause of compression in some patients. Even slight subluxation (spondylolistheses, as discussed below) may also contribute to the stenosis in the anteroposterior dimension. Later, the canal is also narrowed from side to side (reduced interpedicular distance).


Neurology_Adams

Neurology_Adams. The typical features are of fluctuating aching and sharp pain in the low back, buttock and sciatic distribution, occasionally including femoral areas, and generally elicited by prolonged sitting, standing, or walking and relieved by rest. Some patients have virtually constant pain in these areas but still have relief with rest in one or another body position.


Neurology_Adams

Neurology_Adams. In a distinctive presentation that occurs in some cases of lumbar stenosis, termed “neurogenic claudication,” standing or walking causes a gradual onset of numbness and weakness of the legs, usually with asymmetrical sciatic, calf, or buttock discomfort that forces the patient to sit down. When the condition is more severe, the patient gains relief by squatting or lying with the legs flexed at the hips and knees. Often the numbness begins in one leg, spreads to the other, and ascends as standing or walking continues. The ankle tendon reflexes may disappear after walking a distance, only to return on flexing the spine. Pain in the low back and glutei is variable. Disturbances of micturition and impotence are infrequent unless there has been an additional more acute disc herniation. In some patients with lumbar stenosis, neurologic symptoms persist without relation to body position. The process is distinguished from vascular claudication of the legs by its appearance in the standing


Neurology_Adams

Neurology_Adams. patients with lumbar stenosis, neurologic symptoms persist without relation to body position. The process is distinguished from vascular claudication of the legs by its appearance in the standing position, the prominence of numbness in some cases, relief by bending forward at the waist and elongating the lumbar spine, and, of course, by the preservation of distal leg pulses and loss of ankle reflexes. This “claudication of the cauda equina” was known to Dejerine and described by van Gelderen in 1948, and it was shown by Verbiest to be caused not by ischemia but by encroachment on the cauda, for which reason his name has been attached to the claudication syndrome.


Neurology_Adams

Neurology_Adams. A prominent feature of many cases of the degenerative spinal disorder is spondylolisthesis. This displacement and malalignment of one vertebral body in relation to the adjacent one may cause little difficulty at first but eventually the patient complains of limitation of motion and pain in the low back radiating into the thighs. In the extreme case examination discloses tenderness near the segment that has “slipped” forward (most often L5, occasionally L4 in middle-aged women) or a palpable “step” of the spinous process forward and shortening of the trunk with protrusion of the lower abdomen (forward shift of L5 on S1, spondyloptosis). Compression of the corresponding spinal roots by the displaced vertebrae causes paresthesia and sensory loss, muscle weakness, and reflex impairment. These neurologic features, however, tend not to be severe. When spondylolisthesis is unstable, meaning the slippage between adjacent vertebrae increases with lumbar flexion or extension, or with standing,


Neurology_Adams

Neurology_Adams. neurologic features, however, tend not to be severe. When spondylolisthesis is unstable, meaning the slippage between adjacent vertebrae increases with lumbar flexion or extension, or with standing, new symptoms may appear abruptly in the form of foot drop, urinary retention, or overflow incontinence. The instability is evidenced on conventional radiographs by a change in the diameter of the spinal canal as the patient moves between the flexed and extended position of the back.


Neurology_Adams

Neurology_Adams. A striking syndrome that has been attributed to lumbar stenosis consists of painful legs–moving toes, described by Spillane. There is burning leg pain and continuous and complex rhythmic movements of the toes, as the name implies. Symptoms may begin on one side but become bilateral. Lumbar nerve root compression, most often from stenosis, but sometimes from other types of peripheral damage, underlie most cases. It is worth comment from our own experience that certain symptoms are sometimes incorrectly attributable to lumbar stenosis; these include imbalance and falling, isolated Romberg sign, and painless progressive foot or leg weakness. Each of these may be embedded in an otherwise typical case of lumbar stenosis but they are more often attributable to other problems such as polyneuropathy or cervical spondylosis.


Neurology_Adams

Neurology_Adams. Surgical treatment of lumbar stenosis Decompression of the spinal canal relieves the symptoms of lumbar stenosis in a large proportion of cases, but the results have been inconsistent. Patients must be chosen carefully for surgery, and success is likely if the clinical features conform to the typical syndrome, mainly pain that altered in various positions and at least partially relieved by rest, with definite evidence of root compression by imaging. In perhaps the most careful trial comparing surgery to conservative treatment for lumbar spinal stenosis, pain and overall function at 2 years was several-fold better in those who had operations (Weinstein et al, 2008). However, interpretation was hampered by a large number of patients who crossed over between arms of the study.


