Spinal Disorders
Abstract
Spinal disorders are relatively common and include diagnoses such as disk herniation, stenosis, and spondylosis. These and other disorders of the spine may be found in the cervical, thoracic, and lumbar spine, causing a variety of symptoms, including pain and motor or sensory disturbances. Treatment may include observation, medical, or surgical intervention. Nurses should be knowledgeable on the many types of spinal disorders, as well as level of spinal involvement and associated symptoms.
Keywords: degenerative disk disease, disk herniation, myelopathy, radiculopathy, spinal stenosis, spondylolisthesis, spondylosis
11.1 Spinal Disorders
Spinal disorders may result from trauma, congenital factors, underlying diseases, or normal degenerative processes. Many painful acute and chronic conditions can be attributed to disorders of the spine. Although age-related degenerative changes are the most common cause, spinal disorders are not always the result of normal aging processes (Box 11.1 Causes of Spinal Disorders Other than Normal Aging).
This chapter will address common degenerative spinal disorders of each spinal region—cervical, thoracic, and lumbar. It will focus on clinical manifestations, treatment, and nursing care considerations for patients with these conditions.
Box 11.1 Causes of Spinal Disorders Other than Normal Aging
Trauma
Fracture
Hematoma
Ligamentous strain
Dislocation
Tumors
Schwannoma
Ependymoma
Metastatic
Vascular
Arteriovenous malformation
Cavernous malformation
Infarction
Infection
Osteomyelitis
Epidural abscess
Systemic diseases
Rheumatoid arthritis
Ankylosing spondylitis
11.2 Specific Types of Spinal Disorders
11.2.1 Degenerative Disk Disease
Degenerative disk disease (DDD) is part of the natural aging process (Box 11.2 Degenerative Disk Disease) that is thought to begin during the third decade of life. DDD can result in loss of disk height, development of tears or fissures of the annulus fibrosis, formation of bone spurs, compression of nerve roots and facet joints, and vertebral end plate changes. It is the likely precursor to other spinal disorders, including the following:
Disk herniation
Spondylosis (i.e., degenerative changes due to osteoarthritis)
Spondylolisthesis (i.e., forward displacement of one vertebra over another)
Spinal stenosis (i.e., narrowing of the spinal canal)
DDD results from the loss of normal elasticity and flexibility of the vertebral disk, but it may be accelerated or exacerbated by several factors as follows:
Smoking
Sedentary lifestyle
Obesity
Repetitive injuries
Congenital abnormalities
Degenerative disk disease is a part of normal aging
Not everyone with degenerative spinal changes develops pain or neurologic impairments
Many people without symptoms have incidental magnetic resonance imaging findings of abnormalities (e.g., disk herniation, degenerative changes, spinal stenosis)
Etiology of Degenerative Disk Disease
The annulus fibrosis becomes less supple with age and is more easily torn (▶ Fig. 11.1)
The nucleus pulposus starts to dry out and shrink, resulting in loss of disk height
The entire spine becomes less flexible because of deteriorated disks.
Fig. 11.1 Normal vertebral disk versus disk with degenerative disk disease.
Epidemiology of Degenerative Disk Disease
Affects about 20% of the U.S. population
Slightly more prevalent among women
Most common among those aged 45 to 75 years
Causes loss of mobility and significant physical disability
11.2.2 Spondylosis
Spondylosis is a term that refers to osteoarthritis of the spine, but it is often used to describe any manner of spinal degeneration. It leads to the formation of bone spurs, or osteophytes, where the vertebral body and disk connect to the end plate (▶ Fig. 11.2). It can occur at any level of the spine and is categorized according to the affected level (i.e., cervical, thoracic, or lumbar).
Fig. 11.2 Spondylosis, with arrows indicating osteophytes of the lower cervical spine.
