Orthopaedics: Spine

Spine

Fractures of the Spine

·                 see Neurosurgery

·                 4 main types of :fractures (see Table 9)

Table 9. Fracture Type and Column involvement

Cervical Spine

General Principles

·                 Cl = atlas: no vertebral body, no spinous process

·                 C2 = axis: odontoid= dens

·                 7 cervical vertebrae; 8 cervical nerve roots

·                 nerve root exits above vertebra (Le. C4 nerve root exits above C4 vertebra)

·                 radiculopathy = Impingement of nerve root

·                 myelopathy = Impingement of spinal cord

Special Testing

·                 Compression test pressure on head worsens radicular pain

·                 Diattaction test: traction on head relieves radicular symptoms

·                 Valsalva test: Valsalva maneuver increase intrathecal pressure and causes radicular pain

Table 10. Cervical Radiculopathy/Neuropathy

X-Rays for C-Spine

·                 AP spine: alignment

·                 AP odontoid: atlantoaxial articulation

·                 lateral

o       vertebral alignment: posterior vertebral bodies should be aligned (translation >3.5 mm is abnormal)

o       angulation: between adjacent vertebral bodies (> 11 • is abnormal)

o       disc or facet joint widening

o       anterior soft tissue space (at C3 should be =<3 mm; at C4 should be =<8-10 mm)

·                 oblique: evaluate pedicles and intervertebral foramen

·                 ± swimmer's view: lateral view with arm abducted 1800 to evaluate C7-T1 junction if lateral view is inadequate (must see C7-T1 in all trauma situations)

·                 ± lateral flexion/extension view: evaluate subluxation of cervical vertebrae

Differential Diagnosis of C-Spine Pain

·                 trapezial sprain, whiplash, cervical spondylosis, cervical stenosis, rheumatoid arthritis (spondylitis), traumatic injury

Thoracolumbar Spine

General Principles

·                 spinal cord terminates at conus medullaris (Ll)

·                 individual nerve roots exit below pedicle of vertebra (ie. LA nerve root exits below LA pedicle)

Special Tests

·                 Straight leg raise (SLR): passive lifting of leg (30-70°) reproduces radicular symptoms of pain radiating down post/lat leg to knee, ± into foot

·                 Lasegue maneuver: dorsiflexion offoot during SLR makes symptoms worse or, if leg is less elevated, dorsiflexion will bring on symptoms

·                 Femoral stretch test: with patient prone, flexing the knee of the affected side and passively extending the hip results in radicular pain

Table 11. Lumber Radiculopathy/Neuropatlly

Diffarantial Diagnosis af Bilek Pain

1 . mechanical or nerve compression (>90%)

·                 degenerative (disc, facet, ligament)

·                 peripheral nerve compression (disc herniation)

·                 spinal stenosis (congenital. osteophyte, central disc)

·                 cauda equJna syndrome

2.others

·                 neoplastic (primary. metastatic, multiple myeloma)

·                 infectious (osteomyelitis, TB)

·                 metabolic (osteoporosis)

·                 traumatic fracture (compression, distraction, translation, rotation)

·                 spondyloarthropathies (ankylosing spondylitis)

·                 referred (aorta, renal, ureter, pancreas)

DEGENERATIVE DISC DISEASE

·                 loss of vertebral disc height with age results in:

o       bulging and tears of annulus fibrosus

o       change in alignment of facet joints

o       osteophyte formation

·                 can cause back-dominant pain

·                 management

o       non-operative

o       ––staying active with modified activity

o       ––back strengthening

o       ––NSAIDs

o       ––do not treat with opioids; no proven efficacy of spinal traction or manipulation

·                 operative - rarely indicated

o       decompression ± fusion

o       no difference in outcome between non-operative and surgical management at 2 years

SPINAL STENOSIS

·                 definition: narrowing of spinal canal <10 mm

·                 etiology: congenital (idiopathic, osteopetrosis, achondroplaai.a) or acquired (degenerative, iatrogenic- post spinal surgery, ankylosmg spondylosis, Paget's disease, trauma)

·                 clinical features

o       ± bilateral back and leg pain

o       neurogenic claudication (see Table 13)

o       ± motor weakness

o       normal back flexion; difficulty with back extension

·                 investigations: cr1MRI reveals narrowing of spinal canal, but gold standard = CT myelogram

·                 treatment

o       non-operative: vigorous PT (flexion exercises, stretch/strength exmises), NSAIDs, lumbar epidural. steroids

o       operative: decompression surgery if conservative methods failed >6 months

MECHANICAL BACK PAIN

·                 definition: back pain NOT due to prolapsed disc or any other clearly defined pathology

·                 clinical features

o       dull backache aggravated by activity

o       morning stiffness

o       no neurological signs

·                 treatment: symptomatic (analgesics, PT)

·                 prognosis: symptoms may resolve in 4-6 weeks, others become chronic

LUMBAR DISC HERNIATION

·                 definition: tear in annulus fibrosus allows protrusion of nucleus pulposus causing either a central, posterolateral or lateral disc herniation, most commonly at LS-Sl > 14-5 > L3-4

·                 etiology: usually a history of flexion-type injury which tears the annulus fibrosus allowing for protrusion of the nucleus pulposus

·                 clinical features

o       –back dominant pain (central herniation) or leg dominant pain (lateral herniation)

o       –tenderness between spines at affected level

o       –muscle spasm ± loss of normal lumbar lordosis

o       –neurological disturbance is segmental and varies with level of central herniation

o       –––motor weakness (L4, LS, Sl)

o       –––diminished reflexes (14, Sl)

o       –––diminished sensation (L4, 15, Sl)

o       +ve straight leg raise

o       +ve Lasegue test

o       bowel or bladder symptoms, decreased rectal tone suggests cauda equina syndrome due to central disc hernation - surgical emergency

·                 investigations: MRI

·                 treatment

o       symptomatic

o       –extension protocol (PT)

o       –NSAIDs

o       –90% resolve in 3 months

o       surgical discectomy reserved for progressive neurological deficit, failure of symptoms to resolve within 3 months or cauda equina syndrome due to central disc herniation

SPONDYLOLYSIS

·                 definition: defect in the pars interarticularis with no movement of the vertebral bodies

·                 etiology

o       trauma: gymnasts, weightlifters, backpackers, loggers, labourers

·                 clinical features: activity-related back pain

·                 investigations

o       oblique x-ray: "collar" break in the "Scottie dog's" neck

o       bone scan

o       CT scan

·                 treatment: activity restriction, brace, stretching exercise

SPONDYLOLISTHESIS

·                 definition: defect in pars interarticularis causing a forward slip of one vertebrae on another usually at LS-Sl, less commonly at L4-5

·                 etiology: congenital (children), degenerative (adults), traumatic, pathological, teratogenic

·                 clinical features: lower back pain radiating to buttocks

 Table 14. Classification and Treatment of Spondylolisthesis

Class: Percentage of Slip & Treatment

 0-25% Symptomatic operative fusion only for intractable pain

 25-50

 50-75 Decompression for spondylolisthesis and spinal fusion

 75-100

 >100

Specific Complications

·                 may present as cauda equina syndrome due to roots being stretched over the edge of LS or sacrum