Neurology_Adams

Neurology_Adams. Issues pertaining to the methodology of operation, particularly the need for fusion of the lumbar spine to limit mobility are of interest because of their increased cost over simple decompression but also because patients may query the neurologist about these matters. When there is spondylolisthesis and instability of adjacent segments, current opinion appears to favor fusion in order to reduce worsening spondylolisthesis and back pain. In the absence of slippage and instability, there is evidence from one trial that better patient satisfaction is attained with fusion after the second year compared to simple decompression (Ghogawala et al) but another series has shown little difference before that time. There is also concern about the rates of reoperation at the original level or at adjacent levels, which are destabilized by surgery and subject to spondylolisthesis and restenosis. Some cases of advanced lumbar stenosis have “autofused” adjacent segments may not benefit from the more


Neurology_Adams

Neurology_Adams. levels, which are destabilized by surgery and subject to spondylolisthesis and restenosis. Some cases of advanced lumbar stenosis have “autofused” adjacent segments may not benefit from the more extensive operation.


Neurology_Adams

Neurology_Adams. Epidural glucocorticoid injections have been used for some time as a temporizing treatment for the pain of lumbar stenosis but a randomized trial conducted by Friedly and colleagues found no difference in disability or leg pain 6 weeks after one or two such injections. Nevertheless, the procedure is still widely used and some patients report relief, which is difficult to separate from the natural course of the process. A series of cases of meningitis that resulted from contaminated drug obtained wide attention but is less likely to occur in the future. Various physical therapy maneuvers and exercises may be helpful in the short run but none has been validated in comparison to others. Insofar as lumbar stenosis can cause a cauda equina syndrome, its differential diagnosis is also considered in Chap. 42 on diseases of the spinal cord. Degenerative Osteoarthritis of the Spine


Neurology_Adams

Neurology_Adams. Chronic and recurring back pain caused by degenerative arthritic disease is among the most common disorders in general practice. It occurs in later life and may involve all or any part of the spine but is most prevalent in the cervical and lumbar regions. The pain is described as a stiffness that is centered in the affected part of the spine. It is increased initially by movement and is associated with limitation of motion but is often worse on arising in the morning. In contrast to the spinal claudicatory syndrome of lumbar stenosis, warming up and progressive mobilization make the pain better. There is a notable absence of systemic symptoms such as fatigue, malaise, or fever, and, more importantly, there are usually no features of radicular compression although vague aching may be felt in a sciatic distribution. In contrast to conventional lumbar root compression, the straight-leg raising tests do not elicit pain. The sitting position is usually comfortable, although stiffness and


Neurology_Adams

Neurology_Adams. in a sciatic distribution. In contrast to conventional lumbar root compression, the straight-leg raising tests do not elicit pain. The sitting position is usually comfortable, although stiffness and discomfort are accentuated when the erect posture is resumed.


Neurology_Adams

Neurology_Adams. The severity of the symptoms often bears little relation to the radiologic changes; pain may be present despite minimal radiographic findings; conversely, marked osteophytic overgrowth with spur formation, ridging, bridging of vertebrae, narrowing of disc spaces, subluxation of posterior joints on flexion, and air in the disc spaces can be seen in both symptomatic and asymptomatic persons.


Neurology_Adams

Neurology_Adams. This syndrome has been somewhat clarified in recent years but its definition remains imprecise. In one form, osteoarthritic degeneration of the facet joint gives rise to a focal parasagittal lumbar back pain, with variable tenderness over the joint but without signs of nerve root compression. The pain can be quite severe, worse at night, and prevent sleep if no comfortable position can be found. Nonsteroidal anti-inflammatory drugs are helpful. Some patients have discovered that they may obtain temporary relief from facet pain by forcefully twisting or stretching the back and creating an audible pop at the affected joint, comparable to chiropractic manipulation. Over time, they acquire a laxity of the supporting structures of the joint, which may actually perpetuate the problem.


Neurology_Adams

Neurology_Adams. The diagnosis is confirmed when the pain is relieved for a variable period by injection of the joint with local anesthetic. Often one is uncertain whether it was the analgesic effect on the joint or the infiltration of the region around the nerve root that has relieved the pain. Two controlled studies have suggested the procedure of corticosteroid injections into the facet joints is ineffective, both in the short and long term (Carette et al, 1991; Lilius et al). Notwithstanding these reports, we have found the injection of analgesics and steroids in and around the facet to be a useful temporizing measure in some patients. Epidural injections of steroids have no clear role in the treatment of this condition. If the diagnosis is established by local injection, many centers offer radiofrequency ablation of the small recurrent sensory nerves that innervate the joint as a means of permanent relief. This has met with some success, but has not been studied systematically.


Neurology_Adams

Neurology_Adams. Some writers have used the term facet syndrome to describe a painful state from facetal hypertrophy that gives rise to a lumbar radiculopathy, indistinguishable from that caused by a ruptured disc or spondylotic disease. Reynolds and colleagues have documented such cases. At operation, the spinal root is compressed against the floor of the intervertebral canal by overgrowth of an inferior or superior facet. Foraminotomy and facetectomy, after exploration of the root from the dural sac to the pedicle, have relieved the pain in some operated cases.


Neurology_Adams

Neurology_Adams. With the disappearance of oil based media for myelography, this is now infrequently encountered. It is a thickening and opaqueness of the arachnoid membrane of the lumbar spinal cord or thickening of the arachnoidal sheaths around the individual roots (normal roots have essentially no epineurium). According to one review, lumbar arachnoiditis even in the past was rare, having occurred in only 80 of 7,600 myelograms, and it should only rarely occur with modern group of water-soluble dyes for myelography if they are used a proper concentration. The clinical features are intractable low-back and leg pain and paresthesia, all positionally sensitive, in combination with neurologic abnormalities referable to lumbar spinal roots.


