Spine
General Topics
1 Spinal Biomechanics
Take-Home Message
• Motion segment – disc and paired facet joints
• Must have at least 50 % of the facet joints intact for stability:
• White and Panjabi criteria for stability
• Spinal stability: general defi nition is that motion segment provides mobility while at the same time protecting neurologic structures and function and implies non-painful movement.
• White and Panjabi.
• C ervical spine stability when less than 3.5 mm of translation at each segment and less than 11° of fl exion relative to adjacent motion segments.
• Motion at each segment of the spine largely defi ned by facet joint orientation.
• Occiput-C1 provides for fl exion/extension.
• C1/C2 provides for rotation due to unique anatomy.
• Subaxial cervical spine provides fl exion/extension and lateral bending coupled with rotation.
• Thoracic motion is rotational.
S. E. Smith , MD
Department of Orthopaedics, Denver Health Medical Center,
777 Bannock Street, Denver 80204 , CO , USA e-mail: samuel.smith@dhha.org
© Springer-Verlag France 2015 345
C. Mauffrey, D.J. Hak (eds.), Passport for the Orthopedic Boards and FRCS Examination, DOI 10.1007/978-2-8178-0475-0_13
• Lumbar motion is combined. Flexion and extension with lateral bending and rotation which are limited by the unique orientation of the lumbar facet joints, lateral bending, and rotation are coupled.
• Instantaneous axis of rotation is the posterior half of the disc.
• I n general, the anterior column experiences compression forces; cages and structural grafts best resist this compression; anterior plates confer some advantage but do not resist fl exion well.
• Lateral plates are a little better.
• In general, the posterior column experiences tension forces, and a screw and rod construct resists this best and also resists shear forces.
Bibliography
1 . W hite 3rd AA, Johnson RM, Panjabi MM, Southwick WO. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop Relat Res. 1975;109:85–96.
2 Degenerative Cascade
Take-Home Message
• Read Kirkaldy-Willis
• R epresents the continuum of degenerative changes in the motion segment of the spine
Defi nition
• T he degenerative changes over time which occur in the motion segment of each spinal level
• Involves both disc and facet joint degenerative changes
Etiology
• Chondrocyte degeneration
• Water loss and disc desiccation
• Instability
• Hypertrophic change
Pathophysiology
• A continuum of degenerative changes which start with chondrocyte degeneration of the surrounding cartilage matrix
• Leads to instability and the natural process of hypertrophic change – Mother Nature’s attempt at stability
• Leads to stenosis, deformity, slip, etc.
• Infl ammatory changes ensue
Radiographs
• M arginal osteophytes causing a change in the surface area of disc and facet joint
• Spondylolisthesis
• Endplate sclerosis
• Degenerative subchondral cystic change
Bibliography
1. Kirkaldy-Willis WH, Farfan HF. Instability of the lumbar spine. Clin Orthop Relat Res. 1982;165:110–23.
3 Imaging of the Spine
Take-Home Message
• X-rays: easy, inexpensive, best to see bony pathology and deformity.
• Risk is radiation.
• CT: detailed bony anatomy, neurologic information improved with myelography.
• Risk is high doses of radiation.
• MRI: useful for anatomic information from bone and neurologic structure and provides some physiologic information.
• B est for tumor, imaging of spinal cord and nerves, imaging of discs.
• Risks not entirely known as yet.
• DEXA: essential to defi ne bone density, osteoporosis is a huge health problem now and into the future.
• N uclear medicine is useful but not as specifi c, and radiation dose is high; indium labeling may be useful with infection.
• Understand the need to relate the imaging fi ndings with the patient’s his-tory and physical assessment; large number of patients with degenerative changes and no symptoms.
Bibliography
1. Boden SD, Wiesel SW. Lumbar spine imaging: role in clinical decision making.
J Am Acad Orthop Surg. 1996;4(5):238–48.
4 Spine Infection
Take-Home Message
• Requires high index of suspicion.
