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Neurosurgery Session 1 - Back Pain Zakariya VansohLearning Objectives • Appreciate the bony structures and joints of the vertebral column, with specific attention to the atlas and axis • Recognise common degenerative changes to both the joints, as well as the common fracture types at different levels, and explain the clinical significance • Explain the gross anatomy of the spinal cord, including the roots and spinal nerves, as well as formation of the cauda equina • Understand the aetiology and clinical signs of spinal cord compressions at different levels, including the red flag features of cauda equina; describe the surgical management of both (notably laminectomy) • Describe the connective tissue structure of the vertebral column • Describe the aetiologies, presentations and management of disc herniation, as well as the layers that must be passed through by a needle when performing lumbar punctureLearning Objectives • Understand the importance of the pars interarticularis and the clinical significance of pars fractures - especially “hangman fractures”Vertebral Column AnatomyVertebral Column AnatomyVertebral Column Anatomy Specialized vertebrae – C1 C1- Atlas • No body or spinous process • Anterior Arch • Posterior Arch • Superior Articular Surface • Inferior Articular SurfaceVertebral Column Anatomy Specialized vertebrae – C2 C2-Axis • Rounded Superior Articular Facets • Dens (odontoid processVertebral Column Anatomy C1 and C2: Joints Atlanto-axial Joint C1/C2 Rotation Dens (odontoid process) Atlanto-occipital Joint C1/Occipital Bone ‘noddingVertebral Column AnatomyVertebral Column Anatomy Movements of the vertebral column Factors influencing movement: ● IV discs Shape of articular facet ● Joint capsule ● Surrounding tissues and structureVertebral Column Anatomy- Summary ● The vertebral column has 33 vertebrae grouped as cervical, thoracic, lumbar, sacral, and coccygeal. ● Atlas (C1) & Axis (C2): Specialised for head movement. ● Tenables rotation.tal joint allows nodding, and the atlantoaxial joint ● Movement depends on intervertebral discs, facet joints, and surrounding tissues.Vertebral Column Anatomy- SBA Question Which of the following structures is responsible for the primary rotational movement of the head? A) Atlanto-occipital joint B) Atlanto-axial joint C) Intervertebral discs D) Facet joints of the lumbar spineVertebral Column Anatomy- SBA Question Which of the following structures is responsible for the primary rotational movement of the head? A) Atlanto-occipital joint B) Atlanto-axial joint C) Intervertebral discs D) Facet joints of the lumbar spinePathology of the Vertebral Column Back Pain ● Mechanical back pain (remember most do not have a clear pathoanatomic cause) ● Lumbar radiculopathy a.k.a sciatica ● Osteoarthritis ● Spinal cord compression, cauda equina syndromePathology of the Vertebral ColumnPathology of the Vertebral Column Ankylosing spondylitis ● Back pain ● Insidious onset ● Improved by exercise, worsens with rest ● Pain in the buttocks ● Hip painPathology of the Vertebral Column Sacroiliac jointPathology of the Vertebral Column SacroiliitisPathology of the Vertebral Column Ankylosing spondylitis-Treatment ● Patient education-exercise and posture training ● Patient support groups ● Stop smoking ● Physiotherapy ● Non-steroidal anti-inflammatory drugsPathology of the Vertebral Column Lumbar radiculopathyPathology of the Vertebral Column Lumbar vertebraePathology of the Vertebral Column Lumbar vertebraePathology of the Vertebral Column Lumbar vertebraePathology of Vertebral Column - Summary ● Ankylosing Spondylitis: Chronic inflammatory condition, young men, sacroiliac joint involvement, “bamboo spine” on X-ray. ● Mechanical Back Pain: Most common, often non-specific, self-limiting. ● Sciatica (Lumbar Radiculopathy): Due to nerve root compression, typically from disc herniation. ● Osteoarthritis: Degenerative changes affecting facet joints and discs. ● Spinal Cord Compression: Can be due to disc herniation, tumors, or trauma.Vertebral Column Anatomy- SBA Question spondylitis? following is NOT a feature of ankylosing A) Morning stiffness improves with activity B) Strong association with HLA-B27 C) Sacroiliac joint involvement D) Increased risk of cervical spondylosisVertebral Column Anatomy- SBA Question Which of the following is NOT a feature of ankylosing spondylitis? A) Morning stiffness improves with activity B) Strong association with HLA-B27 C) Sacroiliac joint involvement D) Increased risk of cervical spondylosisAnatomy of the spinal cord The spinal cord is an oval cylinder that tapers slightly as it descends