Neurology_Adams

Neurology_Adams. Multiple previous myelograms (largely a problem of the past), disc rupture, operative procedures, infections, and subarachnoid bleeding have been associated with the process. Some cases have followed spinal anesthesia and even epidural anesthesia by a period of months or years but the mechanism is often not clear. The presumption is that the dura had been breached and often there were clinical signs of aseptic meningitis soon after the procedure. In the absence of such an acute reaction, the later diagnosis of arachnoiditis rests on less-certain grounds.


Neurology_Adams

Neurology_Adams. The MRI shows eccentrically thickened meninges in the spinal canal with arachnoid adhesions and collections of CSF that displace nerve roots (Fig. 10-5). Abnormalities may be even more striking on CT myelographic studies in which the contrast is loculated and fails to outline the roots. Treatment is generally unsatisfactory. Lysis of adhesions under an operating microscope and administration of intrathecal steroids have been of little value, although some experienced surgeons claim otherwise. Epidural injection of steroids is occasionally helpful according to some of our orthopedic surgeon colleagues.


Neurology_Adams

Neurology_Adams. This disorder, referred to in the past as rheumatoid spondylitis and as von Bechterew or Marie-Strümpell arthritis, predominantly affects young adult men. Approximately 95 percent of patients carry the histocompatibility antigen HLA-B27 (which is present in only 7 percent of nonaffected persons of European extraction). Pain, usually centered in the low back, is the main early complaint. Often it radiates to the back of the thighs and groin. At first, the symptoms are vague (tired back, “catches” up and down the back, sore back), and the diagnosis may be overlooked for many years. Although the pain is recurrent, limitation of movement is constant and progressive and comes to dominate the clinical picture. Early in the course of disease there is only morning stiffness or an increase in stiffness after periods of inactivity similar to lumbar osteoarthritis but unusual for the affected age group. In advanced stages, a cauda equina compression syndrome may complicate ankylosing


Neurology_Adams

Neurology_Adams. in stiffness after periods of inactivity similar to lumbar osteoarthritis but unusual for the affected age group. In advanced stages, a cauda equina compression syndrome may complicate ankylosing spondylitis, the result apparently of an inflammatory reaction and proliferation of connective tissue (Matthews). Limitation of chest expansion, tenderness over the sternum, decreased motion and tendency to progressive flexion of the hips, and the characteristic immobility and flexion deformity of the spine (“poker spine”) may be present early in the course of the disease.


Neurology_Adams

Neurology_Adams. The typical imaging hallmarks are destruction and subsequent obliteration of the sacroiliac joints, followed by bony bridging of the vertebral bodies to produce the characteristic “bamboo spine.” When this change becomes apparent, the pain usually subsides, but the patient by then has little motion of the back and neck. An unusual additional feature, almost unique to this condition, is an extreme dilatation of the lumbar thecal sac. Ankylosing spondylitis may also be accompanied by the Reiter syndrome, psoriasis, and inflammatory diseases of the intestine (see also Chap. 42). The great risk in this disease is fracture dislocation of the spine from relatively minor trauma, particularly flexion–extension injuries.


Neurology_Adams

Neurology_Adams. Occasionally ankylosing spondylitis is complicated by destructive vertebral lesions. This complication should be suspected whenever the pain returns after a period of quiescence or becomes localized. The cause of these lesions is not known, but they may represent a response to nonunion of fractures, taking the form of an excessive production of fibrous inflammatory tissue. When it is severe, ankylosing spondylitis may involve both hips, greatly accentuating the back deformity and disability. Rheumatoid arthritis of the spine may be confined to the cervical region and creates risk of fracture–dislocation; it is considered again further on in this chapter. Neoplastic and Infectious Diseases of the Spine (See Also Chap. 42)


Neurology_Adams

Neurology_Adams. Metastatic carcinoma (breast, bronchus, prostate, thyroid, kidney, stomach, uterus), multiple myeloma, and lymphoma are the common malignant tumors that involve the spine. The primary lesion may be small and asymptomatic, and the first manifestation of the tumor may be pain in the back caused by metastatic deposits. The pain is constant and dull; it is often unrelieved by rest and is generally worse at night, interrupting sleep. Radicular pain may be added if the metastasis extends laterally. A fracture of a vertebral body in an otherwise healthy young or middle-aged person should alert the physician to the possibility of an underlying metastasis. At the time of onset of the back pain, there may be no radiographic changes on plain radiographs; when such changes do appear, they usually take the form of destructive lesions in one or several vertebral bodies with little or no involvement of the disc space, even in the face of a compression fracture. However, the changes are evident on CT


Neurology_Adams

Neurology_Adams. the form of destructive lesions in one or several vertebral bodies with little or no involvement of the disc space, even in the face of a compression fracture. However, the changes are evident on CT and MRI or radioactive isotope scan that detects areas of osteoblastic activity caused by neoplastic or inflammatory disease.