• P ost-op infection rate varies in the literature, depends on length and complexity of the procedure and patient comorbidities.
• Obesity and diabetes increase risk of surgical site infection.
• Spondylodiscitis – mostly treated with antibiotics.
• Epidural abscess with neurologic defi cit requires surgery, but remember these occur often in patients who are immunocompromised.
Defi nition
• S SI or surgical site infection – infection within 30 days of surgery, can be superfi cial or deep and can be hard to distinguish.
• S pondylodiscitis/osteomyelitis is a hematogenous infection – often associated with IV drug abuse and in immunocompromised patients.
Etiology
• SSI: contamination at surgery.
• Obesity increases risk.
• Poor diabetic control increases risk.
• Longer operating times. • Hematogenous seeding.
Pathophysiology
• SSI: bacteria contaminate with local wound immune compromise due to hema-toma and dead space
• Hematogenous spread from other sources, i.e., poor oral health, open sore
Radiographs
• X-ray: not often useful for SSI; spondylodiscitis may show endplate erosions and disc collapse.
• CT: can show bony destruction and soft tissue swelling or fl uid collection
• MRI: bright signal in disc, endplate erosion, may show epidural abscess or epi-dural phlegmon, may need contrast to see rim enhancement
Classifi cation
• SSI: superfi cial or deep
Treatment
• SSI
Nonoperative
• Antibiotics alone for cellulitis
• Antibiotics and bracing for spondylodiscitis
• Antibiotics alone for some cases of epidural abscess without neurologic defi cit Operative
• SSI: surgical debridement for deep infections of all necrotic debris, need to remove bone graft that is not adherent to soft tissue, save hardware if stable, remove if loose
• Spondylodiscitis for cases of instability or deformity
• E pidural abscess with neurologic changes; most favor surgery, but studies are mixed.
Complications
• Death from sepsis and multiorgan failure
• Neurologic injury
• Failure to clear infection
Special Situations
• Granulomatous disease – will likely need anterior/posterior surgery for kyphosis or neurologic defi cit
• Antibiotic important for TB especially and may need control of disease before surgery
• Stage surgery when possible
• Pediatric discitis – mostly antibiotic and surgery only for refractory cases
Bibliography
1. A rko 4th L, Quach E, Nguyen V, Chang D, Sukul V, Kim BS. Medical and surgical management of spinal epidural abscess: a systematic review. Neurosurg Focus. 2014;37(2):E4. doi: 10.3171/2014.6.FOCUS14127.
2. H sieh PC, Wienecke RJ, O’Shaughnessy BA, Koski TR, Ondra SL. Surgical strategies for vertebral osteomyelitis and epidural abscess. Neurosurg Focus. 2004;17(6):E4.
5 Spine Tumors
Take-Home Message
• Need to defi ne spinal stability and risk of deformity.
• Need to determine neurologic status.
• Pain caused by tumor and above factors.
• Metastatic disease most common.
Defi nition
• Tumor is present in the bone and surrounding tissues of the spine, causing destruction and potentially making the spine unstable or prone to neurologic injury.
Etiology
• Metastatic disease:
– Breast, lung, thyroid, prostate, renal
• Multiple myeloma is the most common primary tumor, often presents as osteo-porotic compression fracture.
• Other primary bone tumors are very rare:
– O steoid osteoma (most often posterior elements), osteoblastoma, osteosarcoma, chondrosarcoma, GCT, ABC
Pathophysiology
• Neoplastic growth
• Causes osteoclasts to resorb bone
Radiographs
• X-rays: bony destruction, deformity, and fracture; look for destruction of the pedicle on AP view of the lumbar spine.
• CT: bony defi nition of the spine and canal.
• MRI: neurologic compromise, bone and soft tissue involvement.
• Bone scan: screen for bony metastases throughout skeleton.
• PET scan.
