Spine

Cervical

Cervical Degeneration

Cervical Myelopathy

DefinitionCervical Myelopathy MRI

 

Spinal cord dysfunction
- extrinsic compression of the cord or its vascular supply
- caused by degenerative disease of spine

 

Epidemiology

 

Most common spinal cord dysfunction in patients > 55 years old
 

C5/6 commonest level


Pathophysiology

 

Congenital

- congenital / developmental stenosis
- decreased space available for cord
- average mid cervical spine is 17 – 18 mm

 

Acquired

1. HNP

2. Osteophytes from facet and uncovertebral joints
3. Ligamentum Flavum

4. Instability

5. Kyphosis
- stretches spinal cord over posterior vertebral bodies and discs
- dictates an anterior approach

6. Ossification of PLL
- more common in certain Asian populations i.e. Japanese

 

DDx
 

Need to exclude other causes of spinal cord dysfunction

 

Supratentorial
- CVA / AVM / Tumour / Hydrocephalus

- Metabolic or alcoholic encephalopathy

 

Spinal
- demyelinating disease / MS / MND
- syringomyelia / Tabes dorsalis

- myopathy / peripheral neuropathy

 

History

 

Neck pain

 

Parasthesia
- global, non dermatomal distribution over upper extremities

 

Difficulty walking / unsteadiness on feet

 

UL > LL

- have central cord like presentation
- distal worst than central

 

UL
- pain , numbness and weakness
- clumsiness of hands common
- difficulty with fine motor function
- may also have radicular symptoms

 

Bladder dysfunction uncommonly occurs

 

May present acutely with central cord syndrome

 

Examination

 

UMN in extremities below lesion

LMN signs at level of lesion

 

Ataxia

 

Wide based gait

Unable to heel toe

 

Poor proprioception
 

1.  Finger escape sign
- deficient adduction or extension of ulnar digits of affected hand

 

2.  Romberg Positive

 

Hyper-reflexia

 

1.  Hoffman Reflex
- flexion of ipsilateral IPJ of index and thumb when long finger DIPJ flexed

- extension of neck increases sensitivity

 

2.  Inverted Brachioradial Reflex

- spontaneous flexion of digits when BR reflex elicited
- indicates cord compression at C5 and C6 / commonest levels

 

3.  Babinski Reflex


X-ray

 

Narrowed joint space
- C5/6 commonest level followed by C6/7

 

Osteophytic lipping
- foraminal and uncovertebral osteophytes seen

 

Alignment
- lordosis v kyphosis
 

Cervical Stenosis Kyphotic AlignmentLordotic Cervical SpineCervical Spinal Kyphosis Flexion View

 

Ossification PLL

 

Cervical Spine OPLL

 

Flexion / Extension views show instability
- > 3 o
- > 11 mm

 

Pavlovs Ratio
- AP diameter of spinal canal divided by the AP diameter of body at same level
- indicator of developmental stenosis
- should be 1.0

- < 0.8 is narrowed and stenotic

 

AP diameter / SAC
- normal (17mm)
- relative (13mm)
- absolute stenosis (10mm)

 

NB: X-ray estimates of space available for cord

- do not take into account ST i.e. discs and ligamentum flavum

 

CT

 

Helps distinguish disc from osteophytes

- soft v hard disc

 

OPLL

 

OPLL Cervical Spine

 

MRI

 

Disc herniation

- high incidence of asymptomatic findings
- 19% of asymptomatic patients have abnormality on MRI

 

Cervical Myelopathy Herniated Discs

 

Cord changes
- cord oedema with signal change seen

 

Cervical Myelopathy Cord Changes

 

AP diameter thecal sac < 10 mm

 

Compression Ratio
- banana cord
- divide the smallest AP diameter by largest transverse diameter at same level of spinal cord
- ratio of < 0.4 after decompression particularly with myelopathy > 6 months has poor prognosis

 

Cervical Myelopathy Compression Cord Ratio

 

Cross sectional area of spinal cord
- < 30 mm2 poor prognosis

 

NHx

 

Natural history suggests that > 50% of patients become worse if not treated
- some stable
- most slowly progressive
- < 5% acute deterioration

 

Management

 

Non operative

 

Cervical collar
NSAIDS
Physiotherapy with isometric strengthening
Ice , heat and massage

Follow up every 6-12 weeks initially followed by yearly if no progression

Traction and manipulation contraindicated

Must counsel them to the risks of trauma

 

Operative

 

Absolute Indications

 

1. Progressive neurological deficit
2. Failure of symptoms to improve with 6 months of non operative treatment
- base on severity of clinical neurological fingings

 

Relative indications

 

1. Compression ratio < 0.4
2. Transverse spinal cord diameter of < 40 mm2
3. Increased signal intensity of cord on T2 of MRI
4. Acute central cord syndrome
- initially collar and methylprednisolone
- no operation if near full recovery
- decompress if residual neurological deficit

 

Order

 

The patient with cervical and lumbar stenosis

- should have the cervical spine decompressed first

- risk of intubation damage to cervical spine
- reduces need for lumbar surgery
- leg symptoms may improve after the cervical decompression

 

Prognosis

 

Surgery can be expected to halt progression

- may improve motor, sensory and gait disturbance

 

The best spinal cord recovery seen in those treated
- decompression within 6 - 12 months
- early, mild myelopathic signs
- transverse area of cord greater than 40 mm2 postoperatively
- age < 60

 

Preoperative Considerations

 

NSAIDS ceased 2 weeks prior to surgery

 

Positioning should avoid hyperextension of the cervical spine

- may need awake fibreoptic intubation

 

Options

 

1.  Laminectomy & fusion

2.  Laminoplasty

2.  ACDF

3.  Corpectomy

 

1. Laminectomy & Fusion

 

Cervical Myelopathy Posterior Decompression InstrumentedCervical Myelopathy Posterior Decompression Instrumentation

 

Concept

 

Any posterior decompression procedure is an indirect technique

- requires posterior shifting of the cord in the thecal sac

- to diminish the effect of the anterior compression

 

Indications


Lordotic cervical spine / no kyphotic deformity


Ossification of PLL

- dura may be adhered

- high risk of irreparable dural tears with anterior approach

 

Indications for fusion
 

Instability

 

Technique

 

Positioning for the posterior approach
- prone
- Mayfield head tongs in neutral

- protect eyes / elbows (ulna nerve) / knees (CPN)
- pneumatic compression stockings
- IDC
- infiltration of skin with adrenaline solution

 

Decompression

- wide laminectomy +/- foraminotomy

 

Instrumentation
- avoids progressive kyphotic deformity
- lateral mass screws

 

Cervical Myelopathy Posterior Decompression

 

Complications

 

Postoperative instability / kyphosis
- > 50% facet resection = instability
- avoid by fusion or laminoplasty

 

2.  Laminoplasty

 

Concept

- divide lamina unilaterally

- elevate to decompress

- insert device to keep lamina elevated

 

Advantage

- maintains stability

- no need to insert pedicle screws

 

Indication

- no kyphotic deformity

 

3. ACDF / Corpectomy and Arthrodesis

 

2 Level ACDFACDF

 

Indication

- anterior cord compression

- pathology primarily at disc level

- kyphotic deformity

 

Advantages
-
removes entire disc

- can maintain / restore lordosis

- restores foramina / decompresses nerve root

 

Disadvantages
- difficulty decompressing the nerve roots in foramen from front
- difficult access to the posterior osteophytes

 

Technique

 

Smith - Robinson approach

 

Positioning
- supine with interscapular roll
- head turned slightly to right for left sided approach

 

Disc removal in full
- MRI reviewed carefully to exclude free disc lying behind the PLL
- resect the disc until the longitudinal fibres of PLL seen

- inspect carefully for defect
- if no defect on MRI findings then should not routinely remove the PLL

 

Insertion cage 

- contains autograft / allograft / BMP & collagen
- sized first, check on x-ray
- insert cage, ensuring not too posterior
- aiming to decompress foramina

 

Anterior plate for stability

 

4.  Corpectomy and strut Graft

 

 

 

Indication

- multilevel disease

- soft and hard disc causing compression

- kyphotic deformity

 

Technique

 

Anterior approach
- decompression of disc above and below

- resection of vertebral body with burr
- leave lateral walls to protect vertebral artery
- typical midline channel is 16 – 18 mm

 

Bone Grafting Technique
- single level, iliac crest
- multiple level, fibular strut
- autograft superior to allograft

 

Instrumentation
- maintains alignment / improves graft stability
 

Post op
- usually require HTB

 

Complications

 

1. Transient sore throat or difficulty swallowing

- most common complication

- superior laryngeal nerve

 

2. Recurrent Laryngeal Nerve paralysis
- more common in right sided approach
- post operative hoarseness

 

3. Respiratory compromise
- drains
- strict monitoring

- emergency release of wound stitches if haematoma

 

4. Neurological injury 1 – 2%

 

5. Injury vertebral artery

 

6. Dural tears
- more common if OPLL
- fibrin glue, fascial patch

 

7. Graft related
- dislodgement
- fracture
- severe settling
- pseudoarthrosis

Cervical Radiculopathy

Definition

 

Clinical diagnosis

- based on a sclerotomal distribution of motor &/or sensory symptoms or signs

 

Caused by impingement of exiting nerve roots

- HNP

- zygo-apophyseal / facet joint hypertrophy

- neuro-central joint hypertrophy

 

May be acute or chronic

 

Epidemiology

 

M>F

 

Peak age 50-54

 

C7 > C6

 

Natural History

 

Mayo Clinic Natural History Radiculopathy

- 50% of population at some stage

- ~50% recurrent

- 90% asymptomatic at 5 years

 

Anatomy

 

Each subaxial C-spine motion segment has 5 articulations

 

A. Intervertebral disc

 

B.  2 neurocentral / uncovertebral joints

- along posterolateral vertebral body / Joint of Luschka

- lie between disc & nerve root

- each body has upturned postero-lateral uncinate process

- pedicle is attached below uncinate process

 

C.  2 facet joints

- angulated 30-50° to transverse plane

 

Intervertebral foramina boundaries

 

A. Anterior

- both vertebral bodies, uncinate process & disc

 

B.  Posterior

- facet joints

 

C.  Above & below

- pedicles

 

Foramina are 45° to sagittal plane

 

Transverse process

 

3 elements

1. Embryological TP to posterior tubercle

2. Embryological rib to anterior tubercle

3. Tubercles joined by intertubercular lamella

 

Foramen transversarium in middle with vertebral artery

Dorsal root ganglion and ventral ramus spinal nerve on intertubercular lamella

 

Tubercles

 

Posterior tubercle

- Scalenus medius

 

Anterior tubercle

- Scalenus anterior, longus coli & capitus

- progressively enlarge from C3 down to C6

- C6 Chassaignacs tubercle

 

Cervical Nerve Roots

 

Each cervical root exits above the pedicle for which it is named except C8

- C5/6 – C6

- C6/7 – C7

- C7/T1 – C8

 

Pathophysiology Nerve root compression

 

1.  HNP

- in contrast to lumbar spine

- both posterolateral and central HNP compress exiting nerve root

- inflammatory and ischaemic components

 

A. Central - myelopathy

B. Posterolateral - mainly motor weakness

C. Intraforaminal - most common / often dermatomal distribution

 

Cervical Spine Central Disc HerniationCervical MRI Posterolateral Disc

 

2.  Spondylosis / Disc degeneration

- loss of height / annular bulging

- foraminal compression

 

3.  Bony 

 

A.  Uncovertebral osteophytes / hard discs

- compress nerve root anteriorly

 

B.  Superior articular facet osteophyte

- extend from ventral surface to compress the neural foramen

- are less common

 

Clinical

 

Pain / parasthesia

- often don’t follow dermatomal distribution

 

Weakness

- 60-70% motor deficiency

 

Spurling maneuver

- hyperextension with tilt toward affected side 

- stimulates radiculopathy symptoms

 

Nerve root signs (C6 and C7 most common)

 

C2 Posterior occipital headaches

C3 Occipital headache

C4 Neck and trapezial pain +/- shoulder / scapula pain

C5 Pain lateral upper arm (epaulet) / deltoid weakness / biceps jerk decreased

C6 Radial forearm and hand pain / weak biceps and wrist extension / BR reflex decreased

C7 MF pain / weak triceps / absent triceps jerk

C8 Pain ring and little fingers / weak finger flexors

T1 Ulna forearm pain / weak hand intrinsics

 

DDx Myopathy

 

Entrapment syndromes (ulna / median nerves)

Thoracic outlet syndrome

RC disease

 

X-ray

 

Demonstrate loss of disc height and degeneration

 

MRI

 

Note

- 19% of asymptomatic patients will have evidence of nerve root compression

- difficult to distinguish between hard and soft discs

 

CT

 

Adds complementary information to MRI in C spine

 

Demonstrates the posterolateral impingement is from “hard” disc

- i.e. uncovertebral spur 

 

Cervical nerve root injections

 

Confirm diagnosis

- should get some temporary symptomatic relief

 

EMG / NCS

 

Indication

- concern re peripheral nerve entrapment

 

SNAP

- are usually normal because lesion proximal to DRG

 

CMAP

- amplitude decreased proportional to muscle atrophy

 

Nerve conduction velocity

- not abnormal unless severe demyelination of axons

 

EMG

- best for differentiating peripheral nerve root compression from central

- fibrillations

 

Management

 

Non operative

 

Options

 

Rest

Pharmaceutical / NSAIDS

Physio

- hot / cold

- electrical stimulation

- ROM / stretching

- isometric strengthening exercises 

Cervical traction

Collar

HCLA / nerve root injections

 

Results

 

Lellad et al Ann Phys Rehabil Med 2009

- RCT demonstrating benefit of reducing symptoms with cervical traction

 

Cervical Traction

 

Kuijper et al BMJ 2009

- RCT demonstrating benefit of wearing semi-hard collar for 3 weeks 

 

Operative

 

Indications

- severe pain

- severe neurological impairment

- failure non operative treatment

 

Options

 

ACDF

Disc replacement

Corpectomy

Laminoforaminotomy

 

1. ACDF

 

ACDF 2ACDF C34

 

Definition

 

Anterior Cervical Discectomy and Fusion

 

Concept

- anterior approach

- interbody fusion

- iliac crest bone graft / synthetic bone graft / allograft / cage

- anterior plate / eliminates need for brace

 

Advantage

- deal with HNP and uncovertebral osteophytes

- opens up the neuroforamina and decompresses the nerve

- fusion relieves pain of spondylosis

- anterior approach dissects little muscle and has little pain

- scar very cosmetically acceptable

 

Technique

 

Smith & Robinson / anterior approach

- divide platysma and deep cervical fascia

- SCM laterally

- divide pretracheal fascia / carotid sheath laterally

- divide prevertebral fascia in midline, separate longus colli

 

Discectomy

- decorticate end plates

- excision of osteophytes controversial

- generally only if causing compression

- otherwise will absorb with stability

 

Complications

- pseudarthrosis

- graft / cage displacement posteriorly

- wrong level

- insufficient decompression

- neurological injury (quadriplegia /  nerve root / RLN / Superior Laryngeal Nerve)

- injury to other structures (carotid artery / oesophagus)

- degeneration at second level

 

Cervical Disc Degeneration Above Fusion

 

 

 

2. Disc replacement

 

Technique

- as above

- insert disc replacement

- no anterior plate

 

Advantage

- maintain some motion

- preserve other disc segments

 

Results

 

Murrey et al Spine 2009

- RCT of ACDF v disc replacement

- disc replacement maintained 4o of motion

- significant reduced reoperation rate in disc replacement (1 v 8%)

 

3. Corpectomy

 

Indication

- multilevel hard and soft compression

- can remove body with disc above and below

- decompress 2 levels

 

Cervical HNP 2 Levels

 

Cervical Corpectomy APCervical Corpectomy

 

4. Laminoforaminotomy

 

Technique

- posterior approach

- deroofing of foramina

 

Results

 

Herkowitz et al Spine 1990

- compared ACDF with posterior laminotomy / foraminotomy

- patients with both central and posterolateral discs

- combination of radiculopathy and myelopathy symptoms

- 4 year followup

- 95% vs 75% G/E

 

Johnson et al Spine 2000

- prospective study of patients with posterolateral disc and radiculopathy

- patients had no neck pain

- removal of HNP + uncovertebral osteophytes

- 91% improved or resolved

- 9% revision (ACDF / repeat posterior foraminotomy)

 

 

 

 

Cervical Spondylosis

Definitions

 

Cervical spondylosis

- chronic disc degeneration & associated facet arthropathy

 

Cervical myelopathy

- spinal cord dysfunction

- secondary to extrinsic compression of cord or its vascular supply

 

Cervical radiculopathy

- sclerotomal distribution of motor &/or sensory symptoms or signs

- due to compression of nerve root

 

Epidemiology

 

Usually begins at age 40-50

 

M>F

 

Most common at C5/6 > C6/7 > C4/5

 

Pathology

 

Spondylosis

 

Degenerative changes at disc / facet joints / uncovertebral joints

 

Clinical Features

 

Neck pain / headaches / local tenderness

 

Reduced ROM

 

X-ray

 

Typical changes of spondylosis

- disc space narrowing

- osteophyte formation

- degenerative facet & uncovertebral joints

 

May be present in asymptomatic individuals

 

Cervical Spine Degeneration

 

CT scan

 

Degenerative changes

 

Cervical Spondylosis CT

 

MRI

 

Degenerative disc changes

- dessicated (loss of fluid), narrowed, end plate changes

 

Space available for cord

 

Neural compression

- intrinsic cord changes

- cord compression / ratio / cross sectional area

 

Cervical Spine Degeneration MRI

 

Management

 

Non-operative

 

Education & Reassurance

- analgesics

- local modalities

- exercise programme

- traction

 

Operative

 

Indications

 

Spondylosis

- failure non operative treatment

- disease isolated to 1 or 2 levels

 

Options

 

Posterior Instrumented Fusion

 

Cervical Pedicle Screws LateralCervical Pedicle Screws AP

 

ACDF

 

ACDF

 

Advantage

- restores disc height and aligment

- decompresses foramina

 

Options

- autograft

- allograft

- cage

 

Jacobs et al Cochrane Database Review 2011

- autograft superior to discectomy alone

- autograft superior to cage in fusion rate but with higher complications

 

Disc Replacement

 

Advantage

- elevate / decompress foramin

- maintain motion / decrease degeneration at subsequent levels

 

Burkus et al J Neurosurg Spine 2010

- prospective multicentred RCT 541 patients with single level disc degeneration

- disc replacement v ACDF

- improved outcome scores and neurological outcome in disc replacement

- no difference in rates of subsequent level surgery

 

PLOS One March 2015

- meta-analysis of 19 RCT of ACDF v disc replacement

- disc replacement had better scores, better pt outcome, better ROM, and decreased secondary degeneration

 

 

Technique ACDF

Anterior Cervical Discectomy and Fusion

 

ACDF C5 6

 

Position

 

Place the patient in the supine position

- small roll placed under the shoulder blades to drop the shoulders from the field

- exposes the anterior neck

- strap the shoulders at the side with minimal traction 

- allows visualization of the lower cervical spine on lateral radiographs

- apply skull traction with Gardner-Wells tongs

- keep head rotation to a minimum because deep dissection will depend on identifying the vertebrae midline

- prevents inadvertent injury to adjacent structures

- reverse Trendelenburg position facilitates venous drainage and results in less bleeding during surgery

 

Dissection

 

Anatomic landmarks for incision 

- hyoid bone overlying C3

- thyroid cartilage overlying the C4/5 interspace

- cricoid cartilage overlying the C6 level

 

Use transverse incision for exposure in most cases

- more cosmetic

- from the midline to the anterior border of SCM in Langer's lines

- divide the deep cervical fascia and platysma muscle exposing the middle layer of the cervical fascia

- bluntly dissect the pretracheal fascia and palpate the carotid pulse

 

When three or more levels are approached, use a longitudinal incision

 

Dissection through the pretracheal fascia places several structures at risk

- superior and inferior thyroid arteries extend through the pretracheal fascia from the carotid artery to the midline

- travel at the C3/4 and C6/7 levels, respectively

- intervening area provides a relatively avascular plane for dissection

 

Recurrent laryngeal nerves

- right recurrent laryngeal nerve ascends in the neck after passing around the subclavian vessels

- courses medially and cranially at the C6–C7 level, often along with the inferior thyroid artery

- left recurrent laryngeal nerve ascends after curving around the aortic arch along the tracheoesophageal groove

- more midline and protected position

- left-sided procedure may be safer, especially when lower cervical segments are approached

- the thoracic duct is often visible on the left at the C7–T1 level and must be protected

 

Retract the sternocleidomastoid muscle and the carotid sheath medially

- contents (common carotid artery, internal jugular vein, and vagus nerve)

 

Retract the midline structures, including the trachea, esophagus, and thyroid gland medially

- complete blunt dissection through the deeper levels to the prevertebral fascia and vertebral bodies

 

Once the midline is identified, incise the prevertebral fascia

- elevate the medial edges of the longus colli muscles

- place blunt self-retaining retractors under the leading edges of the muscle

- Tramline retractor is used (Medial Lateral)

- take care to avoid dissecting along the longus colli muscle because of injury to the cervical sympathetic plexus

- screws in vertebral bodies for vertebral distraction

 

Discectomy

 

Identify

- vertebral bodies by their concave appearance 

- the discs by their more convex contour

 

Localize the disc space with a radiopaque marker and lateral radiograph

 

Remove disc

- incise the disc with an annulotomy blade

- cut lateral to medial away from the vertebral artery

- remove the disc contents and endplate cartilage to the PLL

- use thorough evaluative preoperative imaging to determine the presence of a sequestered disc behind the PLL

- palpate the PLL for the presence of a rent that may also indicate a sequestered fragment

- in the event that a rent is noted, or if an expected disc fragment is not identified, remove the PLL with Kerrison rongeurs

- beware of routine removal of the PLL, because reports of postoperative epidural hematoma have been associated with this technique

 

Removal of endplate and uncovertebral osteophytes is controversial

- disc space distraction reduces ligamentum flavum buckling and increases neuroforaminal area

- it is believed that fusion will arrest spur progression, and stability may allow for resorption over time

- however, this is not a consistent phenomenon

- the location and size of the offending spur must be carefully considered when performing decompression

- exposure of the uncinate processes is critical to safely remove osteophytes

- utilize a high-speed burr to excise the spur from medial to lateral

 

Foraminotomy

- judge the adequacy of foraminotomy

- ability to place the tip of a curret anterior to the exiting nerve root without significant resistance

 

 

Fractures

Atlantoaxial Instability

Definition

 

Loss of ligamentous stability between atlas and axis

 

Spectrum of conditions

1.  Subluxation AP / insufficiency transverse ligament

2.  Rotatory / insufficiency apical ligament

 

Epidemiology

 

Most common older children and adolescents

 

Aetiology

 

Primary

 