Neurology_Adams

Neurology_Adams. Infection of the vertebral column, osteomyelitis, is usually caused by staphylococci and less often by coliforms and mycobacteria. The patient complains of subacute or chronic pain in the back, which is exacerbated by movement but not materially relieved by rest. Motion becomes limited, and there is percussion-induced tenderness over the spine in the involved segments and pain with jarring of the spine, as occurs when the heels strike the floor. Often these patients are afebrile and do not have a leukocytosis. The erythrocyte sedimentation rate and C-reactive protein are elevated as a rule. CT and MRI characteristically demonstrate involvement of both the vertebral body and the adjacent intervertebral disc, and the finding of a breached disc space with involvement of two adjacent vertebral bodies is one of the features that differentiates infectious from neoplastic diseases of the spine. A paravertebral mass is often found, indicating an abscess, which may, particularly in the case of


Neurology_Adams

Neurology_Adams. bodies is one of the features that differentiates infectious from neoplastic diseases of the spine. A paravertebral mass is often found, indicating an abscess, which may, particularly in the case of tuberculosis, drain spontaneously at sites quite remote from the vertebral column. We have also encountered a number of patients with subacute bacterial endocarditis who complained of severe midline thoracic and lumbar back pain but had no evident infection of the spine.


Neurology_Adams

Neurology_Adams. Tuberculous spinal infection and the resultant kyphotic deformity (Pott disease) represent a special condition that is common in developing countries (see Chaps. 31 and 42).


Neurology_Adams

Neurology_Adams. Emphasis is placed on spinal epidural abscess, which usually necessitates urgent surgical treatment. Failure to properly identify this lesion has led to cases of paraplegia or death from sepsis. Most often this is caused by staphylococcal infection, which is carried in the bloodstream from a septic focus (e.g., furuncle) or is introduced into the epidural space from an osteomyelitic lesion. Another important avenue of infection is the intravenous self-administration of drugs and use of contaminated needles. Rarely, the infection is introduced in the course of a lumbar puncture, epidural injection, or laminectomy for disc excision. In some instances, the source of an epidural abscess cannot be ascertained. The main symptoms are low-grade fever, leukocytosis, and persistent and severe localized pain that is intensified by percussion and pressure over the vertebral spines. Additionally the pain may radiate in a radicular distribution. These symptoms mandate immediate investigation by MRI


Neurology_Adams

Neurology_Adams. pain that is intensified by percussion and pressure over the vertebral spines. Additionally the pain may radiate in a radicular distribution. These symptoms mandate immediate investigation by MRI or CT myelography and surgical intervention, preferably before the signs of paraplegia, sphincter dysfunction, and sensory loss become manifest. Small abscesses and granulomas that are the residua of previous and partially treated abscesses can be sometimes treated successfully with antibiotics alone as discussed further on and in Chap. 42 on “Diseases of the Spinal Cord.”


Neurology_Adams

Neurology_Adams. Intraspinal Hemorrhage (See Chap. 42) Sudden, excruciating midline back pain (le coup de poignard or “the strike of the dagger”)—often with rapidly evolving paraparesis, urinary retention, and numbness of the legs—may announce the occurrence of subarachnoid, subdural, or epidural bleeding. The most common causes of such an event are a coagulopathy (mainly from warfarin) and a spinal arteriovenous malformation (AVM), as discussed in Chap. 44. Spinal arterial aneurysms are much-less-common underlying lesions. It should be mentioned that focal back pain of comparable intensity may mark the onset of acute myelitis, spinal cord infarction, compression fracture, and, occasionally, Guillain-Barré syndrome.


Neurology_Adams

Neurology_Adams. This is the name applied to pain localized to the “tail piece,” the three or four small vestigial bones at the lower-most part of the sacrum. The trauma of childbirth, a fall on the buttocks, avascular necrosis, a neurofibroma or glomus tumor, other rare tumors and anal disorders, and, of course, pilonidal cyst, can sometimes be established as the cause of pain in this region. Far more often, the source remains obscure. In the past, patients in this latter group were indiscriminately subjected to coccygectomy, but more recent studies have demonstrated that most cases respond favorably to injections of local anesthetic and methylprednisolone or to manipulation of the coccyx under anesthesia (Wray et al).


Neurology_Adams

Neurology_Adams. It is a safe clinical rule that most patients who complain of low back pain have some type of primary or secondary disease of the spine and its supporting structures or of the abdominal or pelvic viscera. However, even after careful examination, there remains a sizable group of patients in whom no basis for the back pain can be found. Two categories can be recognized: one with postural back pain and pain after injury, and another with aggravating psychiatric illness, but there are always cases where the diagnosis remains obscure.