Classifi cation
• Depends on tumor staging classifi cations
Treatment
• Work up tumor and get tissue type.
Nonoperative
• Radiation.
• Chemotherapy.
• Try to avoid bracing for palliative measures.
Operative
• Stabilize.
• Decompress.
• If metastatic disease, try to operate prior to radiation.
• En bloc resection for curable primary tumors.
• With short life expectancy, try to make spine immediately stable.
• Renal cell carcinoma is vascular and may benefi t from preop embolization.
Complications
• Failure of fi xation
• Infection
• Local recurrence
• Neurologic injury
• DVT/PE – malignancy increases hypercoagulability
• Bleeding
Bibliography
1. Perrin RG, Laxton AW. Metastatic spine disease: epidemiology, pathophysiol-ogy, and evaluation of patients. Neurosurg Clin N Am. 2004;15:365–73.
2. White AP, Kwon BK, Lindskog DM, Friedlaender GE, Grauer JN. Metastatic disease of the spine. J Am Acad Orthop Surg. 2006;14(11):587–98.
Infl ammatory Disorders
1 Ankylosing Spondylitis
Take-Home Message
• Infl ammatory enthesopathy, facet infl ammation
• Related to HLA-B27 antigen, males more often than females
• Causes bamboo spine appearance
• Involves SI joints
• Osteoarthritis of the hips
Defi nition
• Enthesis – where the tendon, muscle, or ligament attaches to bone.
• A nkylosing spondylitis is an infl ammatory disorder where the anterior longitudinal ligament attaches to bone.
Etiology
• Autoimmune phenomenon
• Associated with HLA-B27 antigen
S. E. Smith , MD
Department of Orthopaedics, Denver Health Medical Center,
777 Bannock Street, Denver 80204 , CO , USA e-mail: samuel.smith@dhha.org
© Springer-Verlag France 2015 353
C. Mauffrey, D.J. Hak (eds.), Passport for the Orthopedic Boards and FRCS Examination, DOI 10.1007/978-2-8178-0475-0_14
Pathophysiology
• Enthesitis of discs and facets.
• Syndesmophytes are marginal.
• SI joints involved.
• Other organ systems involved.
• Causes kyphosis especially the cervicothoracic junction.
• Fractures can occur with little trauma.
Radiographs
• X-rays: Marginal syndesmophytes
• CT: Bony defi nition in case of fracture
• MRI: Can identify occult fracture
• Nuclear medicine to look for occult fracture and SI infl ammation
Classifi cation None
Treatment
Nonoperative
• NSAIDs.
• DMARDs: TNF-alpha-blockers.
• Postural and fl exibility exercises.
• Treat bone density.
Operative
• Fractures may need posterior and anterior fi xation.
• Epidural hematoma may need draining.
• Chin on chest deformity: Cervicothoracic osteotomy.
• M ay need corrective osteotomies anywhere in the thoracic or lumbar spine areas.
Complications
• Failure of fi xation
• Neurologic injury very high risk
• Death
• Failure around long lever arm
Bibliography
1. de Peretti F, Hovorka I, Aboulker C, Bonneau G, Argenson C. Fracture of the spine, spinal epidural haematoma and spondylitis. Report of one case and review of the literature. Eur Spine J. 1993;1(4):244–8.
2. Masiero S, Bonaldo L, Pigatto M, Lo Nigro A, Ramonda R, Punzi L. Rehabilitation treatment in patients with ankylosing spondylitis stabilized with tumor necrosis factor inhibitor therapy: a randomized controlled trial. J Rheumatol. 2011;38(7):
1335–42. doi: 10.3899/jrheum.100987. Epub 2011 Apr 1.
Infl ammatory Disorders 355
2 Rheumatoid Spondylitis
Take-Home Message
• C ranial settling because C1 can settle on C2 as distinct from basilar invagination which may occur with osteoporosis of the skull base
• C 1/C2 instability fundamental, erosion of transverse ligament of the atlas
• Subaxial subluxations
• Pain and myelopathy
Defi nition
• Rheumatoid arthritis is a synovial proliferative disease.