Secondary to laxity of transverse ligament

- DIAL HOME CS

- Larsen's / Marfans

 

Secondary

 

1. Infection

- retropharyngeal abscess / Grisel's syndrome

 

2. Trauma

 

3. Hypoplasia

- Down's Syndrome (15%)

- SED

- Achondroplasia

- Morquio

 

4. Inflammatory

- Rheumatoid arthritis

 

5. Developmental

- Os Odontoideum

- Klippel Feil

 

Anatomy

 

Cruciform ligament

A. Transverse ligament

- tubercles medial aspect lateral mass C1

B. Longitudinal bands from transverse ligament

- up to occiput

- down to C2

 

Alar ligament

- side of the dens up to the lateral margins foramen magnum

- prevent excessive lateral rotation

 

Apical ligament

- dens to occiput

 

Tectorial membrane

- extension of PLL

- behind transverse and alar ligaments

 

Symptoms

 

Neck pain

Occipital neuralgia

Rarely vertebro-basilar insufficiency

 

Examination

 

Atlanto-Axial Rotatory Subluxation (AARS)

- Cock Robin Tilt

- Torticollis

- facial asymmetry in children

 

DDx

 

Torticollis

- fibrosis SCM

 

Ondontoid fracture

 

Os ondontoid

 

Xray

 

Flexion / Extension views

 

ADI < 3.5 mm in flexion – transverse ligament intact

ADI 3-5 mm – transverse ligament insufficient / type II injury

ADI > 5mm – failure alar ligaments / type III rotatory subluxation

 

Open mouth xray

 

Lateral mass C1 rotated & asymmetric

Wink Sign - C1 facet locked over C2

 

CT Scan

 

Confirms above diagnosis

 

MRI

 

Assess transverse ligament

 

Classification Fielding & Hawkins

 

Type I

 

Definition

- rotary subluxation with no anterior displacement (ADI < 3mm)

- transverse ligament intact

 

Treatment

- often resolves spontaneously

- soft collar and analgesics

- may need correction with halter traction with application HTB

 

Type II

 

Definition

- rotation about one intact facet with increase ADI 3-5 mm

- transverse ligament insufficient & unilateral capsular tear

- alar ligs intact

- one lateral mass displaced

- other lateral mass acts as pivot

 

Treatment

- holter traction till reduced + application HTB

 

Type III

 

Definition

- bilateral anterior subluxation with ADI > 5mm

- failure of the alar ligament

- Wink sign positive / C1 facet locks over C2

 

Treatment

- traction till reduced

- C1/2 fusion

 

Type IV

 

Definition

- complete posterior displacement of the atlas

- really a posteriorly displaced type II dens fracture

- rare 

 

Management

 

Specific Conditions

 

Children

- often no history of trauma

- reasonable to observe for 1-2/52 as often corrects spontaneously

 

Down's Syndrome

- may have peg hypoplasia

- increased ADI secondary to transverse ligamentous laxity more common

- ADI > 5mm & asymptomatic = avoid contact sports

- ADI > 5mm & symptomatic = fusion

 

JRA

- transverse ligament incompetent

- often zygapophyseal fusion has occurred

- rarely peg base can be eroded

 

Operative Management

 

Indications

- neglected fixed deformity

- failure to correct with nonoperative management

- type III & IV

- instability

- neurological problems

- ADI > 10 mm

 

Surgery

 

Posterior C1-C2 arthrodesis

- Gallie / Brooks

- Magerl's screws / transarticular

- Harms

 

 

Lower Cervical Spine Fractures

Background

Anatomy Lower Cervical Spine

 

Movement

- 50% of cervical rotation

- 60% of cervical flexion / extension

 

Uncovertebral joint

- lateral projections of body 

- medial to vertebral artery

 

Facet joints

- sagittal orientation 30 – 45o

 

Spinous processes

- bifid C3-5

- prominent C7

 

ATLS

 

Awake, alert, neurologically normal & no neck pain very unlikely to have C-spine injury

 

Lateral C-Spine C1-T1

- will detect 85% of fractures

- need swimmers view if cannot visualise T1

 

Swimmers View

 

AP + Lateral + Peg view

- 92% of fractures

 

C-spine fracture

- 10% risk another cervical spine fracture

- 30% risk fracture other level in spine (may be masked by neurological injury)

 

Stability

 

The ability of the spine under physiological loads to maintain the relationship between vertebrae

- without neurological compromise

 

Instability  / Panjabi & White Spine 1976

 

Scoring

- Anterior elements destroyed    2

- Posterior elements destroyed   2

- Sagittal translation >3.5 mm   2

- Sagittal rotation >11°             2

- Positive Stretch Test > 1.7mm 2

- Medullary cord damage           2

- Root damage                          1

- Abnormal disc narrowing         1

- Dangerous loading anticipated  1

 

Total of 5 or more = Unstable

 

Stretch Test

- medical supervision / tongs + roll under head

- add 3lb / wait 5 min / add 2lb to max 40lb / xray

- repeat until weight a third body weight / neurological changes / abnormal separation occurs >1.7mm

 

Mechanism of Injury / Allen & Ferguson Classification

 

Determined by

1. Position of the neck at the time of injury - flexion / extension / neutral

2. Direction of the force - compression / distraction / lateral bending

 

6 Types

- flexion compression / wedge

- vertical compression / burst

- flexion distraction / facet dislocation

- extension compression

- extension distraction 

- lateral flexion

 

Subaxial Injury Classification Scoring System / SLIC

 

Dvorak et al Spine vol 32 no 23

 

1. Injury Morphology / Pattern injury

No abnormality                        0       

Compression                            1 

Burst                                       2          

Distraction / facet perch            3         

Rotation / translation                 4

 

2. Discoligamentous complex

Intact                                        0                     

Indeterminate (MRI change only) 1   

Disrupted                                   2

 

3. Neurological status

Intact                                        0                     

Root Injury                                1                                   

Complete cord injury                  2            

Incomplete cord injury               3    

Continuous cord compression    +1

 

5 or more - surgery                   3 or less - non operative                4 - equivocal

 

Problem

- burst + disrupted ligaments + intact nerves = 4 / equivocal

 

 

 

Burst Fractures

 

Definition

 

Burst fractures

- injury to anterior and middle columns +/- posterior column

 

Mechanism

 

Vertical compression

 

Epidemiology

 

10% cervical fractures

Most commonly C5/6

 

Pathology

 

Anterior & middle columns fail

- if severe, posterior ligament complex fails

 

Canal compromise / neurological injury

- retropulsed fragments

- typically one or two main retropulsed fragments

 

Clinical

 

Neck pain

 

Complete / incomplete cord lesion

 

X-ray

 

AP

- widening between pedicles is hallmark on AP

 

Lateral

- > 50% anterior column loss of height very suspicious

- loss of posterior vertebral height

 

CT

 

Assess retropulsion / canal compromise

 

MRI

 

Assess integrity of posterior column

 

Non operative Management

 

Indications

 

< 50% height loss

Minimal kyphosis 

Nil neurology

Posterior column intact / nil instability

 

SLIC score 4+

 

Treatment

 

Collar for 6 weeks

 

Operative Management

 

Indications

 

Instability

Neurology

 

Neurology

 

Incomplete cord lesion (urgent / good prognosis)

Complete cord lesion (may gain 1 or 2 levels recovery which is very significant)

 

Aim

 

Decompression of retropulsed fragments and stabilisation

 

Technique

 

Tongs + Traction

- incomplete neurology / will decompress canal

 

Anterior corpectomy / discectomy and fusion

- tricortical graft + anterior plate

- may sometimes need supplemental posterior fixation / cervical lateral mass screws

 

Results

 

Complete v Incomplete lesion is best prognostic predictor

 

 

 

Facet Joint Dislocation

Definition

 

Facet joint dislocations secondary flexion distraction injury

 

Epidemiology

 

10%

 

Stages

 

1. Unifacet subluxation - interspinous process widening

2. Unifacet dislocation - 25% anterolisthesis

3. Bifacet dislocation - 50% anterolisthesis

4. Complete vertebral translation - 100% anterolisthesis

 

Unilateral Facet Joint Dislocation

 

Epidemiology

 

C5/6 or C6/7

 

Mechanism

 

Flexion / Distraction / Rotation about contralateral intact facet

 

X-ray

 

Unilateral facet subluxation

- widening of interlaminar or interspinous spaces

 

Unilateral facet dislocation

- 25% subluxation on lateral X-ray (<50%)

 

C56 Unilateral Facet Dislocation

 

CT

 

Unilateral Facet Joint Dislocation CT

 

Management Principles

 

1.  Exclude Herniated Nucleated Pulposis

 

Issue

- large disc could worsen neurology with tong traction

- indication for anterior approach / discetomy / fusion

 

Problem

- disc always looks injured on MRI

- look for herniation

 

2.  Reduce and fuse

 

Will improve partial neurology

May gain 1 or 2 levels of recovery in complete

Unreduced unifacet dislocations painful

Facet joint dislocation is a ligamentous injury / poor healing potential

 

Treatment Algorithm

 

1.  No neurology

- MRI to exclude HNP

- awake tong traction reduction if conscious and non obtunded

 

2.  Stable Neurology

- complete or non progressive incomplete neurology

- MRI to exclude HNP

- awake tong traction reduction if conscious and non obtunded

- if successful reduction / collar / fusion when able

- unsuccessful /  reduce in OT and fuse

 

3. Progressive Neurology

- MRI to exclude HNP

- emergent open reduction and fusion

 

4.  HNP

- anterior approach / discectomy / fusion

 

Reduction

 

Options

- tong traction

- MUA

- open reduction

 

MUA v tong traction

 

Lee 1994 JBJS

- 210 patients MUA vs traction

- traction more success 88%vs 73%

- traction safer as patient awake & can monitor neurology

 

Tong traction

 

Indication

- no HNP on MRI

- patient awake and able to communicate if neurology worsening

 

Contra-indication

- obtunded patient

 

Technique

- Gardener Wells tongs 1" above  and behind pinna

- below equator / maximum diameter of skull to prevent slippage

- place towels under head to recreate flexion deformity

- best performed in OT, can use cross table II

- start 10 lb for head, then 5 lb for each cervical level every 10 min

- repeat X-ray after each weight increase

- monitor neurological status

- if neurology worsens, release all traction

- maximum 40% body weight

- once facet unlocked, removed towels to extend head

 

Successful reduction

- place in HTB

- fusion when able

 

MUA

 

Indication

- experienced surgeon

- failure closed reduction

- intention to proceed to open reduction + fusion if required

 

Open reduction

 

Indication

- failure closed reduction

- herniated disc

- reduction + fusion

 

Technique

- GA + II + Tongs

- head flexed 45° & rotated 45° away from side of facet dislocation

- traction in above position, then rotate to side of facet dislocation

- should hear click on reduction

- gently extend to stabilize

- similar method if bilateral, but no rotation (flexion / traction / extension)

 

MRI Post Closed Reduction

 

MRI Post C5 Unilateral Facet Dislocation

 

ORIF

 

Options

 

1.  ACDF

- remove herniated disc / anterior plate

ACDF post C56 Unilateral Facet Dislocation

 

2.  Posterior stabilisation

Unilateral Facet Dislocation Posterior Stabilisation

 

Bilateral Facet Joint Dislocation

 

X-ray

 

>50% forward subluxation

 

Cervical Bilateral Facet Joint Dislocation Xray

 

CT

 

Evidence of bilateral facet joint dislocation

 

Cervical Bilateral Facet Dislocation CTCervical Bilateral Facet Dislocation CT 2

 

Pathology

 

Cervical Cord Injury Post Unilateral Facet Dislocation

 

Cord injury common

 

HNP 47%

 

Unstable - posterior & middle ligament failure

 

Management

 

As for unilateral facet joint dislocation

- MRI first to exclude HNP

- closed reduction with traction if safe with elective anterior / post fusion

- open reduction if HNP / failure closed reduction

 

Other fractures

Extension distraction

 

Epidemiology

- 20%

- common with ankylosing spondylitis / DISH

 

Stages

 

1. Anterior ligament failure

– disc space widening (or transverse fracture of vertebral body)

 

2. Posterior ligament failure with retrolisthesis of superior vertebral body

 

Articular process fracture

 

Superior process fracture

 

Cervical Spine Facet FractureCervical Superior Articular Facet Fracture0001Cervical Superior Articular Facet Fracture0002

 

Can allow superior vertebrae to dislocate anteriorly

- incidence of spinal injury

 

Management

- undisplaced - hard collar

- displaced - anterior fusion

 

Superior Articular Process Fracture

 

Inferior process fracture

- don’t allow significant displacement

- Stable ->Orthosis

 

Clay Shoveller's

 

Spinous process avulsion C7 secondary to Ligamentum Nuchae

- sudden single overload 

- treat symptomatically

Teardrop Fracture

Mechanism

 

Hyperflexion

- diving into swimming pool type injury

- 3 column injury

- high incidence of spinal cord injury

 

Xray / CT

 

Large antero-inferior body fragment

- > 20 %

- stays attached to  ALL

 

Posterior superior fragment retropulsed into canal

 

Sagittal fracture on CT

 

DDx

 

Extension tear drop injury

- fragment much smaller

- stable injury

 

Management

 

Reduction with tong traction

- improves canal / aids neurology 

 

Anterior corpectomy + plate

- may need posterior stabilisation as well

 

 

 

 

Wedge Fracture

 

Definition

 

Anterior compression / wedge fractures

- injury to anterior column

 

Mechanism

 

Flexion compression

 

Epidemiology

 

20% 

Most common at C4/5/6

 

Management

 

Usually stable

- rule out burst fracture

- suspicious if > 50% anterior height loss

- CT scan

 

Collar

ORIF Cervical Spine Fractures

C1/2 fusion

 

Options

 

1. Sublaminar wiring

- Gallie / Brooks

2.  Transarticular / Magerl screws

3.  Harms technique

- C1 lateral mas screws

- C2 pedicle screws

 

Gallie Fusion

 

Gallie Fusion C12

 

Indication

- C1/2 instability

- peg fracture with anterior displacement

- rupture of transverse ligament

 

Advantages

- relatively easy technique

- graft firmly fixed between two arches of C1 and C2

- aids in reduction of the anterior subluxation

 

Disadvantages

- sublaminal wiring technique

- can't use with C1 arch fracture

- not suitable for posterior peg displacement

 

Technique

 

Prone position

- head in line traction with tongs

- midline incision occiput to C4

- soft tissue dissection from midline

- no further than 1.5cm from midline to avoid vertebral artery and venous plexus

- clear soft tissues of posterior arch C1 circumferentially to allow passage of wire

- 1.2mm wire is fashioned as loop with a hook

- loop is passed deep to C1 arch from inferior to superior

- then passed over arch superficially so loop ends up around C2 spinous process

- unless C1 and 2 are reduced significant risk of injury to cord at this point

- decorticate arch of C1 and C2

- corticocancellous rectangular graft 3x4cm removed from post iliac crest

- fashioned into a "H" to fit snugly around SP's

- fashion cancellous surface to fit snugly on post arches

- notch graft laterally to fit wire 

- tie wire over graft to secure in place

- pack with cancellous graft around op site

 

Post-op

- HTB for 3/12

 

Brooks and Jenkins

 

Indications

- C1/2 fusion with sublaminar wiring

- biomechanically superior to Gallie technique

- more rotational control

- able to use with posterior displacement of peg

 

Technique

- clear C1 and C2 post arches circumferentially

- 2 lateral wire loops around each lamina 

- 1.5 x 3.5cm wedged corticocancellous grafts between lamina C1 and C2 both sides

 

Trans-articular / Magerl Screws

 

Indications

- C1/2 fusion

- acute and chronic atlanto-axial instability

- suitable for posterior arch fracture and posterior dislocation

 

Disadvantage

- technically difficult

 

Preop CT

- determine sufficient bone for 3.5 mm screw / sagittal reconstructions

- exclude overriding vertebral artery / axial view

 

Technique

- patient prone

- ensure reduction with II

- flex neck

- approach midline occiput to C7

- expose posterior elements C1-C3 as above

- persistent anterior dislocation may be reduced by pushing on C2 SP or pulling on C1

- expose C2 lamina not out to vertebral artery

- under lateral image control pass 2.5mm drill C2 to C1

- entry at lower edge of caudal articular process C2 

- 3mm from inferior surface and 2mm lateral to medial edge

- drill passing through posteromedial surface of lateral mass atlas

– 25o cranially, under II

- drill to anterior cortex and place appropriate 3.5mm cortical screw

- following screw fixation posterior fusion performed

 

Post-op

- Collar 6-10 weeks

 

Harms Technique

 

Harms Technique C12 fusion

 

Indication

 

Technique

- C1 lateral mass screws

- C2 lateral mass screws

 

Ondontoid

 

Dens Screw

 

Advantage

- maintain motion

- less blood loss

 

Disadvantage

- technically difficult 

- 17% major complication rate 

 

Contra-indications

- obesity

- short fat necks

- irreducible fracture

- reverse obliquity

- comminution

- delayed or nonunion / unable to debride or bone graft

 

Technique

 

Approach

- anterior approach at level C5/6

- this allows correct angle for wire insertion

- split platysma, open deep fascia

- SCM and carotid sheath laterally

- blunt dissect to prevertebral fascia medially

- split prevertebral fascia / between longus colli

- palpate inferior aspect of C2

 

Reduction

- anterior displacement easy: extend neck

- posterior displacement more difficult: traction and bring head forward

 

Cannulated wire insertion

- need good AP and lateral x-rays

- wire inserted at C5/6 disc

- need sufficient anterior bone in C2 to prevent cut out

- 2 wires inserted for rotation control

- 1 single 3.5 mm cortical screw just penetrating tip for extra fixation

 

Lower C spine

 

Posterior Wiring C2-T1

 

Many techniques

- interspinous wiring simplest

- TBW of posterior elements

- Sublaminar wires here have high neurology rate

 

Technique

 

Midline posterior approach

- essential to identify correct level with II

- hole drilled in each side of spinous process of upper vertebrae of injured segment

- junction upper and middle 1/3's

- connect holes with towel clip

- 1.2mm wire is passed through hole and around inferior spinous process leaving interspinous soft tissue intact

- wires pulled tight then passed around inferior spinous process and tied superiorly

- lamina are decorticated and cancellous graft applied

 

Triple Spinous process wire

 

Concept

- through spinous process

- about bone graft each side

 

Technique

 

First wire through transverse hole base SP

- two rectangular graft blocks each side

- second wire through superior SP & each end into superior holes blocks 

- third wire through lower SP & bottom block holes 

- tie ends second and third wires together

- decorticate post laminae

 

Screw Fixation

 

Cervical Pedicle Screws

 

Lateral mass screws

- poly axial heads

 

Preoperative CT

- location and orientation of foramen and vertebral artery

 

Entry point

- middle of lateral mass / 1 mm medial to centre

- aim 10 - 15o lateral 

- parallel to superior articular facet

 

 

 

Upper Cervical Spine Fractures

Atlas Fractures

3 types

 

1. Posterior Arch

 

Mechanism

- axial compression with hyperextension

 

Associations

- 50% incidence other C1/2 fracture

- i.e. ondontoid fracture

 

Management

- stable

- soft / philadelphia collar

 

2. Isolated lateral mass fracture

 

Mechanism

- asymmetrical axial compression / lateral bend

- fracture runs anterior, posterior or through articular surface

 

3. Jefferson (3 or 4 part)

 

Jefferson Fracture 4 Part Axial CT

 

Jefferson Fracture

 

Mechanism

 

Symmetrical axial compression

 

Management depends on integrity of transverse ligament

 

Ruptured transverse ligament

 

1. Peg view

 

C1 lateral mass displacement

- C1 overlapping on C2 bilaterally

- > 6.9 mm displacement of both lateral masses in total

-  rupture of transverse ligament likely

 

Jefferson CT Peg View

 

2. > 5mm ADI on dynamic flexion / extension xray

 

3. Avulsed fragment on CT

 

MRI

 

Transverse ligament

- avulsion

- midsubstance tear

 

Treatment

 

1. Undisplaced

 

Manage with collar

 

2. Displaced

 

Reduce with ligamentotaxis / traction tongs

 

A.  HTB

- 8 weeks

- check flexion / extension views

 

Jefferson HTB XrayJefferson Fracture Flexion Extension Views Stabe0001Jefferson Fracture Flexion Extension Views Stabe0002

 

B.  Fuse if midsubstance tear transverse ligament

- unlikely to heal

- as opposed to avulsion

 

3. Peg + Jefferson

 

Unstable & requires fusion

 

NB Elderly > 70

- increased mortality with HTB 20 – 36%

- often don’t tolerate hard collar

- soft collar / trial of life

Background

Definition

 

Bony Occiput / Atlas / Axis

 

Anatomy

 

Occiput / atlas joint

- occipital condyles - lateral masses

- synovial joint

- often flatter in children which explains increased incidence of injury in children

 

Atlas / axis

- 3 synovial joints

- posterior atlas and dens

- lateral facet joints

 

Ligaments

 

1.  Extrinsic

- anterior tubercle attaches ALL and longus colli

- posterior tubercle attaches ligamentum nuchae

 

2.  Intrinsic (dorsal to ventral)

 

A. Tectorial Membrane

- continuation of PLL 

- posterior body of axis to anterior foramen magnum

 

B. Cruciate ligaments

- anterior to tectorial membrane / behind odontoid

- transverse ligament (posterior odontoid to anterior arch of atlas)

- vertical bands (from axis to foragmen magnum)

 

C. Odontoid ligaments

- from tip of odontoid

- paired alar ligs to occipital condyles (strong)

- small apical ligament to foramen magnum

 

Strongest

- Tectorial

- Alar

 

Movement

- 40 – 45o flexion / extension (equal between C0/1 and C1/2)

- 40 – 45o rotation (mainly C1/2)

 

Ossification

 

Atlas

- 3 parts 

- 2 neural arches and one body

 

Axis

- 4 parts

- dens + 2 neural arches and one body

 

Goals of treatment

 

Protect the neural structures

Reduce and stabilise injured segment

Provide long term stability

 

Clinical

 

Neck pain

Paraesthesia / Paralysis

Head / scalp lacerations

Palpate spine / Step-off Tenderness

 

X-ray

 

3 trauma series

 

Anterior Soft Tissue

- "6 at 2 and 2 at 6"

- 6 mm at C2 normal

- 2 cm at C6 normal

- not applicable in children

 

SAC / Space available for Cord

- PADI

- 1/3 Peg 1/3 Cord 1/3 Space

- if < 10mm cord compression

 

ADI

- children < 5mm

- Adults < 3mm

 

Stress Xray

 

High suspicion posterior ligamentous injury

- stretch test

- > 1.7mm increased disc space

- > 11° angle

 

Low suspicion ligamentous injury

- supervised flexion / extension view

- contra-indicated in decreased consciousness

 

CT Scan

 