Neurology_Adams

Neurology_Adams. Low back pain may be a major symptom in patients with hysteria, malingering, anxiety, depression, and hypochondriasis as well as in many persons whose symptoms do not conform to any of these psychiatric illnesses. It is good practice to assume that pain in the back in such patients may signify disease of the spine or adjacent structures, and this should always be carefully sought. However, even when some organic factors are found, the pain may be exaggerated, prolonged, or woven into a pattern of invalidism because of coexistent primary or secondary factors. This is especially true when there is the possibility of secondary gain (notably workers’ compensation or settlement of personal injury claims). Patients seeking compensation for protracted low back pain without obvious structural disease tend, after a time, to become suspicious, uncooperative, and hostile toward their physicians or anyone who might question the authenticity of their illness. One notes in them a tendency to


Neurology_Adams

Neurology_Adams. disease tend, after a time, to become suspicious, uncooperative, and hostile toward their physicians or anyone who might question the authenticity of their illness. One notes in them a tendency to describe their pain vaguely and a preference to discuss the degree of their disability and their mistreatment at the hands of the medical profession. The description of the pain may vary considerably from one examination to other. Often also, the region(s) in which pain is experienced and its radiation are nonphysiologic, and the condition fails to respond to rest and inactivity. These features and a negative examination of the back should lead one to suspect a psychologic factor. A few patients, usually frank malingerers, adopt bizarre gaits and attitudes, such as walking with the trunk flexed at almost a right angle (camptocormia), and are unable to straighten up. Or the patient may be unable to bend forward even a few degrees, despite the absence of muscle spasm, and may wince at the


Neurology_Adams

Neurology_Adams. at almost a right angle (camptocormia), and are unable to straighten up. Or the patient may be unable to bend forward even a few degrees, despite the absence of muscle spasm, and may wince at the slightest pressure, even over the sacrum, which is seldom a site of tenderness unless there is pelvic disease.


Neurology_Adams

Neurology_Adams. The depressed and anxious patient with back pain represents a difficult problem. The disability seems excessive for the degree of spinal malfunction. Anxiety and depression may become important components of the back syndrome and the patient may ruminate about an undiagnosed cancer or other serious illness. In these circumstances, common and minor back ailments—for example, those caused by osteoarthritis and postural ache—are enhanced and rendered intolerable. Such patients are still subjected to unnecessary surgical procedures. It is not clear if one can depend on the diagnostic features of a response to drugs that alleviate depression.


Neurology_Adams

Neurology_Adams. Among the most difficult patients to manage are those with chronic low back pain who have already had one or more laminectomies and sometimes a fusion without substantial relief. In one perhaps dated but large series of patients operated on for proven disc prolapse, 25 percent were left with troublesome symptoms and 10 percent required further surgery (Weir and Jacobs). In such patients our suggestion has been to repeat the MRI or CT myelography. In a fair number it will be found that the disc has reruptured, or that there is unaddressed lateral recess stenosis, or that a disc or degenerative disease has appeared at the level just above, or less frequently, below the site of previous decompression. Whether decompression with fusion reduces or exaggerates the frequency of this last problem is not clear. EMG and nerve conduction studies, searching for evidence of a radiculopathy, are also helpful. If there is evidence of a radiculopathy but no disc material, or only scar tissue is seen


Neurology_Adams

Neurology_Adams. is not clear. EMG and nerve conduction studies, searching for evidence of a radiculopathy, are also helpful. If there is evidence of a radiculopathy but no disc material, or only scar tissue is seen on MRI, one cannot know whether the pain relates to injury from the initial rupture or is the aftermath of surgery (see reviews by Quiles et al and by Long).


Neurology_Adams

Neurology_Adams. One would suppose that these patients with chronic pain could be subdivided into a group with continued radicular pain and another with referred pain from disease of the spine. However, once the pain becomes chronic, the separation is not easy. Pressure over the spine, buttock, or thigh may cause pain to be projected into the leg. Lidocaine blocks of nerve roots have yielded inconsistent results. Transcutaneous stimulators, posterior column stimulators, intrathecal injections of analgesics, and epidural steroid injections have seldom helped for long in our experience, but we have seen striking exceptions, especially with epidural pumps that administer analgesics. At present, the best that can be offered the patient is weight reduction (in appropriate individuals), stretching and progressive exercise to strengthen abdominal and back muscles, as well as mild nonnarcotic analgesics and antidepressant drugs. A trial of epidural steroid injection, physiotherapy or a limited course of


Neurology_Adams

Neurology_Adams. exercise to strengthen abdominal and back muscles, as well as mild nonnarcotic analgesics and antidepressant drugs. A trial of epidural steroid injection, physiotherapy or a limited course of spinal chiropractic manipulation is reasonable.


Neurology_Adams

Neurology_Adams. PAIN IN THE NECK, SHOULDER, AND ARM It is useful to distinguish three major categories of painful disease of the neck and arms—that originating in the cervical spine, in the brachial plexus, and in the shoulder. Although the distribution of pain from each of these sources may overlap, the patient can usually indicate its site of origin. Pain arising from the cervical part of the spine is felt in the neck or back of the head and is projected to the shoulder and upper arm; it is evoked or enhanced by certain movements or positions of the neck and is accompanied by limitation of motion of the neck and by tenderness to palpation over the cervical spine.


Neurology_Adams

Neurology_Adams. Pain of brachial plexus origin is experienced in the supraclavicular region, or in the axilla and around the shoulder; it may be worsened by certain maneuvers and positions of the arm and neck (extreme rotation). A palpable abnormality above the clavicle may disclose the cause of the plexopathy (aneurysm of the subclavian artery, tumor, cervical rib). The combination of circulatory abnormalities and signs referable to the medial cord of the brachial plexus is characteristic of the thoracic outlet syndrome, described further on.


