Miscellaneous

Adult Scoliosis

Definition

 

Presentation of scoliosis deformity after skeletal maturity

- must be > 21 years at first presentation

- any of usual causes

 

Typically

- thoracolumbar / lumbar

 

Epidemiology

 

Idiopathic 

- most common cause of adult scoliosis

- incidence is  ~ 5% in population

- 5000 adults having IVPs - 4% had lumbar scoliosis >10°

 

Symptoms

 

Pain / Progressive deformity

 

Examination

 

As per scoliosis examination

 

Xray

 

Standing PA & lateral

- Cobb angle

- balance

- degenerative change

 

NHx

 

<30° don't progress

 

Progression seen in

- >60° & thoracic

- lumbar portion of double major curve

- progression is usually 1° per year

- some progress faster especially lumbar with severe degenerative changes

 

Respiratory compromise seen curve > 60o

 

Increased mortality when curve >90°

 

Weinstein & Ponsetti

- Ppogression from 1o per month to 1o per year for curves > 30o

- Average 13o over 40 years 

 

Management

 

Non-operative

 

Analgesics, bracing, physical therapy, injections

 

Operative

 

Indications

 

1. Progressive deformity

- progressive thoracic curves >60° (young adults)

- thoracic curve >80° with decreased pulmonary function (older patients)

- lumbar curves with rotatory subluxation & pain or stenosis

 

2. Pain not relieved by non-operative measures

- surgery for relief of pain alone ~ 50% successful

 

Options

 

1.  Decompression alone

- stenosis with no major coronal or sagittal deformity & no rotational deformity

- flexion / extension & side bending radiographs show minimal movement

- should not destabilise spine as long as not performed at apex

 

2.  Decompression & Posterior instrumented fusion

 

3.  Decompression with Anterior & Posterior Instrumented Fusion

- severe deformities in both coronal & sagittal planes

- curve >80° or kyphosis > 70°

- not correctable on side bending or hyperextension lateral radiographs

- need anterior release / ACDF first

- then posterior decompression and instrumented fusion

 

 

 

 

Ankylosing Spondylitis

Definition

 

A HLA B27 positive, seronegative spondyloarthropathy with sacroiliac joint & spine involvement

Mainly affects the cartilaginous joints of the axial skeleton

 

Diagostic Criteria (1966 New York)

 

1. Positive X-ray Sacroiliitis

 

Sacroilitis Ankylosing Spondylitis

 

2. One or more of

- lumbar spine pain 

- lumbar spine stiffness

- chest expansion < 1" at 4th intercostal space

 

Epidemiology

 

1/1000 Caucasian

 

FHx in 15 - 20% patients

 

M:F = 3:1

 

Females

- less progressive spinal disease

- more peripheral disease

 

Average onset 25 years

 

Aetiology

 

HLA-B27

 

Autosomal Dominant

- 95% of cases

 

B27 linked to susceptibility factor

- ? Trigger

- ? GIT infection with Klebsiella

 

Pathology

 

Two basic lesions

1. Enthesitis

2. Synovitis of Diarthrodial Synovial Joint

 

Enthesitis

 

Enthesis is insertion of tendon, ligament or capsular into bone

 

A.  Discs / Manubriosternal joints / Symphysis pubis

B.  Hip / Shoulder

C.  Spinous processes of vertebrae / Crests / GT

D.  Pelvis Crests / GT /  Ischial tuberosities / Iliac spines / Pubic symphysis

E.  Heels / Achilles / Plantar fascia

 

Synovitis

 

Similar changes to RA

- villous proliferation of synovium / pannus destroys cartilage 

- joint ankylosed by fibrous tissue

- converted to bone

 

TL spine

 

A. Spondylodiscitis / Anderson lesion 

- erosion of enthesis at anterolateral annulus at endplate

 

B.  Romano's lesion

- lesions heal by forming new bone / early squaring 

 

C.  Marginal syndesmophyte

- with repeated episodes forms thin vertical bone due to ossification of annulus fibrosis

 

Ankylosing Spondylitis Marginal Syndesmophytes

 

D.  Bamboo spine

- fusion / bony disc casing 

 

 Ankylosing SpondylitisAnkylosing Spondylitis CT Spine SagittalAnkylosing Spondylitis CT Spine Coronal