Etiology of Spondylosis
Results from degenerative changes in intervertebral disks
Disks become stiff, subjecting the bony end plates to increased load bearing and dynamic stress, causing thickening and sclerosis, which over time leads to the formation of osteophytes
Osteophytes affect other structures around the vertebrae, such as the surrounding ligaments (e.g., anterior longitudinal ligaments, posterior longitudinal ligaments, and ligamenta flava), disks, facet joints, and laminae
Osteophytes can occur anteriorly or posteriorly
Anterior osteophytes rarely produce symptoms
Posterior osteophytes can result in stenosis of the spinal canal or neural foraminal stenosis
Epidemiology of Spondylosis
Between 27 and 37% of the population in the United States is thought to have asymptomatic lumbar spondylosis
Affects between 50 and 75% of the U.S. population by age 50 years, 90% by age 60 years
Roughly 74% of women and 84% of men have vertebral osteophytes (usually at T9-T10 or L3)
About 28% of women and 30% of men between 55 and 64 years have osteophytes of the lumbar spine
11.2.3 Intervertebral Disk Herniation
Extruded disk material is referred to as herniated nucleus pulposus (Box 11.3 Terms for Herniated Disk). A herniated disk can result from trauma, although DDD is often a contributing factor.
Box 11.3 Terms for Herniated Disk
Herniated intervertebral disk
Herniated nucleus pulposus
Prolapsed intervertebral disk
Slipped disk
Ruptured disk
Sequestered disk
Etiology of Herniated Disk
Disk extrusion can be a bulge or complete herniation through the annulus fibrosis
Herniation may be lateral or central (▶ Fig. 11.3, ▶ Fig. 11.4), but central herniation is less common
Disk herniation can result in disk fragmentation (i.e., pieces of disk material found outside the disk space, usually in the epidural space)
Nerve root compression resulting from a herniated disk may cause radiculopathy (i.e., disease of the nerve root caused by compression or inflammation)
Radiculopathy causes pain to radiate from a specific spinal segment to a distal site (i.e., to the arm or hand if a cervical nerve root is compressed; to the truncal region if thoracic nerve root is compressed; and to the buttocks, groin, or lower extremities if a lumbar nerve root is compressed)
Radiculopathy is dermatome-specific to the spinal level and the side of disk herniation.
Fig. 11.3 Lateral disk herniation.
Fig. 11.4 Central disk herniation.
Epidemiology of Disk Herniation
Affects men more often than women
Average age at onset is 30 to 50 years
Occurs more often in the lumbar spine than in the cervical spine; it rarely occurs in the thoracic spine
About 10% of patients experience herniation at multiple levels
11.2.4 Spondylolisthesis
The abnormal movement or slippage of one vertebral body onto another is called spondylolisthesis (▶ Fig. 11.5).
Degree of displacement can be determined using the Meyerding Grading System (▶ Table 11.1). This scale measures the ratio of the overhanging portion of the vertebral body to the anteroposterior length of the inferior vertebral body. The grade of spondylolisthesis may help facilitate treatment decisions
The most severe degree of spondylolisthesis is referred to as spondyloptosis. This rare condition is characterized by the complete anterior dislocation of the L5 vertebral body from the sacrum.
Fig. 11.5 Spondylolisthesis of L5 onto S1.
Table 11.1 Meyerding Grading System for spondylolisthesis
Grade
Degree of subluxation
Grade I
0–25%
Grade II
26–50%
Grade III
51–75%
Grade IV
76–99%
Grade V (spondyloptosis)
100%
Etiology of Spondylolisthesis
May be congenital or developmental (i.e., present at birth or having developed during childhood)
May be acquired from daily stress or from force exerted on the spine (e.g., resulting from arthritis, trauma, overuse, or as a complication of infection)
Epidemiology of Spondylolisthesis
Can occur at any spinal level but is most common in the lower lumbar spine
Affects approximately 5 to 6% of men and 2 to 3% of women
Most common in individuals involved in physically demanding activities or sports (e.g., gymnasts, weightlifters, and football players)
Symptoms of spondylolisthesis are more common in men, as they are more likely to be involved in highly physical activities
11.2.5 Stenosis
Stenosis is narrowing of either the spinal canal or the neural foramen, leading to compression of the spinal cord or spinal nerve roots (▶ Fig. 11.6).
