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Figure 11-6 Severe lumbar arachnoiditis causing back pain, sciatica, and paresthesias years after spinal analgesia Lumbar MRI performed with infusion of gadolinium showing thickened arachnoid and displacement of cauda equina roots by acquired arachnoid cysts
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dency to progressive exion of the hips, and the characteristic immobility and exion deformity of the spine ( poker spine ) may be present early in the course of the disease The radiologic hallmarks are, at rst, destruction and subsequently obliteration of the sacroiliac joints, followed by bony bridging of the vertebral bodies to produce the characteristic bamboo spine When this occurs, the pain usually subsides, but the patient has by then little motion of the back and neck An unusual additional feature, almost unique to this condition, is an extreme dilatation of the lumbar thecal sac Ankylosing spondylitis may also be accompanied by the Reiter syndrome, psoriasis, and in ammatory diseases of the intestine (see also Chap 44) The great risk in this disease is fracture dislocation of the spine from relatively minor trauma, particularly exion-extension injuries Occasionally ankylosing spondylitis is complicated by destructive vertebral lesions This complication should be suspected whenever the pain returns after a period of quiescence or becomes localized The cause of these lesions is not known, but they may represent a response to nonunion of fractures, taking the form of an excessive production of brous in ammatory tissue When it is severe, ankylosing spondylitis may involve both hips, greatly accentuating the back deformity and disability When it affects the spine, rheumatoid arthritis may be con ned to the cervical region; it is considered further on in this chapter
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Neoplastic and Infectious Diseases of the Spine (See Also Chap 44) Metastatic carcinoma (breast, bronchus, prostate, thyroid, kidney, stomach, uterus), multiple myeloma, and lymphoma are the common malignant tumors that involve the spine The primary lesion may be small and asymptomatic, and the rst manifestation of the tumor may be pain in the back due to metastatic deposits The pain is described as constant and dull; it is often unrelieved by rest and is generally worse at night, often interrupting sleep Radicular pain may be added, as described earlier in this chapter At the time of onset of the back pain, there may be no radiographic changes; when such changes do appear, they usually take the form of destructive lesions in one or several vertebral bodies with little or no involvement of the disc space, even in the face of a compression fracture Before such destructive changes become evident, a CT or radioactive isotope scan may be helpful in detecting areas of osteoblastic activity due to neoplastic or in ammatory disease and characteristic changes are also evident on MRI Infection of the vertebral column, osteomyelitis, is usually caused by staphylococci and less often by coliforms and mycobacteria The patient complains of pain in the back, of subacute or chronic nature, which is exacerbated by movement but not materially relieved by rest Motion becomes limited, and there is percussioninduced tenderness over the spine in the involved segments and pain with jarring of the spine, as occurs when the heels strike the oor Often these patients are afebrile and do not have a leukocytosis The erythrocyte sedimentation rate is elevated as a rule Highly characteristic is the demonstration by CT scanning and MRI of involvement of both the vertebral body and the adjacent intervertebral disc the nding of a breached disc space is one of the features that differentiates infectious from neoplastic diseases of the spine A paravertebral mass is often found, indicating an abscess, which may, in the case of tuberculosis, drain spontaneously at sites quite remote from the vertebral column We have also encountered a number of patients with subacute bacterial endocarditis who complained of severe midline thoracic and lumbar back pain but had no evident infection of the spine Tuberculous spinal infection and the resultant kyphotic deformity (Pott disease) represent a special condition that is common in developing countries (see pages 611 and 1061) Special mention should be made of spinal epidural abscess, which necessitates urgent surgical treatment Indeed, in some series, failure to properly identify this lesion has led to cases of paraplegia or death from sepsis Most often this is due to staphylococcal infection, which is carried in the bloodstream from a septic focus (eg, furuncle) or is introduced into the epidural space from an osteomyelitic lesion Another important avenue of infection is the intravenous self-administration of adulterated drugs and use of contaminated needles Rarely the infection is introduced in the course of a lumbar puncture, epidural injection, or laminectomy for disc excision In some instances the source of the epidural infection cannot be ascertained The main symptoms are fever, leukocytosis, and persistent and severe localized pain, intensi ed by percussion and pressure over the vertebral spines; additionally the pain may acquire a radicular radiation These symptoms mandate immediate investigation by MRI or CT myelography and surgical intervention, preferably before the signs of paraplegia, sphincter dysfunction, and sensory loss become manifest Exceptionally small abscesses can be treated successfully with antibiotics alone This process is discussed further on page 1060 A nonin ammatory form of acute epidural compression may be due to hemorrhage (anticoagulant therapy, vascular malformation) and, in the cervical region, to rheumatoid arthritis (see further on)
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