Neurology_Adams

Neurology_Adams. Pain localized to the shoulder region, worsened by motion, and associated with tenderness and limitation of movement, especially internal and external rotation and abduction, points to a tendonitis, subacromial bursitis, or tear of the rotator cuff, which is made up of the tendons of the muscles surrounding the shoulder joint. The term bursitis is often used loosely to designate these disorders. Shoulder pain, like spine and plexus pain, may radiate vaguely into the arm and rarely into the hand, but sensorimotor and reflex changes—which always indicate disease of nerve roots, plexus, or nerves—are absent. Shoulder pain of this type is very common in middle and late adult life. It may arise spontaneously or after unusual or vigorous use of the arm. Local tenderness over the greater tuberosity of the humerus is characteristic. Plain radiographs of the shoulder may be normal or show a calcium deposit in the supraspinatus tendon or subacromial bursa. MRI is able to demonstrate more subtle


Neurology_Adams

Neurology_Adams. of the humerus is characteristic. Plain radiographs of the shoulder may be normal or show a calcium deposit in the supraspinatus tendon or subacromial bursa. MRI is able to demonstrate more subtle abnormalities, such as muscle and tendon tears of the rotator cuff or a labral tear of the joint capsule. In most patients the pain subsides gradually with immobilization and analgesics followed by a program of increasing shoulder mobilization. If it does not, the injection of small amounts of corticosteroids into the bursa, or the site of major pain indicated by passive shoulder movement in the case of rotator cuff injuries, is often temporarily effective and allows the patient to mobilize the shoulder. The problem of the “frozen shoulder” is addressed further on.


Neurology_Adams

Neurology_Adams. Osteoarthritis and osteophytic spur formation of the cervical spine may cause pain that radiates into the back of the head, shoulders, and arm on one or both sides. Coincident compression of nerve roots is manifest by paresthesia, sensory loss, weakness and atrophy, and tendon reflex changes in the arms and hands. Should bony ridges form in the spinal canal, as described in detail in Chap. 42, the spinal cord may be compressed, with resulting spastic weakness, ataxia, and loss of vibratory and position sense in the legs (cervical spondylosis). The bony changes are evident on plain films but are better seen by CT and MRI. There may be difficulty in distinguishing cervical spondylosis with root and spinal cord compression from a disc (see further on) or from a primary neurologic disease (syringomyelia, amyotrophic lateral sclerosis, or tumor) with an unrelated cervical osteoarthritis. Here the MRI is of particular value in revealing compression of the spinal cord, but this study is


Neurology_Adams

Neurology_Adams. (syringomyelia, amyotrophic lateral sclerosis, or tumor) with an unrelated cervical osteoarthritis. Here the MRI is of particular value in revealing compression of the spinal cord, but this study is prone to overinterpretation when a bony ridge barely comes into contact with the cord but does not deform it (see “Cervical Spondylosis with Myelopathy” in Chap. 42).


Neurology_Adams

Neurology_Adams. Spinal rheumatoid arthritis may be restricted to the cervical facet joints and the atlantoaxial articulation. The usual manifestations are pain, stiffness, and limitation of motion in the neck and pain in the back of the head. In contrast to ankylosing spondylitis, rheumatoid arthritis is rarely confined to the spine. Because of evident disease of other joints, the diagnosis is relatively easy to make, but significant involvement of the cervical spine may be overlooked. In the advanced stages, one or several of the vertebrae may become displaced anteriorly, or a synovitis of the atlantoaxial joint may damage the transverse ligament of the atlas, resulting in forward displacement of the atlas on the axis (atlantoaxial subluxation). In either instance, serious and even life-threatening compression of the spinal cord may occur gradually or suddenly. Cautiously performed lateral radiographs in flexion and extension are useful in visualizing atlantoaxial dislocation or subluxation of the


Neurology_Adams

Neurology_Adams. of the spinal cord may occur gradually or suddenly. Cautiously performed lateral radiographs in flexion and extension are useful in visualizing atlantoaxial dislocation or subluxation of the lower segments. Occipital headache and neck pain related to degenerative changes in the upper cervical facets is discussed with other cranial pains in “‘Third Occipital Nerve’ Headache” (so-called third occipital nerve pain) in Chap. 9.


Neurology_Adams

Neurology_Adams. Traumatic and whiplash injury Injury to ligaments and muscles as a result of forcible extension and flexion of the neck can create a number of difficult clinical problems. The injury ranges from a minor sprain of muscles and ligaments to severe tearing of these structures, to avulsion of muscle and tendon from vertebral body, and even to vertebral and intervertebral disc damage. The latter lesions can be seen with MRI and, if severe, can result in root or spinal cord compression or, occasionally, in cartilaginous embolization of the spinal cord (see “Fibrocartilaginous Embolism” in Chap. 42). If there is preexisting cervical osteoarthritis, there may be considerable pain, and in extreme cases, cord compression.