To define bony fractures

- more sensitive upper cervical spine

 

MRI

 

To detect HNP prior to attempted reduction with incomplete lesion

Demonstrate oedema i.e. suspicious of C0-1 dislocation

 

 

Dens Fracture

Classification Anderson & D'alonzo

 

Type 1

 

Tip avulsion

- alar ligament avulsion

- fracture off one side of tip of dens

 

Management

- associated with atlantoaxial instability

- manage in collar

 

Type 2

 

Fracture of base of dens

 

Dens Fracture Type 2 Undisplaced0001Dens Fracture Type 2 Undisplaced0002

 

Type 3

 

Fracture through body of axis

- union rates 95%

 

Type 3 Dens Fracture Coronal CTType 3 Dens Fracture CT Coronal

 

Management

- elderly / Philidelphia collar

- young / HTB

 

Type 2 Dens Fracture

 

Issue

 

Undisplaced v displaced

- risk of nonunion 30% higher with displacement

 

Non-union

 

Risk factors

- > 65 years

- > 5 mm displaced

- >10° angulation

- posterior displacement

- comminution

- delay in treatment

- smoker

 

Type 2 Dens Fracture Displaced

 

Management Acute Fracture

 

1. Undisplaced 

 

HTB 3/12

 

Platzer et al Neurosurgery 2007

- 90 patients average age 69 years treated in HTB

- union in 84%

- non union associated with elderly / displacement / delay in treatment

 

2. Displaced

 

A.  Traction

- reduces dens

 

B.  Ondontoid screw

 

C.  C1/2 Fusion

 

Gallie / Brooks fusion

 

Magerl fusion

- trans-articular screws

 

Harms fusion

- poly axial screw and rod fixation

- C1 lateral mass screws

- C2 pedicle screws

 

Dens Nonunion C12 fusion

 

3.  Elderly

 

Issue

- high risk of failure of fixation due to poor bone

- risk of HTB

- risk of non union

 

Koech et al Spine 2008

- 42 patients > 70 treated in HTB or collar

- 50% osseous fusion and 90% fracture stability in collar

- 37% osseous fusion and 100% fracture stability in HTB

 

Ondontoid Screw Fixation

 

Advantages

- preserves motion compared to C1/2 fusion

- 50% rotation from C1/2

 

Contra-indications

- irreducible fracture

- comminution

- osteopenia

- ondontoid + transverse ligament injury / will remain unstable

- oblique fracture configuration / need to place screw perpendicular to fracture

 

Results

 

Platzer et al Spine 2007

- ondontoid screw fixation in 102 patients

- nonunion rate 4% in patients < 65

- nonunion rate 10% in patients > 65

 

Management Nonunion

 

Issues

- pain

- instability / myelopathy / risk sudden death

 

Type 2 Dens NonunionType 2 Dens Nonunion Coronal CT

 

1.  Patients < 65 years

 

C1/2 fusion

 

Dens Nonunion Instability0001Dens Nonunion Instability0002Dens Nonunion C12 fusion

 

2.  Elderly

 

Most patiens have a fibrous nonunion

- stable on flexion / extension views

 

Hart et al Spine 2000

- series of elderly patients with unstable nonunions

- treated non operatively

- no development of myelopathy or sudden death

 

 

 

Hangman's

Definition

 

Bilateral Pars Fracture C2

- traumatic axis spondylolisthesis

 

NHx

 

Neurological injury uncommon

- fragments separate and decompress

 

Different to judicial hanging where spinal cord is severed

 

Xray

 

Hangmans Fracture XrayHangmans Xray

 

Levine & Irving Classification

 

Type I

 

Vertical pars fracture with no displacement / <3mm

 

Hangmans CT Undisplaced0001Hangmans CT Undisplaced0002Hangmans CT Undisplaced0003

 

Type II

 

Vertical pars fracture translated anteriorly > 3mm

- hyperextension injury / windshield

 

Hangmans Fracture Type 2Hangman's Fracture Type 2 Axial

 

Type IIA

 

Oblique fracture pars with angulation and displacement

- flexion & distraction injury

- entire C2/3 Disc avulsed & fails in flexion

- only ALL left intact

 

Type III

 

Bilateral facet dislocation C2/3 and pars fracture

 

Management

 

Algorithm

 

Type I

- manage in semi-rigid collar 8/52

- flexion / extension views to ensure stability

 

Type II

- traction + extension

- application HTB 8/52

- flexion / extension views

 

Type IIA

- traction contra-indicated

- extension and HTB

- some centres advocated fusion if high level angulation

 

Type IIIA

- reduction / HTB or fusion

 

Results

 

Vaccaro et al Spine 2002

- HTB treatment of 27 type II and 4 type IIA

- all type IIA went on union

- 21 type II went on to union

- high initial degree angulation associated with failure treatment

 

Operative Management

 

Options

 

C2/3 instrumented fusion

C2 transpedicle stabilisation

Anterior cage and plate construct

 

Results

 

Ma et al Spine 2011

- C2/3 pedicle screw fusion for unstable hangman's fracture

- 35 patients, solid and stable union achieved in all patients

 

Hangmans Fracture Non Union Posterior Fusion

 

 

 

Occipital Condyle Fractures

Epidemiology

 

Rare

- unilateral

- bilateral

 

Mechanism

 

Compression

Lateral Compression

Rotation

 

Clinical

 

Skull base pain

Cock Robin

Cranial nerve injury

 

Classification Anderson & Montesano

 

Type I

 

Impaction of a condyle 

 

Management

- Stable / Brace 8/52

 

Type II

 

Condyle fracture associated with basilar / skull fracture

 

Management

- Stable / Brace 8/52

- Displaced / HTB 8/52

 

Type III

 

Condyle avulsions fracture secondary to rotation

- rupture strong alar ligaments

 

Management

- unstable 

- HTB / fusion (C0 - C2)

 

Results

 

Maserati et al J Neurosurg Spine 2009

- follow up of 104 occipital condyle fractures

- occipital-cervical fusion in 2 who had evidence of craniocervical malalignment

- remainder all treated with collar

- no late instability / malalignment / nerve compression

 

 

Occipito Atlantal Dislocation

Epidemiology

 

Deadly & rare

- usually post mortem

 

More common in children due to

- immature joints 

- larger head to body ratio

- relative ligamentous laxity

 

Aetiology

 

High velocity trauma

- MVA

 

Mechanism

- hyperextension, distraction & rotation

 

Types

 

Pure ligament injury usually

 

Direction

- anterior occipital displacement (most common / head anterior)

- vertical

- posterior (rare)

 

Diagnosis

 

Basion anterior to tip ondontoid

- most common is anterior occipital displacement

- should be located at tip of ondontoid

 

Basion-Dens Interval / BDI

- most sensitive

- from basion to dens

- assesses vertical displacement

- should be less than 12 mm

 

Basion-Axial Interval / BAI

- distance to posterior axial line / line posterior border ondontoid

- increased > 12 mm with anterior displacement

 

Power's Ratio BC/AO > 1 

- head goes anterior

- basion to posterior arch / opisthion to anterior arch

 

Management

 

Reduction / HTB

 

Reduce in OT

- II

- putting sandbags under thorax

- allows head to reduce posteriorly

- assess with II

- apply HTB

- add compression

 

HTB 3 months

- assess stabilty with flexion / extension views

 

Stabilisation

 

Is a ligamentous injury and inherently unstable

- may require atlanto-occipital fusion

 

 

Pseudo subluxation

Definition

 

Subluxation in children up to 8

- C 2/3 in 40% children

- C 3/4 14%

- up to 4 mm

 

Aetiology

 

Horizontal facet joints

- flat orientation of paediatric facets and laxity of ligaments

 

Become more vertical with age

 

Diagnosis

 

1. Swischuk's Line

- drawn along spinolaminar line C1 & C3

- C2 should be within 1.5 - 2mm of this line

 

2. Pseudosubluxation will reduce with extension

 

Rheumatoid Neck

Epidemiology

 

Neck involved in 86%

- second most common site after hands and feet

- closely associated with MCPJ subluxation

 

Associations

 

Males / Steroid use / Seropositivity Nodules / Severe long standing disease

 

Conditions

 

Atlanto-axial subluxation

Subaxial subluxation

Superior migration ondontoid

 

1.  Atlanto - Axial subluxation (AAI / AAS)

 

Aetiology

 

A. Attrition of transverse ligament

B. Erosion of peg

 

Epidemiology

 

Most common of RA cervical deformities

- occurs in up to 50% of patients

 

May cause myelopathy

 

Diagnosis

 

1.  Lateral view AADI

- anterior atlantodental interval

- AADI > 3 mm

 

Cervical Flexion Instability Increased AADI

 

2.  AADI

 

A.  Instability : > 3 mm difference in flexion / extension views

 

RA neck Flexion View AADA /> 3 mmRA Neck Extension View AADI 1 mm

 

B.  Severe instability: > 7 mm difference

 

AADI greater than 5 mm

 

3.  PADI

- posterior atlantodental interval / SAC (space available for cord)

- > 14 mm 94% predictive no neural deficit

- < 14 mm 97% predictive neural compression

 

2.  Superior Migration of Odontoid / Pseudobasilar Invagination / Atlantoaxial vertical subluxation

 

Superior Migration Ondontoid CT CoronalSuperior Migration Ondontoid CT Sagittal

 

Definition

- vertical translocation of Dens into foramen magnum

- compresses medulla

 

Pathology

- due to erosion of lateral masses of atlas and occipital condyles

- can lead to compression of brain stem

- risk of myelopathy / sudden death

 

Epidemiology

- seen in 40% of RA patients

 

Symptoms

- C1/C2 compression gives occipitocervical pain

- ventral pressure can compress respiratory centre and cause sudden death

 

Diagnosis

 

Superior Migration Ondontoid Lateral XraySuperior Migration Ondontoid Lateral Xray Close Up

 

Ranawat measurement < 13 mm

- line between anterior and posterior arch atlas

- centre of pedicle of C2

 

SMO Ranawat Measurement

 

McCrae

- line of foramen magnum

- tip of dens should not protrude above this line

 

SMO McCrae LineSMO McCrae Line CT

 

McGregor line > 4.5 mm

- line hard palate to posterior occiput

- if tip of dens > 4.5 mm above this line = vertical settling

- severe > 8 men or > 10 women

 

SMO McGregor Line

 

Redlund-Johnell measurement

- assesses entire occiput to C2 complex

- base of dens to McGregor line

- men <34mm & women <29mm = abnormal

- if abnormal -> highly correlated with severe disease & neurology

 

SMO Redlund-Johnell

 

3.  Subaxial Subluxation (SAS)

 

Definition

- anterior subluxation of one vertebral body on another

 

Rheumatoid Arthritis Subaxial InstabilityRheumatoid Arthritis Subaxial Instability Extension View

 

Diagnosis

 

A.  Instability on Flexion / Extension views

- > 3mm

- > 11o

 

B.  Space available for cord / SAC

- subaxial canal diameter on lateral

- < 13 mm high incidence neurology

 

RA Subaxial Subluxaton SAC

 

Aetiology

- facet erosions / ligament incompetence

 

Epidemiology

- 10-20% of RA patients

 

Pathology

- may see at multiple levels with stepladder type deformity & kyphosis

- occurs beneath previous cervical fusions

- anterior subluxation / destructive changes of facet joints / destruction of disc

- can result in 2° canal stenosis

 

Cervical Spine MRI Subaxial Subluxation

 

Neurological Classification Ranawat

 

I        No neurological deficit

II      Subjectively weak / hyperreflexia & dysesthesia

IIIA   Objectively weak / ambulatory

IIIB   Objectively weak / non ambulatory

 

Clinical Features

 

Pain

- neck radiating to shoulders / occipital headaches

- occipital neuralgia / greater occipital nerve compression

- ear pain / greater auricular nerve compression

- facial pain / trigeminal

 

Stiffness

 

Parasthesiae

- most common & earliest symptom 

- pain & temp / spinothalamic tract compression

 

Weakness

 

Frequency or retention / constipation

 

NHx

 

Incidence of cervical involvement increases with duration of disease

- after 10 years 60% will have AAS

 

Postmortem study of 104 patients with RA

- 10% died 2° medullary compression

- impossible to predict which patients will progress

 

MRI

 

Supplanted CT

- site of compression

- accurate SAC / account for soft tissue

 

Dimensions

1.  Foramen magnum SAC < 14 mm = neurological compression

2.  C1-2 SAC < 13mm

3.  Subaxial spine SAC < 12mm

 

Rheumatoid Arthritis Limited Space Available for Cord

 

Cervicomedullary angle (MRI)

- long axis brainstem to long axis cord

- normal angle is 135-175°

- <135° = vertical settling & is correlated with myelopathy

 

Management

 

Goals of Treatment

 

1. Prevent development of neurologic deficit

2. Prevent sudden death due unrecognised neurological compromise
- 10% of deaths in RA occur suddenly due neurological complications

 

Screening

 

Cervical spine flexion / extension xray

- mandatory in all patients pre-operatively

 

Management

 

2 Groups 

1.  Intractable pain or neurologic compromise -> fuse

2.  No pain & no neurology – controversial

 

AAS

 

Algorithm

1. PADI >14mm -> observe

2. PADI < 14mm MRI

3. Cervicomedullary angle <135° / SAC < 13 - fusion

 

Options

 

1.  C1/2 fusion

- if instability reducible / no decompression needed

 

2.  Occipito-cervical fusion

- instability irreducible

- must decompress / remove lamina C1

 

C1/2 fusion

- fusion in situ if reducible and no neurology

- laminectomy C1 + fusion if fixed deformity with neurology

 

A. Gallie / Brooks fusion

- contra-indicated if any displacement or neurology

- unable to perform decompression / laminectomy

 

C1 C2 Posterior Spinous Process WiringC1 C2 Posterior Spinous Process Wiring

 

B.  Transarticular / Mageryl screws

- 95% fusion rates

- +/- laminectomy of C1 if displaced or with neurology

- pannus resorbed in 19 of 22 patients with fusion

 

Occipitocervical fusion

 

C0 C3 fusion AAI Rheumatoid

 

Results

 

90% of pts improve 1 Ranawat grade if have neurology pre-op

- PADI < 10mm predicts patinet unlikely to improve

 

Problem

- due to bone erosion may be insuffiency bone quality for C1/2 fusion

- may need C0 - C3

 

SMO

 

More serious & should be treated more aggressively

- xray screening

- MRI in flexion to evaluate cord compression

 

Algorithm

1. No symptoms & no cord compression on MRI

-  observe

2. Cord compression

- occipitocervical fusion

- +/- C1 laminectomy +/- anterior dens excision if fixed deformity & neurology

 

Results

- 75% improve

 

Occipital Cervical Fusion LateralOccipito Cervical Fusion AP

 

SAS

 

Algorithm

- SAS >14mm & no symptoms -> observe

- SAS < 14, MRI for true SAC

- SAC < 13 or instability - surgery

 

Surgery

1.  Anterior decompression and fusion

 

Subaxial Stabilisation

 

2.  Posterior laminectomy and fusion

- may need long fusion to prevent SAS above and below

 

Cervical Spine Posterior Fusion for SASCervical Spine Posterior Fusion for SAS

 

 

Smith Robinson Approach

Via the carotid triangle

 

SCM / posterior belly digastric / superior belly omohyoid

 

Indication

 

Exposes inferior body C2 - T1

 

Position

 

1.  Supine in tongs

2.  Sit on head board with head taped and slightly extended

 

Table 30° up

Turn head away from side of incision

 

Which Side

 

Most surgeons approach from the left

- the course of the Recurrent Laryngeal Nerve / RLN is more predictable on left

 

Right sided approach

- used sometimes for C7/T1 to avoid thoracic duct

 

Recurrent Laryngeal Nerve

 

Right side

- given off the vagus at the level of the subclavian artery

- slopes from lateral to medial across lower part of wound to reach the oesophagus / trachea interval

- crosses the surgical approach in 50% of cases

- usually at C6/7

- may be at C5/6

 

Left side

- arises at the level of the aortic arch

- doesn't slope across the wound

 

3 Fascial layers

 

1.  Deep Cervical Fascia

- under the subcutaneous fat

- invests neck like collar

- clavicle / sternum / spine scapula - mandible / base of skull

- invests SCM & trapezius

- Have to incise so can retract SCM

 

2.  Pretracheal

- covers trachea

- deep to the strap muscles

- extends from hyoid into chest

- splits to enclose thyroid

- fuses laterally with carotid sheath

- have to divide to retract carotid sheath laterally

 

3.  Prevertebral

- base of skull to T3

- invests longus colli and sympathetics

- divide to separate longus colli muscles to approach verebrae

 

Landmarks

 

Medial border SCM

Carotid Artery lateral to SCM

 

Levels

- Hyoid = C3

- Thyroid Cartilage = C4/5

- Cricoid = C6

- Carotid Tubercle = C6

 

Incision

 

Inject LA with adrenaline

Transverse incision at level required from midline to posterior border SCM

 

Superficial Dissection

 

Divide Platysma vertically at anterior border SCM

 

Superficial plane

- through investing layer of deep cervical fascia

- between strap muscles (Sternohyoid & Sternothyroid) & anterior border SCM

 

Deep Dissection

 

Palpate the Carotid Artery 

- divide the pretracheal fascia medial to the Carotid Sheath

- open plane between carotid sheath & medial structures

- medially oesphagus, trachea & thyroid

- note that anterior carotid sheath fuses to pretracheal fascia

- retract the carotid sheath & SCM laterally

 

Vessels

 

C3/4

- superior thyroid artery / superior laryngeal nerve behind

- common venous trunk of superior thyroid / lingual / facial vein

 

C6/7

- ligate middle thyroid vein

- inferior thyroid artery

 

Blunt dissection medially

- behind the oesophagus

- expose the vertebrae covered by Longus Colli, prevertebral fascia & ALL

- sympathetic chain lies on the Longus Colli, just lateral to the vertebrae

- incise the Longus Colli in the midline

- subperiosteally expose the Vertebrae

- place retractors under Longus Colli

 

Check level with II

 

Dangers

 

1. Recurrent Laryngeal Nerve

- lies between trachea & oesphagus

- on right crosses field from subclavian artery at C6/7 with inferior thryoid artery

 

2. Superior Thyroid Artery/ Superior Laryngeal Nerve

- C3/4

- superior thyroid artery pass from the Carotid Sheath medially to the midline structures

- superior laryngeal nerve runs with artery

- can divide artery but must preserve nerve

- otherwise get dysphagia

 

3.  Inferior Thyroid Artery

- lower approach may pass from lateral to medial

 

4. Sympathetic Chain on transverse processes

5. Vertebral Artery

6. Carotid Sheath with Vagus inside

7. Oesophagus

8. Trachea

9. Thoracic duct on left at C7 / T1 level

 

 

 

Cord Injury

Cauda Equina

Definition

 

Compression of some or all of the nerve roots in the cauda equina

- bladder dysfunction

- bowel dysfunction

- saddle anaesthesia

- variable motor and sensory loss

 

Aetiology

 

HNP

- most common

 

Epidural haematoma

- post surgical

- spinals and anticoagulation

 

Epidural abscess

 

Tumours

- metastatic prostate / lung / breats

 

Trauma

 

Chronic stenosis / spondylithesis

 

Post surgical

- seen post stenosis decompression

- cause unknown

 

Anatomy

 

Spinal cord ends at L1 / conus medullaris

- L3 in children

- spinal cord appears to migrate proximally with growth

- relative greater growth of the spinal column

 

Conus medullaris

- attached to coccyx

- filum terminale

 

Dural sac containing L2 - S5

 

Neurology

 

Lower motor neurone symptoms in leg

- weakness

- sensory loss

- decreased / absent reflexes

 

Bladder dysfunction

 

S2-4 disruption

- parasympathetic nerves

- promote bladder emptying

- contract detrusor & relax internal sphincter

 

Unable to feel bladder filling

 

Unable to void

- retention

- eventual overflow

 

Pathology

 

Nerve roots

- very susceptible to compression

- don't have 3 layers like peripheral nerve roots

- endoneurium only

- then CSF and dura

 

May develop ischaemia

- radicular arteries

- form of compartment syndrome

 

Issue

 

Injury to the sacral nerve roots can be permanent

- need early decompression < 24 hours

- otherwise permanent bladder and bowel dysfunction

 

Symptoms

 

Two groups

- acute presentation - severe pain

- insidious presentation - stenosis / spondylolithesis

 

Bladder dysfunction

- difficulty initiating / stopping stream

- progresses to retention

- progresses to overflow incontinence

 

Bowel

- unable to feel or control / incontinence

 

Other symptoms

- severe back pain

- severe sciatica

- lower leg weakness and parasthesia 

- saddle anaesthesia / can't feel toilet paper

 

Signs

 

Perianal sensation

- may have preserved light touch

- may need pin prick

- S 3,4,5

 

Rectal tone

- decreased

 

Bladder

- full

- increased volume on bladder scan

- cannot feel tug on catheter

 

MRI

 

Usually a disc will take up > 1/3 of canal diameter

 

Management

 

Urgent Decompression

 

Timing

- evidence of improved outcomes for decompression within 48 hours versus > 48 hours

- no evidence for < 24 hours

- reasonable to do so as soon as able

 

Outcomes

 

Buchner and Schiltenwolf Orthopedics 2002

- 17 / 22 regained full urinary function

 

Outcome likely related to

- duration of symptoms / timing of decompression

- severity of initial symptoms / signs / bladder dysfunction

 

 

 

Central Cord Syndrome

Epidemiology

 

Most common pattern cord injury

 

Hyper-extension injury in middle aged man with osteoarthritic spine

 

Usually C3/4 and C4/5

 

Mechanism

 

Most common type / in older patient with pre-existing spondylosis / OPLL

- hyperextension injury

- compression of the cord

- anteriorly by osteophytes

- posteriorly by infolded ligamentum flavum

 

Pathology

 

Injury of central gray matter

- weaker in arms than legs

- LMN in arms 

- UMN in legs

- sacral sparing common

 

Examination

 

Flaccid paralysis in upper limbs

 

Spastic paralysis in lower limbs

- more likely to be preserved

 

Xray

 

Typically normal / no fractures

 

MRI

 

Demonstrates stenosis

 

Cord

- high signal intensity on T2

- localise level of injury

 

Management

 

NHx

 

Usually regain walking and bladder function

Hands have the worst prognosis

 

Prognosis

 

Aarabi et al J Neurosurg Spine 2011

- 42 patients, 82% men, average age 58

- admission ASIA scores and midsagittal diameter of cord most related to prognosis

 

Issue

 

Decompression v non operative management

 

Surgical Timing

 

Chen et al J Neurosurg Spine 2009

- review of surgical decompression in 49 patients

- no difference between decompression < 4 days or > 4 days

- younger patients did significantly better

- 1/3 patients dissatisfied with outcome

 

Algorithm

 

Observe initially

- maximise medical treatment / HTN / oxygenation

 

