Diseases, Disorders information

How about disc herniation? This is kind of the classic disease that Mixer and Bard described in 1934, with disc herniation and prolapse, we’re thinking about sciatica, referred pain, we’re thinking about neuropathic pain, difference in characteristics, neuropathic pain, remember, tends to respond to membrane stabilizing agents, tends to respond to steroids, will respond to narcotics in extremely high doses, if it’s pure neuropathic pain almost to the point of sedation. Mechanical pain on the other hand, tends to respond to narcotics and nonsteroidal anti-inflammatories, so that’s another important differential point. If someone gets a good deal of relief from a narcotic, you should be thinking a little bit more about mechanical pain than you are neurogenic pain. Well of course, a disc herniation results in sciatica, so the main problem here is not back pain, but leg pain. The sciatica can be caused by disc herniation, subarticular stenosis in the area of the foramen and facet, and those degenerative pictures, lateral recess stenosis, again, is an accompaniment of the degenerative cascade. If one decompresses this with a microdiscectomy or laminotomy discectomy, remember you are treating the leg pain only. You are not going to get the patient’s back pain better, in fact, a recent study from Scandinavia has shown that up to 20% of patient’s after a laminotomy discectomy, will have significant enough back pain so as to require additional care of even in some cases, intervention.
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On physical examination, a patient who presents with a trunk shift, should alert you to the possibility of a disc prolapse and sciatica. If you have a disc prolapse far lateral here, so this is coming down on top of the ganglia, the patient will tend to shift away from that, shifting ipsilaterally with provoke the sciatica like-wise, if the prolapse is in the axilla of the root, a contralateral shift will result in sciatica, ipsilateral shift will tend to decompress that. So if you see a patient with a trunk shift that you really can’t reduce, do think about some form of nerve root entrapment.
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Again, here is the slide from Netter and physical examination, this is in the hand-out, as promised coming back to the acute cauda equina syndrome, and this is really the only the only surgical emergency that you are going to see in spine patient’s. This is usually on the basis of a large central disc herniation entrapping multiple nerve roots as shown at the bottom line, clinically, these patient’s will tell you the diagnosis very clearly because they will be some of the most miserably uncomfortable patient’s that you will see. A typical history, as I was unable to find a comfortable position, I tried to sleep sitting in a chair, tried to sleep in flexion, tried to sleep with a trunk shift to unload the neural compression, the classic triad is bilateral sciatica, GU of GI signs and saddle anesthesia from sacral nerve involvement. The GU sign is retention, not incontinence, very important differential point. You may get overflow incontinence if you have a large distended bladder, but incontinence is more frequently due to stress incontinence and has nothing whatsoever to do with spine pathology, so this is somebody with retention. The GI sign again is constipation, not incontinence and that’s because of the involvement of the sympathetics and the sacral nerve roots. If you see someone with this, an immediate MRI or myelogram, immediate surgery and even if you get these patient’s to the operating room within 24 hours, up to 40% still have some neurologic residual.