Yakin Doğu Üniversitesi - Near East University Neurosurgery Study Notes

Yakin Doğu Üniversitesi - Near East University Neurosurgery Study Notes

General Information

  • Course Title: Generative Spine Diseases
  • Instructor: Prof. Dr. Uygur ER
  • Faculty: Medical Faculty
  • Semesters: 5th and 6th

Course Aim

  • Overview of spinal diseases,
    • Disc herniation
    • Cervical, Thoracic, and Lumbar spine pathologies
    • Narrow Spinal Canal conditions
    • Lumbar Listhesis

Course Structure

1. Flow of Topics
  • Epidemiology: Study of disease distribution.
  • Signs and Symptoms: Clinical presentations of spine diseases.
  • Diagnosis: Methods to identify spinal disorders.
  • Treatment: Approaches to managing spine diseases.
  • Surgery: Surgical interventions for severe cases.
  • Follow-up: Post-treatment monitoring and assessment.
2. Intervertebral Disc (IVD)
  • Function:
    • Allows stable movement of the spine.
    • Provides support and distributes loads during movement.

Cervical Disc Herniation (CDH) - Epidemiology

  • Age Group: >40 years old
  • Common Age Range: 50-60 years
  • Gender Ratio: M/F = 3/2
  • Common Levels Affected: C5-6 and C6-7
  • Incidence: 5-20 per 1000 individuals.

Clinical Signs of CDH

Cervical Radiculopathy
  • Hereditary Levels: C4-5:
    • Requires 2% of cervical discs
    • Compressed nerve root at C5.
    • Symptoms include:
      • Diminished reflexes in deltoid and pectoralis muscles.
      • Motor weakness affecting deltoid and forearm flexion.
  • Level Specific Symptoms:
    • C5-6 (19%): Affects biceps & brachioradialis, hand intrinsics, potential wrist drop, sensation loss in shoulder, thumb, and radial forearm.
    • C6-7 (69%): Affects finger-jerk responses, paresthesia, and hypesthesia in fingers 2 & 3.
    • C7-1 (10%): Affects C8 and T1, pain with full extension.
Important Clinical Details of CDH
  • Pain types:
    • Axial neck pain
    • Pseudoangina at Left C6
    • Partial Horner's Syndrome in C8 and T1
    • Pain induced through head extension
    • Presence of Lhermitte's sign.
Radiculopathy Evaluations

  • Lower Motor Neuron (LMN) Signs:

    • Weakness limited to a myotome and unilateral.
    • Possible muscle atrophy and fasciculations.
    • Assessment of dermatomal sensations and Deep Tendon Reflexes (DTR).

  • Upper Motor Neuron (UMN) Signs:

    • Weakness in lower extremities, spasticity, and walking difficulties.
    • Assess for signs like:
    • Hoffmann's sign, Clonus.

Lumbar Disc Herniation (LDH) - Epidemiology

  • Lifetime Risk: 30% in individuals over 40.
  • Common Age Range: 30-50 years.
  • Gender Ratio: W/M = 2/1.
  • Most Affected Levels: L4-5 and L5-S1.
  • Incidence: 10-20 per 1000 individuals.
  • Prevalence: 1-3% of the population.
Testing for LDH
  • Tests:
    • Ipsilateral SLR (Straight Leg Raise)
    • Crossed SLR (positive if pain is elicited on the opposite side)
    • Ankle jerk and patellar reflex assessment.
    • Evaluation of strength in knee extension (quadriceps), dorsiflexion (anterior tibialis), and plantarflexion (gastrocnemius).
  • Comments on Testing:
    • Positive result occurs if pain is noted at elevation <60°
    • Reproduction of contralateral pain suggests potential upper LDH.

Hernia Types in LDH

  • Categories:
    • Posterior Longitudinal Ligament (PLL)
    • Extraforaminal Zone (Far Lateral Zone)
    • Foraminal Zone
    • Subarticular Zone (Lateral Recess)
    • Central Canal Zone
Root Syndromes in LDH
  • Common Symptoms:
    • Weakness, diminished reflexes.
    • Levels affected include:
    • L3-4 (3-10% prevalence)
    • L4 (40-45%)
    • L4-5 (45-50%)
    • L5 (40% prevalence)

Narrow Spinal Canal (NSC) - Epidemiology

  • Most Frequent Level: L4-5 among individuals >= 60 years old.
  • Radiologic Findings: 20% prevalence, with symptomatic manifesting in 4%.
  • General Prevalence: 5 per 100,000 annually.
  • Gender Ratio: W/M = 2/3.
NSC Definition
  • Spinal Stenosis: The narrowing of spinal spaces occupied by neural structures.
    • Types:
    1. Central narrowing of spinal canal
    2. Foraminal stenosis
    3. Lateral recess narrowing
Clinical Features of NSC
  • Neurogenic Claudication (Pseudoclaudication):
    • Symptoms resulting from compressive ischemia of nerves, needing differentiation from Vascular Claudication.
    • Symptoms include:
    • Pain, weakness, paresthesia, and cramps.
Differences between Neurogenic and Vascular Claudication

  • Neurogenic Claudication:

    • Pain in the distribution of affected nerve (dermatomal).
    • Symptoms can be variable based on exercise; exacerbated by prolonged postures. 65% experience pain on standing at rest.
    • Relief often requires resting in certain postures like sitting.

  • Vascular Claudication:

    • Pain pattern distributed according to muscle group vascular supply (sclerotomal).
    • Symptoms consistently reproduced by fixed exercise amounts; rare at rest.
    • Immediate relief upon cessation of exercise.

Central Narrowing of Canal Causes

  • Congenital: Short pedicle syndrome appearing at a younger age, compressing emerging root.
  • Acquired: Due to factors such as:
    • Facet hypertrophy
    • Ligament calcification & hypertrophy

Diagnostic Approaches

  • Lateral Flexion-Extension X-rays: Used for instability detection.
  • Non-contrast CT: Assess bony anatomy, calcifications, defects, fractures.
  • Myelo-CT: Detailed view of the canal and surrounding structures.
  • Non-enhanced MRI: Provides anatomy assessment of soft tissues.

Electromyography (ENMG) Diagnosis

  • Physiology-Function:
    • If a thorough motor examination is performed, ENMG may not provide new insights.
    • A normal motor examination indicates a normal EMG.
  • Sensitivity and Specificity:
    • Not sensitive in radiculopathy, but has high specificity when abnormalities are present.
    • Criteria for radiculopathy include:
    • Observing fibrillation/sharp waves in two muscles innervated by a single root.
    • Presence of abnormal paraspinal responses.