Re:Differnetial Diagnosis and Management of spinal nerve root-related pain 정리

[문형철]

신경근과 관련된 통증에 대한 논문 정리

1. Root-related pain can emerge from the tension events in the dura mater and nerve tissue associated with primary disc related disorders, including disc protrusion, prolapse, and extrusion. Conversely, secondary disc-related degeneration can produce compression on the nerve roots within the surrounding “container,” resulting in chemical and mechanical consequences imposed on the nervous tissue within the spinal canal, lateral recess, intervertebral foramina, and extraforminal regions.

- 급성기 tension event .. 이후 compression으로 인한 화학적, 기계적 문제

2. the lumbar canal achieves an adult size within the first 12 months postpartum at the L3 and L4 bony levels.

Canal at the fifth lumbar segment develops more slowly and does not reach an adult size until the fifth year

3. 개념 Batson plexus, retrodural fat pad

At the pedicular level of the canal the pedicles, laminae, ligamentum flavum and retrodural fatpad form the lateral and posterior walls of the canal. The intertransverse membranes, inferior articular processes, ligamentum flavum and retrodural fatpad border the infra-pedicular level of the canal. Finally, the intervertebral disc, PLL, zygapophyseal

joint (ZAJ) capsule, and ligamentum flavum border the discal level of the canal.

Disc derangements, as well as hypertrophic changes in both bony and soft tissue structures in the canal, can lead to neural compromise. Vertebral bodies can develop degenerative changes that lead to canal compromise. These degenerative changes frequently occur in response to the increased ‘wobble’ associated with a segmental hypermobility.

In response to this hypermobility, the segment attempts to stabilize in context with progressive disc fibrosis and reduced

disc height.

This adaptation produces ventral, dorsal and lateral lipping(골극) on the vertebral body margins, thus representing a segment’s attempt to stabilize the hypermobility. 

Although these bony changes do not serve as a pain generator, they can reduce the diameter of the spinal canal, compress the dural sac and cauda equina, increase intradural pressure, and produce root-related pain.

4. posterior longitudinal ligament

The posterior longitudinal ligament (PLL) is comprised of two layers and courses posterior to the vertebral column on the anterior wall of the spinal canal. The superficial layer is 8-10 mm wide and extends along the midline of the column from the cervical to sacral bony levels. Deeper fibers of the superficial PLL are hourglass shaped and fan out laterally, attaching to the posterior disc-annulus complex. The deep layer of the PLL is very narrow (2 to 3mm width) and is continuous with the hourglass shape of the superficial PLL, attaching to the lateral borders of the annulus and loosely to the vertebral

body. Superficial and deep layers of the PLL are interconnected at each level where the deep layer joins the disc-annulus complex.