 

Extraskeletal Manifestations

 

Acute Anterior Uveitis 20-40%

Aortitis + secondary Aortic Regurgitation 90%

Pulmonary fibrosis

 

Symptoms

 

Lower back pain

- insidious onset

- usually dull & poorly localised

 

Back stiffness

- worse in am & after inactivity

- improved by warming up

- improves with exercise

 

Neck pain & stiffness

 

Signs

 

1.  Altered posture

- increased thoracic kyphosis

- loss of cervical & lumbar lordosis

 

2.  Positive "Wall Test"

- cannot put heels / buttocks and Occiput on wall

 

3.  Reduced ROM

- decreased extension earliest & most severe

- decreased flexion

- Schober's Test < 4cm

- decreased lateral flexion

 

4.  Pain & tender SIJ

- SIJ Stress Tests / FABER  

- pain on downward pressure on knee in fig 4 

 

5.  Decreased chest expansion 

- <1" at 4th ICS

- secondary to costovertebral joint ankylosis

 

Bloods

 

ESR

- increased in 75% / elevated for life-time

 

HLA-B27

- positive 90%

 

X-ray

 

Sacro-iliac joint

- erosion / sclerosis / finally ankylosis

 

Spine

- marginal erosions / squaring of anterior body concavity

- marginal syndesmophytes

- bamboo spine

 

Ankylosing Spondylitis AP C SpineAnkylosing Spondylitis Latera C SpineAnkylosing Spondylitis Lateral C spine 2

 

Hip & Shoulder

- concentric joint space narrowing

- bony ankylosis

- protrusio

 

DDx

 

Seronegative Seroarthropathies

- Reiters / Psoriasis / Enterocolitis

 

DISH 

- °Inflammatory / no SIJ involvement

- non-marginal syndesmophytes

 

Scheuermann's

- end plate changes

 

Management

 

Non-operative

 

Simple analgesia

NSAID

Physio

Maintain ROM & posture especially extension

 

Operative Management

 

Issues

 

1.  Spinal fracture

2.  Kyphotic deformity

3.  THR

 

Spinal Fractures

 

Ankylosing Spondylitis Thoracic Fracture CTAnkylosing Spondylitis Thoracic Fracture CT CoronalAnkylosing Spondylitis Fracture MRI Spine

 

Pathology

- fused spine acts as long bone

- fracturs at cervico-thoracic junction / thoraco-lumbar junction

 

Non operative management

- stable, minimally displaced lesion

- no neurological deficit

 

Operative Indications

- unstable fractures

- incomplete neurological deficit

- failure of bracing

 

Ankylosing Spondylitis Thoracic Fracture Stabilisation APAnkylosing Spondylitis Thoracic Fracture Stabilisation Lateral

 

Kyphosis

 

Indication for corrective osteotomy

 

A.  Severe cervical kyphotic deformity

- difficulty in looking forward / opening mouth

 

B.  Respiratory compromise

- chin on chest position

 

Contra-indication

- elderly

- aortic calcification

 

A.  Cervical

 

Use brow-chin angle to calculate osteotomy size

 

Closing wedge extension osteotomy 

- fulcrum must be posterior elements of C7-T1

- avoids vertebral artery at C6

- canal is relatively wide at this level

- C8 nerve root most mobile & expendable

- decompress C8 nerve roots

- short-acting GA when close osteotomy

- wake up test

- HTB post-operatively

 

Belanger et al JBJS Am 2005

- 26 patients

- average 38o correction

- 1 quadriplegia who died due to subluxation at osteotomy site

- 2 delayed unions

- 5 patients had irritation of C8 nerve root

 

B.  Thoracolumbar

 

Options

 

Smith-Peterson Osteotomy with instrumentation

- osteotomies in SP above & below central vertebra

- centre of correction is disc / must be healthy

- 10o per level / maximum 30o

- major risk is to aorta

 

Pedicle subtraction osteotomy

- 30 - 40o per level

- centre of correction vertebral body

- more dangerous / increased correction with better union

 

THR

 

Good functional outcome

- no increased loosening seen

- must restore centre of rotation

 

Main complication is HO

- 20% > Brooker III

- indomethacin indicated

 

