Current Diagnostic and Treatment Algorithm for Spinal Cord Diseases
Spinal cord diseases are a heterogeneous group of conditions that cause damage or dysfunction of the spinal cord. They include tumors, infections, inflammatory disorders, bone pathologies of the vertebral column (such as spondylosis, spinal stenosis, osteoarthritis, spondylolisthesis), vascular diseases and disorders that affect the meninges or perimeningeal spaces that surround the spinal cord, trauma to the spinal cord and vertebral column.
Spinal cord disorders present a tremendous challenge for the clinician, as they show great variability in clinical presentation but can have potentially devastating sequelae. The acute and sometimes urgent nature of therapeutic management is highly dependent on the underlying disorder, often necessitating a combination of approaches including surgical or conservative therapies (including immunomodulatory therapy) and an interdisciplinary approach to achieve the best outcomes. In such cases, the treatment should be carried out in specialized local centers. If needed, the partner specialists from German Health Advisors could give a Second Opinion using the secure Telemedicine platform. For this purpose, detailed information about the patient and radiology tests performed need to be shared. The patients with chronic spinal cord disorders can get either Second Opinion and come to Germany for further diagnostic procedures and treatment. Below, we describe the diagnostic approach and main treatment options for these patients.
Diagnostic Approach to Spinal Cord Diseases
We need detailed information about the patient for either getting a Second Opinion and/or arranging treatment in Germany. Initial diagnostic work up of overseas patients is usually incomplete at the time they contact us for a second opinion and/or any subsequent treatment recommendations. The system used by German Health Advisors, however, allows for the completion of this stage while patients are in their homeland. Usually it is not necessary to come to Germany for diagnostic procedures. You will be informed if there are any obstacles in the diagnostic processes. For the diagnostic procedures of Spinal Cord Diseases, please bear in mind the following:
- Medical history, physical examination with neurological exam (checking the vision, hearing, balance, coordination, strength and reflexes), blood count and differential, liver and renal function tests (see the request form for German Health Advisors). This will usually be carried out by our local colleagues and documented in the form of a doctor’s letter.
- The conventional radiography (X-ray) continues to be the most basic and the most widely used diagnostic imaging technique. It is the first line technique used in bone pathologies (stenosis, scoliosis and spondylosis), fractures of the vertebrae and disc herniations. X-rays also help us to visualize the bony tumors of the spinal cord. It is usually the first diagnostic method to be requested in cases of a trauma of the spine. X-rays are not helpful in visualizing the soft tissues (of the spinal cord) but they give a clear picture of the bony structures of the vertebral column.
- Computerized tomography scan (CT scan) is a commonly used technique for the investigation of spinal fractures, scoliosis, spondylosis, herniated discs, spinal stenosis and in bony tumors of the spine. Helical/spiral scanning enable us to collect information from multiple angles simultaneously. The vascular supply of the spine can be envisioned by using this technique.
- Magnetic resonance imaging (MRI) is a miraculous development in the field of medicine. It is a very safe investigation as no radiations are being used in it. Even pregnant women can have an MRI safely. MRI is the most effective tool to visualize the soft tissue in the body. MRI is the investigation of choice for conditions such as myelopathy due to disc herniation or spondylosis. It will show any damage to the cord by trauma or other insults (eg inflammation). The advantage of using MRI is that in addition to giving us a clue about the pathology of the outer layers eg. bones, it will also tell us the effects of the condition of the cord. It can show spinal cord or nerve root compression and pinched or inflamed nerves. It can reveal any abnormalities in the spine or spinal cord that may be causing spinal pain.
- MR angiography might be needed to be performed and can help us visualize the blood supply of the spinal cord and will mark the areas that do not get a good blood supply. It is the best means of doing an angiography as it can be performed without using any contrast. It helps to point out vascular malformations like aneurysms etc.
- MRI DWI (diffusion-weighted imaging) can detect ischemia earlier than the CT scan can do so.
- Functional MRI (fMRI) can be used to assess blood flow while performing specific tasks eg. Speaking, performing calculations etc) to map out the different areas functioning while performing these tasks.
