Spinal Disorders
Spinal Disorders
Spinal Disorders
Definition-
• Disc protrusion: Pressure on the vertebrae causes the gelatinous core, called the nucleus
pulposus to move and press against the annulus fibrosus This bulge compresses a spinal
nerve and thus causes pain.
• Disc herniation: (= disc extrusion or disc prolapse): A tear in the annulus fibrosus results in
extrusion of the nucleus pulposus and potential compression of the spinal nerve
• Disc sequestration: Extrusion of the nucleus pulposus and separation of a fragment that enters
the spinal canal and may cause compression of the spinal nerve.
Epidemiology-
Epidemyology-
Sex: ♂ > ♀ (3:1)
Age: 15–40 years
Lifetime prevalence in the US: ∼0.5%
Etiology-
Genetic predisposition: 90–95% of patients are HLA-B27 positive.
Articular symptoms
Most common presenting symptoms: back and neck pain
Gradual onset of dull pain that progresses slowly
Morning stiffness that improves with activity
Pain is independent of positioning, also appears at night
Tenderness over the sacroiliac joints
Limited mobility of the spine (especially reduced forward lumbar flexion)
Inflammatory enthesitis (e.g., of the Achilles tendon, iliac crests, tibial tuberosities):
painful on palpation
Dactylitis
Arthritis outside the spine ( hip , shoulder, knee joint)
Extra-articular manifestations
Most common: acute, unilateral anterior uveitis (∼ 25% of cases)
Fatigue, weakness, fever, weight loss
Restrictive pulmonary disease due to decreased mobility of the spine and thorax
Gastrointestinal symptoms: associated with chronic inflammatory bowel disease (∼ 5–10% of
cases, see also: ulcerative colitis or Crohn disease)
Prostatitis
Rare
Cardiac: aortic root inflammation and subsequent aortic valve insufficiency, atrioventricular
blocks
Kidney: IgA-nephropathy
Diagnostic approach
Physical examination, patient history, and pelvic x-ray: If results are conclusive, no additional testing is required!
If inconclusive → HLA-B27 testing
If still inconclusive → pelvic MRI
Clinical tests
X-ray
Helps confirm a diagnosis and evaluate the severity of disease
Changes are generally more evident in later disease.
The changes usually occur symmetrically.
Pelvis (best initial test): to examine the sacroiliac joints
Signs of sacroiliitis, including ankylosis (fusion of the articular surfaces)
Spine
Loss of lordosis with increasing abnormal straightening of the spine
Sclerosis of the vertebral ligamentous apparatus
Syndesmophytes resulting in a so-called 'bamboo spine' in
anteroposterior radiograph in the later stages
(see the table in “Differential diagnosis” below)
Signs of spondyloarthritis, including ankylosis of intervertebral joints
Thorax: ankylosis of costosternal and costovertebral joints
MRI
More sensitive than CT scan for detecting sacroiliitis
Best method for early detection
Treatment--
Physical therapy
Consistent and rigorous physical therapy
Independent exercises
Medical therapy
First choice: NSAIDs (e.g., indomethacin)
Additional options
Tumor necrosis factor-α inhibitors (e.g., etanercept, adalimumab)
[12]
In case of peripheral arthritis: DMARDs (especially sulfasalazine)
In severe cases: temporary, intra-articular glucocorticoids
Surgery: in severe cases to improve quality of life
Indications
Severe deformity of the spinal column
Instability of the spine
Neurologic deficits
Procedures
Osteotomy
Joint replacement
Spinal fusion