Etiology
• Viral, autoimmune causing synovial proliferation
Pathophysiology
• A nterior arch of C1, synovial joint exists between odontoid and tranverse ligament of the atlas, facet and synovial joints are relatively large compared to the overall motion segment in the cervical spine, thoracic and lumbar spines are spared
• Rheumatoid pannus possible behind the odontoid, instability possible between C1/C2 and occiput C2
Radiographs
• X -ray: C1/C2 instability, check fl exion/extension fi lms, ADI greater than 3 mm
• R eview Ranawat, McGregor, Chamberlin, etc. lines, defi ne the relationship of the odontoid to foramen magnum
• MRI: C1/C2 relationship and pannus formation, spinal cord compression and cord signal, cervicomedullary angle should be less than 135°, can be compressed by the odontoid in the foramen magnum
• M yelography/CT when MRI not possible or when bony anatomy needs defi nition for operative therapy
Classifi cation
• Know classifi cation schemes for myelopathy, Nurick, Ranawat, Japanese Orthopedic Association.
Treatment
Nonoperative
• DMARDs
• Steroids
• Observation
Operative
• O ccipitocervical fusion, C1/C2 fusion, C1 posterior arch resection or enlargement of the foramen magnum with fusion, transoral odontoid and pannus removal, multilevel fusion which may span from the occiput to cervical spine depending upon pathology
Complications
• Death with or without operative therapy
• Neurologic injury
• Pseudarthrosis
• Vertebral artery injury and posterior or cerebellar stroke
• CSF leak
• Sagittal sinus injury from occipital fi xation
• Continued progression of myelopathy in spite of adequate decompression
• DVT/PE
Bibliography
1. Shen FH, Samartzis D, Jenis LG, An HS. Rheumatoid arthritis: evaluation and surgical management of the cervical spine. Spine J. 2004;4(6):689–700.
Trauma
1 Spinal Cord Injury
Take-Home Message
• Know the different cord syndromes, anterior, posterior (rare), central, and Brown-Sequard (hemisection).
• Use of steroids for spinal cord injury is controversial, may cause root spar-ing, and complication rate is high in some series.
• Know how to defi ne level of injury.
Defi nition
• Damage to tissue of the spinal cord altering its function and causing varying degrees of paralysis
• Level of spinal cord injury defi ned by lowest level of normal sensory and motor function bilaterally
Etiology
• Blunt trauma
• Penetrating trauma – this is where hemisection is more likely.
S. E. Smith , MD
Department of Orthopaedics, Denver Health Medical Center,
777 Bannock Street, Denver 80204 , CO , USA e-mail: samuel.smith@dhha.org
© Springer-Verlag France 2015 357
C. Mauffrey, D.J. Hak (eds.), Passport for the Orthopedic Boards and FRCS Examination, DOI 10.1007/978-2-8178-0475-0_15
Pathophysiology
• Direct trauma
• Edema
• Vascular insult
• Free radicals
Radiographs
• Needs myelogram/CT or MRI to look at the cord
• MRI – only way to see substance of the cord
Classifi cation
• ASIA (American Spinal Injury Association)
• A – complete, B – sensory preservation distally, C – sensory and motor activ-ity less than Grade 3, D – sensory and motor activity greater than Grade 3, E – normal
Treatment
• Steroids are controversial.
• Stabilize the spine injury from the fi eld to the ER.
• D ecompress the spinal canal when appropriate and operatively stabilize the spine.
• DVT prophylaxis – rate of DVT and PE high
• Gunshot wound – leave alone unless intrathecal or causing progressive neuro-logic defi cit
Complications
• DVT
• Pressure sores
• Urinary tract infection
• Autonomic dysfunction – bradycardia, hypotension, autonomic dysrefl exia from visceral distention especially the bladder
Bibliography
1. Eidelberg E. The pathophysiology of spinal cord injury. Radiol Clin North Am.
1977;15(2):241–6.
