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Differential Diagnosis of Skull and Spine Disorders

Low Back Pain in Adults!!navigator!!

  • 80% of population experiences lower back pain at some time in their lives
  • A specific cause is accurately determined in 5–10% of patients with acute symptoms + in 50% with chronic symptoms
    Cause: viscerogenic, vascular, psychogenic, neurogenic
    1. spondylogenic / degenerative disease (most prevalent)
      Age: 50% at 40 years; >85% at 80 years
      1. Disk herniation
      2. Facet disease
      3. Acquired stenosis
      4. Spondylolisthesis
    2. infectious
      1. Diskitis
      2. Osteomyelitis
    3. inflammatory
      1. Rheumatoid arthritis
      2. Ankylosing spondylitis
      3. Sacroiliitis
    4. trauma, iatrogenic
    5. congenital: congenital stenosis
    6. metabolic: osteoporosis
    7. neoplastic: primary, metastatic

Low Back Pain in Childhood!!navigator!!

Frequency: in 40% of pediatric + adolescent population; structural causes in 12–26%

99mTc methylene diphosphonate (MDP) SPECT bone scintigraphy with coregistered CT is an important tool in imaging workup of pediatric low back pain, because of its utility in assessment of spondylolysis.

  1. Spondylolysis (60–83%)
  2. Spondylolisthesis
  3. Osteomyelitis, diskitis
  4. Leukemia
  5. Histiocytosis X
  6. Osteoid osteoma, osteoblastoma
  7. Facet arthropathy / fracture

Abnormalities of Posterior Elements

  1. Spondylolysis
  2. Lumbar interspinous bursitis = Baastrup disease
  3. Spinous process avulsion / transverse process fracture
  4. Facet hypertrophy
  5. Osteochondroma

Endplate and Disk Abnormalities

  1. endplate-apophyseal injury
    1. Schmorl node = central disk herniation
    2. Limbus vertebrae
  2. degenerative disk disease
  3. endplate compression fractures

Sacroiliac Abnormalities

  1. Bertolotti syndrome
  2. Sacroiliac joint syndrome
  3. Sacral stress fracture

Lumbosacral Postsurgical Syndrome!!navigator!!

= FAILED BACK SURGERY SYNDROME

= signs of dysfunction and disability + pain and paresthesia following surgery

◊Interpretation in immediate postoperative period difficult, stabilization of findings occurs in 2–6 months

Frequency: failure of improvement in 5–15%

  1. OSSEOUS CAUSE
    1. mechanical instability
      1. Spondylolisthesis
      2. Pseudarthrosis
    2. osseous stenosis
      1. Central stenosis
      2. Foraminal stenosis
  2. SOFT-TISSUE CAUSES
    1. Perioperative intraspinal hemorrhage (onset <1 week)
    2. Residual disk herniation (onset <1 week)
    3. Recurrent disk herniation (onset 1 week – 1 month)
      • no enhancement on early T1WI (appears enhanced ≥30 min post injection)
    4. Spinal / meningeal / neural inflammation / infection
      (onset 1 week – 1 month) = Postoperative diskitis
      • elevated ESR + frequently normal WBC count
      • deceased marrow signal intensity on T1WI
      • contrast enhancement of disk + adjacent vertebral bodies
    5. Intraspinal scar formation (onset >1 month)
      1. Epidural fibrosis (scarring)
        • enhancing epidural plaque / mass
        • heterogeneous enhancement on early T1WI (maximum at about 5 min post injection) most pronounced within 9 months of surgery
      2. Fibrosing arachnoiditis = adhesive arachnoiditis
        • thickened irregular clumped nerve roots
        • adhesion of roots to wall of thecal sac
        • abnormal enhancement of thickened meninges + matted nerve roots
  3. SURGICAL ERRORS
    1. Wrong level / side of surgery
    2. Direct nerve injury
  4. Remote phenomena unrelated to spine

mnemonic: ABCDEF

  • Arachnoiditis
  • Bleeding
  • Contamination (infection)
  • Disk (residual / recurrent / new level)
  • Error (wrong disk excised)
  • Fibrosis (scar)

Cauda Equina Syndrome!!navigator!!

= constellation of signs + symptoms resulting from compressive lesion in lower lumbar spinal canal

Cause:

  1. Displaced disk fragment
  2. Intra- / extramedullary tumor
  3. Osseous: Paget disease, osteomyelitis, osteoarthrosis of facet joints, complication of ankylosing spondylitis
  • diminished sensation in lower lumbar + sacral dermatomes
  • wasting + weakness of muscles; decreased ankle reflexes
  • impotence; decreased sphincter tone
  • disturbed sphincter function + overflow incontinence

Outline