 

 

Blood Supply Spine

Blood Supply Spine

 

62 segmental arteries as 31 paired structures branches

- aorta 

- subclavian

- vertebral 

- internal iliac arteries 

 

Cervical spine 

- vertebral artery  (77%)

- additional supply is from branches of the subclavian artery (thyrocervical and costocervical)

 

Cervicothoracic spine

- branch from ascending pharyngeal in 60%

- vertebral artery responsible for only 36% of supply

 

Thoracic and lumbar spine

- aorta gives segmental arteries

- divide into lateral and dorsal branches 

 

Sacral spine

- internal iliac gives rise to iliolumbar artery (5th lumbar segmental artery) and lateral sacral artery

- additional supply from middle sacral artery

 

Blood Supply of the Spinal Cord 

 

General Features

- cord dependant on all three longitudinal vessels

- metabolic demands of grey matter greater than that of white matter

- longitudinal arterial trunks larger in cervical and lumbar regions due to ganglionic enlargements

 

Anterior Spinal Artery / ASA

- formed by union of anterior spinal branches of vertebral arteries at foramen magnum

- runs in anterior median fissure from medulla oblongata to conus medullaris

- narrows and may become absent in thoracic cord

- variable segmental supply

- probably supplies entire cord except posterior columns

 

Posterior Spinal Artery / PSA

- smaller than anterior spinal artery

- bilateral

- aries from posterior inferior cerebellar arteries or vertebral arteries at foramen magnum

- usually double running in between and behind posterior rootlets of spinal nerve

- anastomoses with anterior spinal artery particularly at conus

- may be noncontiguous areas

- variable segmental supply but more numerous and smaller than ASA

 

Segmental Supply

- average of 8 ASA radicular arteries (range 2-17)

- average 12 paired PSA radicular arteries (range 6-25)

- T4-T8 is narrowest portion of longitudinal supply and usually is fed by a single radicular artery

- thoracolumbar cord supplied by one or more prominent arteries

 

Artery of Adamkiewicz  

- originates on left from T9-T11 in 80% of cases (range T7-L4)

 

Cord Distribution

- ASA and PSAs give off central end arteries and peripheral branches

- central branches penetrate the cord via sulci

- peripheral branches anastomose with small pial branches of segmental vessels

- supply the periphery of the cord and are responsible for sacral sparing in ASA lesions

 

Venous Drainage

 

External venous plexus

- anterior to vertebral bodies

 

Internal venous plexus

- in epidural space

- anterior median spinal veins drains anterior cord

 

Posterior spinal veins are double and receive small radial veins from the posterior columns

- subsequent drainage into anterior and posterior medullary veins

- unite to form a segmental vein which anastomoses with the external plexus

- ultimate drainage into vertebral, azygous and lumbar veins and IVC

 

Surgical Considerations

 

T4-T9 is the critical vascular zone in which interference with the circulation is most likely to result in paraplegia

 

Principles of anterior spinal surgery

- ligate segmental spinal arteries only as necessary to obtain exposure

- ligate segmental spinal arteries at aorta rather than cord

- ligate segmental arteries on one side only

- limit dissection in vertebral foramina to a single level to preserve  anastomoses

 

 

 

 

 

Burners & Stingers

Definition

 

Neurological pain in arm after injury in sport

- usually due to brachial plexus injury

 

Epidemiology

 

Contact sports

- ice hockey

- rugby

- american football

- basketball

 

Pathology

 

Brachial plexus injury

Cervical nerve root injury

 

Aetiology

 

Traction injury

- hit onto shoulder

- head pushed in opposite direction to arm

 

Clinical

 

Pain / Parasthesia / Burning down arm

Temporary weakness

 

May last minutes to weeks

 

DDX

 

A stinger is a diagosis of exclusion

 

Cervical spine fracture

Herniated disc

Brachial plexus injury

 

Xray / MRI

 

Important to exclude fracture / HNP

 

Management

 

Rest

Soft Collar

Physiotherapy

NSAIDS

 

Self limiting condition

- return to sport when asymptomatic

 

Recurrence prevention

- sports collars

- change tackling techniques

 

 

 

 

Coccydynia

Definition

 