If improving

- non operative

 

No improvement

- operative management

 

 

 

Spinal Cord Injury

Definition

 

Complete Lesion 

- bulbocavernosus reflex present 

- no cord function below lesion

- very poor prognosis for recovery

 

Incomplete Lesion

- bulbocavernosus reflex present

- some cord function below lesion

- good prognosis for recovery

 

Anatomy

 

Vertebral Canal narrowest at T8/9

- Also area of vascular watershed

 

Dorsal Columns 

- light touch, vibration & proprioception

- CTLS (cervical fibres central, sacral fibres lateral)

- decussate in medulla

- Cuneate Nucleus = Cervical & Thoracic

- Gracile Nucleus = Sacral & Lumbar

 

Lateral Corticospinal Tract

- motor tract

- CTLS (cervical central, sacral fibres peripheral)

- decussate in medulla

 

Anterolateral Spinothalamic Tract

- pain & temperature

- decussate immediately after cord entry

 

Incomplete Patterns

 

1.  Central Cord Syndrome

- most common

- hyperextension injury

- UL > LL due to arrangement of fibres in dorsal column and anterior corticospinal

- CTLS

- distal > proximal

- sacral sparing

 

2.  Anterior Cord Syndrome

- complete paralysis with dorsal column sparing

- anterior spinothalamic & lateral corticospinal tracts lost

- secondary to ischaemic event

- maintain BP and oxygenate patient

- very poor prognosis

 

3.  Brown Sequard

- cord hemisection

- usually secondary to laceration

- ipsilateral dorsal columns & motor

- contralateral loss pain & temperature

 

4.  Posterior Cord Syndrome

- rare

- dorsal column loss only

- due to tumour / iatrogenic (sublaminar wires etc)

 

5.  Cauda Equina Syndrome

- injury below L1

- only nerve roots at this level

- LMN injury to lumbar and sacral nerve roots

- large L5/S1 disc commonest cause in narrow canal < 100 mm2

- faecal incontinence + urinary incontinence

- nil anal tone or sensation

 

6.  Conus medullaris injury

- cord ends at L1

- injury at this level results in LMN LL weakness and UMN sacral lesions

- may have a spastic bladder which enables urination without catheterisation

- T12 / L1 burst fracture most common cause

 

Sacral Sparing

 

Triad of

- anal voluntary contraction

- perianal sensation

- FHL function

 

Indicates

- incomplete injury

- potential for recovery

- due to pial arteries on cord surface supplying small amount of tissue 

 

Blood Supply

 

Anterior Spinal Artery

- arises from vertebral arteries at foramen magnum

- supplies entire cord except for dorsal columns

- narrows and may become absent in thoracic region

 

Posterior Spinal Arteries

- paired

- smaller

 

Segmental Arteries

- average of 8 paired arteries

- may be single segmental supply between T4 and T8

- Artery of Adamkiewicz from left between T9-11 in 80% cases

 

Micturition control

 

Stretch receptors in bladder wall

 

As distension occurs

- afferent signal travels up pelvic splanchnic nerves (S2/3/4)

- sacral cell bodies send signal back via efferent in same nerves

- produce contraction of detrusor

 

Parasympathetic control

- this is a lower motor neuron reflex arc

- override by higher cortical centres with development

 

Cauda Equina

- LMN to S2-4

- flaccid bladder / overflow incontinence

 

Conus medullaris injury

- results in UNM changes at that level

- detrusor mm spastically contracts

- higher cortical control disrupted

- result is spastic bladder - incontinence

 

Surgical division sacral nerve roots 

- produces LMN effect

- if leave at least 1 S3 - 100% continent

- if leave at least 1 S2 - 50% continent

- if above S2 incontinent because pelvic splanchnics removed

 

Assessment

 

Spinal shock

 

Refers to flaccid paralysis due to physiologic disruption of all spinal cord function

- all motor, sensory and reflexes absent below level of injury

 

An accurate assessment can only be made when spinal shock has resolved

- 48 hrs in 99%

 

Absence of SS confirmed by the return of cord mediated reflexes below the anatomic level of the injury

- bulbocavernosus reflex is the lowest and thus the first to return

 

Frankel Grading

 

A Complete

- no motor or sensory function in the sacral region

 

B Incomplete

- sensory intact

- no motor function below the neurological level and includes sacral segments S4-S5

 

C Incomplete

- motor function is preserved below the neurological level 

- at least half the muscles have power < grade 3

 

D Incomplete

- motor function is preserved below the neurological level 

- at least half the muscles have power > grade 3

 

E Normal motor and sensory function

 

MRC Power Grading (Medical Research Council)

 

0 - no visible movement

1 - palpable or visible contraction

2 - active movement with gravity eliminated

3 - active movement against gravity

4 - active movement against some resistance

5 - active movement against full resistance

 

ASIA Dermatomes (American Spinal Injury Association)

 

C5 Elbow Flexor / Lateral Arm Sensation

C6 Wrist Extension / Dorsal thumb

C7 Elbow Extension / Dorsum MF

C8 Finger Flexion (MF DP) / Dorsum LF

T1 Interossei / Medial Arm sensation

T2 Armpit sensation

 

L1 Inguinal ligament sensation

L2 Hip Flexors / Middle Medial Thigh

L3 Knee extension / Knee sensation

L4 Ankle DF / Medial malleolus

L5 Long toe extension / First web space

S1 Ankle PF / Heel 

S2 Back of knee sensation

 

Each muscle rated 0 - 5 for power

- score out of 50 for R and L

- total score out of 100

 

Sensory Levels

 

T4 - nipple

T7 - xiphisternum

T10 - umbilicus

T12 - groin

 

Reflexes

 

Cremasteric Reflex T12-L1

- stroke thigh & scrotal contraction

 

Anal Wink S2-4

- stroke cleft for anal contract

 

Babinski

- upgoing = UMN

 

Oppenheimer

- stroke tibial crest & toes go up

 

Bulbocavernosus Reflex

 

Technique

- squeeze glans / clitoris or pull on catheter

- anal contracture

 

If present with complete cord lesion

- indicates S2-S4 region firing

- spinal shock resolved

- can prognosticate about level of neurological injury

 

Timing

- returns in 99% in 24 hours

- indicates end of spinal shock

 

TL fracture may permanently damage BCR

 

Medical Treatment

 

Steroids

 

Bracken N Engl J Med 1990

- randomised multi-centre trial

- methylprednisone v naloxone or placebo

- suggested benefits of corticosteroids within 8/24 but not after

- based on oedema reduction

- GIT haemorrhage may result or be exacerbated

 

Bracken Cochrance Database Syst Review 2012

- review of 8 randomised control trials

- shown that methylprednisolone, if given within 8 hours, improves motor recovery

 

Canadian Spine Society

- some of the efficacy seen in trials is only in post-hoc analysis

- evidence is actually very weak, level II and III

- side effects include sepsis, pneumonia and GI complications

- is not standard of care, but only a treatment option

 

Dosing

 

Methylpred

- 30 mg/kg bolus

- 5.4 mg/kg/hr for 23/24

 

Contra-indications

- > 8 hours after presentation

- penetrating spinal injury

- infection

- diabetes

- < 13 years old

- pregnancy

 

Surgical Decompression

 

Timing

 

Progressive neurology 

- urgent decompression

 

Non Progressive Neurology

- decompress as soon as stable

- timing uncertain

 

Results from decompression

 

Cervical

- improvement in both incomplete & complete cord injury

- 1 or 2 extra levels in cervical spine improves function significantly

 

Thoracolumbar

- improvement in incomplete cord injury

- no improvement with complete cord injury

- extra level in thoracic spine doesn't improve fuxnion

- prevents late degeneration / deformity / pain

 

 

 

 

Spinal Cord Injury Management

Epidemiology

 

RTA 50%

Falls 20%

Sport 20%

 

Unconscious after MVA or fall

- 10% chance cervical spine injury

- Cervical > Thoracic > Lumbar

- cervical spine is mobile & not protected

- quadriplegia more common than paraplegics

- assume cervical spine injury till cleared 

 

Permanent paralysis 10%

- incomplete > complete deficit

 

Natural History

 

Death in first year secondary to CRF and Infection

- 20% of Quadriplegics

- 10% of Paraplegics

 

Useful recovery

- complete lesions < 10% chance

- incomplete ~ 75% chance

 

Quadriplegics

- inpatient stay ~ 9/12

- OT doesn't decrease this

- life expectancy decreased by 10 years

 

Paraplegics

- inpatient stay ~ 4/12

- OT does decrease this 

- life expectancy normal

 

Mechanism of injury

 

Primary response / Mechanical

- Contusion (No.1) / Compression / Stretch / Laceration

 

Secondary response

- Ischaemia / Vascular Injury / Vasoactive Substance / Inflammation

 

Definition

 

Neurological level

- lowest level at which motor and sensory function is normal

 

Complete lesion / no sacral sparing

- absence of sensory and motor function in the lowest sacral segment

- no sacral sparing

 

Incomplete lesion / sacral sparing

- presence of sacral and motor function in the lowest sacral segment

- indicates preserved function below the defined neurological level

 

Complete Cord lesion

 

NHx

 

90% recovery of one & 20% recovery two root levels

- if motor grade at level is 2/5 at one week, will gain functional recovery

- if pinprick spared in dermatome, will likely recovery functional > 3/5 strength

- this may be significant i.e. diaphragm, elbow extension C7

- may be increased with surgical decompression

- majority recovery in first 6 - 9 months

 

Function

 

C1-3

- portable ventilation

 

C4

- need CPAP at night

- mouth controlled wheelchairs

 

C5

- active elbow flexion

- dependant for transfer and bed position

 

C6

- shoulder stability (RC)

- wrist extension

- can give them tenodesis grip

 

C7

- triceps

- can roll over and transfer

- eat independently

 

C8-T1

- independent

 

Walking

- > grade 3 hip flexion on one side

- > grade 3 knee extension on other side

 

Neurogenic Shock

 

Cause

 

2° unopposed parasympathetic vagal tone

- sympathetic tone lost

- loss of vasomotor tone with marked vasodilatation

- result is hypotension + bradycardia

 

Diagnosis

- hypotensive + bradycardia + warm periphery 

 

Management

 

Response to fluids moderate (CVP)

- trendelenburg position

- Atropine (0.6 mg push)

- may require inotropic support / Dopamine

 

Pharyngeal suction & intubation stimulate vagus

- may produce bradycardia & cardiac arrest

 

Respiration

 

Midcervical lesion

- C3/4/5

- phrenic nerve defunctioned

- paralysis of diaphragm

 

Low cervical / high thoracic lesion

- paralysis of intercostal muscles

 

Accessory muscles & abdominal respiration used in both circumstances

 

At The Scene

 

Unconscious  Patient

 

Assume spinal fracture secondary to force that caused unconsciousness

- place neck in neutral

- stabilise with gentle longitudinal traction

- hard collar + sandbags

 

Conscious Patient

 

Spinal injury assumed if

- complaining of sensory abnormality / weakness / paralysis

- back or neck pain

 

Immobilisation

- as above

 

Transportation

 

Spinal care / log roll

- monitor airway & O2 saturations

- beware overhydration

- keep patient warm

 

Initial Hospital Management

 

History

- Mechanism of injury

- any neurological deterioration / improvement since injury

 

ATLS

- paraesthesia masks abdominal & leg injuries

 

Vertebral assessment

- log-roll to allow visualisation

- palpate for tenderness / step

- perform PR (saddle anaesthesia / anal tone)

 

Features cord injury

- flaccid areflexia

- lax anal tone

- diaphragmatic breathing

- pain > clavicle only

- hypotensive & bradycardic

- priapism

 

Neurological Assessment / SMART

 

Sensation

- spinothalamic tracts (Pin prick)

- posterior column (Fine touch, Proprioception)

Motor - Corticospinal Tracts

Autonomic ~ Priapism

Reflexes - DTR / Abdominal / Anal / BCR

Tone

 

X-ray

 

Lateral film  

- must see C7/T1

- swimmer's view may be necessary

- pick up 85-90%

 

Cervical trauma series

- AP + Peg / Ondontoid View + Lateral

- up to 95%

 

CT / MRI

 

Early Management

 

1.  Stabilise Spine

 

Cervical

- unstable - Gardner Wells Tongs 4 kg initially

- stable - bed rest, hard collar

 

Thoracolumbar

- patient lies supine

- no flexion

 

2.  Respiratory

 

Worse if chest trauma 

- monitor ABG's

- physiotherapy

- incentive spirometry / triflow

- if respiratory function deteriorates may require intubation

 

3.  CVS

 

Avoid hypotension

- maintain SBP > 90 mmHg

- CVP monitor

- IDC monitor urine output

 

4.  Urinary

 

Bladder usually acontractile

- initial retention

- stretching of Detrusor muscle may delay return of function

- initial IDC followed by intermittent catheterisation

- high incidence UTI & calculi 

 

5. GIT

 

Paralytic Ileus 

 

Usually occurs

- NBM 48/24

- NGT 

 

Abdominal distension splints diaphragm

- vomit & aspiration may occur

- monitor electrolytes & supplement K+

 

Constipation 

- problem after a few days

- microlax & laxatives

 

Gastric ulceration

- can be masked

- ranitidine

 

6.  Skin & Position

 

Turn every 2 hours & inspect skin

- 4 Person lifts

- Edgerton Tilt bed

- Stryker frame

 

7.  Joints & Limbs

 

Daily Passive ROM

- foot drop splints

- hand splints 

 

Spasm 

- Baclofen, Dantrolene

 

HO common

- especially with head injury

- presents as hot red swelling

 

8.  Medication

 

Anticoagulants

- high risk of DVT & PE 

- anticoagulation indicated if no contra-indications i.e. surgical stabilisation

- subcutaneous Heparin & TEDS

 

Steroids

- controversial

- main reason why spinal injuries progress is lipid peroxidation

- bolus dose of Methylprednisolone could inhibit peroxidation

 

Antibiotics

- prophylaxis not indicated

- treat infection only

 

9.  Autonomic Dysreflexia

 

Occurs > T5

- usually with cervical spine injuries

- splanchnic nerves / sympathetic exit at T8 and are interrupted

 

Distended viscus / bladder or bowel

- efferent sympathetic outflow from cord

- vasoconstriction causes HTN

- HTN stimulates carotid body

- centrally mediated vagal response

- bradycardia & vasodilation

 

Presentation

- 80% within the first year

 

Signs

- severe HTN / systolic BP > 200

- headache / facial flushing / bradycardia

 

May result in

- cerebral hemorrhage

- seizures

- pulmonary oedema

 

Managment

- decompress organ - IDC / fecal disimpaction

- sublingual nifedipine

- IV Hydralazine

 

 

Tendon Transfer

Epidemiology

 

Nearly 2/3 cervical level injury survivors have C6 root level function

- biceps and wrist extension function

 

Requirements

 

1. Transfer / Triceps

 

2. Object manipulation

- grip 

- key grip / self catheterisation 

 

Timing

 

Consider > 18/12

 

Allows

- serial evaluation

- psychological adjustment

 

Delayed if evidence of neurological recovery

 

Principles

 

1. Start on side with most function / or dominant limb

 

2. If 2 point discrimination > 10mm

- operate on only one limb, as patient uses visual cues

 

3. Keep treatment simple

 

4. Restore elbow extension first if C6

- Moberg Deltoid - Triceps

- aids transfer

 

5. Perform only one operation at time

 

6. Don't transfer spastic muscles

-  ? dynamic EMG

 

7. Remember principles of tendon transfer

 

Classification

 

Neurologic level 

- lowest level with normal motor & sensory function bilaterally

- level of bony fracture doesn't exactly correspond with level of cord injury

 

Frankel Grade

 

A Complete neurological deficit

B Sensory only below injury level

C Motor < 3 below level

D Motor < 5 below level

E Normal

 

Transfer summary

 

C5

- Moberg deltoid to triceps transfer

 

C6

- Moberg deltoid to triceps transfer

- FPL tenodesis

 

C7

- BR to EDC / EPL for finger extension

- ECRL to FDP for finger flexion

 

C8

- Zancolli FDS tendodesis to prevent intrinsic plus

 

C5 Quadriplegia

 

Intact

- deltoid / supraspinatus / biceps

 

Require

- elbow extension / Moberg deltoid to triceps

- forearm pronation / Zancolli Biceps tendon re-routing

 

A.  Deltoid to Triceps transfer  - Moberg

 

Indications

- Triceps < Grade 3

 

Benefits

- helps stabilisation in wheelchair

- helps transfers

- improves control of self-help devices

 

Procedure

- posterior 1/3 of deltoid isolated

- dissect up till see AXN entering posterior deltoid & stop

- preserve as much of its tendinous insertion

- tendon grafts obtained / EDL or T anterior

- tendon grafts interlaced between distal deltoid belly & triceps aponeurosis

 

Post op

- elbow immobilised in extension for 6/52 with GHJ adducted

- then slowly flex 10° per week

- avoid transfer for 3/12 

 

B.  Zancolli Biceps Tendon Rerouting 

 

C5 level patients lack ability to place hand in working position

 

Procedure

 

1.  Obtain passive pronation first

- removal of interosseous membrane + DRUJ

 

2. Biceps tendon exposed

- Z Plasty

- distal 1/2 rerouted around neck of radius

- sutured to at tension to obtain full pronation & yet allow extension

 

C6 Quadriplegia

 

Intact

- wrist extension - BR, ECRL, ECRB 

- pronation

 

Require

- elbow extension / Moberg biceps to triceps transfer

- stronger wrist extension / BR to ECRB

- Key pinch / BR to FPL / Moberg FPL tenodesis 

 

A.  Moberg FPL Tenodesis

 

Indication

- strong wrist extensors with no finger flexors i.e. C6 lesion

- creates key pinch

 

Mechanism

- tenodesis of FPL to provide flexion with wrist extension

 

Procedure

 

Release of A1 pulley of thumb

- permits bowstringing

- increases mechanical advantage

 

FPL tenodesis to volar radius

- exposed in forearm

- divided 6 cm proximal to wrist

- tenodesed to volar radius by passing through hole in radius & sutured to itself 

 

Dorsal tenodesis of extensor hood of thumb MCPJ 

- stops MCPJ hyperflexion

- hood sutured to dorsum of MC through drillholes

 

Fusion of IPJ of Thumb

- at zero degrees

- via longitundinal K wire

 

Post op

- thumb spica for 4/52

 

B.  BR to FPL 

 

Indications

- strong ECRL or ECRB

 

C.  BR to ECRB

 

Indications

- strong BR with weak ECRB/ ERCL

 

Advantage

- allows wrist extension for tenodesis effect of finger flexors

- gives grasp

 

C7 Quadriplegia

 

Intact

- triceps

- EDC

 

Require

- finger & thumb flexion

 

Criteria

 

Many SCI patients can be helped with hand surgery - 75%

 

Suitable criteria

- 2 point discrimination < 10mm

- plateau of neurology 12-18/12

- grade 4 MRC power of transfer (lose minimum 1 grade)

- no uncontrolled spasticity

- no excessive pain in hand

- psychologically stable

 

Zancolli 2 Stage procedure

 

Stage I / Finger & thumb extensors

- BR to EPL / EDC

- use CMCJ thumb 

- thumb MCPJ volar plate capsuloplasty / suture plate to MC neck / stop hyperextension

- transfer BR to EPL & ED via long radial incision

- immobilize for 4/42

 

Stage II / Grasp

- 6/12 later

- ECRL to FDP

 

Options to power FPL

1. TT to ECR Tertius if present

2. Side to side suture to ECRB

3. Passive tenodesis (Moberg)

 

C8 Quadriplegia

 

Intact

- FDP/FDS

 

Require

- prevent MCPJ hyperextension

 

Zancolli FDS Lasso tenodesis

 

Technique

- divide FDS slips at A2 level

- pass proximal slips under A1 

- suture slips to FDS above A1 

- effectively suture FDS to A1

 

 

 

Infection

Epidural Abscess

Definition

 

Pus collection in the epidural space

 

Epidemiology

 

Usually haemotogenous seeding

 

Very rare

- 37 / 1 000 000 patients with LBP

- 1 /10 000 admissions

- most common in old men

 

Average age 68 years

 

3/4 males

 

Rare in paediatrics

 

Mortality > 12%

 

Risk Factors

 

IV drug abuse

Remote infection / UTI

Alcoholics

Invasive spinal procedures / Epidurals

Spinal instrumentation

Immunosuppression

- DM / RA / CRF / Transplant / CA /HIV

Blunt trauma / vertebral fracture

 

Relhsaus et al Neurosurg Rev 2000

- meta-analysis of 900 cases epidural abscess

- most common risk factors DM / trauma / IVDU / alcoholism

- 5% had had an epidural

- skin infection / abscess most common cause

 

Pathology

 

Site

- thoracic spine

- cervical & lumbar spine less common

- spans average of 4 vertebrae

 

May be anterior or posterior to thecal sac

- dorsal thoracolumbar spine 

- ventral 2° vertebral OM / more common in cervical spine

 

Microbiology

- S aureus 60%

- Streptococcus 10%

- E coli 20% (IVDU, UTI)

- TB

- often unknown

 

Bacterial Route

 

1.  1/2 Haematogenous 

- remote infection

- UTI / Drug abuse 

 

2.  1/4 Direct Spread

- vertebral osteomyelitis

- abscess usually anterior

 

3.  Following Spinal instrumentation / Surgery/ Epidural injection

 

4.  Adjacent foci

 

Abscesses

- psoas / pelvic / retropharyngeal / perinephric

 

1/4 Unknown

 

Spinal Cord Injury

 

1. Direct Compression

- mass effect of pus

- ? causes early symptoms

- pus usually tracks freely in epidural space

 

2. Vascular Occlusion

- decreased arterial flow or epidural vein thrombosis

- responsible for clinical features later in course

- probably more important 

 

Stages

 

1.  Back pain and fever

2.  Radicular irritation

3.  Weakness / sensory deficit / sphincter incontinence

4.  Paralysis

 

Clinical Features

 

Classical triad of

1. Back pain & tenderness

2. Fever

3. Elevated ESR

 

Symptoms

 

Back pain is hallmark

- 95% / usually very severe / may have nerve root pain

- develops over 72-96 hours

 

Cord compression < 50%

- weak / numb / urinary Retention

 

Signs

 

Fever

- present in 2/3

- may be absent with chronic abscess or antipyretics

 

Local Signs

- tenderness

- pain on movement

 

Neurological deficit

- weakness / sensory loss / urinary retention

- may be ambulatory weak / non ambulatory paralysed

- meningitis

 

Investigations

 

ESR

- almost always elevated

- usually~ 100

 

WCC

- usually elevated 

 

Blood Culture

- often identifies organism

 

MRI

 

Investigation of choice

- T1:  Low signal intensity mass 

- T2:  High signal intensity mass

- 85% sensitivity

 