Central canal stenosis is classified by the spinal level
Foraminal stenosis can occur left, right, or bilaterally at any level and is classified accordingly
Foraminal stenosis causes compression of individual spinal nerve roots as they exit the spinal canal through the neural foramen
Neurologic symptoms are related to the affected spinal level
Stenosis may be asymptomatic; if symptoms are present, they vary based on which structure is compressed
Symptoms may involve radiculopathy or myelopathy (Box 11.4 Myelopathy vs. Radiculopathy)
Radiculopathy can occur at any level, usually from foraminal stenosis and resultant nerve root compression
Myelopathy results from severe central canal stenosis that compresses the spinal cord
Severe central canal stenosis together with compression of multiple descending nerve roots in the lumbar spine is referred to as cauda equina syndrome, which is described in Section 11.5.2 of this chapter.
Fig. 11.6 Normal spinal canal versus spinal canal with central and neuroforaminal narrowing.
Box 11.4 Myelopathy versus Radiculopathy
Myelopathy
Spinal cord compression
Subtle symptom onset with slow progression
Does not improve without decompressive surgery
Patients do not usually seek medical care early given that they do not have pain
Results in weakness, difficulties with ambulation may develop later
Radiculopathy
Painful
Usually caused by herniated disks
Patients often do well with conservative treatment
Dermatome specific
Etiology of Stenosis
Stenosis is usually caused by a combination of congenital and acquired factors.
Congenital
Spina bifida
Narrow spinal canal
Acquired
Spinal trauma or fracture
DDD, thickened ligaments, and hypertrophied facets
Spondylosis
Spondylolisthesis or subluxation
Epidemiology of Stenosis
More common in the lower lumbar spine than in the cervical spine
Rarely occurs in the thoracic spine
11.3 Disorders of the Cervical Spine
11.3.1 Herniated Cervical Disk
Affects men more often than women
About 70% of cervical herniated disks occur at C5–C6 or C6–C7
About 90% of patients are estimated to improve without surgery
Clinical Manifestations of Herniated Cervical Disk
Symptoms are related to the following various factors:
The size of the herniation
The affected cervical spine level
The presence and degree of spinal cord compression
Symptoms can be of sudden onset with a known eliciting event or may develop slowly over time
Examination findings indicative of cervical disk herniation may include the following:
Neck or arm radiculopathy relative to the affected cervical spine level (though central disk herniation may result in bilateral arm symptoms)
Arm muscle weakness with possible atrophy of associated arm muscles
Numbness or decreased sensation relative to the affected cervical spine level
Decreased range of motion of the neck, shoulders, and arms
Headache elicited by certain head movements (sometimes referred to as cervicogenic headache)
Cervical myelopathy may occur along with spinal cord compression, resulting in disturbance of motor or sensory function with or without pathologic change in the spinal cord (Box 11.5 Symptoms of Cervical Myelopathy).
Box 11.5 Symptoms of Cervical Myelopathy
Neck stiffness
Deep aching or pain in the neck
Arm or shoulder pain (i.e., cervical radiculopathy)
Stiffness or clumsiness while walking
Heavy feeling in the legs
Deterioration in fine motor skills (e.g., buttoning a shirt or writing)
Intermittent electric-like shooting pains in the arms and legs, especially when the head is bent forward (this is known as Lhermitte’s sign)
Treatment of Herniated Cervical Disk
Conservative therapy
Bed rest; usually no more than 2 days
Analgesics (over-the-counter or prescription) and muscle relaxants should be administered sparingly (▶ Table 11.2). Pain relievers are available in oral, topical, or injectable forms
Topical pain medications are applied directly to the skin of the affected region to reduce pain resulting from arthritis or muscle soreness
Topical remedies, such as Icy Hot, ArthriCare cream, Zostrix, Aspercreme, Bengay, and various store brands, are available over the counter
A pain-relief patch such as Flector Patch is available with a prescription
Epidural steroid or analgesic injections
Physical therapy
Possible cervical traction
Surgical therapy
Surgical therapy may be indicated when conservative therapy fails. This may be the case in patients with myelopathy and severe central stenosis or in patients with unmanageable pain. Possible surgical intervention may include the following:
Anterior cervical diskectomy and fusion
Anterior or posterior foraminotomy; see Chapter 15: Neurosurgical Interventions.