Pain in region of coccyx

 

Epidemiology

 

Women

- often obese

- mean age 40 years

 

Aetiology

 

Fracture

 

Difficult vaginal delivery

 

Subluxation / hypermobile coccyx

 

Anatomy

 

3 or 4 fused coccygeal vertebrae

 

Triangular structure

 

Usually a joint with sacrum

- can be fused

 

Pathology

 

Symptomatic patients

- no evidence increased number of segments

- often more angular

- increased rate of sacral - coccygeal fusion

 

Symptoms

 

Pain in coccyx

Difficulty sitting

 

Signs

 

Painful to touch

 

Xray

 

Coccyx Xray

 

Dynamic radiographs

- standing and sitting radiographs

- looking for hypermobility

- > 25o

 

Note: Not all coccygodynia is from hypermobile coccyx

 

Spicule on coccyx

- may be seen in immobile coccygodynia

 

Bone scan / MRI

 

Show inflammation

 

Management

 

Non Operative

 

Options

 

Analgesia

Cushions

HCLA

 

HCLA

 

1.  HCLA

 

Mitra Pain Physician 2007

- injection HCLA under II in 14 patients

- patients with acute pain / < 6 months fared much better

 

2.  Manipulation

 

Maigne et al Spine 2006

- randomised trial of intra-rectal manipulation (x3) v physiotherapy

- mild improvements in group with manipulation

- best results in patients with acute, traumatic coccydynia

 

Operative

 

Excision of Coccyx

 

Preparation

 

Bowel prep

 

Oral metronidazole

- 24 hour treatment

- day before surgery

 

Pre-op and post operative antibiotics

- Penicillin / Gentamicin / Metronidazole

 

Technique

- patient prone on 4 poster

- want to flex hips as much as possible

- vertical incision away from perianal skin

- through fascia

- G max reflected

- subperiosteally dissect coccyx

- ensure don't leave tip

 

Results

 

Trollegard et al JBJS Br 2010

- 41 patients with coccygectomy

- post trauma / childbirth / idiopathic onset

- 33/41 good or excellent results

- 5 superfical infections

 

DISH

Definition

 

Diffuse Idiopathic Skeletal Hyperostosis

- non-inflammatory disease

- ossifying enthesopathy / bone forming diasthesis

- most commonly involves spine / anterior longitudinal ligament

 

AKA  Forestier's disease

 

DDx

 

Ankylosing Spondylosis

 

DISH

- non inflammatory

- no facet or SIJ involvement

- no squaring of anterior vertebral body

- non marginal syndesmophytes

 

Diagnostic Criteria for DISH

 

1.  Flowing ossification along the anterolateral aspect of at least 4 contiguous vertebrae

2.  Preservation of disc height / relative absence of significant degenerative changes

3.  Absence of facet joint ankylosis or sacroiliac erosion

 

DISH Thoracic VertebraeDISH Thoracic Vertebra LateralLumbar DISH Lateral

 

Epidemiology

 

Common 

- 1/3 over age 65

 

Middle-aged or elderly 

 

Associations

 

Diabetes

Hypertension

Gout

Obesity

 

Normal incidence of HLA B27

 

Clinical Presentation

 

Principal symptom is LBP

 

Occasional dysphagia

- anterior osteophytes in cervical spine impinging on oesophagus

 

Occasional spinal stenosis 

- due to ossification of PLL

 

Achilles tendonitis

 

X-ray

 

Thoracic vertebra

 

DISH Right sided

 

Most common right sided and unilateral

- anterior & lateral spine

 

Non marginal syndesmophytes 

- flowing / candle wax  

- marginal osteophytes of ankylosing spondylitis very vertical

 

Integrity of disc spaces & facet joints maintained 

- not an arthritis

 

Cervical spine

- less frequent

 

Cervical DISHDISH Cervical Spine Lateral

 

Lumbar spine

- least common

 

DISH LumbarDISH Lumbar VertebraLumbar DISH

 

Other

 

Pelvis

- osseous whiskering at sites of ligament attachment

- iliac crests / ischial tuberosity / trochanters

 

DISH Pelvis Osseous Whiskering

 

Pelvic Whispering DISH

 

Heel 

- calcaneal spurs / achilles tendonitis

 