Cervical Epidural Abscess T2 MRICervical Epidural Abscess T1 MRI

 

Gadolinium enhancement T1

- peripherally or homogenous / typical of all abscess on MRI

- increases sensitivity to 95%

 

Assess levels

- multi level epidural pus 

- need multilevel laminectomy and passage of catheter to aid washout

 

Also assess

- vertebral body osteomyelitis

- cord pathology

- other DDx (HNP, tumour, cord infarct) 

 

Bone Scan

 

For non specific symptoms

- fever / malaise

- pyrexia of unknown origin (PUO)

- guides further investigation

 

DDx

 

Initial diagnosis incorrect in 80% patients

- delayed diagnosis typically

 

Mechanical LBP

Vertebral OM

Meningitis

Vertebral metastasis

HNP

Transverse Myelitis

 

Management

 

Issue

 

Mainstain of treatment is diagnosis and treatment before neurology develops

- this gives patient best prognosis

 

Delayed diagnosis most common problem

- 70% patients present with fever and back pain

 

Poor Prognosis

 

Delay in diagnosis

Neurology

Cervical / high thoracic

Diabetes

Immunocompromise

 

Non Operative Management

 

Indication

 

Poor surgical candidates

Complete paralysis > 3/7

No neurology

 

Technique

 

CT guided biopsy

- obtain cultures / guide antibiotic

- aspiration and drainage of collection

 

Antibiotics

 

Treat broad spectrum initially (flucloxacillin + gentamicin)

- 60% S aureus

- 30% Gram negative

- duration of therapy 4 - 8 weeks

 

Operative Management

 

Aims

- decompress cord

- debridement / drainage 

- MCS of organism

- stabilise spine if needed

 

Options

 

1.  Posterior laminectomy

- posterior abscess with no anterior body OM

- washout +++

- leave drain in

 

2.  Anterior vertebrectomy and stabilisation

- severe vertebral OM

 

Prognosis

 

No significant improvement despite medical advances

 

Karikari et al Neurosurgery 2009

- 104 patients treated over 10 years

- mortality 17% in non operative / 23% in operative

- 30% with dorsal abscess were quadriplegic / paraplegic

- 7% in the ventral abscess group

- 11% improvement in non operative group

- 25% improvement in operative group

 

 

Postoperative Infection

Incidence

 

Decreasing incidence in recent decades most likely attributable to preoperative antibiotics

 

Ris

 

Conventional discectomy </= 1%

Fusion 2%

Fusion & instrumentation 5-6%

 

Instrumentation doubles infection rate in lumbar fusion

 

Risk factors 

 

Diabetes 

Poor nutritional status

Rheumatoid arthritis

Steroid use 

History of previous infection

Previous wound irradiation

 

MRI

 

Cervical Post op Abscess

 

Options

 

Aggressive wound debridement of devitalised tissue with adequate drainage mandatory

- may leave open & packed

- antibiotic loaded beads 

- removal of hardware may leave spine unstable

 

Postoperative discitis

SymptomsT45 discitis

 

Period of pain relief after disc surgery

- followed by increasing back pain & occasional leg pain

 

Pain may be disproportionate to physical findings

 

Low grade fever common

 

SLR & femoral stretch tests elicit pain in some cases 

 

Bloods

 

Normal WCC common 

ESR & CRP elevated 

 

Xray / MRI

 

Discitis XrayDiscitis MRI

 

MRI with Gadolinium

 

Investigation of choice

- well vascularized inflammatory tissue enhances on T1

 

MRI Gadolinium Post Operative Discitis T1MRI Gadolinium Post Operative Discitis T2

 

Osteomyelitis changes include

- confluent hypointensity of involved bodies on T1

- hyperintensity of involved bone and disc on T2

- loss of distinction of involved bone & disc

- abnormal disc appearance

 

Management

 

Medical management

 

CT guided aspirate if culture required

- appropriate antibiotics

- brace

 

Surgical Indications

 

Failure non operative management

Epidural abscess

Deformity

 

Post Op Discitis with Deformity

 

Options

 

1.  Percutaneous Discectomy and Drainage

 

Li et al Arch Orthop Trauma Surg 2011

- 31 patients with post-operative discitis

- half had positive cultures, other half sterile

 

2.  Laminectomy and Drainage

Spinal Tuberculosis

Epidemiology

 

Most common site for skeletal TB

- usually haematogenous spread

- can be direct from lung

 

3 patterns

 

1.  Peridiscal (50%) - originating in metaphyseal region

2.  Central - high incidence of vertebral collapse

3.  Anterior - instability less common with less bony destruction

 

Pathology

 

Affects multiple contiguous vertebrae

- starts anterior 1/3 vert body

- doesn't stay within body

- spreads along fascial planes

- spreads under ALL

 

More likely to produce kyphosis

 

Disc sequestered rather than destroyed

 

Posterior elements frequently involved unlike pyogenic

 

Xray

 

Short kyphotic deformity

- known as Gibbus Deformity

 

DDx

 

May be mistaken for neoplasia

 

Similar Xray appearance 

- brucellosis, hydatid disease

- fungus (aspergillosis / Cryptococcus / candidiasis)

 

Prognosis

 

Age influences risk of paralysis

 

Cervical in patient younger than 10 years

- 17% risk of cord injury

 

Cervical in patient older than 10 years 

- up to 81% risk of paralysis

 

Management

 

Non operative

 

British Medical Research Council

- 77% settled with drug treatment alone

- no patients with neurology / paralysis

- drug treatment for 12/12

- spontaneous fusion can be expected

 

Operative

 

Indications for Surgery

 

1.  Deformity

- kyphosis

- >50% verterbral body destruction

 

2.  Neurology

 

3.  Biopsy

 

4.  Failure nonoperative treatment

 

Technique

 

Hong Kong Procedure

- debridement of infected bone

- decompression of spinal canal

- correction of kyphotic deformity using structure grafting

- instrumentation

 

Vertebral Osteomyelitis

Epidemiology

 

M:F =2:1

 

30-40 years

 

20% diabetic

 

50-80% identifiable source

 

Site

 

Lumbar (50%) > Thoracic > Cervical (<10%)

 

Pathogenesis

 

1.  Haematogenous

- arterial rather than venous

 

Risk factors

- UTI (40% of all cases)

- IVDU

- elderly

- respiratory infection

- immunocompromised

- DM

 

2.  Direct spread

- pelvis or psoas

- percutaneous or open spinal procedures

 

Organism

 

Staph aureus 60%

 

Streptococcus

 

Gm negative

- Ecoli, Proteus

- UTI / GUT procedures

 

Salmonella in sickle cell

 

Pseudomonas in IVDU

 

TB / Fungus

- in immunocompromised

- may require life long therapy

 

Patients

 

Elderly

IVDU

Immunocompromised

- steroids

- transplant

- DM, RA

 

Pathology

 

Initial focus at end plates

- septic emboli to end arterial circulation

- series of inter-metaphyseal artery allows infection of contiguous vertebrae

- spreads by direct extension to adjacent vertebrae unlike TB

 

Disc destruction

- disc is avascular 

- allows infection to spread here as well

- forms collection / abscess

 

Deformity

- due to body and disc destruction

- kyphotic

 

Neurology

- compression from epidural abscess

- infarction of regional supply to cord

- pathological fracture fragments

- kyphosis

 

Clinical Presentation

 

Back pain / tenderness + fever + elevated ESR

 

Diagnosis often delayed 4-6/12 due to vague symptoms

 

90% back pain

- insidious, non-mechanical, night pain

- localised tenderness

 

50% fever

 

< 10% neurological deficit

 

Bloods

 

ESR elevated > 90%

- most sensitive test

 

WCC elevated 35%

 

Blood culture's

- often negative

- especially if low virulence

 

Urine culture

 

Malnutrition

- albumin / lymphocyte count

 

X-ray 

 

Changes 4-6/52

 

Findings

- loss of disc height

- end plate irregularities/erosions

- vertebral destruction

- contiguous vertebrae

- collapse usually without severe kyphosis of TB

 

CT

 

Soft tissue involvement

Good for TB 

 

Cervical Osteomyelitis CT

 

Bone Scan

 

Localise area of problem if diagnostic dilemma

 

MRI 

 

Vertebral Osteomyelitis MRICervical osteomyelitis

 

Investigation of choice

- 95% accurate

- diagnose vertebral osteomyelitis

- look for epidural abscess

 

Early

- T1 loss of distinction between disc and end plate

- T2 loss of normal disc intranuclear cleft

- specific for infection

 

Gadolinium T1

- ring enhancement

 

DDx

 

Tumour 

- preservation of disc

 

TB 

- no increased T2 in disc

 

CT guided biopsy 

 

Indication

- If organism unknown

 

Technique

- aspiration if abscess

- bone biopsy otherwise

 

Results

- culture 75% of microbes prior to antibiotics

- only 25% after antibiotics given

 

Open biopsy

 

Indication

- if no CT available / unsuccessful

 

Technique

- posterior approach

- specimen obtained through pedicles 

- T-spine through costotransversectomy

 

Results

- culture aerobic / anaerobic / AFB / fungus

- diagnostic in > 80% cases

 

TB VS Pyogenic

 

Pyogenic                         TB

Single focus                      Multisegments involved

Symmetric collapse           Kyphosis

Spread bone                     Fascial planes

Disc destroyed                  Disc sequestered

Anterior column                All 3 columns (posterior inv)

Epidural abscess               Paravertebral abscess

More acute                       Insidious

 

Management

 

Non-Operative

 

Principles

 

1.  Important to delay antibiotics until cultures taken

- BC's

- urine M/C/S

- CT biopsy

 

2.  After biopsy

- most settle with antibiotics

- 6-8 weeks IV treatment (until ESR norm)

- continue orals 3-6/12

 

3.  Immobilisation important

- Bed rest

- TLSO

 

4.  Adequate nutrition important

- serum albumin

- WCC

- transferrin

 

5.  Spontaneous fusion occurs in 60%

 

Operative Management

 

Indications

 

1.  Biopsy for diagnosis and M/C/S

 

2.  Failure medical management

- systemically unwell

 

3.  Neurological deficit

 

4.  Deformity / instability

 

Anterior approach & corpectomy

 

1.  Adequate debridement crucial

 

2.  Autograft preferred

- iliac crest, fibula, rib

- can use allograft 

 

3.  Instrumentation

- anterior +/- supplemental posterior

 

Results

 

Lu et al Neurosurgery 2009

- review of 36 patients treated with corpectomy + titanium cage

- nearly all patients required anterior + posterior instrumentation

- 2 infection recurrences, 1 each with autograft and allograft

- all had neurological improvement

- 81% pain free

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

 

 

ThoracoLumbar

Approaches

Options

 

Anterior

- thoracotomy

- thoracoabdominal

- abdominal

 

Posterior

 

Anterior Approaches

 

C2 - T2

- anterior cervical approach

- may have to split manubrium / sternotomy for lowest levels

 

T3 - T7

- thoracotomy

- patient on side left side up to avoid veins

- always easier to mobilise aorta

- scapular in the way of the ribs

- release scapula and lift away from ribs

- go through bed of appropriate rib

- usually rib 2 above vertebra

- have to deflate lung with double lumen ETT

- divide segmental artery away from foramen

- identify discs (hills) and vertebral bodies (valleys)

 

T7 - T12

- thoracotomy

- patient on side

- bed of rib 2 above vertebra

- can usually push lung out of way without deflation

 

T12 - L1

- thoracoabdominal

- patient on side

- through bed of 10th rib

- diaphragm attaches at T12/L1 and 12th rib

- must take down diaphragm if need to instrument or cross T12/L1

 

L2 - L5

- anterolateral flank / retroperitoneal approach

- incision below 12th rib

- patient on side

 

L5/S1

- anterior / transabdominal approach

- pelvis blocks flank approach

 

Retroperitoneal Approach L2 - L4

 

Position

- patient left side up 45o

- surgeon stands on right

 

Technique

 

Incision

- in line with 12th rib and towards pubic symphysis

 

Approach

- split musculature / external and internal oblique / transversalis

- identify and preserve peritoneum / stay retroperitoneal

- dissection done with peanuts

- ureter and genitofemoral nerve on psoas / reflect medially

- stay anterior to psoas to preserve nerve roots

- symphathetic chain medial to psoas

- aorta and IVC on vertebral bodies

- tie off segmental arteries

- gently reflect vessels

 

Transabdominal Approach L4 - S1

 

Position

- patient supine

 

Technique

 

Paramedian incision

- stand on right / approach from left

- midway between umbilicus and symphysis

- through skin and subcutaneous fat

- divide anterior rectus sheath (external and internal oblique)

- separate left rectus muscle from posterior rectus sheath

- posterior rectus sheath is deficient by L4/5, ending in semilunar membrane

- divide posterior rectus sheath (transversalis / internal oblique), staying outside peritoneum

- divide peritoneum

- mobilise bowel

 

Aorta bifurcates at L4/5

- common iliac artery and vein on medial psoas

- identify sacral promontory between

- divide posterior peritoneum in midline distal to bifurcation

- superior hypogastric plexus on common iliac vein / sympathetic

- injury causes retrograde ejaculation

 

L4/5

- reflect artery and vein medially

- have to divide and ligate iliolumbar vein

 

L5/S1

 

Access between common iliac vessels

- must divide median sacral vein

 

 

 

Crush Fractures

Definition

 

Minimal trauma fracture

- secondary to osteoporosis

- wedge fractures

 

Epidemiology

 

F > M

More common in elderly patients

 

Uncommon in men < 75

- look for alternative diagnosis

 

DDx

 

Renal failure

Malignancy - metastasis

Infection

 

Clinically

 

Can present with pain

Can be asymptomatic

 

Issues

 

1.  Pain

 

2.  Deformity / kyphosis

 

Management

 

Non operative Management

 

Algorithm

 

1.  Exclude other diagnosis

- metastasis

- primary malignancy

- infection

- CRF

 

2.  Pain relief

- analgesics as required

 

3.  Manage osteoporosis

- DEXA scan

- bisphosphonates

- vitamin D + calcium

 

4.  Bracing

- indicated if kyphotic deformity > 20o

 

5.  Early mobilisation

 

Operative Management

 

Options

 

Vertebroplasty

Kyphoplasty

Fusion

 

Vertebroplasty

 

Indications

 

Pain

- non responsive to non operative treatment

 

Technique

 

Percutaneous

- trochar into pedicle under fluoroscopy

- injection PMMA

 

KyphoplastyKyphoplasty Lateral

 

Results

 

Klazen et al Lancet 2010

- RCT of vertebroplasty v non operative treatment

- 431 patients over 50, all T5 or lower

- no complications

- immediate pain relief which was maintained at 1 year follow up

 

Kyphoplasty

 

Indication

- pain relief

- restoration of deformity

 

Technique

 

Kyphoplasty InsertionKyphoplasty Insertion LateralKyphoplasty Balloons APKyphoplasty Balloons Lateral

 

Insert a balloon first and inflate

- bilaterally into each pedicle

- will restore some anatomy

- then inject PMMA

 

Kyphoplasty cement APKyphoplasty cement Lateral

 

Results

 

Liu et al Osteoporosis Int 2010

- RCT of vertebroplasty v kyphoplasty

- improved vertebral height with increased injected PMMA in kyphoplasty

- no difference in outcome regards to pain relief

- 2/50 adjacent segment fractures in kyphoplasty group

- recommended vertebroplasty

 

Fusion

 

Crush Fracture CompressionCrush Fracture Fusion 2

 

Degenerative Scoliosis

Definition

Lumbar Degenerative Scoliosis

 

Lateral deviation of the spine that develops after the age of 50

- minimal structural vertebral deformity

 

Lower lumbar

- convex left

 

Aetiology

 

Unknown

- only very weak links to osteoporosis and degenerative disc disease

 

NHx

 

Progression

- larger curves > 30o

- increased rotation

- lateral lithesis > 6mm

- inter-crest line through or below L4/5 space

 

Larger curves more likely to have pain

 

Symptoms

 

LBP

 

Neurogenic claudication

 

Radiculopathy

- nerve roots compressed in concavity

 

X-ray

 

Degenerative Scoliosis APDegenerative Scoliosis Lateral

 

MRI

 

Myelopathy

 

Decreased height of nerve foramina

 

Degenerative Scoliosis MRI

 

Management

 

Non Operative

 

Epidural Steroids

 

Operative 

 

Technique

 

Multilevel decompression and posterior instrumented fusion

- laminectomy / foraminotomy

- +/- interbody cages to increase foraminal size

 

Deformity correction rare

 

Fusion Degenerative Scoliosis

 

 

 

Lumbar Discectomy Techniques

Disectomy Technique for Posterolateral L4/5 disc 

 

Anatomy

 

L4/5 disc at level of facet joints

 

Interlaminar space is below disc

- have to take inferior aspect of superior lamina

 

Pedicle and transverse process at same level

 

Disc usually on one side

- hemilaminotomy

- no need to remove spinous process

- this preserves stability

 

Position

 

4 poster support

- abdomen free (decrease venous drainage) / Jackson Table

- knees below hips

- pillows under legs and feet

- pressure care knees

- arms forward on supports

- back level & slightly head down

- protect eyes / CPN at knees / ulna nerve at elbows

 

Pre-Operative antibiotics

 

Often dressing + betadine in natal cleft

 

Levels

 

Careful correlation of clinical and MRI

- level of disc

- side of disc

 

Iliac Crests L4/5

- mark

- prep with antimicrobial solution

- insert 18G needle into L4/5 interspinous space

- obtain cross table xray to confirm level

- this centres incision

 

Incision

 

Square drape

LA with adrenalin

Incise skin L4 spinous process to S1 spinous process

 

Superficial Dissection

 

Divide thoracolumbar fascia

- in midline down to spinous processes

- subperiosteal dissection down side of spinous process

- with cobb / diathermy

- preserve suprasinous ligament

 

Subperiosteal dissection to lamina on lesion side

- expose but don't disturb facet joint capsule

- self retractor inserted

- don't go between transverse processes

 

Lamina spreader between spinous processes

- under supraspinous ligament

- opens up interlaminar space

 

Recheck level at L4/5 interspinous

 

Disc Localisation

 

5 ways to identify L5/S1

 

Sacrum

- hollow sound 

- non mobile

- midline crest with no ligamentum flavum / interlaminar space

- anterior slope L5 lamina

- large L5 S1 interlaminar space

 

Lumbosacral Junction

 

Deep Dissection

 

Expose Ligament Flavum 

- attaches on top of inferior lamina to superior lamina

- find midline raphae

- incise flavum with scalpel over inferior laminae

- create flap of flavum

- use Watson Cheyne Dissector to gently dissect off dural adhesions

- remove flavum laterally 

- 1, 2 or 3 mm 40° Kerrison Rongeur

- see fat overlying blue dura

 

Remove inferior aspect of superior lamina

- will take up to L4/5 disc 

- resect medial two thirds of superior facet /  lower one third inferior facet

 

Lumbar Spine PosteriorLumbar Spine HemilaminotomyLumbar Intervertebral Foramen

 

Exiting L4 nerve root

- above L5 pedicle

 

L5 nerve root

- below L5 pedicle

- remove inferior lamina and pars

 

Discectomy

 

Retract dura gently

- dural retactor

- remove sequestered disc with pituitary rongeur

- cruciate incision in PLL to remove protruding / extruding disc

 

L5 nerve root

- exit under pedicle L5 inferiorly

- medial facetectomy

- follow root out laterally around pedicle

- ensure free passage through foramina 

- should be able to pass Watson Cheyne easily

 

L4 nerve root

- L3/4 interlaminar space

- remove inferior lamina and pars

- will pass under pedicle of L4 inferiorly

- medial facetectomy of L3/4 facet joint

- access L4 pass under pedicle of L4 superiorly

 

Wiltse Approach to Extra-Foraminal Disc

 

Incision

 

Paramedian incision

- 2 fingerbreadths / 5cm lateral to midline

 

Superficial Dissection

 

Muscles split to intertransverse ligament

- between Longissimus & Multifidus

- always a bleeder on the way down

- clear transverse processes

- preserve posterior ramus by hooking finger around & then follow ramus to nerve

 

Deep Dissection 

 

Removed intertransverse ligaments and fascia between TP

- nerve root anterior to fascia and just below TP

- runs at a 45o angle

- follow nerve medially and identify disc

- retract nerve laterally & remove disk

- may have to incise annulus to remove bulge

- if intra-foraminal element, remove lateral facet

 

Post operatively

 

Symptoms should be immediately relieved

 

Analgesia

Watch retention

No anticoagulation

Mobilize ASAP

No heavy lifting 6/52

 

 

Lumbar Fusion Techniques

PLIF / Posterior Lumbar Interbody Fusion

 

PLIF APPLIF Lateral

 

Technique

 

1.  Wide laminotomy 

- resection flavum, significant cranial lamina

- preserve if possible the posterior elements

- spinous processes, supra and interspinous ligaments

- these provide tension stability

- resect medial two thirds of superior facet /  lower one third inferior facet

 

2.  Resect disc

- retract dura and traversing nerve root medially

- distract disc space with lamina spreader

- disc space retractors (insert wedge, then turn on side) 

- remove end plates

 

3.  Insert interbody device 

- carbon or titanium cages

- wedge shaped

- allows correction of sagittal deformity

- allows restoration of disc height

- immediate stability

- facilitates fusion

- usually contain morcellised allograft / BMP

- check under II that interbody device not too posterior

 

4.  Stabilise with pedicle screws

 

Complications

- dural tears

- nerve palsy

- hard ware failure

- psedoarthrosis

 

ALIF / Anterior Lumbar Interbody Fusion

 

Surgical Technique L2 - L5

 

Patient supine, stand on right

- find level with II

- make incision through skin and subcutaneous fat

- divide external and intenal obliques and transversus

- mobilise peritoneum around, until see psoas

 

All dissection with swabs on sticks or peanuts

- ureter lifted up with peritoneum

- diva retractors for bowel, as per general surgery

- self retainers attached to side of bed

 

Common iliac artery and vein on medial psoas

- mobilise vessels medially, psoas laterally

- will see large sympathetic trunk, mobilise either way (don't damage to avoid retrograde ejaculation)

- may need to divide iliolumbar vein

 

Identify disc

- check level again with needle

 

Steinman type pins in vertebral body to keep back bowel

 

Divide ALL (can keep as layer, especially in Disc replacement)

- remove entire disc

- knife, rongeurs, normal and ring curettes 

 

Distract disc space

- special lamina spreaders

- disc distractors (wedges inserted then turn on side i.e. 10 - 14 mm)

- pins in bodies above and below and add distracting device as per cervical fusion

 

Remove end plate to bleeding bone

 

Interbody cage

- trial for height, depth and angle

- i.e. 6o 10 mm

- check II to make sure not too far back

- insert real prosthesis

- augment with plate

 

Surgical Technique L5/S1 Fusion

 

