Extremity Pain
Upper and lower extremity pain can have a variety of causes, but extremity pain that is associated with spinal pathology typically is radiating in quality. It may also be associated with numbness or tingling. The following list includes some of the spinal conditions associated with extremity pain.
- Disc herniation
- Spinal stenosis
- Spondylolisthesis
- Spondylolysis
- Scoliosis
- Spinal fracture
- Cauda equina syndrome
- Spinal cord tumor
Cervical Disc Herniation
The intervertebral disc is made up of a fibrous outer layer called the annulus fibrous and a soft inner layer called the nucleus pulposus. In the cervical spine, each of the seven vertebral bodies is separated by an intervertebral disc. The cervical disc can be bulging, when it extends beyond the peripheral limits of the disc space. It can also be herniated, when the soft inner portion displaces outside of its normal boundaries. Disc herniations can compress a spinal nerve root, causing pain, numbness or weakness into one of the arms. This type of pain is called radiculopathy. Large herniated discs may also cause compression of the spinal cord, which can lead to difficulty walking and feeling off balance.
Diagnosis
The diagnosis of cervical disc herniation is similar to the process for lumbar disc herniation. The presentation of the patient symptoms combined with clinical examination is the first approach. Then an MRI scan is ordered to visualize the disc material and nerve structures. If you are unable to have an MRI, a myelogram and CT scan will be ordered.
Treatment
Conservative treatments include medications and physical therapy. Surgery may also be indicated, when conservative treatments fail or if you develop a neurological deficit.
This cervical spine MRI shows a disc herniation from a sagittal view, causing some pressure towards the spinal cord.
Spondylolisthesis
When one vertebral body is moved in relation to another, it is termed spondylolisthesis. Spondylolisthesis can be due to degenerative changes, trauma or congenital abnormalities in the bony architecture of the spinal column. Degenerative spondylolisthesis occurs over time, as a process of intersegmental instability. Fractures in certain parts of the vertebral body can also lead to instability. Congenital malformations in the neural arch, specifically the pars interarticularis, lead to spondylolysis and slippage. Patients with spondylolisthesis present with back pain and/or extremity pain that may change with bending.
Diagnosis
X-rays will confirm the presence of spondylolisthesis. These may be ordered with you bending forwards and backwards to evaluate for movement at the level of the spondylolisthesis. The MRI scan will show the nerves and possible compression. In addition, a CT scan may be ordered to evaluate for possible congenital defect in the bone that can lead to spondylolisthesis.
Treatment
Conservative treatments include medications, bracing, physical therapy and injections. Surgery may be necessary to decompress the spinal cord and nerves with spinal fusion.
Clinical Images
This lateral lumbar xray shows that the vertebral bodies are in good alignment.
Compare this xray to the previous one. This lateral view shows one vertebral body slipped forward in relation to the other, at the L5-S1 level. The bones are outlined in red color to make it easier to see.
This sagittal view shows on MRI the corresponding spondylolisthesis at the L5-S1 level.
Spondylolysis
A congenital failure of the neural arch to form together is termed spondylolysis. These patients have a defect in the pars interarticularis region of the vertebrae. Spondylolysis leads to slippage, or spondylolisthesis. Often, patients are asymptomatic. However, back pain with or without radiculopathy may develop.
Diagnosis
The best test to visualize spondylolysis is a plain CT scan. X-rays and MRI scans can suggest spondylolysis, but the CT scan is a more definitive test.
Treatment
The treatment of spondylolysis is often conservative, including medications, physical therapy and sometimes a brace. Surgery, when indicated, involves a fusion procedure to stabilize the region.
Clinical Images
This is a CT scan from the lumbar spine, viewed as if you were looking at the spinal canal from the top-down. Notice how the white bone forms a ring. This ring encloses the spinal canal.
Compare this CT to the previous image. Notice in the red circles, the bony ring is interrupted.
Scoliosis
Scoliosis refers to an abnormal S-shaped curvature that occurs in the lateral direction. Scoliosis can be congenital, and some individuals require corrective fusions in childhood. However, scoliosis can also be degenerative as a result of degenerative disc disease and ligament laxity. Scoliosis can lead to back pain and extremity pain, if spinal nerves are compressed.
Diagnosis
Scolioisis is best seen on an x-ray. A CT scan can be used to further evaluate the direction of rotation of each of the bones. Often, a CT scan is also used for surgical planning in cases of fusion. MRI scans are used to evaluate for nerve compression.
Treatment
Treatment for scoliosis begins with conservative measures, including physical therapy, medications and sometimes bracing. Pain management consultation for injections is also considered. If a patient has failed the above treatment options, surgical strategies can be discussed. The choice of surgical intervention depends on the patient’s symptoms and also the degree of scoliosis and stenosis. There are some cases in which the nerves can be decompressed with a minimally-invasive approach. There are some cases, however, where a fusion procedure is required to stabilize the spine after the nerves have been decompressed.