Table 11.2 Pharmacology for management of spinal disorders
Drug
Category
Indication
Nursing implication
Ibuprofen
(Motrin, Advil)
Naproxen
(Aleve, Naprosyn)
Ketorolac
(Toradol)
NSAIDs
Mild or moderate back or neck pain, tenderness, inflammation, and stiffness
May irritate the stomach
Should be taken with food
Use with caution in elderly patients and in those with renal disease or hypertension
Has mild blood thinning effect
Some IV preparations are available
Celecoxib
(Celebrex)
COX-2 inhibitor (subclass of NSAIDs)
Arthritic pain
Inflammation
Available by prescription
Prolonged use should be avoided
Acetaminophen
(Tylenol)
Analgesic
Mild to moderate pain
Take with food
Watch for dosing limits
Methylprednisolone
(Medrol)
Corticosteroid
Pain due to inflammation or irritation (i.e., radiculopathy)
May irritate the stomach
Should be taken with food
Oxycodone with acetaminophen
(Percocet)
Hydrocodone with acetaminophen
(Vicodin, Lortab)
Opioid analgesics
Moderate to severe pain; acute pain; postoperative pain
Sedating
Respiratory depressant
Constipating
May cause urinary retention
Habit-forming
Not effective for neuropathic pain
Additional preparations for sustained release and IV administration
Baclofen
(Lioresal)
Carisoprodol
(Soma)
Cyclobenzaprine
(Flexeril)
Muscle relaxants
Muscle stiffness or spasm
Be aware of sedative side effects, especially when used with narcotics
Diazepam
(Valium)
Benzodiazepine
Used for more severe spasm
Heaviest sedative; potential for drug dependence
Abbreviations: COX-2, cyclo-oxygenase 2; IV, intravenous; NSAIDs, nonsteroidal anti-inflammatory drugs.
11.3.2 Cervical Stenosis
Clinical Manifestations of Cervical Stenosis
Symptoms are associated with the affected cervical level (▶ Fig. 11.7)
Symptoms are usually insidious and progressive, and they may include the following:
Neck and arm pain
Decreased motor function and dexterity
Altered sensory function
Spinal cord compression with severe stenosis
Difficulty walking
Spinal cord compression with no or little pain
May cause cervical myelopathy.
Fig. 11.7 Cervical stenosis resulting from multilevel degenerative disk disease.
Treatment of Cervical Stenosis
Surgical therapy; see also Chapter 15: Neurosurgical Interventions.
Decompressive laminectomy
Anterior cervical diskectomy
11.4 Disorders of the Thoracic Spine
Thoracic spinal disorders rarely occur without a precipitating traumatic event.
DDD may predispose one to traumatic disk herniation
Even a small thoracic herniation is associated with neurologic symptoms
11.4.1 Herniated Thoracic Disk
Epidemiology of Herniated Thoracic Disk
More common in men than in women
Thoracic disk herniations account for less than 1% of all herniated disks
Clinical Manifestations of Herniated Thoracic Disk
There is no characteristic presentation in a patient with a herniated thoracic disk (▶ Fig. 11.8). The condition is often misdiagnosed as angina, pleurisy, cholecystitis, arthritis, muscle strain, or fibromyalgia.
Symptoms are variable and include the following:
Localized pain in the upper back or chest
Numbness, weakness, or spasticity
Radicular pain
Pain that often precedes neurologic symptoms
Myelopathy
Hyperactive reflexes such as clonus (e.g., rapidly alternating muscle contraction and relaxation in a continuous reflex tremor) and Babinski sign (e.g., plantar reflex with dorsiflexion of the big toe and fanning of the smaller toes elicited by stroking the bottom outer edge of the patient’s foot).
Fig. 11.8 Herniated thoracic disk compressing spinal cord.
Treatment of Herniated Thoracic Disk
Surgical therapy may be indicated in patients with unmanageable pain or with myelopathy. Several types of surgery may alleviate a herniated thoracic disk; see Chapter 15: Neurosurgical Interventions.
Surgical therapy
Anterior
Thoracoscopic surgery
Thoracotomy for transthoracic diskectomy, with or without fusion
Posterior
Costotransversectomy
Transpedicular diskectomy and fusion, with or without anterior graft
11.5 Disorders of the Lumbar Spine
11.5.1 Herniated Lumbar Disk
Common cause of low back pain (▶ Fig. 11.9)
Frequently asymptomatic.
Fig. 11.9 Herniated lumbosacral disk.
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