2 Cervical Spine Injury
Take-Home Message
• Look for other injuries – head, chest.
• Look for noncontiguous spine fractures, vertebral artery injury.
• Protect the spinal cord.
• Know protocol or have one in place at your institution for collar removal.
Defi nition
• Injury to the bone and ligamentous structure of the cervical spine from the occiput to C7
Etiology
• Trauma:
– Fall, MVC, penetrating trauma
• Beware of spine injury associated with ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, ossifi cation of the posterior longitudinal ligament, osteoporosis, and cervical spondylosis (risk of central cord syndrome even without fracture).
• Risk by mechanism: high-speed MVC, fall greater than 10 ft, head injuries.
Pathophysiology
• Fracture
• Ligament injury
• Cord injury
• Edema
• Bleeding
• Vertebral artery injury
Radiographs
• Clearance protocols
• C T scans for intoxicated patients, distracting injuries, i.e., other fractures, midline tenderness
• C T-angiogram for high risk of vertebral artery injury (C1/C2 or transverse foramen injuries)
Classifi cation
• Depends on specifi c injury
Treatment
• Depends on specifi c injury
Complications
• Airway compromise
• Respiratory failure
• Neurologic injury
Bleeding into the canal or cord
• DVT/PE
• Pressure sores
Pediatric Cervical Spine Trauma
• Occiput/C1 injuries more common.
• X-rays interpreted differently due to immature skeleton.
• More physiologic motion can be confused with instability.
• S oft tissues anterior to the cervical spine wider than in the adult, i.e., 6 mm at C2 and 22 mm at C6.
• ADI in kids 5 mm compared to 3 mm in adults.
• A ccount for the size of the child’s head compared to the thorax when stabilizing the cervical spine, relatively large head causes fl exion on a fl at surface.
• Beware that atlantoaxial instability can occur with pharyngitis.
Bibliography
1. Lebl DR, Bono CM, Velmahos G, Metkar U, Nguyen J, Harris MB. Vertebral artery injury associated with blunt cervical spine trauma: a multivariate regression analysis. Spine (Phila Pa 1976). 2013;38(16):1352–61. doi: 10.1097/ BRS.0b013e318294bacb .
2. McCall T, Fassett D, Brockmeyer D. Cervical McCall T, Fassett D, Brockmeyer D.
Cervical spine trauma in children: a review. Neurosurg Focus. 2006;20(2):E5.
3 Occiput/C1 Injuries
Take-Home Message
• R arely survive but survival more common with improved resuscitation of patients at the scene
• By defi nition occiput/C1 dissociation unstable
• Always needs surgery
Defi nition
• Disruption of ligamentous connection between occiput, C1, and C2 Etiology
• High-energy trauma:
– Children more susceptible due to relatively large size of the head compared to the trunk
Pathophysiology
• Disruption of occiput/C1 joint capsule
• Disruption of paired alar ligaments of the dens
Radiographs
• Diffi cult to see, review Power’s ratio – establishes anterior/posterior relationship of occiput to C1
• CT – essential to see bony relationships
• MRI to look for soft tissue and spinal cord injuries
Classifi cation
• Anterior
• Posterior
• Distractive
Treatment
• Operative always as it is grossly unstable:
– O cciput to C1 or more commonly C2 fusion, wiring or screw, occipital plate and rods
Complications
• Neurologic injury pentaplegia
• CSF leak from occipital screws
• Injury to transverse sagittal sinus with potential for death
• DVT/PE
• Infection
Bibliography
1 . G ire JD, Roberto RF, Bobinski M, Klineberg EO, Durbin-Johnson B. The utility and accuracy of computed tomography in the diagnosis of occipitocervical dissociation. Spine J. 2013;13(5):510–9. doi: 10.1016/j.spinee.2013.01.023. Epub 2013 Feb 22.