Clinical Images
This is a normal AP view of a lumbar spine x-ray. Note that the spine appears to be straight.
This xray view of the lumbar spine shows the S-shaped curve that is found in patients with scoliosis.
Spinal Fracture
There are many different types of spinal fractures.
Compression fractures appear as a loss of height in the vertebral body. These fractures are commonly related to osteoporosis, but malignancy can also predispose an individual to develop compression fractures by weakening the bony matrix of the spinal column. These kinds of fractures more commonly occur in the thoracic and lumbar regions of the spine. Patients typically have pain in the middle to lower back and can be tender to the touch. They may or may not have radiculopathy. Often these patients can be treated conservatively, with bracing, medications and physical therapy. There is also a surgical procedure, called kyphoplasty, which can be performed if conservative treatment is ineffective. When there is a significant amount of compression, patients may require more extensive surgery to stabilize the fracture.
Fractures in the cervical spine can fall into many different classifications. Often, these are traumatic fractures. Patients require a thorough neurological assessment to evaluate for any deficits or possible spinal cord injury. Treatment will depend on the type of fracture. Most patients require immobilization and/or surgical stabilization.
This lateral xray shows a compression fracture in the lumbar spine. You will notice how the fractured vertebrae appears to have less height than the other vertebral bodies.
Cauda Equina Syndrome
The cauda equina is a group of nerve endings in the lower end of the spinal column. During development, the bony structures of the spinal column lengthen at a faster rate than the spinal cord. In most adult persons, the spinal cord ends at the level of the L1-L2 vertebrae. From this point, the cauda equina occupies the remainder of the spinal column. With compression of the cauda equina, patients have disturbance of the urinary and anal sphincters, saddle anesthesia, lower extremity weakness and sexual dysfunction. Patients also may have absent reflexes in the legs. Compression of the cauda equina can result from a large disc herniation, tumor, trauma or epidural hematoma.
This patient presented with lower extremity pain and urinary incontinence. The large disc herniation was found in the lumbar spine, causing cauda equine syndrome. Following urgent surgery, the patient had resolution in the leg pain and a significant improvement in urinary function.
Diagnosis
Clinical presentation is crucial in the diagnosis of cauda equina syndrome. In order to avoid a delay in treatment, the physician will have a high suspicion of the diagnosis based on your signs and symptoms. MRI scan is often ordered STAT to avoid a treatment delay.
Treatment
Surgical decompression is necessary and ideally should be performed early to avoid long term deficit.
Spinal Cord Tumor
Spinal cord tumors may be classified into one of the following groups:
- Extradural—Arise outside the spinal cord and dural sac
- Intradural extramedually—Arise inside the dural sac, but outside the spinal cord; often these are tumors that involve spinal membranes
- Intramedullary—Arise in the substance of the spinal cord
Most primary spinal tumors are benign and present when they become large enough to compress a nerve or the spinal cord, producing radiculopathy or myelopathy. Malignant primary spinal tumors are less common, but can occur. Metastatic spinal tumors can also arise from malignancy elsewhere in the body.
Diagnosis
Diagnosis of spinal cord tumor is often made with MRI scans. CT scans are useful, especially in diagnosis of extradural tumors that invade bone tissue. Based on the type of tumor, additional studies may be ordered to evaluate additional areas for involvement.
Treatment
Treatment of spinal cord tumor is dependent on the type of tumor and clinical presentation. In many cases, surgical resection is the best approach. With any type of tumor surgery, the goal of surgical resection is to remove as much of the tumor as is safely possible and spare functional neural tissue. Radical resection can often be achieved in benign tumor types. A limited resection or biopsy combined with multidisciplinary medical treatments may be recommended for malignant tumors. We work closely with both medical oncologists and radiation therapists to maximize the possibility of complete recovery.
Clinical Images
This patient presented to see Dr. El-Kadi with lower back pain that radiated into the right leg. They had significant weakness in the right leg, and an MRI was ordered of the lumbar spine. These MRI films show a large tumor that attacked the bony structure surrounding the spinal canal. It is an extradural tumor. You can see that it is putting pressure where the spinal canal and nerves on the right side.
On this CT scan taken from the same patient, you can appreciate how much bone was affected by this tumor.
This patient underwent surgical resection of the tumor with fusion. Compare the upper MRI, which is preoperative, to the lower image which is a postoperative film. The tumor has been removed.
The above patient required fusion due to the large amount of bone that had been destroyed by the tumor.
This patient presented to Dr. El-Kadi complaining of lower extremity pain and numbness. MRI was ordered, which showed a focal mass. This intraoperative photo shows a large schwannoma that is attached to a nerve root. These tumors are very slow growing and may cause symptoms by compressing a nerve root.
This MRI image of a large intramedullary tumor was found in a young patient who had an unsteady gait and was falling frequently. The patient presented with clinical symptoms consistent with cervical myelopathy. He underwent surgical resection of the tumor and had significant improvement in his balance.