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spinal & Back and Neck Pain part-4

Facet joint hypertrophy can produce unilateral radicular symptoms, due to bony compression, that are indistinguishable from disk-related radiculopathy. Patients may exhibit stretch signs, focal motor weakness, hyporeflexia, or sensory loss. Hypertrophic superior or inferior facets can often be visualized radiologically. Foraminotomy results in long-term relief of leg and back pain in 80 to 90% of patients.

Lumbar adhesive arachnoiditis with radiculopathy is the result of a fibrotic process following an inflammatory response to local tissue injury within the subarachnoid space. The fibrosis results in nerve root adhesions, producing back and leg pain associated with motor, sensory, and reflex changes. Myelography-induced arachnoiditis has become rare with the abandonment of oil-based contrast. Other causes of arachnoiditis include multiple lumbar operations, chronic spinal infections, spinal cord injury, intrathecal hemorrhage, intrathecal injection of steroids and anesthetics, and foreign bodies. The spine MRI appearance of arachnoiditis includes nerve roots clumping together centrally and adherent to the dura peripherally, or loculations of cerebrospinal fluid (CSF) within the thecal sac that obscure nerve root visualization. Treatment is often unsatisfactory. Microsurgical lysis of adhesions, dorsal rhizotomy, and dorsal root ganglionectomy have resulted in poor outcomes. Dorsal column stimulation for pain relief has produced varying results. Epidural steroid injections have been of limited value.

Arthritis, Arthritis is a major cause of spine pain.,Spondylosis

Osteoarthritic spine disease typically occurs in later life and primarily involves the cervical and lumbosacral spine. Patients often complain of back pain that is increased by motion and associated with stiffness or limitation of motion. The relationship between clinical symptoms and radiologic findings is usually not straightforward. Pain may be prominent when x-ray findings are minimal; alternatively, large osteophytes can be seen in asymptomatic patients in middle and later life. Hypertrophied facets and osteophytes may compress nerve roots in the lateral recess or intervertebral foramen. Osteophytes arising from the vertebral body may cause or contribute to central spinal canal stenosis. Loss of intervertebral disk height reduces the vertical dimensions of the intervertebral foramen; the descending pedicle may compress the nerve root exiting at that level. Osteoarthritic changes in the lumbar spine may rarely compress the cauda equina.

Ankylosing Spondylitis

This distinctive arthritic spine disease typically presents with the insidious onset of low back and buttock pain. Patients are often males below age 40. Associated features include morning back stiffness, nocturnal pain, pain unrelieved by rest, an elevated sedimentation rate, and the histocompatibility antigen HLA-B27. The differential diagnosis includes tumor and infection. Onset at a young age and back pain characteristically improving with exercise suggest ankylosing spondylitis. Loss of the normal lumbar lordosis and exaggeration of thoracic kyphosis are seen as the disease progresses. Inflammation and erosion of the outer fibers of the annulus fibrosus at the point of contact with the vertebral body are followed by ossification and bone growth. Bony growth (syndesmophyte) bridges adjacent vertebral bodies and results in reduced spine mobility in all planes. The radiologic hallmarks of the disease are periarticular destructive changes, sclerosis of the sacroiliac joints, and bridging of vertebral bodies by bone to produce the fused "bamboo spine." Similar restricted movement may accompany Reiter's syndrome, psoriatic arthritis, and chronic inflammatory bowel disease. Stress fractures through the spontaneously ankylosed posterior bony elements of the rigid, osteoporotic spine may result in focal spine pain, spinal cord compression or cauda equina syndrome. Occasional atlantoaxial subluxation with spinal cord compression occurs. Bilateral ankylosis of the ribs to the spine and a decrease in the height of axial thoracic structures may cause marked impairment of respiratory function.

Other Destructive Diseases

Neoplasm

Back pain is the most common neurologic symptom among patients with systemic cancer.  Back pain may be the presenting symptom because the primary tumor site may be overlooked or asymptomatic. The pain tends to be constant, dull, unrelieved by rest, and worse at night. In contrast, mechanical low back pain is usually improved with rest. Plain x-rays usually, though not always, show destructive lesions in one or several vertebral bodies without disk space involvement. MRI is the studies of choice in the setting of suspected spinal metastasis, but the trend of evidence favors the use of MRI.

Infection

Vertebral osteomyelitis is usually caused by staphylococci, TB but other bacteria or the tubercle bacillus (Pott's disease) may be the responsible organism. A primary source of infection, most often from the urinary tract, skin, or lungs, can be identified in 40% of patients. Intravenous drug use is a well-recognized risk factor. Back pain exacerbated by motion and unrelieved by rest, spine tenderness over the involved spine segment, and an elevated erythrocyte sedimentation rate are the most common findings. Fever or elevated white blood cell count are found in a minority of patients. Plain radiographs may show a narrowed disk space with erosion of adjacent vertebrae; these diagnostic changes may take weeks or months to appear. MRI and CT are sensitive and specific for osteomyelitis; MRI definition of soft tissue detail is exquisite. CT scan may be more readily available and better tolerated by some patients with severe back pain.

Spinal epidural abscess (Chap. 368) presents with back pain (aggravated by palpation or movement) and fever. The patient may exhibit nerve root injury or spinal cord compression accompanied by a sensory level, incontinence, or paraplegia. The abscess may track over multiple spinal levels and is best delineated by spine MRI.

Osteoporosis and Osteosclerosis

Considerable loss of bone may occur with or without symptoms in association with medical disorders, including hyperparathyroidism, chronic glucocorticoid use, or immobilization. Compression fractures occur in up to half of patients with severe osteoporosis. The risk of osteoporotic vertebral fracture is 4.5 times greater over 3 years among patients with a baseline fracture compared with osteoporotic controls. The sole manifestation of a compression fracture may be focal lumbar or thoracic aching (often after a trivial injury) that is exacerbated by movement. Other patients experience thoracic or upper lumbar radicular pain. Focal spine tenderness is common. When compression fractures are found, treatable risk factors should be sought. Compression fractures above the midthoracic region suggest malignancy.

Osteosclerosis is readily identifiable on routine x-ray studies (e.g., Paget's disease) and may or may not produce back pain.

Referred Pain from Visceral Disease

Diseases of the pelvis, abdomen, or thorax may produce referred pain to the posterior portion of the spinal segment that innervates the diseased organ. Occasionally, back pain may be the first and only sign. In general, pelvic diseases refer pain to the sacral region, lower abdominal diseases to the lumbar region (around the second to fourth lumbar vertebrae), and upper abdominal diseases to the lower thoracic or upper lumbar region (eighth thoracic to the first and second lumbar vertebrae). Local signs (pain with spine palpation, paraspinal muscle spasm called Myofacial pain) are absent, and minimal or no pain accompanies normal spine movements.

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Pathalogy in CIDP and autoimmune diseases