Common cervico/lumbar pathologies beyond the

herniated discKatie Krause MD, PhD

Virginia Mason Neurosurgery

Cervical

• Cervical spondylotic myelopathy

• Ossification of the Posterior Longitudinal Ligament (OPLL)

• Diffuse idiopathic skeletal hyperostosis (DISH)

• Rheumatoid arthritis pannus

Cervical spondyloticmyelopathy (CSM)

• Spondylosis: general term referring to the degeneration of intervertebral discs, vertebral bodies, and ligamentous structures

• A process associated with aging

• Rare before the age of 50

• CSM likely multifactorial

• Dynamic forces: increased motion

• Static forces: ischemic changes

Davies et al BMJ 2018;360:k186

• Normal anterior-posterior canal diameter 13-17 mm

∙<13 mm considered stenotic

Cervical spondyloticmyelopathy (CSM)

• Presentation• Vague complaint of axial neck pain/stiffness, dull

arm pain• Numbness• Clumsiness• Weakness• Difficulty with gait• Loss of bladder/bowel control

• Exam: • True pyramidal weakness, upper limb > lower• Sensory loss• Hoffman’s• Clonus• Hyperreflexia• Gait disturbance

Cervical spondyloticmyelopathy (CSM)

• Treatment

• Conservative therapies with rare success

• Mostly a surgical disease

• Depending on the severity of the disease, the goal is to halt progression, with secondary goal to reverse injury

Anterior cervical discectomy and fusion (ACDF)

• Offers direct decompression of the spinal cord when the offending cause is a protruding disc or osteophyte

• Offers indirect decompression when a graft is placed within the disc space, widening the foramen

• Can help restore any loss of lordosis

Anterior cervical discectomy and fusion (ACDF)

• Complications:

• Dysphagia

• Dysphonia

• Esophageal perforation

• Vertebral artery damage

• Horner’s syndrome (ptosis, miosis, and anhidrosis)

• Post-operative neck hematoma leading to airway compromise

Ossification of the Posterior Longitudinal Ligament (OPLL)

• Hyperostosis and calcification of the PLL

• Twice as common in men > women

• More common in the Asian population (2-4%), but can be found in all

• Pathogenesis generally unknown, although associated with increased BMP-2, and often inherited

Ossification of the Posterior Longitudinal Ligament (OPLL)

• If symptomatic, commonly presents in the 5th- 6th

decade

• 25% of patients with myelopathy have evidence of OPLL

• Decreases the space available for the spinal cord

• Can be worse in the setting of congenitally narrowed canal or hyper-extension injury

• Treatment

• None if asymptomatic

• Surgery if myelopathic

• Abiola et al Global Spine J. 2016 Mar; 6(2): 195–204

Laminoplasty

• Expansion of the posterior arch providing direct decompression

• Allows the spinal cord to drift backward, providing indirect decompression

• Non-fusion alternative

• May decrease accelerated adjacent segment disease

• No risk of pseudarthrosis associated with fusion procedures

• May prevent/lessen post-laminectomy kyphosis

• Weinberg et al J Spine Surg. 2020 Mar; 6(1): 290–301

Diffuse Idiopathic Skeletal Hyperostosis (DISH)

• Characterized by the ossification of ligaments, most often affecting the spine

• Bulky ossification Anterior Longitudinal Ligament• 4 contiguous vertebrae

• Preserved disk height

• Absence of ankylosis of facet joints

• Often described as “candle wax dripping down the spine”

• Seems to be age-related, rather than a disease process

• Thought to affect 25% of older adults

• Twice as common in men > women

• Associated with DM2 and obesity• Suggested to be phenotypic expression of

metabolic syndrome

Diffuse Idiopathic Skeletal Hyperostosis (DISH)

• Presentation• Can be asymptomatic

• Axial neck/back pain

• Stiffness

• Dysphagia

• Generally no loss of range-of-motion

Diffuse Idiopathic Skeletal Hyperostosis (DISH)

• Predisposes to major fracture from minor trauma

• 4-8 fold risk of fracture from low-impact trauma

• Especially prone to fracture in hyper-extension injuries

• High risk of unstable fracture pattern and neurological injury

• Treatment

• Generally empiric, conservative management

• Surgery often for fracture or dysphagia

Rheumatoid Arthritis (RA)

• Chronic systemic autoimmune inflammatory polyarthropathy that mostly involves the hand and feet, although any joint lined by synovial membrane may be involved

• Female: male = 3:1

• White more affected than non-whites

• Onset 35- 50 years

• Autoimmune response that stimulates proliferating inflammatory cells, resulting in a build-up of granulation tissue

• Destroys cartilage, ligaments, tendons, bone

Rheumatoid Arthritis (RA)

• Does not typically affect the axial spine

• Atlantoaxial joint is synovial-lined and thus susceptible to proliferative synovitis and pannus formation