Access between vessels

- much easier than going to the lateral side of one and mobilising it medially

- identify sacral promontory, big angle as sacrum dives away

- use pins and retractors as before

 

Resect disc and minimal end plate

- just to bleeding bone for fusion

- not too much so bone is soft and cage or disc subsides

 

Trial for height & angle, II for depth

- insert cage

- these made of plastic with same modulus as bone

- doesn't compress but at same time doesn't subside into bone

- cage is radiolucent except for small opacities to see on x-ray

- cage has cental hole

- fill with synthetic bone graft, mixed with patient's blood and rolled as sushi in BMP membrane

- insert cage, can put more synthetic BG/BMP around it

- check II, ensure not too posterior

- application of anterior plate and screws

 

Pedicle Screws

 

Concepts

 

Advantage

- superior to sublaminar wires or hooks

- purchase in all 3 columns

- cross-linkage and converging screws enhances pullout strength

 

Considerations

- essential to have fit & fill of pedicle

- bone mineral density of vital importance with pedicle screws

- minor osteoporosis OK

- marked osteoporosis hooks as good as screws

- bicortical fixation improves strength but only safe in S1

- pedicle screws not safe in S2 at all

- if fracture pedicle greatly reduces strength of construct

 

Objective

 

To place screw through centre of pedicles 

- parallel to upper end plate or slightly angled downward

- screws also converge towards midline

- up to 20% depending on spinal level

- this is to ensure do not penetrate lateral wall of vertebral body

 

Radiation

- II facilitates insertion

- can use computer navigation

 

Entry Points

 

1.  Thoracic spine

- entry just below rim of upper facet near base of TP

- angle 7-10o towards midline & 10-20o caudally

 

2.  Lumbar Spine

- entry at junction TP & superior facet

- angle: screws converge 5o at TLJ and increase 10-15o as one progresses from L2-L5

 

3.  Sacrum

- S1 only safe level

- line tangential to lateral border superior articular facet &

- line along inferior border of superior articular facet

- angle: screws converge towards midline / aim at anterior corner of promontorium

 

Technique

 

Osteotome away facet joint

- reveal cancellous bone

- entry with curved awl

- ball tip guide, bone on all 4 sides, check II

- pass tap

- insert screw (6.5, 5.5, 4.5, 30 - 40 mm long)

- usually poly-axial heads

 

Complications

 

Union rate >90%

 

Screw misplacement 4%

 

Nerve and spinal injury 1-20%

- most misplaced screws don't cause neural injury

- higher risks with power over hand preparation

 

Infection 1.1-4.2%

- usually can leave metal in situ with early washout & debridement

 

Screw breakage 2-60%

 

 

 

 

Lumbar Herniated Discs

Epidemiology

 

Sciatica > 2/52 1.6%

 

M:F = 1:1

 

Most common L4/5 

L5/S1 inherently stable 

 

Risk factors

 

Sedentary lifestyle

Smokers

Frequent driving

Heavy lifting 

 

Anatomy

 

Annulus Fibrosis

- circumferential, multilayered rim

- type 1 collagen fibres at 30o to horizontal

- peripheral nerve endings

- high resistance to torsional and axial loads

 

Nucleus pulposis

- hydrophilic PG + 70% water

- type 2 collagen

- resist axial compression

 

Avascular

- nutrients diffuse from the end plate

 

Wiltse Classification

 

1.  Bulge 

- annulus diffusely extends beyond the plane of the disc space

- annulus intact / nil focal protrusion

 

2.  Protrusion

- focal bulging within margin of annulus

- diameter of base is greater than diameter of tissue displaced beyond disc space

 

Lumbar Disc Protrusion

 

3.  Extrusion

- under PLL

- mass of discal tissue of greater diameter than the aperature through which it has passed

 

Lumbar Disc ExtrusionL5 S1 Extruded Disc

 

4.  Sequestration

- free disc in canal

- fragment with no continuity with tissue in disc of origin

 

Sequestered Disc MRI 3Sequestered Disc MRI 2Sequestered Disc MRI 4Sequestered Disc MRI 1

 

Anatomical Classification

 

1. Central

 

Lumbar Central Disc Herniation MRICentral Lumbar Disc Herniation

 

2. Lateral Recess / Posterolateral

- between dura and foramina

- anterior: disc (annulus) and vertebral body

- posterior: facet joint, lamina, ligamentum flava

- lateral: foramen, L5 pedicle

 

Herniated disc lateral Recess S1 nerve root compressionL45 Posterolateral Disc

 

3. Foraminal

- anterior: body of L5, L5/S1 disc

- posterior: pars, apex of superior facet of S1

 

Foraminal Disc MRIForaminal Disc 2 MRI

 

4. Extra- Foraminal / Far Lateral

 

Pathophysiology Nerve Root

 

Compression

 

Poorly resistant to compression

- dural sheath instead of perineurium

- tethered between dura and foramen

- compression impairs blood flow to nerve

 

Problem

- asymptomatic nerve compressions

- studies suggest that normal nerve roots do not generate pain when compressed

 

Biochemical

 

Chemical factors

- make nerve root more susceptible to effects of compression

 

Anatomy

 

L4/5

- traversing nerve root is L5

- exiting nerve root is L4

 

Posterolateral disc

- compresses traversing nerve i.e. L4/5 disc hits L5 nerve root

- this is most common situation

 

Foraminal disc

- compresses exiting nerve root i.e. L4/5 disc hits L4 nerve root

- require partial medial facetectomy / stand on opposite side of table

 

Far Lateral / Extra-foraminal disc

- compresses nerve root already exited i.e. L4/5 disk hits L4 nerve root

- Wiltse approach or complete facetectomy / follow nerve out

 

Symptoms

 

Typical patient 20-45 year old male

 

Pain

- leg in dermatomal distribution

 

Neurology

- numbness / parasthesia / weakness

 

Cauda Equina Syndrome

- saddle anaesthesia / urinary incontinence / weak EHL

 

Signs

 

Tension signs

 

1.  SLR / Straight leg raise / Lasegue's Sign

- elevate leg from hip with knee straight

- reproduce pain below knee

- L5 / S1 nerve roots

 

Deville et al Spine 2000

- meta-analysis

- SLR very sensitive 90% but lower specificity 26%

- crossed SLR low sensitivity 29% but more specific 88%

 

2.  Femoral nerve stretch test

- patient prone, knee flexed, extend hip

- reproduces pain

- L4 nerve root

 

Neurology

  Pain Sensation Weakness Reflex Test
L2 Lateral thigh Lateral thigh HF    
L3 Medial knee Medial knee Quads    
L4 Anteromedial knee Medial Malleolus T Ant Knee Jerk Femoral Stretch
L5 Dorsum foot First webspace EHL   SLR
S1 Sole / lateral foot Sole / lateral foot FHL Ankle Jerk SLR

DDx L4 nerve root

- CPN / DPN palsy

- test peroneals, tibialis posterior

 

DDx L5 nerve root

- CPN / DPN / Sciatic palsy

- test peroneals / abductors

 

DDx S1 nerve root

- tibial nerve

- test tibialis posterior

 

MRI

 

T2 Sagittal - myelogram

 

Lumbar MRI T1 Herniated DiscHerniated disc lateral Recess S1 nerve root compressionCauda Equina MRI

 

T1 Axial - see nerve root against white fat

 

Lumbar HNP T1 Axial

 

DDx

 

Infection / Tumour / Fracture

 

Management

 

Non-operative Management

 

NHx

 

Recovery  

- 80% improve after 6/52

- 90% improve after 3/12

- 95% improve after 6/12

 

Weakness just as likely to resolve as pain

 

Results Operative v Nonoperative

 

Peul et al BMJ 2008

- RCT of conservative treatment v microdiscectomy

- symptoms 6 - 12 weeks

- earlier symptomatic relief in surgical group

- no difference at one or two years

 

Options

 

Medications

- NSAIDs / opiates / steroids / tricyclic antidepressants

 

Physiotherapy / lumbar stabilisation exercises

 

Traction

 

Chiropractic manipulation

 

Epidural steroids

 

Price Health Technol Assess 2005

- multicentred RCT placebo control

- 220 patients with unilateral sciatica

- minimal and transient value over placebo at 3 weeks

- no difference after 6 weeks

- not cost effective / drain on resources

 

Arden et al Rheumatology 2005

- WEST study

- exactly the same findings

 

Transforaminal CS / Nerve Root Injections

 

Nerve Root Injection

 

Riew et al JBJS Am 2000

- RCT of patients with unilateral nerve root compression

- all considered suitable for operative intervention

- effectively prevented need for surgery in more than half of the patients

- LA + steroid more effective than LA alone

 

Operative Management

 

Absolute Indications

 

Cauda Equina Syndrome

 

Relative Indications

 

Failure of non operative treatment

Severe debilitating anatomical leg pain

Progression neurological deficit

 

Prediction of good operative outcome

 

6/6 Nachemson

 

1. Leg > back pain

2. Symptoms consistent with root irritation

3. Signs consistent with root irritation

4. Tension signs / positive SLR

5. Imaging consistent with Symptoms & Signs

6. Pain > 6 weeks

 

Options

 

Chemonucleolysis

Standard Discectomy

- open

- microdiscecotmy

Percutaneous / Endoscopic Discectomy

 

Chemonucleolysis

 

Mechanism

- chymopapain dissolves nucleosus pulposis

- older technique largely out of favour

 

Results

 

Muralikuttan et al Spine 1992

- RCT of discectomy v chemonucleolysis

- inferior short term results with chemonucleolysis

- no difference at one year

 

Discectomy

 

Advantage

- suitable for noncontained disc

 

Results

 

Dewing et al Spine 2007

- prospective followup of 183 single level lumbar discectomies

- average age 27

- 85% satisfied with surgery

- recurrent disc herniation in 3%

- better outcomes in L4/5 than L5/S1

- better outcomes in sequestered / extruded discs than contained discs

- poorer outcomes in smokers and patients with predominance of back pain

 

Righesso et al Neurosurgery 2007

- RCT of open v microdiscectomy

- no difference in outcome

- longer scar and inpatient stay in open group

- longer surgical times in microdiscectomy

 

Percutaneous Discectomy

 

Indications

- contained disc

 

Technique

- image guidance / endoscopic techniques

- interlaminar or transforaminal

- discectomy with cutting / suction probe

 

Advantage

- minimal scar

- rapid recovery

 

Results

 

Ruetten et al Spine 2008

- RCT of endoscopic interlaminar and transforaminal v microdiscectomy

- 82% relief of leg pain, no difference in each group

- 6% recurrence, no difference in each group

- reduced back pain and complications with improved rehab in endoscopic group

 

Complications Discectomy

 

Wrong level surgery

 

Neural injury

- paraplegia 1: 25 000

- nerve root injury

- cauda equina 0.2%

 

Dural tears

 

A.  Intraoperative Management

- head down

- stop ventilating / hand ventilate / anaesthetic valsalva

- ensure free abdomen

- CSF can make nerve root in danger / protect with patty

- attempt primary repair with 6.0 prolene non cutting needle

- supplement with Tisseel glue

- +/- fat graft / thoracolumbar graft

- subfascial drain

- bed rest 2 days

 

B.  Postoperative CSF leak

- ensure no meningitis symptoms

- glucose / microscopy test to confirm

- adequate fluids / head down / quiet room / bed rest

- antibiotics controversial

- MRI: small leak or large leak

 

Non operative Management

- insert drain below conus

- decreases CSF pressure

- bed rest / leave drain for 5 - 7 days

 

Operative Management

- failure nonoperative / large leak

- thoracolumbar fascia / synthetic graft repair

 

Incomplete decompression / failure to relieve symptoms

 

Infection 2%

 

Thromboembolism 1%

 

Arachnoiditis / Intradural fibrosis

 

Incidence 5%

 

MRI changes

1.  Central root clumping

2.  Empty sac appearance

3.  Soft tissue mass in subarachnoid space

 

HNP recurrence

 

Incidence

- life long 6 - 7%

- second time 50%

- third time 90%

 

Investigation

- gadolinium MRI

- scar enhances but recurrent HNP does not

 

Management

- disc resection +/- fusion

Lumbar Spine Degeneration

DefinitionLumbar Disc Degeneration Xray

 

Lumbar spondylosis

- disc degeneration causing arthritis / lower back pain

 

Discogenic lower back pain

 

Anatomy

 

Annulus fibrosis

- outer aspect of disc

- type I collagen

- fibres continuous with endplate & ALL/PLL

- provides tensile strength to contain NP

 

Nucleus Pulposus

- water + type II collagen + PG

- semifluid gel

- turns solid as ages and becomes brown

- Keratan : Chondroitin ratio increases as age

 

Epidemiology

 

100% at autopsy > 90 years

- males > females and earlier

 

Aetiology

 

Unknown in 90%

 

Associations

- heavy labour

- obese & tall

- driving / vibration

- smoking

- previous back injury

 

Pathogenesis

 

1.  Dysfunction (15 - 45 years)

 

Disc degenerates with age / dessication

- concentration of PG declines

- decrease number of chondrocytes

- decrease water content

- collagen fibres thicker in cross section

 

Lose ability to resist torsional loads

- circumferential & radial tears in disc

- localised synovitis of facets

 

2.  Instability (35 - 70 years)

- disc herniation

- resorption of disc

- degeneration of facet joint with capsular laxity / subluxation & erosion / osteophytes

 

3.  Stabilisation (>60 years)

- ankylosis of discs & facets

 

Symptoms

 

Lower back pain

- usually worse with activity

- especially bending & lifting

 

Maybe referred to 

- buttocks / posterior thigh / groin

 

Signs

 

General

- loss of lordosis

- decreased ROM, especially flexion

 

X-ray

 

Unexpected finding in 1:2500

- infection, fracture, tumour

 

Disc degeneration

- disc space narrowing

- vertebral sclerosis

- osteophytes

 

MRI 

 

Disc

 

Spine MRI Normal and Degenerative Discs

 

Normal disc / bright T2 signal

Degenerative disc / dark T2  

 

Very sensitive

- 30% of asymptomatic patients < 60 years have abnormality

- 60% > 60 years have abnormality

 

Modic End Plate Changes

 

Lumbar Disc Degeneration Modic Changes

 

Classification of bone marrow changes in bone marrow adjacent to vertebral end plates

 

Type 1:  High on T2 / Low on T1

Type 2:  High on T2 / High on T1 (lipid changes)

Type 3:  Low on T2 and T1 (sclerotic)

 

Discography

 

Aim

- confirm isolated disc degeneration responsible for pain

- must check disc below and disc above

 

Technique

- inject contrast under pressure / LA and II guidance

- look for dye leak

- look for reproduction of symptoms

 

Alternative / Discoblock

- inject LA

- positive test if relieves pain

 

Results

 

Ohtori et al Spine 2009

- only operative on patients with positive discogram or discoblock

- 15 patients in each group

- treated with anterior discectomy and interbody fusion

- significantly improved results in discoblock group

 

Natural History

 

90% lower back pain resolves < 2/12

- 10% chronic

- prognosis poor if pain > 6/12

 

DDx

 

Traumatic

- crush fracture / isthmic spondylolisthesis

 

Infective

- vertebral osteomyelitis / discitis / epidural abscess

 

Tumour

- Benign (Haemangioma / OO / OB / EG / Giant Cell / ABC)

- Malignant (Chordoma / Myeloma / Metastasis)

 

Inflammatory

- AS / Reiter's / Psoriatic arthritis / Enteropathic disease

 

Neurogenic

- primary pathology of nerve roots (Neurilemmoma, neurofibromata, ependymoma)

 

Viscera / Vascular

- Pelvic viscera / retroperitoneal cancer

- AAA / Superior gluteal artery claudication / Claudication 2° PVD 

 

Management

 

Non-operative Management

 

Acute LBP

 

Initial

- rest 2 days

- local measures - massage / local NSAIDs

- pain relief - acetominophen / NSAIDS

 

Once pain settles

- exercise

- general fitness important

- core strengthening

- brace no benefit

 

Chronic LBP

 

Back School / Structured rehab programme / Lifestyle modification

Relaxation \ Exercise

Avoid narcotics

 

Epidural Steroids

 

Indication

- lumbar pain without HNP / radiculopathy

 

Manchikanti et al Pain Physician 2010

- HCLA epidural injections

- 86% significant pain relief at 12 months

 

Operative Management

 

Indications

 

Unremitting pain & disability > 1 year

MRI single level disc degeneration

 

Isolated L5 S1 Disc Degeneration

 

Options

 

1.  PLF / Posterolateral Fusion +/- instrumentation

 

2.  Instrumented PLIF / Posterolateral Interbody Fusion

 

3.  ALIF / Anterior Lumbar Interbody Fusion

 

4.  Disc Replacement

 

PFL

 

Concept

- decortication of pedicles / lamina / transverse process

- bone graft applied

- instrumentation added to improve fusion rate

 

Advantage

- high fusion rate

- no risk of interbody graft / cage migration

- low risk neural injury

 

Results

 

Fritzell et al Spine 2001

- RCT of surgical treatment v non surgical with 2 year follow up

- back pain reduced 33% to 7%

- return to work 36% v 13%

 

Fritzell et al Spine 2002

- RCT of PLF v instrumented PLF v PLIF

- no significant difference in reduction in pain and disability

- complications 6% v 16% v 30%

- fusion rate 72% v 87% v 91%

 

Instrumented PLIF

 

PLIF L5 S1 LateralPLIF L5 S1 AP

 

Principles

- wide post decompression and removal of entire disc

- graft / fusion cage placed between vertebral bodies

- 360o fusion (PLF + interbody)

 

Advantages over PLF

- excise disc & decompress nerve roots

- disc height restored with graft decompressing foramina vertically

- fusion of anterior column / increased fusion surface / site of arthrodesis compressed

 

Disadvantages

- wide post decompression needed / newer minimally invasive techniques

- risk of canal compromise by graft

 

Results

 

Leufven et al Spine

- 29 patients treated with PLIF

- fusion in 27/29

- excellent results in 31% and good in 21%

- fair in 21% and poor in 27%

 

ALIF

 

Concept

- anterior approach + complete discectomy and graft

 

Results

 

Penta et al Spine

- 108 patients with ALIF at 10 years

- only 34% good or excellent

- not related to fusion rates

- psychological rating intially and at review correlated with outcome

 

Disc Replacement

 

Concept

- maintain small degree of motion

- prevents adjacent level degeneration

 

Results

 

Herkowitz et al JBJS Am 2006

- RCT of disc replacement v ALIF

- 304 patients with single level disease L5S1 or L45

- 2 year follow up

- clinical success 64% in disc replacement v 56% ALIF
- better ROM and restoration disc height in disc replacement

 

Harrop et al Spine 2008

- systemic review looking at adjacent level degeneration in lumbar fusion v disc

- radiographic degeneration 34% in fusion v 9% in disc replacement

- symptomatic degeneration 14% in fusion v 1% in disc replacement

 

Complications

 

Mortality 0.2%  

Infection 1.5%

DVT 4%

PE 2%

Neural injury 3%

Instrument failure 7%

Failed back surgery syndrome

Lumbar Stenosis

DefinitionLumbar Stenosis

 

Reduction of space available for neural elements in spinal canal or intervertebral foramina

- due to degenerative changes, congenital abnormalities or both

- involves compression of the thecal sac or nerve roots

 

Epidemiology

 

Onset 50 - 60's

- M = F

- associated with onset OA spine

 

L3/4 & L4/5 most common

 

Aetiological Classification

 

1. Congenital

 

Achondroplastic

- short thick pedicles and narrowed interpedicular distance

 

SED

 

Idiopathic ~ Polynesians

- trefoil-shaped canal

 

Congenital narrow spinal canal

- most syptomatic patients have canals at lower end of spectrum

 

Prematurity

- narrow L3

 

Ostepetrosis

 

2. Acquired

 

Degenerative

- most common aetiology

- disc desiccation / loss of height / bulging of annulus

- facet subluxation / capsular hypertrophy / osteophytes

- overall shortening of lumbar spine / decreased volume

- ligamentum flavum hypertrophy

 

Spondylolisthesis

 

Kyphosis

 

Iatrogenic

- post-laminectomy

- post-fusion

 

Miscellaneous

- Paget's disease

- Fluorosis

- DISH

- Ankylsing spondylitis

- Tumour

- Infection - TB

 

Traumatic / Post fracture

 

Anatomical Classification

 

1.  Central Canal Stenosis

 

2.  Lateral Recess Stenosis

 

3.  Foraminal

 

Anatomy

 

1.  Central canal

 

Posterior wall - ligamentum flavum & laminae

Lateral wall - medial facet joints & intervertebral foramina

Anterior wall - annulus fibrosis & posterior vertebral body

 

2.  Lateral recess

 

Extends from where nerve root leaves dural sac to where nerve root enters foramen

 

Posterior wall - ligamentum flavum & superior part of lamina

Anterior wall - posterior vertebral body & annulus fibrosis

Lateral wall - medial & inferior pedicle

 

3.  Intervertebral foramen

 

Extends from inner to outer foramen

 

Superior wall - inferior part of pedicle above

Inferior wall - superior part of pedicle below

Anterior wall - above is body, below is disc

Posterior wall - pars interarticularis, ligamentum flavum & apex of superior facet of vertebrae below

 

Pathology

 

Stenosis typically at disc level either due to disc or facets

 

1.  Central Canal

- bulging of annulus posterior

- facet osteophytes posterolateral

- hypertrophied ligamentum flavum posterolateral

 

Lumbar MRI Stenosis Trefoil Canal

 

2.  Lateral Recess

- facet subluxation & osteophytes + hypertrophied ligamentum flavum

 

3.  Intervertebral Foramen

- loss of disc height with approximation of pedicles

- inferior annular bulge

- medial facet hypertrophy

 

Effects

 

Mechanical

- increased canal narrowing with extension

- also get posterior disc protrusion and redundancy of ligamentum flavum

- root lacks perineurium & hence more susceptible to compression

 

Ischaemia

- interference with metabolic demands of nerve root

- exercise increased nutritional requirements & waste production

- canal constriction limits response = relative ischaemia

 

Symptoms

 

Back Pain

 

Sciatica

- L5 most common, then S1

 

Neuropathic claudication

- insidious onset

- usually bilateral

- diffuse / no dermatomal pattern

- buttocks / thighs / calves

- heaviness / weakness / burning / cramping / tingling / numbness

 

Worse with walking, standing & lumbar extension

 

Relieved by sitting, flexion, walking upstairs, squatting

 

Signs

 

Often none, but can overlap with HNP

 

DDx

 

Vascular claudication

- calf pain with exercise

- rapid relief with cessation walking

- no back pain / no numbness

- abnormal pulses

 

Hip Disease

Diabetic neuropathy

Retroperitoneal pathology

 

X-ray

 

Rule out 

- infection / tumour / fracture

 

Confirm degenerative changes

- facet hypertrophy / disc narrowing

- decreased AP diameter of canal

- identify associated pathology i.e. spondylolisthesis / scoliosis

 