Hip

- periarticular bone formation with intact joint space

- increased risk of HO in THR

 

Shoulder

- hyperostosis deltoid insertion, LT, GT

 

Elbow

- olecranon spurs

 

Management

 

Symptomatic

 

Analgesia

NSAID

Physiotherapy to maintain motion

 

Issues

 

Surgery rarely required to remove osteophytes

- sometimes in cervical spine to relieve symptoms

 

Trauma

- high risk of fracture

- need to be carefully assessed

- high risk of neurology and instability

Inflammatory Arthopathies

Gout

 

No pathognomonic signs for gout

- identification of negative birefringent crystals under polarising light 

- trial of indomethacin if suspected

 

Inflammatory Bowel Disease / Enteropathic

 

Crohn's & Ulcerative Colitis

- spinal manifestation similar to Ankylosing Spondylitis

- 15-60% of IBD

 

Two different forms

- mild & asymptomatic

- HLA B27 positive with progressive & aggressive disease

 

Colectomy does not improve spondylosis

 

Psoriasis

 

20% develop spondylitis

 

Reiter's Spondylitis

 

Men more common

- 3rd decade

- post infectious reactive arthritis

 

Back pain &/or Sacroiliitis

- 20-30%

- usually unilateral compared with Ankylosing Spondylitis

 

Xray

- see juxta-articular osteoporosis

- joint space narrowing & erosive changes

 

Behcet's Syndrome

 

Rare seronegative disease involving many systems

- oral & genital ulcers

- uveitis

- CNS involvement

- + arthritis, thrombophlebitis & skin lesions

 

Aetiology

- ? viral ? immunolgical

- endemic in parts east Europe and Asian

 

Clinical

- asymmetric appendicular arthritis especially knee

- sacroiliitis & spondylitis may occur

 

Alkaptonuria & Ochronosis

 

Inborn error of metabolism in which homogentisic acid can not be oxidised

 

A form of HA 

- black deposit in tissues 

- deposited in connective tissue containing hyaline & fibrocartilage

 

Most common spinal problem is spondylosis

- deposits in disc with ossification & marginal syndesmophytes

- SIJ usually unaffected

 

Neuropathic Spondyloarthropathy

 

Causes

- tabes dorsalis

- syrinx in cervical spine

 

Clinically

- deformity, instability, crepitation & hyper-mobility

 

 

 

Kyphosis

Background

Definition

 

Abnormal posteriorly directed sagittal plane curve of spine

 

Scoliosis Research Society 

 

Thoracic

 

Normal range thoracic kyphosis is 20-40° 

- measured over T1 to T12 by Cobb method

- upper limit of normal thoracic kyphosis < 45°

 

Cervical & Lumbar

- lordosis is normal

- any kyphosis (>5°) considered abnormal

 

Classification Scoliosis Research Society

 

Postural

 

Scheuermann's Disease

 

Inflammatory / Ankylosing Spondylitis

 

Congenital

- failure of segmentation / formation / mixed

 

Iatrogenic

- post laminectomy / tumour excision in child / radiotherapy

 

Traumatic

- acute fracture / anterior wedging

- chonic - osteoporosis, OI

 

Infection

- TB

 

Metabolic

- Osteoporosis

- OI

- Mucopolysaccharidoses

 

Neuromuscular

- Polio

- Spinal muscular atrophy

- UMN Syrinx

- SB

 

Developmental

- Achondroplasia

- SED

- morquio's 

 

Postural Kyphosis

 

Often confused with Scheuermann's

 

Examination

 

Gradual, no angular curve

 

Patient can voluntary correct roundness on stance

 

Prone hyperextension test

- reversal of thoracic spine hyperkyphosis

 

X-ray

 

No structural vertebral changes

 

Corrects on supine xray on bolster

 

Management

 

No treatment necessary

 

Post - Laminectomy Kyphosis

 

Mechanism

 

Occur because posterior supporting structures removed

- normally resist gravity producing kyphosis

 

Adult

 

Following radical laminectomy

- facet joints removed bilaterally

 

Infection post surgery

 

Kyphotic deformity Post Fusion

 

Growing child

 

Usually after excision spinal cord tumour

- radical laminectomy removing facet joints bilaterally

 