2. Lador R, Ben-Galim PJ, Weiner BK, Hipp JA. The association of occipitocervical dissociation and death as a result of blunt trauma. Spine J. 2010;10(12):1128– 32. doi: 10.1016/j.spinee.2010.09.025 .
4 Fractures of the Atlas
Take-Home Message
• 7 mm of lateral mass displacement combined defi nes rupture of the transverse ligament of the atlas.
• Otherwise atlas fractures mostly stable.
• The canal of the occiput to C2 is wide and accounts in part for reduced risk of neurologic injury with these fractures.
• B eware of high rate of contiguous and noncontiguous spine fractures and head injury.
Defi nition
• Fracture of one or both arches of C1 with or without displacement of the lateral masses
Etiology
• Usually axial trauma
Pathophysiology
• T rauma with axial load to the lateral masses causing a disruption of the C1 ring typically involving the arches
Radiographs
• X-ray: open mouth, shows widening between dens and lateral masses and over-hang of C1 lateral masses on C2 superior facets
• CT: shows best and defi nes fracture complexity
• MRI sometimes to show rupture of TAL from bone
Classifi cation
• Type I: anterior arch fracture
• Type II: bilateral arch fractures from bursting injury to C1
• Type III: unilateral mass displacement
Treatment
Nonoperative
• Typically bracing with semirigid collar for 6–8 weeks
Operative
• I f transverse ligament of the atlas is ruptured, C1/C2 fusion with instrumentation needed
• C1 lateral mass and C2 pedicle screws or Magerl’s transarticular technique
• Preop CT needed to make sure that screws can be passed safely without entering the foramen transversarium
Complications
• Neurologic injury: rare
• Infection
• DVT/PE
• Greater occipital nerve injury
• Vertebral artery injury
• Dural tear or leak
Bibliography
1. Jackson RS, Banit DM, Rhyne 3rd AL, Darden 2nd BV. Upper cervical spine injuries. J Am Acad Orthop Surg. 2002;10(4):271–80. Review.
2 . V ergara P, Bal JS, Hickman Casey AT, Crockard HA, Choi D. C1-C2 posterior fi xation: are 4 screws better than 2? Neurosurgery. 2012;71(1 Suppl Operative): 86–95. doi: 10.1227/NEU.0b013e318243180a .
5 Hangman’s Fracture
Take-Home Message
• C lassic presentation of C2 pars fractures with separation of the vertebral body from posterior elements, but there are many variations where fractures involve lateral masses.
• High association with fractures at other levels of the spine.
• Because of the wide canal at this level, patients mostly present neurologi-cally normal.
• Most fracture types are stable and do not require operative treatment.
• Avoid traction in IIA fractures as they have a distraction component and traction therefore dangerous.
Defi nition
• C 2 fracture separating posterior elements from the anterior elements, sometimes with subluxation of C2 on C3
Etiology
• H yperextension, fracturing the pars with subsequent fl exion which may cause C2/C3 subluxation
• Motor vehicle accidents
Pathophysiology
• Most fractures caused by initial hyperextension followed by fl exion.
• IIA fractures include fl exion/distraction component and require different treatment.
Radiographs
• X-rays defi ne basic injury.
• CT best for details of the bony injury.
• CTA to detect vertebral artery injury.
• MRI to look at the cord if needed, also may help defi ne fl exion/distraction component.
Classifi cation
• Type I – may have up to 3 mm anterior displacement but no angulation
• Type II – have displacement up to 3 mm and angulation of C2/C3
• T ype IIA – very important distinction, have no displacement but are angulated and represent a fl exion/distraction injury, do not use traction
• Type III – same as Type I but with dislocated facets at C2/C3
Treatment
Nonoperative
• Type I fractures can be treated in rigid orthosis – autofusion of C2/C3 facets likely.
• Type II fractures can be treated with traction and halo.