Neurology_Adams

Neurology_Adams. However, the more ubiquitous and milder degrees of whiplash injury without the above described structural injuries are so often complicated by psychologic and compensation factors leading to prolonged disability that the syndrome becomes a vexing problem without clear medical definition and occupies a disproportionate amount of time on the part of physicians, compensation boards, and courts (see LaRocca for a review and the book by Malleson for an interesting discussion of the sociology and psychology of this subject). We have no doubt that authentic traumatic neck injuries exist, even at times from minor trauma, but we are in accord with the above-mentioned authors that the high frequency of this putative injury is sustained by societal and legal structures.


Neurology_Adams

Neurology_Adams. A common cause of neck, shoulder, and arm pain is disc herniation in the lower cervical region; the process is comparable to disc herniation in the lumbar region but gives rise, of course, to a different set of symptoms (Table 10-1). The problem appears most often without a clear and immediate cause, but it may develop after trauma, which may be major or minor (from sudden hyperextension of the neck, falls, diving accidents, forceful manipulations as discussed by Kristoff and Odom). The roots most commonly involved are the seventh (in 70 percent of cases) and the sixth (in 20 percent of cases); fifthand eighth-root compression makes up the remaining 10 percent (Yoss et al). The clinical diagnosis is established by a fairly discrete distribution of pain or paresthesias that corresponds to a single cervical root, reflex loss in the segment of the root, and by elicitation of exaggerated root pain with mechanical tests such as the Spurling maneuver, in which the examiner exerts downward


Neurology_Adams

Neurology_Adams. a single cervical root, reflex loss in the segment of the root, and by elicitation of exaggerated root pain with mechanical tests such as the Spurling maneuver, in which the examiner exerts downward pressure on the top of the head with the patient’s head turned to the affected side and the neck slightly extended. The latter test is not very sensitive but is specific in radiculopathy that has been confirmed by EMG or imaging. It is infrequent that the entire syndrome of pain, motor, reflex and sensory loss corresponding to a root is found and the region of pain is particularly variable in cervical radicular disease by comparison to lumbar root disease.


Neurology_Adams

Neurology_Adams. When the protruded disc lies between the sixth and seventh vertebrae, there is involvement of the seventh cervical root as outlined in Table 10-1. The pain is then in the region of the shoulder blade, or spine of the scapula, and posterolateral upper arm; it may project to the elbow and dorsal forearm, index and middle fingers, or all the fingers. Occasionally discomfort is felt in the pectoral or axillary region. Tenderness is most pronounced over the medial aspect of the shoulder blade opposite the third to fourth thoracic spinous processes and in the supraclavicular area and triceps region. Paresthesia and sensory loss are most evident in the index and middle fingers. Weakness involves the extensors of the forearm and sometimes of the wrist; occasionally the handgrip is weak as well; the triceps may be weak and the triceps reflex is usually diminished or absent; the biceps and supinator reflexes are preserved.


Neurology_Adams

Neurology_Adams. With a laterally situated disc herniation between the fifth and sixth cervical vertebrae, the symptoms and signs are referred to the sixth cervical root. The full syndrome is characterized by pain at the trapezius ridge and tip of the shoulder, with radiation into the anterior-upper part of the arm, radial forearm, often the thumb, and sometimes the index finger as well. There may also be paresthesia and sensory impairment in the same regions; tenderness in the area above the spine of the scapula and in the supraclavicular and biceps regions; weakness in flexion of the forearm (biceps) and in contraction of the deltoid when sustaining arm abduction; and diminished or absent biceps and supinator reflexes (the triceps reflex is retained or sometimes has the appearance of being slightly exaggerated because of flaccidity of the biceps).


Neurology_Adams

Neurology_Adams. The fifth cervical root syndrome, produced by disc herniation between the fourth and fifth vertebral bodies, is characterized by pain in the shoulder and trapezius region and by supraand infraspinatus weakness, manifest by an inability to abduct the arm and rotate it externally with the shoulder adducted (weakness of the supraand infraspinatus muscles). There may be a slight degree of weakness of the biceps and a corresponding reduction in the reflex, but these are inconsistent findings. A small patch of diminished sensation commonly overlies the deltoid muscle.


Neurology_Adams

Neurology_Adams. Compression of the eighth cervical root (by a C7-T1 disc) may mimic ulnar nerve palsy. The pain is along the medial side of the forearm and the sensory loss is in the distribution of the medial cutaneous nerve of the forearm and of the ulnar nerve in the hand. The weakness largely involves the intrinsic muscles supplied by the ulnar nerve (see “Ulnar Nerve” in Chap. 43). The reflexes may be unaffected but the triceps jerk is often slightly reduced.


Neurology_Adams

Neurology_Adams. These syndromes are usually incomplete in that only one or several of the typical findings are present. Particularly noteworthy is the occurrence, in laterally placed cervical disc rupture, of isolated weakness without pain, especially with discs at the fifth and sixth levels. Friis and coworkers in the text by Finnesen have described the distribution of pain in 250 cases of herniated disc or spondylotic nerve root compression in the cervical region. Virtually every patient, irrespective of the particular root(s) involved, showed a limitation in the range of motion of the neck and aggravation of pain with movement (particularly hyperextension). Coughing, sneezing, and downward pressure on the head in the hyperextended position usually exacerbated the pain, and traction (even manual) tended to relieve it.