Management

 

Laminectomy

- prevention is key

- must preserve at least 1/2 of each facet joint or one whole facet / level

- if not possible, fusion indicated

 

Child

- must recognise potential for deformity & closely observe child

- orthoses don't often work

- if deformity develops & progresses, fusion usually indicated

 

Post-Traumatic Kyphosis

 

Risk Factors

 

Wedge fracture with initial kyphosis of > 30o

 

Focal kyphosis may develop if there is damage to the anterior column

- worse if posterior column fracture as well

- Most common TL junction

 

Indication for surgical intervention

 

Neurological deficit due to kyphosis

Refractory pain

Progress of deformity

Poor cosmesis 

 

Management

 

If curve < 60°  

- posterior instrumentation & fusion 

 

If curve > 60° 

- anterior approach usually necessary to obtain releases

 

Lumbar Scheuermann

Definition

 

Different entity to thoracic Scheuermann's

- end plate abnormal but no kyphosis or wedging

 

Natural History

 

Self - limiting condition

 

Epidemiology

 

Young athlete / labourer

 

Symptoms

 

Adolescent who presents with low grade levels of low back pain

- more pain than thoracic

 

Signs

 

Rigid marked flattening of the lumbar lordosis 

- hypolordotic

 

Flattening not reversible by hyperextension

- hamstring spasm common

- no lumbar wedging

 

Limbus Vertebrae 

- anterosuperior pseudofractures of the body

 

Xray

 

Diagnostic Criteria

 

1. Irregular endplates

2. Schmorl nodes - diagnostic

3. Disc narrowing

4. No wedging or kyphosis

 

Large defects of the lower thoracic & lumbar vertebral bodies at their anterosuperior borders 

- focal enlargement of vertebral bodies is noted occasionally

- defects anterosuperior bodies resolve, but some kyphos remains

 

Management

 

Respond to TLSO with moulded lumbar lordosis for 12/12 & activity modification

 

No long term sequelae

 

 

 

Scheuermann's kyphosis

Definition 

 

Structural kyphosis of thoracic or thoracolumbar spine

- characterised by vertebral wedging & subsequent growth disturbance of vertebral end plate

 

X-ray Diagnostic Criteria Sorensen 1964

 

1.  Kyphosis > 45°

 

2. > 5° wedging 3 or more adjacent apical vertebrae

 

Other features

- Schmorl nodes

- irregularity & flattening of vertebral end-plates

- narrow disc spaces

- increased AP diameter of apical vertebrae

- spondylosis in adults

 

Epidemiology

 

Prevalence 0.5 to 8%

 

M:F 2:1 

 

High familial predilection

- AD with high penetrance and variable expression

 

Aetiology

 

Many theories proposed / true cause unclear

 

1.  AVN of ring apophysis

- but Ring Apophysis doesn't contribute to vertebral growth

 

2.  Schmorl Nodes

- protrusions of cartilage of disc through endplate into body

- ? nodes decrease enchondral ossification with growth arrest of anterior body

- but nodes present in normal patients (40-75% autopsies)

 

3.  Mechanical Factors

- likely that kyphosis occurs first

- increases pressure on vertebral end-plates anteriorly and causes secondary body wedging 

 

4.  Osteochondritis or Epiphysitis

- but no inflammatory features or necrotic bone

 

5.  Abnormality of Cartilage endplate identified 

- Abnormal matrix

 

6.  Tight ALL

 

Symptoms

 

Onset prior to puberty ~ 10 years old

 

Pain

- mechanical and usually in area of deformity

- ceases with maturity

 

Signs

 

Kyphotic Deformity

- fixed / remains with hyperextension

- worsen's on Adam's forward bending

 

Also

- compensatory lumbar hyperlordosis 

- increased cervical kyphosis 

- associated mild - moderate scoliosis common

 

Lateral standing X-ray

 

Cobb angle

- line along superior & inferior end-plates of each body 

- measure angle of intersection

- often difficult to see T1 - T5

 

Individual vertebral wedging

- > 5o

- > 3 adjacent vertebrae

 

Schmorl nodes

 

Irregularity & flattening of vertebral end-plates

 

Hyperextension Lateral X-ray

 