MRI

 

T2 Sagittal "MRI Myelogram"

 

Lumbar MRI Stenosis Sagittal T2Lumbar Stenosis MRI SagittalLumbar Stenosis MRI

 

Stenotic Measurement

 

A.  Volume

- more accurate

- critical area is 100 mm2

 

B.  AP diameter less accurate

- normal if > 12mm

- absolute stenosis if < 10mm

 

Intervertebral foramina

- no fat about nerve root

- reduced height

 

Lumbar Foraminal Stenosis L45 MRILumbar MRI Tight Intervertebral Foramina L3

 

B.  Axial slices

 

Findings

- no fat about dura

- trefoil shape canal

- lateral recess or foramina compression

- nerve root compression

 

Lumbar MRI Stenosis Trefoil CanalLumbar stenosis axial MRILumbar MRI Axial Stenosis

 

NHx

 

Not clear not all patients progress

 

Johnsson 1993 Clin Orthop

- 32 patients followed 4 years

- 70% unchanged

- remainder: half worse, half better

 

Management

 

Non-Operative Management

 

Options

 

Rest / Avoid aggravating activities

 

Analgesics

- simple analgesia

- short course NSAIDS

 

Back support

- prevent extension

 

Physio

- back strength in flexion

- stabilise abdominal muscles

- aerobic fitness on exercise bike 

 

Epidural steroids

 

Koc et al Spine 2009

- RCT of exercise v epidural steroids v control in spinal stenosis

- exercise and epidural steroids both efficious up to 6 months

 

Calcitonin

 

Podichetty et al Spine 2004

- RCT of calcitonin v placebo

- no difference in two treatment groups

 

Operative Management

 

Indications

 

Absolute 

 

Cauda equina syndrome

 

Relative

 

Failure to respond to non operative treatment

Disabling neurogenic claudication

Progressive neurological deficit

 

Back pain is not an indication

 

Options

 

Decompression +/- fusion

 

Interspinous devices

- limit extension

 

Indications for fusion

 

1.  Degenerative Spondylolisthesis

 

2.  Radiological instability

- > 3mm or > 11o

 

3.  Intra-operative destabilisation

- removal of > 1 facet joint or pars

- i.e. radical decompression required laterally

 

4.  Degenerative scoliosis

 

5.  Significant low back pain / disc degeneration

 

Decompression

 

Define site of compression

- central / lateral recess / foramina

 

Define levels

- single / multilevel

 

Fusion

- must be prepared to fuse if cause instability

- consent

 

Results

 

Operative v Non Operative

 

Weinstein et al Spine 2010

- SPORT trial

- RCT of operative v non operative treatment lumbar stenosis

- 289 patients with 4 year follow up

- substantially improved pain and function in operative group

 

Interspinous Devices

 

Hsu et al J Neurosurg Spine 2006

- RCT of non operative v X Stop interspinous device

- significant improvement in QOL, with results similar to surgical decompression

 

Decompression v Fusion

 

Niggemeyer et al Eur Spine J 1997

- meta-analysis

- if symptoms < 8 years, decompression without fusion yields best results

- if symptoms 15 years or more, decompression with instrumented fusion best results

- decompression and fusion without instrumentation had worst results

 

Complications

 

Epidural haematoma

Instability

Infection

Nerve root injury

Dural Tears

 

Technique L4/5 Decompression

 

Position

- abdomen free to limit venous pressure and bleeding

- 4 poster / knee below hips / arms on bolster

- feet / knees / elbows / face / eyes cushioned

- SCUDS, TEDS

- betadine packs in buttocks

- +/- Jackson table (enables more lordotic position if instrumentation planned)

 

Landmarks / Check level

- iliac crest L4/5 interspinous space

- prep area aseptically, spinal needle

- check with lateral x-ray

- square drape

 

Incision

- inject LA with A

- midline

- meticulous haemostasis

- divide thoracolumbar fascia

 

Superficial Dissection

- subperiosteal elevate of supraspinous muscles (Cobb's and diathermy)

- sequentially pack with rolled swabs / sausages to control bleeding

- out to lateral extent of pars

- expose facet joints, but preserve capsule if not fusing

- beware parafacetal arteries

- don't extend between transverse processes as nerve root at risk

 

Deep dissection (L4/5)

 

L4 5 DecompressionL4 5 Decompression Laminectomy

 

Recheck level

- L4/5 interspinous gap

 

Resect L4 spinous process

- remove ligamentum flavum above and below

- Kerrison Rongeur / knife

- remove all of L4 lamina

- expose L4/5 disc space

- L5 nerve root exits inferior

- L5 nerve root will pass below L5 pedicle

 

Remove L4/5 disc fragments if needed

- nerve root retractor

- gently retract dura to each side

- take out with pituitary rongeur

 

L4/5 medial facetectomy

- above L5 pedicle

- L5 nerve root exits inferior to it

- decompress, pass Watson Chaney

 

Preserve pars & half of facet

- may have to remove entire facet joint & pars

- preserve one facet joint at each level

- can be 1/2 on each side

 

 

 

Spondylolisthesis Degenerative

Definition

Spondylolithesis L4/5

Spondylolithesis caused by

- facet joint degeneration

- no pars or dysplastic pathology

- disc space usually preserved

 

Most common at L4/5 level

 

Epidemiology

 

More common in elderly females

- F: M = 5:1

 

Diabetics

 

Pathogenesis

 

1.  Facet degeneration

- body weight displaces lumbar vertebrae ventrally 

- resisted by facet joints

 

2.  Sagittal orientation of facet joints obviates restraining effect 

 

Boden JBJS 1996

- facet joint angle L4 or L5 >45° to coronal plane

- 25x more likely to have degenerate spondylolisthesis

 

3.  Segmental Instability

 

Pathology

 

Slip usually mild / rarely past Meyerding Grade II

- average 15% 

- maximum 30% 

- facet involvement may be asymmetrical & this causes rotatory component 

 

Symptoms

 

1.  Low Back Pain 80%

 

2.  Radiculopathy

- sciatica 50% 

- usually L5 in lateral recess

- can be L4 via narrowing foramen

 

3.  Neurogenic Claudication 50% 

- worse with standing, relieved by flexion

- claudication distance is variable

- sensory changes

- normal pulses

 

4.  Cauda Equina 5%

 

Signs

 

ROM

- normal lumbar forward flexion

- pain on extension

 

Minimal tenderness & spasm 

 

Neurological deficit 50%

- sensory alteration 30%

- weakness 20%

 

Xray

 

AP

- facet hypertrophy / osteophyte formation 

 

Lateral

- mild forward slip 

 

Dynamic Views

- >10° or 4mm = objective instability

 

CT 

 

Degeneration of facet 

 

Degenerative Spondylolithesis CT 2Degenerative Spondylolithesis CT 1

 

MRI

 

Demonstrate stenosis with spondylolithesis

 

L45 Spondylolithesis MRI

 

NHx

 

Don't tend to progress past Grade II

 

Do well if have no neurological symptoms

 

Often need surgery for neurological claudication / stenosis

 

Management

 

Non-operative

 

Indications

 

Mild symptoms / short duration / unfit for surgery

 

Technique

 

Activity modification / analgesics / physio

 

Results

 

Weinstein et al N Eng J Med 2007

- RCT of operative v non operative, multicentred

- operative group had substantial improvement in pain and function at 2 years

 

Pearson et al Spine 2009

- SPORT

- RCT of operative v non operative

- operative group had significantly better outcomes

- grade 1 better outcome than grade 2 with surgery

- dynamic instability better outcome than static

 

Operative

 

Indications

- failure of non operative treatment 

- radiculopathy / neurogenic claudication

- progressive neurological defect

- bladder or bowel symptoms

 

Principles / Issues

 

1.  Decompress + fusion

- demonstrated superior results in degenerative spondylolithesis

 

Herkowitz et al Spine 1991

- fusion & decompression alone had better results at 3 years than decompression alone 

- slip increased 95% vs 30%

 

2.  Instrumentation

- instrumentation increases fusion rate

- ? solid fusion improves outcome

 

Fischgrund et al 1997

- RCT of PLF with and without instrumentation

- increased fusion rates with pedicle screws (82% v 45%)

- no evidence of superior outcome

 

Martin et al Spine 2007

- systematic review

- fusion leads to better outcome than decompression alone

- evidence that instrumentation increases fusion rate

- no evidence that instrumentation improves outcome

 

3.  Interbody cages

- increase foraminal height / important if radiculopathy

- improve fusion rates

 

Options

 

Decompression + PLF without instrumentation

Decompression + instrumented PLF

Decompression + PLF + interbody cage / PLIF / 360o fusion

 

Results

 

Abdu et al Spine 2009

- SPORT

- 360 patients comparing PLF / instrumented PLF / PLIF (360o fusion)

- no difference at 4 years in outcome

 

Decompression + Instrumented Posterolateral Fusion 

 

Degenerative Spondylolithesis PLF

 

Technique

 

Midline incision

- elevate para-spinal muscles

- expose L4/5 facets and TP's

- laminectomy +/- foraminotomy

- pedicle screws + rods

- decorticate lamina, transverse processes, facet joints

- posterolateral fusion with BMP collagen and synthetic BG sushi rolls

 

Results

 

Decompression and PLIF / 360o fusion

 

Adult Spondylithesis PLIF

Spondylolisthesis Dyplastic Isthmic

Definition 

 

Forward slip of one vertebra relative to inferior one

 

Classification

 

Wiltse  "DID TIP"

 

Dysplastic

Isthmic

 

Degenerate

Traumatic

Iatrogenic

Pathological

 

1. Dysplastic 20 %

 

Congenital Dysplasia of Upper Sacrum 

- occurs at L5-S1

- hypoplasia of superior facets of S1

- dysplastic L5/S1 facet joints

 

Usually around 6 years old

 

Spina bifida ccculta common

- more unstable

 

Prone to more severe slips

 

Most high grade slips are dysplastic

 

2. Isthmic 50 %

 

Pars Discontinuity / Defect

- L5 /S1 80%

- unilateral or bilateral

- can have a pars defect at L4/5

- typically adolescent

- due to repetitive stress with fracture

- increased in competitive sports eg gymnastics, football

- is a genetic predisposition due to increased pelvic incidence

- tend to be mild and non progressive

 

Tend to present in 2 groups

- some present in young patient

- some present in adulthood when the disc degenerates and foramina compressed

 

Isthmic SponydlolithesisL4 Pars Defect

 

3 types

 

A Stress fracture

 

B Elongated type

 

Spondylithesis Elongated

 

C Acute fracture

 

3. Degenerative

 

2° to Facet OA

- L4/L5

- > 40 years old

- associated with DM

- F>M

- compared with lytic the disc tends to be preserved

 

Degenerative Spondylolithesis L45

 

4. Traumatic

 

Bilateral acute fracture through neural arch outside pars

- i.e. hangman's fracture

 

5. Iatrogenic

 

Post surgical

 

6. Pathological

 

Pathological weakening of neural arch or pedicle 

- OI / Larsen / Marfan's / tumour

 

Epidemiology

 

Occurs after walking

- never present at birth 

 

Spondylolysis seen in 5% causcasion population

- 15% develop spondylolithesis

 

Gender

- more common in boys 

- girls more severe slips

 

NHx Lytic

 

Early NHx

- by early adulthood L5-S1 disc narrowed

- anterior sacrum develops sclerotic lip

- further slip unlikely in adulthood

- will only progress whilst skeletally immature

 

Late NHx

- increased incidence of L5-S1 disc degeneration

- significant increase in LBP > 50% slip

- may develop nerve root pain when foramina compressed due to disc degeneration

 

Aetiology Isthmic

 

Fracture of pars  

 

Lumbar extension concentrates shear stresses on thin pars 

- inferior articular process of cranial vertebrae continuously impacts on pars

- nutcracker mechanism

 

Most common

- soldiers /weight lifters / footballer's

- female gymnasts 10%

 

FHx

- positive FHx in 15%

 

Pelvic Incidence

 

Isthmic associated with increased pelvic incidence > 50o

- patients have increase lumbar lordosis with increased shear stress

- predisposed to pars fracture if engage in certain sports with hyperextension

 

Measurement

- line superior border sacrum / sacral slope

- drop perpendicular line from centre of sacral slope line

- line to centre femoral head

- pelvic incidence is line between the two

 

Pelvic IncidencePelvic Incidence > 50 degrees

 

Aetiology Dysplastic 

 

Secondary to posterior element abnormality

- increased incidence of sacral spina bifida

 

FHx

- positive FHx in 33%

 

Pathology

 

1.  Isthmic

 

Usually lower grades

- posterior elements left behind

- canal diameter increased

 

L5 nerve root compression

- fibrocartilage mass at pars defect 

- stretched over posterior sacrum

 

2.  Dysplastic

 

Higher grades

- severe lumbosacral kyphosis

- canal diameter decreased

 

L5 nerve root + cauda equina pressure

- intact neural arch of L5 pulled forward

 

Symptoms

 

Usually asymptomatic in children

- only 10% are painful

- pain usually in growth spurt adolescents 

 

Back pain

- low back / buttocks & thighs 

- initiated by strenuous activity 

- repetitive flexion extension

- relieved by rest

 

Can often recall a specific inciting event

 

Neurology

- radicular pain 

- exiting nerve root / usually L5 in both dysplastic and isthmic

 

Signs

 

Lumbar hyperlordosis

 

Lumbosacral step off with severe slips

 

Numbness in L5 area

 

Scoliosis

- increased incidence in symptomatic slip 

- 25-50% 

- more common with dysplastic

 

Spondylo-crisis

- acute presentation with severe back pain

- hands on knees, hips and knees flexed

- bladder and bowel dysfunction

 

Standing AP and Lateral X-ray

 

Findings

 

May miss subtle listhesis on supine XR

- spondylosis

- Meyerding classification

- slip angle

- sacral inclination

 

Spondylolysis

 

Pars Defect Lateral Xray

 

Definition

- radiolucent defect of pars 

 

Types

- acute - narrow gap & irregular edges 

- pars elongated & thinned

- chronic - wide gap with smooth sclerotic edges

 

Scotty Dog / Oblique Xray

- Ear (superior articular facet) / Nose (TP) / Eye (pedicle)

- Front leg (inferior articular facet) /  Body (lamina and body with superimposed SP)

- Tail (superior articular facet of other side) /  Back leg (inferior articular facet of other side)

- Neck (Pars and if Collar then has defect)

 

Scotty dog NormalPars Defect Oblique Xray

 

Meyerding Classification

 

Degree of slip compared with width of S1

- Grade I 0-25%

- Grade II  25-50%

- Grade III  50-75%

- Grade IV 75-100%

- Grade V  > 100% / Spondyloptosis

 

Stability

- stable / slip < 50%

- unstable / slip > 50%

 

Spondylolithesis Meyerding Classification

 

Slip Angle / kyphotic angle

 

Measurement

- line along inferior border L5

- line along superior border S1

 

Normally L5/S1 disc is in 20-30° lordosis 

- angle is negative

 

As L5 slips forward it slips into kyphosis

- angle becomes positive

- sacrum becomes more vertical with high grade slips 

- this worsens the kyphosis further

 

Dangers

- typically > 10° with dysplastic

-  > 30° high risk progression progression

 

Sacral inclination

 

Angle between posterior border of sacrum and vertical

- > 60o associated with progression

 

Chronic Changes

 

Seen in older presentation

- anterior sacral erosion

- domed sacrum

- L5 Trapezoidal 

- L5/S1 disc degeneration

 

Bone Scan

 

1.  Diagnosis

 

SPECT 

 

2.  Prognosis

 

Hot lesion

- will heal

 

Cold lesion

- not healing

 

CT scan

 

Technique

- reverse gantry

 

Indication

- perform instead of obliques

- oblique x-rays have high radiation dose with little extra information compared with CT 

 

Spondylithesis L5 S1 with disc degenerationPars Defect Bilateral CT

 

MRI

 

Indication

- neurological signs

- rule out other diagnosis

 

DDx

 

Infection - vertebral OM / discitis 

Tumour - osteoid osteoma / cord tumour

Herniated disc 

Inflammatory - Scheuermann's / Ankylosing Spondylitis

 

Management

 

High Risks Progression

 

1. Clinical

- skeletally immature

- female 

 

2.  X-ray

- dysplastic slip 

- grade III or IV (> 50%)

- slip angle  / kyphosis > 30° (normal is -20° i.e. lordosis)

 

Non Operative

 

Indication

 

Minimal symptoms

Low risk progression

- isthmic

- mild slip (Meyerding I / II, slip angle < 30o)

 

Protocol

 

Observation until mature

- review annually to ensure no progression of slip

 

Consists of

- activity modification 

- cease aggravating symptoms

- NSAIDS

- hamstring stretches

- brace

 

Brace 

 

Indication

- spondylosis / grade 1 spondylolithesis

- acute / hot on bone scan

 

Theory

- attempt to heal pars fracture

- healing is not required for symptoms to settle

 

Type

- anti-lordotic

- 3/12 full time, no sport

- 3/12 full time with sport

 

Results

 

Debnath et al Spine 2007

- 42 patients with unilateral spondylysis hot on SPECT

- 6/12 non operative treatment including bracing

- 81% avoided surgery / complete resolution of symptoms

- remainder had CT confirmed non union and underwent unilateral pars fixation

 

Operative Management

 

Indications

 

1.  High risk slip

- slip degree > 50%

- slip angle > 30o

- dysplastic

- skeletally immature

 

2.  Progression of slip

 

3.  Neurological symptoms

- L5 Radiculopathy / Stenotic symptoms / cauda equina

 

4.  Debilitating pain

- spondylysis

- spondylolithesis

 

Options

 

1.  Pars fusion

- painful spondylysis

- minimal spondylolithesis

 

2.  Fusion

 

A.  In situ v reduction

- not required for grade 1 - 2

- consider if sagittal malalignment

- associated with risk neurology especially L5

- controversial if should be performed in high grade slips

 

B.  Instrumented / non instrumented

 

C.  Levels

- L5/S1 if grade I or II / 50% or less

- L4/S1 if 50% for more

 

D.  Interbody cages

- useful in long standing spondylolithesis presenting in adulthood

- degenerative disc disease

- nerve root pain from interforaminal compression

- improves nerve root space

- improves healing rate

 

E.  Posterior v circumferential

- circumferential approaches may improve fusion rates and outcome in high grade slips

 

Fusion of Pars

 

Indication

- normal discs and facets

- pain relieved by pars injection

- failure brace / non operative treatment

- minimal slip

 

Pars Defect LA Injection

 

Technique

- lesion identified / debrided / iliac crest bone graft

 

Options ORIF

 

1.  Screw across lytic defect

- unilateral defect

 

Lytic Pars Grade 1 SpondylolithesisLytic Spondylithesis CT Unilateral Pars Defect

 

Lytic Pars Defect Unilateral Pars Screw0001Lytic Pars Defect Unilateral Pars Screw0002Pars Defect Screw CT

 

2.  Pedicle screw + laminar hook

- bilateral defect

 

Pars Defect Bilateral CTPars Defect Hook and Screw L50001Pars Defect Hook and Screw Lateral

 

Bilateral Pars Defect Union

 

3.  TBW spinous process and transverse process

 

Results

 

Kakluchi et al JBJS Am 1997

- 16 patients with failure non operative treatment bilateral pars defect

- pain relieved by pars injection with LA

- pedicle screw + lamina hook

- nerve root decompression where required

- union in all 16

- 3 patients only had occasional back pain

 

Fusion in Situ

 

A.  Wiltse Lateral Mass Fusion in situ

 

Concept

- in situ fusion via a paraspinal muscle splitting approach

- no reduction or instrumentation

 

Indication

- for L5/S1 with minor slip in young patient

- rarely done these days

- most surgeons perform instrumented fusion

 

Technique

- midline incision

- two paramedian incisions in lumbodorsal fascia 4.5cm lateral to midline

- paraspinous muscle splitting approach 2 fingerbreadths lateral to midline

- split sacrospinalis using finger to dissect through muscle

- don't go anterior to TP or risk damage to nerve root

- decorticate TP / Sacral ala / facet / famina and add crest graft / allograft / BMP

 

Post-op

- spica 3/12 with 1 leg incorporated   

- activity modification for 6/12

 

Instrumented fusion in situ without reduction

 

Indications

- slip grade 1 or II

- grade III or IV with no sagittal malalignment

 

Levels instrumentation

- L5 / S1 grade I or II

- L4 / S1 grade III or IV

 

Options

1.  Pedicle screw instrumentation

 

Spondylolithesis PLF

 

2.  PLIF / interbody cage

 

Isthmic Spondylolithesis PLIFSpondylolithesis PLIF

 

3.  Bohlman procedure

- interbody fusion with fibula strut

- augmented with decompression and PLF

 

Dysplastic Spondylolithesis Bohlman Procedure

 

4.  Transfixing L5 / sacral screw

 

Spondylolithesis Transfixing Screw LateralSpondylolithesis Transfixing Screw Lateral

 

Reduction + Instrumented fusion

 

Indications

- sagittal malignment

 

Disadvantage

- risk of neurology (L5)

- up to 25%, usually transient

 

Advantage

- cosmesis

- less pain from correction of alignment

- more likely fusion, less pseuodoarthrosis

- improved neurological decompression

 

Technique

 

A.  Posterior approach

- wide foraminatomy bilateral to protect L5 nerve root

- disc removed

- screws used to correct angulation +/- some translation

- interbody fusion device to restore height

 

B.  Anterior approach

 

Spondyloptosis 

 

Option

 

A.  L5 vertebrectomy / Gaines procedure

 

B.  Reduction and fusion as above

Thoracic Disc Disease

Epidemiology

 

0.05% incidence

- rare due to stabilising effect of rib cage

- even more rare to have symptoms

 

Reasoning

1.  Discs are narrower

2.  Foramina larger

3.  Thoracic spine

- facet joints orientated for rotation

- lumbar spine for flexion extension

- flexion is typically the motion which ruptures annulus

 

Anatomy

 

Increase in size from T1 to T12

- small pedicles

- long spinous processes

- relatively large intervertebral foramina

- facets nearly vertical

- TP come off the pedicle

- costal articulation TP and vertebral body

 

Thoracic Vertebrae

 

Clinical

 

Present with intercostal radiculopathy or myelopathy

 

Xray

 

Disc space narrowing / degenerative changes

 

> 50% thoracic discs associated with calcified disc material in canal

- probably indicates chronicity

 

Thoracic Disc Calcified CT 1Thoracic Disc Calcified CT 2

 

MRI 

 

Very sensitive 

- 40% incidence asymptomatic thoracic disc protrusion

 

Thoracic Herniate Disc SagittalThoracic Herniate Disc Axial

 

Thoracic Disc MRIThoracic Disc MRI Axial

 

Management

 

Non Operative

 

Indication

- single level disease

- no myelopathy

- operation rarely indicated

- usually settles with physiotherapy / analgesia

 

