Neurology
Summary
The vertebral column serves to protect the spinal cord and nerve roots. However, when the vertebral structure suffers an injury, the vertebral pathology that arises can be categorized in two ways: those affecting the vertebral body and those affecting the vertebral arch. The body is the large weight-bearing component of the vertebra, while the arch consists of the spinous, transverse, and articular processes, as well as the pedicles, lamina, and facets.
The typical patient with vertebral arch pathology is young, has a history of repetitive lifting and has non-radiating back pain most commonly at the L4 and L5 levels. Spondylitis is a general term used for non-specific inflammation of vertebral joints and/or arch, spondylolysis is a fracture of the pars interarticularis of the vertebral arch, while spondylolisthesis occurs due to an anterior displacement of the vertebral body. Vertebral compression fractures are classically wedge-shaped, result in a loss of vertebral body height, and are associated with older patients with a history of osteoporosis and minor trauma.
The intervertebral discs located between vertebral bodies serve as shock absorbers and disc herniation occurs when it's displaced, which can cause local compression or inflammation. If the herniated disc impinges on nerve roots, it can cause radiating pain known as radiculopathy, and if it impinges on the spinal cord, it can lead to myelopathy. Typical first line diagnostic imaging includes X-rays, however, patients with high clinical suspicion should proceed to MRI without contrast. Initial management is generally conservative but patients with severe, refractory or progressive symptoms may require surgical intervention.
Lesson Outline
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FAQs
Patients with vertebral arch pathology often present complaints of non-radiating back pain. Most commonly, the pain is localized at the L4/L5 level. The symptoms may vary depending on severity and specific condition present.
Spondylitis is a general term for inflammation of the vertebral joints and/or the vertebral arch. Spondylolysis is a specific condition where there is a fracture of the pars interarticularis of the vertebral arch, which is the connection point between the facet joints. Spondylolisthesis is a condition that occurs due to an anterior displacement of the vertebral body.
Vertebral compression fractures are characterized by a wedge-shaped deformity resulting in a loss of vertebral body height. They are typically associated with older patients who have a history of osteoporosis and have experienced minor trauma. The susceptibility increases with age and from the presence of degenerative bone diseases.
Disc herniation is a condition where there is displacement of the intervertebral disc (nucleus pulposus), causing local compression and inflammation. Radiculopathy can result from a herniated disc impinging on nerve roots, leading to pain, numbness, or weakness radiating to the limbs. Myelopathy, on the other hand, can occur when a herniated disc impinges on the spinal cord, potentially causing symptoms ranging from mild nerve dysfunction to paralysis.
The evaluation usually starts with an X-ray, although an MRI provides the most detailed examination. Conservative treatment should be attempted initially, unless there is acute neurologic compromise. Initial treatment may include physical therapy, steroid therapy, and/or NSAIDs. If conservative therapy fails, a neurosurgical evaluation may be needed to determine the next course of action.
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