- Nerve conduction studies (NCS) and EMG. EMG (electromyography) is generally performed with NCS and involves needle recording of the muscle electrical potential during rest and contraction. These tests can help to identify any nerve damage due to impingement of the nerve (eg due to disc prolapse and spondylosis). These tests are really important in the diagnosis of conditions like Myasthenia gravis and Lambert Eaton syndrome.
- Myelography is a radiographic examination in which the spinal cord in visualized using X-rays after a dye (contrast) injection in the dura mater (dura mater is the outermost covering of the spinal cord). This investigation is commonly used in the diagnosis of spinal stenosis.
- Discogram is a procedure when a needle is inserted into the intervertebral disc and contrast medium is injected in it to visualize the disc. If the disc is herniated, the contrast will leak out. It is only performed if all the other investigations fail at confirming a diagnosis. The needle can also be placed in the intervertebral disc under fluoroscopic guidance.
Treatment of Spinal Cord Diseases
Treatment decisions are individualized based on the type disorder and the patient's age and physical condition. Treatment often includes a combination of surgery and medical therapy. Below, we list the main current treatment options:
- Discectomy, where the herniating intervertebral disc is removed so that it stops impinging on the nerve roots arising nearby it. It has been conventionally performed by an open method, in which an incision is given in the back and the herniated intervertebral disc is removed. Currently, nano-discectomy is also being performed. It is a minimally invasive procedure. A small needle is inserted under fluoroscopic guidance in the herniating disc and some of the material (nucleus pulposus) is removed. This relieves the symptoms of the disc herniation.
- Laminectomy, where a part of the vertebral bone is removed and this increases the space for the spinal cord. It is the procedure of choice for spinal stenosis. In this procedure, the posterior spinal ligament and some or all of the spinous processes are removed. Carrying on this procedure by the conventional method requires the many muscles of the back to be removed from the vertebral column. A minimally invasive technique eliminates the need to remove the many spinal muscles attached to the vertebral column. This makes it a very safe and preferable procedure for diseases like spinal stenosis.
- Laminotomy is the removal of a mid-portion of one lamina. It is also done for diseases like spinal stenosis. If performed in a minimalistic fashion with the use of tubular retractors and endoscopes, it becomes more safe and feasible procedure to perform.
- Vertebroplasty and kyphoplasty have been performed as open procedures for many decades. But the risks of the procedure outweighed the benefits in most cases. Recently these two relatively new techniques are employed using minimally invasive surgical procedure. Vertebroplasty is a minimally invasive procedure which can even be performed using local anesthesia. A biopsy needle is passed under fluoroscopic guidance and bone cement is injected with it into the collapsed or fractured vertebra. Kyphoplasty attempts to restore the height and shape of the fractured vertebra. A small balloon is inflated in the compressed fractured vertebra and a void is created. The rest of the procedure is the same as the vertebroplasty, that void is filled with cement. It is a minimally invasive procedure.
- Arthroplasty means the surgical reconstruction or replacement of a diseased joint. It is used in conditions like osteoarthritis of the spine, spondylolisthesis, etc
- Joint Fusion, where two vertebrae are joined together to make them one unit so they act as a single solid bone. This eliminates the painful motion of the intervertebral joints.
- Facet Replacement, where the facet joints are replaced by artificial joints. This preserves the range of motion and strength of the vertebral column.
- Artificial Disc Replacement, where the degenerated intervertebral discs in the spinal column are replaced with artificial discs. This procedure is used to treat chronic, severe low back pain and cervical pain resulting from degenerative disc disease.
Follow-Up and Rehabilitation after the Treatment
The recovery period after Spinal Cord Surgery can last up to weeks if not month depending on the severity of the surgery. Rehabilitation after the surgery is, therefore, an extremely important process in helping patients maximize the benefits of their surgery. Please, take this important factor into account, if you opt to get the treatment in Germany. German Health Advisors can help you to go to a specialized physiotherapy center after the surgery, where you will be assisted through their rehabilitation program to aid you to a full recovery.
Keywords: nano-discectomy, arthroplasty, vertebroplasty and kyphoplasty, laminectomy, discectomy
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2. Davidson’s principles and practice of medicine (22nd edition)
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4. Percutaneous Disc Decompression for Lumbar Radicular Pain: A Review Article. Ong D, et al. Pain Pract. 2016.