Neurology_Adams

Neurology_Adams. Unlike herniated lumbar discs, cervical ones, if large and centrally situated, result in compression of the spinal cord (Fig. 10-6). The centrally situated disc is often painless, and the cord syndrome may simulate multiple sclerosis or a degenerative neurologic disease. Bilateral hand numbness, paresthesia, or similar altered sensation is common. Failure to consider a protruded cervical disc in patients with obscure symptoms in the legs, including stiffness and falling, is a common error. A vague sensory change can often be detected on the thorax, the rostral margin of which is several dermatomes below the level of compression. The diagnosis and the level of disc protrusion can be confirmed by MRI or by CT myelography. Nerve conduction studies, F responses, and EMG are helpful in confirming the level of root compression and distinguishing pain of radicular origin from that originating in the brachial plexus or in individual nerves of the arm (see “Brachial Neuritis” in Chap. 43).


Neurology_Adams

Neurology_Adams. Management of Herniated Cervical Disc Conservative measures should be instituted before turning to surgical removal of the disc unless there are signs of a rapidly or subacutely progressing myelopathy (i.e., leg and arm weakness, hyperreflexia in the legs, gait ataxia, sphincteric dysfunction). In the case of cervical disc with radicular pain, a close-fitting foam collar is sometimes beneficial although there is controversy about the efficacy of this type of immobilization. The collar should be fitted so that minimal flexion and extension of the neck are allowed, but it must remain comfortable enough to encourage consistent use. The patient is advised to wear the collar at all times during the day, especially while riding in a car, unless this becomes completely impractical. Although of uncertain value, traction with a halter around the occiput and chin may be of some benefit in cervical disc syndromes. Analgesic medication may be required for a few days.


Neurology_Adams

Neurology_Adams. In most instances the radicular pain subsides over a few weeks or less but severe or intractable cases may require surgery, especially if there is substantial weakness in the muscles corresponding to the affected root. Mild weakness alone is not recognized as an indication for surgery, and in those few cases where weakness alone has occurred, without pain, the same conservative measures outlined above should be considered. Most often the surgeon tackles this problem through an anterior approach (transdiscally), which leaves the posterior elements intact and allows for remaining stability of the spine but, if there is concern for future instability, a fusion of various types is added. Cervical Spondylosis (See Also Chap. 42)


Neurology_Adams

Neurology_Adams. This is a chronic degenerative disease of the mid-and lower cervical spine that narrows the spinal canal and intervertebral foramina, causing compressive injury of the spinal cord and roots. The problem of central disc protrusion, discussed above, often contributes as one component of the narrowing of the canal. Because the main effects of cervical spondylosis are on the cord, this process is discussed in detail in Chap. 42, but cervical spondylosis is also a common cause of neck and arm pain, as described earlier. If minor signs of spinal cord and root involvement are present, a collar to limit movement of the head and neck may halt the progression and lead to improvement. Decompressive laminectomy or anterior excision of single spondylotic spurs and fusion are reserved for instances of the disease with advancing neurologic symptoms or intractable pain as discussed in Chap. 42. As with lumbar stenosis, success is not assured with surgery but can help prevent further progression of


Neurology_Adams

Neurology_Adams. the disease with advancing neurologic symptoms or intractable pain as discussed in Chap. 42. As with lumbar stenosis, success is not assured with surgery but can help prevent further progression of symptoms.


Neurology_Adams

Neurology_Adams. A number of anatomic anomalies occur in the lateral cervical region. These may, under certain circumstances, compress the brachial plexus, the subclavian artery, and the subclavian vein, causing muscle weakness and wasting, pain, and vascular abnormalities in the hand and arm. The condition is undoubtedly diagnosed more often than is justified, and the term has been applied ambiguously to a number of conditions, some of which are almost certainly nonexistent, comparable to the pyriformis syndrome in the buttock.


Neurology_Adams

Neurology_Adams. The most frequent of the abnormalities that cause neural compression, encompassed by the term thoracic outlet syndrome, is an anomalous incomplete cervical rib, with a sharp fascial band passing from its tip to the first rib; a taut fibrous band passing from an elongated and down-curving transverse process of C7 to the first rib; less often, a complete cervical rib, which articulates with the first rib; and anomalies of the position and insertion of the anterior and medial scalene muscles. Thus, the sites of potential neurovascular compression extend all the way from the intervertebral foramina and superior mediastinum to the axilla. Depending on the postulated abnormality and mechanism of symptom production, the terms cervical rib, anterior scalene, costoclavicular, and neurovascular compression have been applied. In addition, a droopy shoulder syndrome has been identified that purportedly stretches the brachial plexus and gives rise to similar symptoms; a majority of the patients


Neurology_Adams

Neurology_Adams. have been applied. In addition, a droopy shoulder syndrome has been identified that purportedly stretches the brachial plexus and gives rise to similar symptoms; a majority of the patients have been young women with asthenic body habitus.