• T ype IIA fractures should not be treated in traction, and rather they are placed in extension and then compressed in a halo.
Operative
• Type III fractures are treated operatively.
• Anterior C2/C3 discectomy, fusion with plate fi xation.
• Posterior C1 to C3 fusion.
• Repair of pars fractures by direct screw fi xation.
• S ome Type II fractures with 5 mm or more of displacement may need surgery.
Complications
• Neurologic injury
• Vertebral artery injury
• Nonunion
• Malunion usually well tolerated
• Infection
• DVT/PE
• Decubiti from being in one position for traction
Bibliography
1. E ffendi B, Roy D, Cornish B, Dussault RG, Laurin CA. Fractures of the ring of the axis. A classifi cation based on the analysis of 131 cases. J Bone Joint Surg Br. 1981;63-B(3):319–27.
2. L evine AM, Edwards CC. The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am. 1985;67(2):217–26.
3. V accaro AR, Madigan L, Bauerle WB, Blescia A, Cotler JM. Early halo immobilization of displaced traumatic spondylolisthesis of the axis. Spine (Phila Pa 1976). 2002;27(20):2229–33.
6 Rotatory Atlantoaxial Instability
Take-Home Message
• Mostly nontraumatic but rather associated with infl ammation or ligamentous laxity
Defi nition
• R otation of C1 on C2 with subluxation or dislocation of C1/C2 lateral mass joints, can also be associated with translational change if there is disruption of the transverse ligament of the atlas
Etiology
• Pharyngeal infl ammation: Grisel’s syndrome
• Joint laxity as in Down’s syndrome or juvenile arthritis
Pathophysiology
• Infl ammatory changes weakening the ligamentous structures of C1/C2 or underlying ligamentous laxity
Radiographs
• Open-mouth X-ray: can look for asymmetry of odontoid lateral mass relation-ship but sometimes hard to see
• CT with dynamic views: best study
• M RI: may be hard to interpret but best way to see the cord and its relationship to the canal
Classifi cation
• Type I: rotational subluxation of C1 on C2 with the odontoid being the axis of rotation
• T ype II: rotation about one of the facet joints as the axis with potential injury to transverse ligament of the atlas
• Type III: both C1 lateral masses translated anteriorly in addition to rotation and defi nes disruption of the transverse ligament of the atlas
• Type IV: posterior displacement and rotation and very rare
Treatment
• For the fi rst week can be observation, perhaps ibuprofen, and wait for spontane-ous location
• Skull traction over 1–3 days to try and relocate
• Manipulation with tongs
• May require halo placement
• May in rare circumstance require C1/C2 fusion
Complications
• Mostly a problem in children and complications rare
• Infection
• Malrotation and fi xed deformity
Bibliography
1. Pang D. Atlantoaxial rotatory fi xation. Neurosurgery. 2010;66(3 Supp):161–83. doi: 10.1227/01.NEU.0000365800.94865.D4 .
7 Odontoid Fracture
|
Take-Home Message • Nonunion higher risk with Type II fractures with any of the following: – 5 mm displacement – Comminution – Angulation more than 10° – Age greater than 50 • Normal atlanto-dens interval on X-ray 3 mm for adult and 5 mm for children |
Defi nition
• Fractures of the odontoid process
Etiology
• Both fl exion and extension mechanisms
• Type I fractures may be associate with occipitocervical injuries
Pathophysiology
• Disrupts the relationship between C1 and C2 with respect to stability.
• T ype I injuries include alar ligament avulsions which attach to C1 and to the occiput.
