SURGICAL DISORDERS OF THE THORACIC AND LUMBAR SPINE: A GUIDE FOR NEUROLOGISTS
- Correspondence to: Mr Nitin Patel, Department of Neurosurgery, Frenchay Hospital, Frenchay Park Road, Bristol BS16 1LE, UK; nitinp{at}lineone.net
- thoracic spine disorders
- lumbar spine disorders
- intervertebral disc prolapse
- lumbar stenosis
- vertebral osteomyelitis
- spinal tumours
Degenerative and pathological disorders of the thoracolumbar spine may present with symptoms which warrant further evaluation by a neurologist. This article aims to provide an overview of the typical presentation and standard management of various thoracolumbar spinal disorders and includes information that is intended to facilitate the investigative and diagnostic process.
▸ LUMBAR INTERVERTEBRAL DISC PROLAPSE
Mixter and Barr in 1934 first described the herniated disc to be a cause of segmental leg pain (sciatica or femoralgia). Acute low back pain is a relatively common condition and is accompanied by sciatica in only 1–2% of cases. Patients presenting with acute low back pain alone are therefore unlikely to have a disc prolapse. Lumbar intervertebral disc prolapse is most prevalent between the ages of 30–50 years, and the L5/S1 and L4/5 intervertebral discs account for 95% of all lumbar prolapses.
A lumbar disc prolapse typically presents with gradual or sudden onset localised back pain radiating through the buttock or hip area into the leg. The episode may have been precipitated by heavy axial loading, flexion or rotation of the spine, but may also occur at rest.
The onset of sciatica often coincides with improvement in localised back pain. The sciatica is initially severe and is often described as a dull aching pain with occasional sharp or shooting exacerbations. The pain may be aggravated by coughing, sneezing, bending or prolonged sitting. The compromised nerve root is usually identified by noting the specific dermatomal distribution of the pain or associated sensory disturbances. The myotomal distribution of any muscle weakness and hyporeflexia further refines the clinical impression. Muscle wasting is rarely seen unless the symptoms have been present for several months. Bilateral leg symptoms, peri-anal or saddle sensory disturbances, and urinary or anal sphincter dysfunction signify a cauda equina syndrome (table 1) caused by the presence of a large …