• 3rd most common joint involved

• Neck stiffness, headache

• Instability/subluxation due to rupture of the transverse ligament

• Myelopathy (Weakness => quadriparesis, sensory deficits, sphincter dysfunction, hyperreflexia)

• Occipital neuralgia due to compression of the C2 nerve

• TIA/cerebellar signs

• Vertebral artery impingement from subluxation

• Basilar artery impingement from upward displacement of dens

Rheumatoid Arthritis (RA)

• Treatment

• NSAIDs, steroids, disease-modifying anti-rheumatic drugs

• Surgery: most often C1-2 fusion

• Can achieve stability, which can lead to resorption of retrodental pannus

Lumbar

• Spondylolisthesis

• Synovial cysts

• Tavlov cyst

• Ankylosing spondylitis

Spondylolisthesis

• The forward slippage of one vertebral body with respect to the one below it

• Most commonly involves L5-S1, followed by L4-5

• 6 types:

• Congenital: agenesis of the superior articular facet

• Isthmic: defect/fracture of the pars

• Degenerative: degeneration of the articular processes

• Traumatic: trauma NOT involving the pars

• Pathologic: ie, malignancy

• Iatrogenic: post-surgical

Spondylolisthesis

• Isthmic: Associated with defects in the pars interarticularis

• May be congenitally defective

• Repeated micro-stress

• Gravity

• Posture

• High intensity maneuvers in childhood

• Results in microfractures of the isthmus, often resulting in fibrous non-union and elongation of the pars, causing listhesis

• Also associated with degenerative disk disease, herniated disc, facet arthropathy, foraminal stenosis

Spondylolisthesis

• Meyerding grading scale, based on the amount of vertebral subluxation in the sagittal plane

• I: <25% vertebral diameter

• II: 25-50%

• III: 50-75%

• IV: 75-100%

• Spondyloptosis: >100%

Spondylolisthesis

• Presents with low back pain and radiculopathy, often exacerbated by motion

• Most common intervention requires an instrumented fusion procedure

• Transforaminal interbody fusion (TLIF)

• Anterior lumbar interbody fusion (ALIF)

Synovial cysts

• Can be found anywhere in the body

• Within the spine, there is a Lumbar predominance• L4-5 most common level

• Benign expansive cysts attached to facet joint

• Epithelium-lined capsule enclosing synovial fluid

• Can encroach into the epidural space, causing compression of thecal sac and nerve

• If symptomatic, present with radiculopathy or neurogenic claudication

• Symptoms can wax/wane with activity as the fluid expands and remits

• Often associated with spondylolisthesis

Synovial cyst

• Well-circumscribed, smooth, extra-dural, adjacent to facet

• Can sometimes be confused with tumor

• Should have same characteristics of synvovialfluid

• Can sometimes contain hemorrhage or calcification

Synovial cyst

• Treatment when symptomatic

• Percutaneous puncture• Can often recur

• Simple decompression with cyst resection often effective

• Instrumented fusion sometimes necessary

Tarlov cyst

• CSF-filled dilations in the nerve root sheath, generally along the dorsal root ganglion

• Most commonly found at the sacral level

• 5-10% of the general population

• 87% female

• Almost always asymptomatic

• If large, can present with coccygodynia, low back pain, buttock pain, radicular pain, possible urinary dysfunction

Tarlov cyst

• Often require no treatment or further investigation

• Can perform EMG, or urodynamics if reassurance required

• Will have same characteristics of CSF on imaging

• May result in bony remodeling if large

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Ankylosing spondylitis

• Multi-system inflammatory disorder that involved mostly the SI joint and spine

• Strong association with HLF-B27 (92%)

• Male: female = 3:1

• More common in white than non-white

• Age of onset young adulthood

• Lesions start with subchondral granulation tissue that erodes the joint, that is gradually replaced by cartilage and ossification

• In the spine, this occurs at the junction of the vertebrae and anulus fibrosus, giving rise to “bamboo spine”

Ankylosing spondylitis

• Lesions start with subchondral granulation tissue that erodes the joint, that is gradually replaced by cartilage and ossification

• In the spine, this occurs at the junction of the vertebrae and anulus fibrosus, giving rise to “bamboo spine”

• Can give rise to spinal deformity and predispose to fracture

Ankylosing spondylitis

• Presents with dull back pain and SI area that flares and remits

• Generally worse in the morning or inactivity, improves with exercise

• Stiffness

• Decreased ROM

• Generalized fatigue, and other systemic manifestations

• Uveiitis: most common

• Enthesitis: inflammation of ligamentous insertion sites

• Peripheral joint involvement: hips, shoulders

• Treatment

• No proven disease-modifying agents, possible success with TNF-a inhibitors

• Surgery indicated for correction of deformity or fracture