Operative

 

Indications

- myelopathy 

- unrelieved radiculopathy

 

Options

 

Posterior approach / discectomy via laminectomy

- contraindicated

- spinal cord does not tolerate retraction 

 

Anterior Approach

- costotransversectomy

- corpectomy (2 level disc)

 

A.  Thoracotomy and Costotransversectomy

 

Definition

- resection of rib + transverse process

 

Indication

- single level disc resection

- unilateral disc

 

Technique

- posterior approach

- remove of rib and transverse process

- ipsilateral pedicle removal

- removal disc protrusion

 

B.  Thoracotomy and Corpectomy

 

Indication

- 2 level disc protrusion

 

Thoracic disc 2 Level Precorpectomy

 

Technique

 

Thoractomy Approach

- loin incision

- removal of rib 2 levels above

- through bed of rib

- extrapleural approach

- from left to avoid IVC

 

Tie off segmental artery on one side

- disc convex, body concave

- allows access to disc protrusion

- discectomy + / - corpectomy as required for exposure / 2 level disc

- anterior +/- posterior stabilisation if corpectomy

- if simply remove disc may not need stabilisation especially in elderly

- will autofuse

 

Thoracic Corpectomy HNP

 

Complications

 

Cord injury

 

Cord infarct 

- ligation segmental artery

- exceedingly rare with unilateral approach

- much higher risk with bilateral approaches

- CTA to look for artery adamkiewicz

 

Intercostal neuritis 

- not uncommon

- treat with repeated intercostal nerve blocks

 

Bleeding

- usually from segmental artery

- patient presents difficulty breathing / hemothorax

- may have high output from drain

- > 200mls / hour clamp drain and urgent return to OT with vascular surgeon

 

 

 

Thoraco Lumbar Fracture

Xray Assessment

 

A:  Alignment

B:  Bony

C:  Canal

D:  Disc

S:  Soft tissues

 

Goals of surgery

 

1.  Correct deformity

2.  Restore stability

3.  Decompress neural elements if required

 

MRI

 

Advantage

- defines level of conus

- may need anterior rather than posterior surgery if lesion above conus

 

Denis's 3 column Classification 1982

 

> 3 columns injured with translation

- unstable

 

Posterior column 

- supraspinous / infraspinous ligament / ligamentum flavum

- neural arch (lamina / pedicle / facet joints / spinous process)

 

Middle column 

- PLL, posterior disc & annulus

- posterior half vertebral body

- most important

 

Anterior column 

- ALL, anterior disc & annulus

- anterior half vertebral body

 

Denis Classification

 

1.  Compression fracture

- anterior column only

 

L1 anterior compression fracture MRI

 

2.  Burst fracture

- anterior and middle column disrupted

- widening of pedicles on AP

- decreased posterior body height compared to anterior

- may have retropulsed fragment

- this occurs at top of vertebral body between pedicles

- obscured by pedicles on lateral xray

 

Burst Fracture CT

 

3.  Flexion-distraction

- distraction of posterior structures

- disruption of middle column

- splaying of spinous processes on AP and lateral

- bony or ligamentous

- chance injury (pure bony)

- anterior column intact / no translation

 

4.  Fracture-dislocation

- all three columns disrupted

- characterised by translation

 

Surgical Indications

 

1.  Neurology 

- decompress 

- complete v incomplete

 

2.  Deformity

- correct deformity

 

Gertzbein SRS 1992

- 1109 patients

- kyphosis >30° associated with increased back pain

 

3.  Stability

- prevent neurology

- prevent deformity / late pain

 

4.  Multi-trauma patient

 

TLISS (Thoracolumbar Injury Severity Score)

 

Spine Trauma Study Group 

- 3 issues

- calculate a score

- gives an indication if patient needs surgery

 

1.  Injury Mechanism

 

Compression 1

Burst 2

Rotation 3

Distraction 4

 

2.  Posterior Ligament Complex

 

Intact 0

Suspected 2

Definite 3

 

3.  Neurology

 

Nil 0

Nerve root 1

Complete cord 2

Incomplete cord 3

Cauda equina 3

 

10 is maximum score

- < 4 no treatment

- 5 or more - surgery

- 4 - either way

 

Burst fracture

- 2 points for burst

- 2 for indeterminate posterior injury

- usually no neurology

- 4 in total

 

Timing

 

Incomplete neurology

- emergency

- especially if neurology worsening

- have more time if neurology stable

- i.e. time to get MRI

 

Complete neurology

- not an emergency

- surgery still indicated

- gain 1 or 2 neurological levels (crucial in C spine)

- prevent syrinx

- prevent development of neuropathic pain

- aid nursing / rehabilitation

 

Bohlman 1985 JBJS

 

184 thoracic spine fractures with complete cord injury

- no recovery with or without OT

- posterior fusion only to speed recovery

 

17 incomplete cord injuries treated with laminectomy

- 7 became worse

- hence contra-indicated

 

8 incomplete cord injuries treated with anterior decompress+ fusion

- all improved  

- decreased rehabilication time by 50% in operative group

 

Approach

 

Posterior

 

Indications

- flexion distraction

- fracture dislocation

- compression fractures

- +/- burst

 

Requires integrity of posterior column

- Gaines score

 

Issue

- disruption of posterior column

- higher risk of dural tears

 

Anterior

 

Indication

- decompression required

- i.e. burst with retropulsed fragment

- perform corpectomy via anterior approach

 

Anterior & Posterior

 

Gaines / Load sharing Classification

 

Enables decision be made

- short segment posterior stabilisation v

- anterior decompression and stabilisation

 

Gaines Class >/=7 = failure with pedicle screw construct alone

 

A. Comminution vertebral body on lateral X-ray

1. <30%

2. 30-60%

3. >60%

 

B. Apposition of Fragments

1. Minimal displacement

2. 2mm or <50% of body

3. > 2mm or >50% body

 

C. Deformity Correction

1. Kyphosis 3o or less

2. 4-9o

3. >10o needed

 

Score of 3-9

 

1.  Compression Fractures

 

DDx

- burst

- pathological

 

CT scan

- xray only 25% accurate distinguishing compression from burst

- indicated if anterior body height < half posterior body height

- i.e. > 50% anterior wedging

- assess integrity of middle column / look for retropulsed fragments

 

Operative Indications

- kyphosis > 30o

 

Non Operative Management

- elderly - mobilise

- young - extension orthosis / TLSO

- check standing X-ray 2/52

- ensure kyphosis < 20 - 30o

 

Surgery

- posterior approach

- instrumentation

 

2.  Burst Fracture

 

Characteristics

- axial load

- most common thoracolumbar junction

- retropulsed fragment here causes conus

 

Definition

- anterior & middle column disrupted

- posterior column injured but no displacement / translation

 

X-ray

- pedicle widening on AP

- posterior body height decreased on lateral < 50%

 

Thoracic Burst Xrays LateralThoracic Burst Xrays AP Widened Pedicles

 

CT

 

Look for canal compromise

- cord signal change

- kyphotic deformity

 

Burst Fracture CT No Canal CompromiseBurst Fracture Coronal

 

Retropulsed fragments

- always between pedicles

- typically one or two main fragments (saloon door)

- assess canal compromise

 

Thoracic Burst CT Canal Fragment SagittalThoracic Burst CT Canal Fragment Axial

 

Burst Fracture Axial CT

 

MRI

- HNP

- cord signal change

- assess posterior ligament integrity

- assess level of conus medullaris

 

Thoracic Burst MRI Sagittal Kyphosis and Cord SignalThoracic Burst MRI Canal Compromise

 

Clinically

 

1.  High association abdominal trauma

- duodenum, aorta, spleen

 

2.  Neurology

- complete v incomplete

- from retropulsed fragments

 

Non-Operative management

 

Indications

- no neurology 

- no deformity / < 30o kyphosis

- stable

 

TLSO

 

Surgical Indications

 

TLISS > 4

- usually means neurology

 

Kyphotic deformity

 

Failure non operative

 

Anterior corpectomy and strut graft

 

Indication

- decompression of retropulsed fragments in patient with neurology

 

Lumbar Burst Fracture0001Lumbar Burst Fracture0002Lumbar Burst Fracture0003Lumbar Burst Fracture0004

 

Technique

- approach as per level

- thoracoabdominal for T11 - L1

- thoracotomy for T2 - T10

- remove disc above and below and remove vertebral body

- remove fragments / need to know if 1 or 2

- screws in vertebral body above and below

- 2 screws in a lateral plane

- insert fibular strut allograft / titanium cage

- augment with cage

 

Posterior instrumentation 

 

Indication

- < 7 gaines criteria

- no neurology

 

Technique

- ligamentotaxis clears canal / PLL acts as bowstring

- pedicle screws lumbar, avoided in thoracic

- use transverse process and pedicle hooks in thoracic

- bone graft inserted via pedicles

- need to do before 5 days post injury

 

Burst Fracture Posterior stabilisation 3Burst Fracture Posterior stabilisation

 

Thoracic Burst Posterior Stabilisation APThoracic Burst Posterior Stabilisation Lateral

 

3.  Flexion Distraction

 

Definition

 

Seat belt injuries

- injury all 3 columns

- posterior fails in tension

- anterior and middle in distraction

- anterior undisplaced with no translation

 

Associated injuries

 

1.  Hollow viscus

 

Anderson et al J Orthop Trauma 1991

- 2/3 have injury to hollow viscus

- duodenum very common as second part fixed

- 1/4 have hemoperitoneum from mesenteric laceration

 

2.  Ileus

- very common

- manage NBM / NGT

 

Types

 

1.  Pure bony

- through vertebral body

- Chance fracture

 

2.  Ligamentous

- through disc space and facet joints

 

Thoracolumbar Chance Fracture CT CoronalThoracolumbar Chance Fracture CT Sagittal

 

3.  Combined

- rare injury

 

Management

 

Bony chance

- can heal in hyperextension orthosis

- assess reduction in brace / < 15o kyphosis

- otherwise can fix with pedicle screws and TP hooks of same vertebrae

 

Ligamentous

- treat surgically as unstable and ligament heals poorly

- respond well to short segment posterior instrumentation

- above and below disc space injured

- i.e. T12 and L1 instrumented

 

TL Chance Fracture Stabilisation LateralChance Fracture Stabilisation APTL Chance Fracture

 

Neurology / deformity

- reduction and posterior stabilisation

- add decompression if required

 

4.  Translational - Fracture / Dislocation

 

T12 L1 Soft Tissue Chance CT 2T12 L1 Soft Tissue Chance CTT12 L1 Soft Tissue Chance MRI

 

Background

 

3 Column injury

- high energy

- unstable by definition

- required operative stabilisation

- profound neurological deficit common

 

Types

1.  Shear

2.  Flexion-distraction with translation

3.  Flexion-rotation

- unilateral facet dislocation

- < 25% translated

 

Management

 

Incomplete or no neurology

- rare

- great care must be taken to not worsen patient

- MRI to exclude disc / determine level of conus

 

Options

- posterior approach / decompression / reduction / stabilisation

- consider anterior approach if HNP / above level conus

 

Levels

- 1 up and 1 down sufficient unless

- osteoporosis

- thoracolumbar junction

 

T12 L1 Soft Tissue Chance OTT12 L1 Soft Tissue Chance Posterior StabilisationT12 L1 Soft Tissue Chance Posterior Decompression

Tumour

Chordoma

Definition

 

Primary malignancy arising from remnants of the notochord

 

Epidemiology

 

Rare malignant tumour

 

Middle-aged adults (50-70)

 

M>F

 

Location

 

In midline in axial skeleton

 

Base of skull 35%

 

Vertebrae 15%

- especially cervical

 

Sacrum 50%

 

Clinical

 

Sacral Tumour

 

Usually presents late (long History LBP)

- slow-growing

- large potential space to expand into

- often very large on presentation

 

Perineal pain

Bladder & bowel dysfunction

Mass effect

Neurological compression

 

Usually can feel rectal mass ~ 50%

 

X-ray

 

Bony destruction is hallmark + soft tissue mass

- 50% Calcification within mass

 

Sacrum

- irregular areas of bone destruction

- sacral expansion

- soft tissue mass

 

CT Scan / MRI 

 

Useful to delineate tumour

 

Sacral Chordoma MRI0001Sacral Chordoma MRI0002

 

Pathology

 

Gross 

- lobulated bluish / gray

- extensive gelatinous translucent areas which are focally cystic & haemorrhagic

 

Histology

- lobular framework of Physaliphorous cells

- cells have bubbly pink cytoplasm & Bulls-Eye nucleus

- vascular fibrous septa

- mucinous matrix

- 1/3 significant Chondroid production (can be mistaken for chondrosarcoma)

 

DDx

 

GCT / ABC

Chondrosarcoma / OS / Ewing's / Myeloma

Metastasis

 

Management

 

Operative

 

Most important predictor of survival is clear surgical margin

- usually difficult due to location

 

Sacral Surgery

- leave at least 1 S3 - 100% continent

- leave at least 1 S2 - 50% continent

- above S2 incontinent because pelvic splanchnics removed

 

Radiotherapy

 

Indications

- resection not possible

- positive margins

 

Rarely effective

 

Prognosis

 

Metastasis 30-50%

- pulmonary mets may occur (late)

 

Death usually 2° local infiltration

 

 

Primary Spinal Tumours

 

DDx

 

Primary

 

Benign

 

Osteoid Osteoma

Osteoblastoma

Osteochondroma

ABC

Hemangioma

Giant Cell tumour

EG

 

Malignant

 

Chordoma

Ewings

Osteosarcoma

Chondrosarcoma

Lymphoma

Multiple myeloma

 

Secondary

 

Leukaemia 

Prostate / Breast / Lung / Thyroid / Kidney

 

DDx by Site

 

Posterior elements

- OO, OB, ABC

- chordoma / osteosarcoma

 

Vertebral body

- giant cell

- hemangioma

 

Sacrum

- chordoma

- Ewing's

 

Benign Spinal Tumours

 

ABC

 

Patient in teens or twenties

Night pain

Posterior elements

 

Treatment

 

Embolisation

Surgical resection

- complete to prevent recurrence

 

Giant cell tumour

 

30 - 40 years

In sacrum

Present with pain

May have bladder and bowel dysfunction

 

Treatment

 

Wide excision

- may get incontinence

Adjunctive radiotherapy

Now using serial embolisation

 

Hemangiomas

 

Hemangioma Spine

 

Very common

- usually asymptomatic and incidental finding

- vertebral body or posterior element

- thoracic spine

 

Xray

- striations

 

MRI

- High signal on T2

 

Treatment

 

Indicated for collapse or neurology

Surgical excision

Embolisation

Radiotherapy

 

Osteoid Osteoma

 

Male between 20 - 40

 

Posterior elements lumbar spine

- < 2 cm

 

Can cause scoliosis

- in apex of convexity

 

Treatment

 

Surgical Removal / High frequency radioablation

Often scoliosis will then resolve if not too long standing

 

Osteoblastoma

 

Osteoblastoma Spine0001Osteoblastoma Spine0002Osteoblastoma Spine0003

 

Similar histology to OO

- > 2 cm

 

Much more aggressive / less common

 

Found in the posterior elements

- male teens, twenties

 

Treatment

 

Osteoblastoma Exision and Fusion0001Osteoblastoma Exision and Fusion0002

 

Wide excision +/- posterior fusion

 

Can recur

- life long follow up

 

Eosinophilic Granuloma

 

Vertebroplanar in young child < 10

 

Treatment

 

Self limiting

- will reconstitute up to 50% vertebral height

 

Primary Malignant Tumours

 

Chordoma

 

Rare slow growing malignant tumours

- arise from primitive nervous system

- slow to metastasise

 

50% sacrococcygea

 

Elderly patients

 

Treatment

 

Surgical Resection

- very difficult

 

Adjunctive Radiotherapy

 

Life expectancy 10 - 15 years after diagnosis

 

Osteosarcoma

 

Uncommon

Vertebral body

 

Treatment

 

Radical excision

Adjunctive radiotherapy and chemotherapy

 

Chondrosarcoma

 

Middle age or older

Males

Patient with Maffucci / Ollier's


Treatment

 

Wide surgical resection

Overall prognosis is poor as this is difficult

 

Lymphoma

 

Can be solitary lesion

Anterior element

 

Treatment

 

Radiotherapy and Chemotherapy

Surgery if unstable / deformity

 

Ewing's

 

50% in sacrum

Young male in teens

 

Treatment

 

Surgical resection

Radiotherapy and chemotherapy

20% 5 year survival

 

Multiple Myeloma / Plasmocytoma

 

50 - 80 years

 

Treatment

 

Radiotherapy and chemotherapy

Surgery for instability

 

Spinal Cord Tumours

 

DDx by Location

 

Extramedullary

- neuroblastoma

- ganglioneuroma

- Ewings sarcoma

- leukaemia

- lymphoma

- synovial cysts

 

Spine Synovial Cysts MRI

 

Extramedullary Intradural

- dermoid

- epidermoid

- meningioma

- neurofibroma

 

Intradural

- astrocytoma

- ependymoma

- lipoma

 

Meningioma

 

Slow Growing

F:M 9:1

Intra-dural / extramedullary

 

Management

- intradural resection

- RTX for residual tumour which is growing

 

Thoracic Meningioma

 

Ependymoma

 

Primary glial tumour of spinal cord

- intramedullary

- tend to be benign in spinal cord (c.f. intracranial

 

Ependymoma Conus MRI SagittalEpendymoma Conus Axial MRI

 

Management

- debulking

- radiotherapy

Spinal Metastasis

EpidemiologyThoracic Metastasis

 

80% cancer patients have spinal metastasis at autopsy 

 

Spine is number one site for bony metastasis (50%)

 

Cause

 

Hexagon: PBBLTK

 

                 Prostate    Breast

 

Bronchus      MM     Lymphoma        Bowel

   

                 Renal        Thyroid

 

NHx

 

20% of develop cord compression

30% survive >12/12

 

Pathology

 

Site

- thoracic spine  - 70%

- lumbosacral > cervical spine

 

Usually multilevel 

 

Vertebral body 

- 85%

- usually posterior body near pedicles

- posterior elements uncommon

 

Symptoms

- neural compression - demyelination / ischaemia

- pathological fracture

- spinal instability

 

Method of Spread

 

1.  Arterial metastasis

- haematogenous via nutrient arteries

- lung / breast

 

2.  Direct invasion

- through intervertebral foramen 

- lymphoma

 

3. Venous 

- via Batson's Plexus

- valveless veins from the pelvis to the internal venous plexus of the spine / prostate

- GIT tumours commonly spread to liver first via the portal system 

- then later to bone

 

4.  Lymphatic

 

Clinical

 

Pain

- 95% neoplastic pain (night and rest pain)

 

Weakness

- 75% at diagnosis

- bilateral & symmetrical

 

Sensory loss

- 50% at diagnosis

- ssually affects the feet first 

 

Loss of sphincter control

- 50% at diagnosis

 

X-ray

 

75% have abnormality

 

Winking Owl Sign

- pedicle loss on AP

 

Lytic / Sclerotic lesion

- need 30% bone loss to see lytic area

 

Vertebral body collapse 

 

Lumbar Metastasis XrayCervical Metastasis MRI

 

Bone Scan

 

Very sensitive 

- detect metastasis > 2mm

- screening tool

 

False positive

- crush fracture

 

False negative

- myeloma

 

"Superscan"

- symmetric increased uptake

- metastatic disease

- renal or endocrine abnormality

 

CT Scan 

 

Define

- bony abnormality

- deformity

- potential instability

 

Cervical Lesions

 

Cervical Spine Metastasis CTDens Metastasis

 

Lumbar

 

Lumbar Metastasis CTLumbar Spinal Met CT

 

MRI

 

Define

- soft tissue masses 

- nerve and cord impingement

 

Lumbar Metastasis MRI

 

Metastatic Tumour L1 MRI T1Metastatic Tumour L1 MRI Axial

 

Cervical Metastasis MRI

 

Classification Harrington

 

Class I

- Minimal bone involvement

 

Class II

- Bone destruction < 1/2 body / no instability / no cord compression 

 

Class III

- Spinal canal compromise due to epidural disease / no significant bone involvement

 

Class IV

- Pathological fracture ± deformity / no significant neurological compromise

 

Class V

- pathological fracture with collapse / instability & neurological compromise

 

Management

 

Prognosis

 

Outcome after treatment = Neurological impairment before treatment

- most ambulatory patients remain ambulatory after treatment

- few paraplegic patients are able to walk after treatment

 

Radiotherapy v Surgery

 

Patchell et al Lancet et al

- randomised multicentred trial

- patients with spinal cord compression from metastasis

- trial had to be stopped

- superior results for surgery c.f. radiotherapy and steroids

- improved patient walking ability / retained walking ability

- better maintenance of continence and Frankel grades

 

Goals

 

1. Preserve neurological function

- ambulation

- bladder and bowel 

 

2. Pain relief

 

3. Spinal stability

 

Decision making

 

Team approach

- oncologists

- radiation oncologists

- palliative medicine

 

Issues

- life expectancy

- fitness for surgery

- tumour type

- spinal stability

 

Harrington Classification

 

Group 1 & 2 +/- 3

- radiotherapy +/- chemotherapy

 

Group 4 & 5

- collapse / instability / impending deformity / deformity / neurology

- surgery

 

Radiotherapy

 

Sensitivity

 

Very - myeloma, lymphoma

Moderate - breast, lung, bowel, prostate

Resistant - thyroid, kidney, melanoma

 

Indications

- Harrington 1 & 2 +/- 3 radiosensitive

- no neurology

- neurology with poor prognosis or unfit for surgery

 

Operative Management

 

Indications

- neurology / cord compression

- failure of radiotherapy

- deformity

- instability

- > 3/12 to live

- fit for surgery

 

Instability

- > 50% height loss

- anterior and posterior columns at same level

- bone loss > 2 vertebrae

 

Options

 

1.  Decompressive laminectomy

- historical operative associated with poor outcomes

 

2.  Percutaneous PMMA / Vertebroplasty

 

Indications

- stable lesion

 

Spinal Met Percutaneous PMMA

 

3.  Posterior stabilisation

 

A.  Long segment stabilisation

 

Thoracic Spine Pathological Fracture StabilisationCervical Tumour Posterior Stabilisation

 

B.  Short segment stabilisation + PMMA

 

Lumbar Metastasis Posterior Stabilisation with PMMAVertebral Met Posterior Stabilisation + PMMA

 

3.  Corpectomy / PMMA / Anterior stabilisation

 

Technique

- remove body and disc to dura

- PMMA sufficient if LE < 6 months

- titanium cage and BG / structural graft if LE > 6/12

- stabilised with anterior plates

 

Cervical Spine Metastasis Anterior StabilisationCervical Spine Anterior Stabilisation 2

 

Post op Radiotherapy

 

Week 2 if no bone graft

Week 6 if bone graft used