In continuation with spinal canal of cervical spine, spinal canal in thoracic and lumbar spine consists of vertebral body, intervertebral disc, posterior longitudinal ligament anteriorly, pedicles, medial aspect of facet joints on either side laterally and ligamentum flavum & laminae posteriorly.
Injury can cause compromise of the spinal canal and the most common cause is posterior bony retropulsion from a burst fracture of the vertebral body.
Dislocations and fracture dislocations of vertebrae leading to translation between adjacent vertebrae can also cause reduction in canal space. Anterirorly displaced fractures of posterior elements [laminae] can also compromise the canal space.
Postraumatic hematoma formation, disc herniations are other causes of compression following injury.
Lumbar canal stenosis is frequent non traumatic cause of reduction of canal space and neural compromise.
Conus medularis is most distal aspect of the spinal cord and its location varies between T12 and L3. Spinal canal dimensions relative to spinal cord dimensions are smallest in the T2-T10 region and for this reason the neurologic injury is more commmon after trauma in this region.
Complete spinal cord injury is six times more common than incomplete injury with high-energy trauma to the midthoracic spine .
In addition to smaller canal space, another factor which is responsible for susceptibility is the lesser vascular supply to the spinal cord. The region between T2 and T10 derives its proximal blood supply from antegrade vessels in the upper thoracic spine and distally from retrograde flow from the artery of Adamkiewicz.
Artery of Adamkiewicz is the largest anterior segmental medullary arterIt typically arises from a left posterior intercostal artery, which branches from the aorta, and supplies the lower two thirds of the spinal cord via the anterior spinal artery
This region is called circulatory watershed area, which can be variably located between T9 to L2.
Studies have repeatedly shown that there is no definite correlation between the degree of compromise of the spinal canal and the severity of the neural deficit.
Due to variations in the spinal canal space and differences in blood supply the damage to neural structures is caused mainly by the severity and level of injury.
Because the spinal canal in the thoracic area is small and the blood supply is less, severe neurological injury is common in the thoracic spine. Due to greater vascularity, greater spinal diameter and lesser vulnerability of cuada equina, injuries the lumbosacral region may cause marked displacement without neurological deficit.
Can damage to the Adamkiewcz artery be repaired to reverse the symptoms of urinary, faecal and muscular control following an endoscopic herniated disc surgery? If so, what treatment would you suggest and how long would it take to resume normal muscle movements? I am a very fit person otherwise. The surgery was done to relieve my sciatica pain on the right leg. But now, I am having difficulty in walking, going to the toilet and standing too long. I have numbness in both my legs and senasation of pins and needles. The sciatica pain has not altogether gone away. Please advise me. Thank you. My surgery was on the 9th November, and I am now hit for six!
Dr Arun Pal Singh Reply:
November 14th, 2010 at 2:07 pm
@Raveen,
Did you talk with your treating physician. What were you told?
Yes Dr. Arun, I did speak to my treating surgeon abo ut my symptons. He is of the opinion that I should rest a while to eliminate any post-surgery traumas, and then see how I feel. So, I am being patient. But the pain is unbearable when I am on my feet! I am for now giving him the benefit of the doubt, you can say! To be honest, the surgeon does not know why I am in this pain cos it has not happened like this to any of his patients before!
I am thinking that I should ask him to do something if the pain level has not changed or got worse by Tuesday, when I am due to go for physiotheraphy.
Is it a problem with my Adamkiewcz?
Thank you,
Raveendran
Dr Arun Pal Singh Reply:
November 27th, 2010 at 6:59 am
@Raveen,
Why has Adamkiewcz come into your thoughts?
How are you now?
Dear Dr. Arun,
I am still in pain on the right leg and this prevents me from walking properly. There is still numbness in my right leg, left leg and in my urinary and rectal muscles. I am taking neurontin 3 times a day because the surgeon thinks that it is my nerves playing up after the surgery. My leg muscles are going weak because of the lack of walking and exercise. I used to run and spin at the gym about 3 times a week before the surgery!
What do you it is? Please give me your opinion from the symptoms I am describing to you.
Thank you,
Raveen
Dr Arun Pal Singh Reply:
December 4th, 2010 at 7:18 pm
@Raveen,
Please talk to your surgeon. Most likely there is a residual problem. May be the intended surgery could not address the actual problem in totality.
It does happen sometimes. Please talk to your treating surgeon.
If that does not help, you may seek a second opinion from the doctor who can examine you.
I hope that helps.
Dear Dr. Arun,
Thank you for your advice.
Do you know of a good spinal consultant for a second opinion. My surgery was an endoscopic surgery, so, I guess the consultant should be one from this field of surgery.
Also, I prefer to see someone who operates from Pantai Medical Centre, Bangsar, KL
Much obliged to you,
Raveendran
Dr Arun Pal Singh Reply:
December 14th, 2010 at 7:34 pm
@Raveen,
Sorry! I do not anyone in that area.
Dear Dr. Arun,
Do you know anyone in Assunta Hospital, Petaling Jaya? Or, Pantai, Cheras, KL? Or, Ampang Puteri in Ampang, KL?
Do you do endoscopic surgery yourself? And do you think you can sort my problem?
I need help, sir, as I think that it is my sciatica which is still not sorted. I don’t know if I should do a MRI for now to see if there is a problem which is causing the pain.
Your assistance in this matter would be greatly appreciated.
Thank you,
Raveendran
Dr Arun Pal Singh Reply:
December 21st, 2010 at 1:42 pm
@Raveen,
Sorry! I do not have any idea of recommending anybody where you live.
You would be best helped by local contacts.
Dear Dr. Arun,
My hunch was right! The MRI revealed that the pain was due to pressure on the nerves caused by the swelling of the spinal cord around the area of the surgery. The pain was radiating right to my legs and had caused the numbness.
I am receiving epidural injections today and tomorrow with the view of reducing the swelling. I am hoping that this will resolve the matter.
Some learning from my experience so are: -
(1) Symptoms like mine should have been picked up by the surgeon or the physiotherapist;
(2) Physiotherapy should never be commenced until all swelling and pain has ceased;
(3) No two patients are alike, even for “no brainer” surgeries, like mine;
(4) Alarm bells should have been triggered when numbness is felt around the abdominal area soon after a spinal surgery;
(5) How do you address scarring after the swelling has cleared because excessive scarring (as aresult of excessive swelling) could lead to future compression of nerves.
(6) Ensocopic spinal surgeries should never be prolonged;
(7) A delayed recovery like mine inevitably leads to muscle wastage and possibly nerve damage.
What are your thoughts on my comments above?
Thank you,
Raveendran
Dr Arun Pal Singh Reply:
December 29th, 2010 at 12:24 pm
@Raveen,
I would better not comment. It would start unnecessary discussion that would serve nobody.
Take care. How are you now?
Dear Dr. Arun,
I am very much better now, thank you. If not for my persistence, I could have suffered longer.
If this a “speak your mind” blog, sir, then we should!
Raveendran
Dr Arun Pal Singh Reply:
December 29th, 2010 at 6:58 pm
@Raveen,
Many of your points were subjective feelings. What I have as information is the information you provided me and it in no way can be considered as enough to comment on your case.
So I refrained from commenting.
Thanks for reminding me “Speak Your Mind”. I never looked at that part of template and what it might inspire.
Its funny though.
I am glad you are better.
All the best.