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Norov Abdurahmon, Republic Scientific Centre of Neurosurgery
Tashkent
E-mail: [email protected]
FEATURES OF THE NEUROLOGICAL COURSE OF THE CERVICAL STENOSIS
Abstract: the scientific article presents the results of an analysis of the neurological signs and symptoms of 81 patients with diagnosis degenerative cervical spinal stenosis. Analysis of the results of the study showed that the clinical picture of degenerative cervical stenosis is variable and polymorphism of neurological syndromes is caused by a polyfactoral compression of the neurovascular formations of the vertebral canal. Neurological course of cervical stenosis is divided into four complex syndrome: radicular, spinal, radiculospinal and vascular.
Keywords: Degenerative cervical spinal stenosis.
Introduction due to the spinal neurovascular compression secondary
Spine degenerative stenosis is a set of clinical syn- to stenosis. The diagnosis was verified at the surgery and dromes, arising from degenerative changes in the spine, confirmed by pathology. The sex distribution was as fol-
leading to the narrowing of the spinal canal and compression of the neural and vascular structures [5].
According to the literature, combination of the progressive dystrophic changes in the intervertebral discs, joints and ligaments of the spine with the relatively small capacity of the spinal canal, due to innate or constitutional features of the spine (vertebral body and arch) is the most common cause of the spinal canal stenosis [1; 4; 5].
Stenosis is diagnosed according to the data of different authors in 5-65.2% ofpatients with long-standing degenerative processes of the spine. From this point of view, stenosis can be considered as one of the final stages of degenerative-dystrophic processes in the spine [1; 3; 4; 5].
The purpose of this study is to identify specific features of the cervical spine degenerative stenosis and to determine the main difference of stenosis from similar in clinical course diseases.
Materials and methods. This work is based on the data analysis from 81 patients with degenerative stenosis of the cervical spinal canal treated at the Scientific Center of Neurosurgery of the Ministry of Health of the Republic of Uzbekistan during the period from 2007 till 2011. All the patients underwent a complete clinical examination (general somatic status, orthopedic, neurological, X-ray, neurophysiology investigation, computer- and magnetic resonance imaging). Patients were operated
lows: men were 59 (72.8%), and women - 22 (27.2%). The age of the patients varied from 27 to 71 years.
Results and discussion. The main reason for the manifestation of the first neurological symptoms was physical overstrain of varying intensity. Physical load and lifting of weights, as the cause of the clinical picture, was diagnosed in 41 (50.6%) patients. From physical overstrain till the first symptoms appearance passed from several days to several months. Cold preceded development of clinical symptoms in 18 (22.2%) patients. In the remaining cases, patients were not able to determine the cause of the disease.
Analysis of the anamnesis data showed that in 32 (39.5%) patients numbness in the cervico-occipital region was the first manifestation of the disease. More often it localized initially either on the back of the neck, or in the distal parts of the hands. As a rule, weakness in the hands was attached to numbness in a short time (from one to three months). In 23 (28.4%) patients, the disease began with gradual development ofweakness in the hands. At the initial stage, patients paid attention only to the "clumsiness" or "slackness" of one hand, mainly in the distal parts. In four cases, at the same time with weakness, small muscles hypotrophy developed first, first in one hand and then in the second. In one case, hand weakness combined with fascicular twitching in the thoracic muscles.
Section 5. Medical science
In 14 (17.3%) patients - weakness, "stiffness" in the legs and walking difficulty were the first signs of the disease. The clinical course of the degenerative stenosis is variable. 24 (29.6%) patients suffered pain in the cervical spine with painful restriction of mobility. Only in 16 (19.7%) cases, the radicular pain was pronounced and was the main factor for hospitalization. In 61 patients out of 81, which is 75.3%, the disease had a progressive course. In other patients, the disease progressed gradually. In 65 patients - neurology was manifested by compressive myelopathy in the form of motor and sensitive disorders of the neurological status. And only in 16 patients were diagnosed an isolated radiculopathy syndrome. Movement disorders were characterized mainly by tetraparesis in 28 (34.6%) patients, lower spastic paraparesis in 24 (29.6%) patients and isolated hands weakness in 13 (16%) patients, which was the most typical sign of radicular compression. The rude motor disorders were diagnosed in 4 patients in the form of the lower paraplegia. Motor disorders were accompanied with the hyperreflexia of the lower extremities in 52 (72.8%) patients and the appearance of pathological reflexes in 46 (69.1%) patients. Brown-Sekar syndrome of varying severity was revealed in 6 (7.4%) cases. Muscle jerking in the extremities and their atrophy were diagnosed in 11 and 12 cases, respectively. Explicit conductive sensitivity disorders were detected in the form ofhypoesthesia in 46 (56.8%) cases. In all 16 patients with isolated radiculopathy, sensitive disorders were characterized by hypoesthesia in the corresponding der-matomes. In 27 (33.3%) patients, sensitive disorders were accompanied by paresthesia. Urination disturbances of the varying severity occurred in 17 (20.9%) cases. In two patients (2.4%), the neurological picture of compressive myelopathy was accompanied additionally by a vertebral artery syndrome. The Kimmerly anomaly was diagnosed on x-ray studies of these patients.