Over bolster

- structural degree of deformity

- degree of correction

 

DDx 

 

1.  Postural kyphosis 

- more flexible,  disappears prone, normal x-ray, disappears with hyperextension lateral

 

2.  Osteoporosis / crush fracture

 

3.  Congenital kyphosis / anterior bar

 

4.  Infection, tumour

 

5.  Ankylosing spondylitis

 

6.  Post laminectomy

 

7.  Congenital / Developmental

- OI / SED / Achondroplasia / Morquio's

 

Natural History

 

Weinstein 1993 Iowa

- 67 patients average kyphosis 71°

- follow up 32 years vs age match controls

 

Findings

1.  More intense back pain but no increased analgesia use

2.  No difficulty with ADL's

3.  Normal recreational activities

4.  No increased numbness

5.  More sedentary jobs 

6.  ROM

- decreased extension

- weaker extension

7.  Normal self esteem

 

Curve <100° 

- normal pulmonary function

 

Curve >100° 

- restrictive lung disease

 

Management

 

Non Operative Management

 

Observe

 

<50°

No progression on serial Xray

No / mild pain

 

Exercise

 

No long-term correction

- useful to maintain flexibility / correct lumbar lordosis

- strengthen extensors of spine i.e. swimming, pilates

 

Brace

 

Indications

- skeletally immature

- curve < 75°

 

Type

- Milwaukee Brace / thoracic kyphosis

- TLSO / TL kyphosis

 

Timing

 

Brace full-time for 18/12

- then part-time until skeletal maturity

 

Issue

- trying to get a 15 year old boy to wear a CTLSO for 3 years

 

Operative Management

 

Indications

 

Adolescent

- pain +++ uncontrolled by brace 

- kyphosis > 75° & progressing

- most surgeons won't operate until 90°

 

Adults

- pain +++ despite non-operative treatment

 

Principles

 

1. Correction of kyphosis

2. Arthrodesis of spine

 

Issues

 

Approach

 

Posterior Approach

- failure rate high with loss of correction & pseudarthrosis if curve large

- fusion on tension side of spine

 

Correction films

- crucial

- posterior instrumentation will only give you 10o correction

- if corrects only to > 50o , need to release ALL

 

One Stage

 

Curve < 75° & corrects to < 50°

- one stage posterior instrumented fusion

 

Two Stage

 

Curve > 75° & corrects to > 50°

- two stage procedure

- anterior thoracotomy / release of ALL

- discectomy & interbody fusion of 5 or 6 apical levels with ribs

- posterior instrumented fusion 2/ 52 later

 

Last Instrumented Vertebra LIV

 

Sagittal line from the posterior edge of the sacrum should intersect the LIV

- supine & standing hyperextension Xrays

- should be distal to first lordotic disc

- usually L1 if apex T6; L2 if apex T8; L3 if apex T10

 

Results

 

Coe et al Spine 2010

- retrospective review of 683 cases

- 50% posterior fusion, 40% anterior and posterior, 10% anterior only

- mean patient age 21

- 4% infection rate

- 2% acute neurological injury

- 4 spinal cord injuries (0.6%)

- 4 deaths (0.6%)

 

 

Red Flags

Red Flags in Back Pain

 

For Cancer

- > 50 years

- history of cancer

- smoker

- pain worse at rest

- night pain

- unexplained weight loss

- anorexia

 

For Infection

- prolonged use of steroids 

- immunosuppression 

- history of IV drug use

- UTI or other infection

- DM

- alcoholic

 

For Fracture

- history of significant trauma

- prolonged use of steroids

- > 70 years

 

 

Sacral Fractures

Mechanism

 

High energy usually

 

Occasionally osteoporotic fracture in elderly

 

Other

- radiotherapy

- fatigue fracture in children

 

Don't present as isolated injury

- associated with pelvic fracture

 

Denis Classification

 

Zone 1

- lateral to foramina

- neurologic injury from proximal migration & compression of L5 nerve root

 

Zone 2

- through foramina

- 28% incidence neurology

- usually S1 compression

 

Zone 3 

- medial to foramina / central canal

- 57% incidence neurology

- loss sphincter tone & cauda eqina

 

Management

 

Zone 1

 

