Overview
This lecture covers the evaluation and treatment of severe spinal pathology, focusing on spondylosis, multi-level disease, and distinguishing neurogenic from vascular claudication.
Severe Spine Pathology: Spondylosis and Imaging
- Spondylosis is arthritis of the spine with hyperintense bony changes and collapsing discs/end plates seen on MRI.
- Severe cases may show pinching of the spinal canal, often from herniated discs.
- Patients typically present with severe back and leg pain caused by nerve compression.
Surgical Decision-Making for Multi-Level Spine Disease
- Treatment options range from extensive surgery (realignment, fusion, decompression) to minimally invasive procedures.
- Determining which spinal level is causing symptoms is crucial for targeted intervention.
- Physical exam and history are essential to identify the primary pain generator.
- Instability of spinal bones (seen on X-ray) requires fusion; decompression alone worsens instability.
- Pain management techniques (e.g., nerve block) can help localize the symptomatic nerve.
Claudication: Neurogenic vs. Vascular
- Claudication is leg pain with exertion and can be neurogenic (nerve-related) or vascular (blood vessel-related).
- Symptoms: non-specific burning, weakness, worsening with walking; can affect one or both legs.
- Neurogenic claudication improves with forward flexion (e.g., biking is tolerated), worsens with extension.
- Vascular claudication is unrelated to position and always worsens with exertion.
- The most useful clinical clue: positional relief suggests neurogenic; lack of relief suggests vascular.
- Assessing pulses in lower extremities is generally outside of neurosurgeon's scope.
Key Terms & Definitions
- Spondylosis — degenerative arthritis of the spine, with bony changes and disc collapse.
- Herniated disc — displacement of disc material that compresses spinal nerves.
- Decompression — surgical removal of bone/disc material to relieve nerve pressure.
- Fusion — surgical joining of two or more vertebrae to prevent movement.
- Claudication — pain and weakness in the legs during activity due to nerve or blood vessel issues.
- Neurogenic claudication — leg pain from nerve compression, position-dependent.
- Vascular claudication — leg pain from reduced blood supply, not position-dependent.
Action Items / Next Steps
- Review the differences between neurogenic and vascular claudication.
- Practice identifying instability and primary pain sources using imaging and clinical history.