Establishment of a topical diagnosis by clinical data presents certain difficulties in patients with cervical my-elopathy syndrome, because according to the results of studies, the tendency to a higher location of the myelopathic focus was confirmed with respect to the level of the location of the compressing factor. In a number of cases, according to the results of the neurological examination of the motor sphere, tendon reflexes of the upper extremities and sensitivity is a clear dissociation of neurological symptoms characterizing the upper level of the
lesion. Sensitivity can serve as the most reliable topical criteria for the upper level of the lesion.
Analysis of neurological symptoms in patients with degenerative stenosis of the cervical spine allowed us to identify the following syndromes:
I. Lateral or radicular syndrome. This syndrome was diagnosed in 16 (19.7%) patients. In this case, structures of the intervertebral disc, osteophytes or hypertrophied articular surfaces compress the nerve roots. Pain appears in the lateral region of the neck, irradiates to the back of the neck or shoulder blade and is exacerbated by movements of the neck. Radicular pain and paresthe-sia in the upper limbs are the most constant symptoms of the lateral syndrome. Also radicular syndrome is characterized by weakness, fascicular twitching, muscle atrophy, weakening or absence of tendon reflexes, decrease in pain and temperature sensitivity.
II. Medial or spinal syndrome. This syndrome was identified in 38 (46.9%) patients. For this case, it is typical that patients have isolated myelopathy without radicular symptoms. Pain in the neck is diverse and most patients note some limitation ofneck movements. Patients note a feeling of stiffness in the legs and a tendency to "foot -dragging" during the walk. Sometimes the gait is so difficult that the patient can hardly move his legs. Ataxic gait and paresthesia in the legs are also typical. Dysfunction of pelvic organs is absent at the early stages of spondylogenic myelopathy. Often upper limbs are affected with paresthesia, awkwardness, atrophy and loss of vibration sense. Examination of the patient reveals spasticity with the significant reflexes increase and the appearance pathological foot reflexes. Motor symptoms are usually asymmetric.
III. Combined medial-lateral (radicular-spinal) syndrome was diagnosed in 18 (22.2%) patients. Symptoms of the upper limbs roots lesion are combined with the symptoms of the pyramidal tract lesion from the lower extremities. Patients have radicular pain or paresthesia in the upper limbs, decrease of tendon reflexes from the biceps or triceps, inversion of the reflex or atrophy of the muscles innervated by C5-C7 segments.
IV. Vascular or ischemic syndrome. Syndrome of ischemic myelopathy was identified in 9 (11.1%) patients. Most often, ischemic myelopathy was manifested by the syndrome of ALS. Myelopathy with ALS syndrome was characterized by the combination of peripheral and central motor neuron dysfunction in the form of asymmetric
atrophy ofthe muscles ofthe shoulder girdle and hand with local fibrillation and pyramidal syndrome. Neurological examination reveals mixed paresis ofthe upper extremities in the combination with spastic lower paraparesis.
Taking in account that asymptomatic cervical spondylosis is a common cause of cervical myelopathy (12%), in reality it is caused more often by other reasons and are found later. Literature review and our own data showed that the clinical and neurological symptoms of the cervical spine stenosis can be polymorphic and can sometimes resemble demyelinating, inflammatory and neoplastic diseases [2].
Conclusion
1. Degenerative stenosis of the cervical spinal canal is characterized by variety of neurological syndromes. Variety of neurological syndromes in degenerative cervical stenosis is caused by a multiple factors of neurovascular compression in the vertebral canal.
2. Clinical and neurological changes in degenerative cervical stenosis occur in the form of radicular syndrome in 19.7% of cases, spinal cord syndrome -46.9%, radicular spinal syndrome in 22.2% cases and ischemic syndrome in 9 (11.1%) cases.
References:
1. Антипко Л. Э. Стеноз позвоночного канала. - Воронеж, - 2000. - 215 с.
2. Adamova B., Vohanka S., Dusek L. Differential diagnostics in patients with mild lumbar spinal stenosis: the contributions and limits of various tests. Eur. Spine J. - 2003. Apr.; 12 (2):190-6. Epub. - 2002. Dec. 21.
3. Kawaguchi Y., Kanamori M., Ishihara H., Ohmori K., Abe Y., Kimura T. Pathomechanism of myelopathy and surgical results of laminoplasty in elderly patients with cervical spondylosis. Spine. - 2003; 28: 2209-14.
4. Lees F., Turner J. W. Natural history and prognosis of cervical spondylosis. Br Med J. - 1963; 2: 1607-10.
5. Van Akkerveeken P. Classification and treatment of spinal stenosis / P. Van Akkerveeken // Ed. by S. W. Wiesel et al. - Philadelphia etc., - 1996. - P. 724-736.