Stable 

- symptomatic treatment only

 

Zone 2 & 3

 

Non weight bearing 8 weeks

 

 

Spinal Braces

Braces

 

1.  Motion Control

 

2.  Spinal Realignment

 

3.  Trunk Support

 

4. Weight Transfer

 

Soft Collar

 

Cheap & Comfortable

- ineffective

- allows 70% Flexion Extension / 80% Rotation / 90% Lateral bend

 

Philadelphia Collar

 

Better than soft collar but less comfortable

- allows 35% Flexion Extension / 40% Rotation / 60% Lateral bend

- excellent immobility in acute situation when combined with sandbags & forehead tape

 

SOMI Brace

 

Sterno-Occipital Mandibular Immobilizer

- effective control C1/2 & C2/3

- allows 30% Flexion Extension / 30% Rotation / 60% Lateral bend

 

Yale Brace

 

Cervico-Thoracic Brace

- Philadelphia Collar but with chest extension & strap 

- best of conventional braces

- allows 10% Flexion Extension / 50% Rotation / 25% Lateral bend

 

HTB / Halo-Thoracic Brace

 

Best overall but highest complications

- 4 % Flexion Extension

- 1 % Rotation

- 1 % Lateral bend

 

HTB Xray

 

Application

- roll patient on side in controlled manner

- fit posterior chest brace

- roll back, apply anterior chest brace, tighten

- size halo

- should have 1 - 2 cm gap from skull

- sits 1 cm above pinna and eyebrows

- 4 pins

- 2 above pinna, 2 above upper and outer eyebrow

- must miss supra-orbital nerve

- can shine torch through holes to mark sites of pins

- LA to sites

- must close eyes before supraorbital pins to avoid problems closing eyes

- tighten to 8 pounds / SI

- often come with snap lock pins

 

Infection

- use oral antibiotics

- may need to remove pins

 

Gardner Wells Tongs

 

Used to obtain and maintain reduction

 

Graphite / MRI compatible available

 

Insertion sites as per HTB

 

Thoraco - Lumbar Orthosis / TLSO

 

Types of TL Orthosis

1. TLSO

2. Three point brace

3. Moulded Body Jacket

 

CTLSO / Milwaukee

 

TLSO with neck brace

 

For lesion with apex above T8

 

Spinal Cord Concussion

Definition

 

Transient disturbance of spinal cord function

- +/- vertebral column injury

- no pathological changes in spinal cord

 

Mechanism

 

Rapid change in velocity following trauma

- football / ice hockey

 

Associations

 

Congenitally narrow spinal cord

Hypermobility

 

Clinical

 

Athlete describes numbness / paralysis in arms and legs

- temporary

- passes after short time

 

NHx

 

Most resolve completely

Can have some sequelae

 

Issues

 

High risk with return to sport

 

Guidelines

 

AP canal < 10 mm

- high risk

 

Reinjury can mean quadriplegia

 

Waddell's Signs

Waddell Spine 1980

 

Non-organic illness behaviour

- operative intervention more likely in their absence

- 3 or more significant

 

DR TOS 

 

1. Distraction 

- perform SLR when not looking, or seated

 

2. Regional 

- non-anatomically numbness or weakness

 

3. Tenderness 

- superficial "Pinch Test" gives pain

 

4. Over-Reaction

- Collapse / Verbalisation / Sweating

 

5. Simulation

- axial loading by head compress causes pain

- passive pelvic rotation

 

Whiplash

Definition

 

Isolated posterior ligament injuries

- PLL / Posterior interspinous ligament / Paraspinal muscles

 

Excludes fracture / dislocation / HNP

 

Aetiology

 

MVA

Sport

Hyperflexion injuries

 

Symptoms

 

Large spectrum clinical presentation

- neck ache 

- nausea & vomiting 

- headache 

- visual symptoms

 

Prognosis

 

Dufton et al Spine 2006

- study of 2000 patients looking at poor prognostic factors

- older age > female > higher pain intensity > legal action

 

Other studies

- radiculopathy symptoms

 

NHx

 

42% Symptoms > 1 years

36% Symptoms > 2 years

 

Chronic pain

 

Likely related to facet joints

 

Management

 

Physiotherapy / Collar / Reassurance