and has two bulges There are 31 Pairs of spinal nerves: 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal Anatomy of the spinal cord White matter consists of ascending and descending tracts of myelinated nerve fibres. Gray matter consists chiefly of cell bodies and unmyelinated nerve fibres. Note the shape of grey matter changes throughout the spinal cord. Also notice the stain, spinal cord (white matter purple! And gray matter lighterAnatomy of the spinal cord ● Conus medullaris ● Cauda equina ● Filum terminaleAnatomy of the spinal cord The spinal cord receives its arterial supply from anterior and posterior spinal arteries that arise from vertebral arteries. Anatomy of the spinal cord Two deep grooves, the anterior/ventral median fissure (deep fissure) and the posterior/dorsal median sulcus Funiculi - 3 white columns dorsal, lateral and ventral Dorsal and Ventral (and lateral) grey hornsAnatomy of spinal cord - Summary ● The spinal cord runs from foramen magnum to L1-L2. ● 31 spinal nerve pairs (8C, 12T, 5L, 5S, 1Co). ● White matter: myelinated nerve tracts. Gray matter: cell bodies. ● Ends in the conus medullaris, continues as cauda equina. ● Blood supply: Anterior & posterior spinal arteries from vertebral arteries.Anatomy of spinal cord SBA At which vertebral level does the spinal cord terminate in most adults? A) T12 B) L1-L2 C) L3-L4 D) S1Anatomy of spinal cord SBA At which vertebral level does the spinal cord terminate in most adults? A) T12 B) L1-L2 C) L3-L4 D) S1 Pathology of the spinal cord Lumbar radiculopathy ● Most commonly due to: -Disc herniation -Spondylosis due to degenerative osteoarthritis Pathology of the spinal cord Lumbar radiculopathy ● Presentation will vary depending on which nerve root is involved -Each nerve root provides sensation to part of the skin (dermatome) -Provides innervation to certain muscles (myotome) ● L5 radiculopathy is most common -Back pain radiating down the lateral aspect of the leg into the foot -Weakness ● Foot dorsiflexion ● Toe extension ● Foot inversion and eversionPathology of the spinal cord DermatomesPathology of the spinal cord Myotomes Pathology of the spinal cord What are red flags? •Progressive or severe motor deficit •Suspected or known cancer (could be due to metastases) •Suspected infection (could be an abscess) •Urinary retention •Urinary or faecal incontinence •Numbness round the anus (saddle anaesthesia), loss of anal sphincter tone •Bilateral symptoms Pathology of the spinal cord Treatment of mechanical back and radiculopathy •Exercise regimen •Keep active •Physiotherapy referral •Cognitive behavioural therapy •Pharmacological adjunct therapy •Nonsteroidal anti-inflammatory drug •Avoid opiates especially for chronic pain Pathology of the spinal cord Cauda equina syndrome •Central disc protrusion •Malignancy -Cancer spread to vertebra and compress lumbosacral nerve roots -Prostate, breast and lung are most common but any malignancy could cause it •Back pain is usually first followed by progressive neurological signs -Lower limb weakness -Bowel and bladder dysfunction including urinary retention -Sensory loss (often less prominent)Pathology of the spinal cord Cauda equina syndrome is a medical emergency •Urgent referral and MR scan spine •Neurosurgical intervention may be required Pathology of spinal cord - Summary Lumbar Radiculopathy (Sciatica): -L5 most commonly affected → weakness in foot dorsiflexion, toe extension. -Symptoms depend on the dermatome & myotome affected. Red Flag Signs for Spinal Pathology: -Progressive motor deficit -Saddle anesthesia -Urinary retention/incontinence -History of malignancy or infection Cauda Equina Syndrome (Medical Emergency!): -Bilateral leg weakness, bladder/bowel dysfunction, perineal numbness. -Requires urgent MRI + surgical decompression (laminectomy).Pathology of spinal cord - SBA Which of the following symptoms suggests cauda equina syndrome? A) Radicular pain down the right leg B) Loss of knee reflex only C) Saddle anesthesia and urinary retention D) Low back pain with normal neurological examinationPathology of spinal cord - SBA Which of the following symptoms suggests cauda equina syndrome? A) Radicular pain down the right leg B) Loss of knee reflex only C) Saddle anesthesia and urinary retention D) Low back pain with normal neurological examinationBack Pain- Summary •Very common -For majority maintaining an active lifestyle will resolve symptoms -Changes in work environment may be needed •Ankylosing spondylitis-inflammatory back pain -Remember to consider this, easy to miss •Sciatica -Understand the nerve roots -Encourage activity •Watch out for signs of cauda equina compression