Radiographs
• X-rays: check lateral and open-mouth views
• C T: ADI of greater than 10 mm or SAC (space available for the cord) less than 17 mm highly associated with neurologic defi cit
• CT/angiography to look for vertebral artery injury
• MRI: looks at the spinal cord and signal changes
Classifi cation
• Anderson and D’Alonzo
– Type I: apical avulsion-type fractures
– Type II: waist fractures at the level of the transverse ligament of the atlas
– Type III: involving the vertebral body
Treatment
Nonoperative
• Halo for young people with Type II odontoid
• Rigid collar for elderly people, more complication with halo party due to osteoporosis
Operative
• Odontoid screw fi xation to preserve rotation about the odontoid
• C1/C2 posterior fi xation and fusion with wires, screws, and rods and bone graft-ing, eliminates rotation between C1 and C2 which is at least 50 % of the total cervical rotation but not all odontoid fractures can be fi xed with a screw
Complications
• DVT/PE especially with spinal cord injury
• Infection
• Nonunion and malunion
• Neurologic
• Blindness
• Positional neuropathies
Bibliography
1. Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis. J Bone Joint Surg Am. 1974;56(8):1663–74.
2 . K onieczny MR, Gstrein A, Müller EJ. Treatment algorithm for dens fractures: non-halo immobilization, anterior screw fi xation, or posterior transarticular C1-C2 fi xation. J Bone Joint Surg Am. 2012;94(19):e144(1–6). doi: 10.2106/ JBJS.K.01616 .
8 Subaxial Cervical Spine Trauma
Take-Home Message
• Know the SLIC
• C ombination of bone, ligament, and neurologic defi cit to defi ne stability of injury and, therefore, operative vs. nonoperative treatment
• Requires bony and soft tissue imaging in conjunction with physical fi nd-ings to accurately defi ne stability
Defi nition
• Trauma to the bone, ligament, and nerve structures of the cervical spine
Etiology
• D ifferent mechanism of force applied to the spine from motor vehicle, trauma, falls, penetrating trauma, violence, etc.
• Flexion, fl exion/distraction, axial load, hyperextension, sheer, lateral bending, and rotational forces
• F or example, hyperextension injuries in the face of preexisting pathology, like DISH
Pathophysiology
• Post-injury infl ammatory change of bone, ligament and neurologic tissue
• Sometimes leads to neurologic defi cit
• Fracture pattern depends on force direction
Radiographs
• X-ray: defi nes bony injury and overall spinal alignment.
• CT: gives accurate 3-D image of bony injury and facet joint location.
• MRI defi nes neurologic and soft tissue injuries.
Classifi cation
• SLIC classifi cation-point system – 4 points is in between, less than four nonoperative, and more than four defi nitely operative
• Morphology
|
Compression fracture |
1 |
|
Burst fracture |
2 |
|
Distraction (can be disc hyperextension or facet perch) |
3 |
|
Translation/rotation |
4 |
• Neurologic involvement
|
Root injury |
1 |
|
Complete cord |
2 |
|
Incomplete cord |
3 |
Continued compression in the face of neurologic defi cit
• Posterior ligamentous complex
|
Intact |
0 |
|
Injury suspected/indeterminate |
2 |
|
Defi nitely Injured |
3 |
Treatment
Nonoperative
• Nonoperative can be observation or bracing, may require halo
Operative
• D epends on pathology, comminution of any burst component and the need to decompress any neurologic injury.
• Can be anterior, posterior, or combined and possibly staged.
• Goal is to decompress, stabilize the spine, and mobilize the patient.
Complications
• DVT/PE especially with spinal cord injury
• Infection
• Neurologic
• Blindness
• Positional neuropathies
• Decubiti
Bibliography
1. Kwon BK, Vaccaro AR, Grauer JN, Fisher CG, Dvorak MF. Subaxial cervical spine trauma. J Am Acad Orthop Surg. 2006;14(2):78–89.
2. Patel AA, Hurlbert RJ, Bono CM, Bessey JT, Yang N, Vaccaro AR. Classifi cation and surgical decision making in acute subaxial cervical spine trauma. Spine (Phila Pa 1976). 2010;35(21 Suppl):S228–34. doi:1 0.1097/BRS.0b013e3181f330ae.
3. Whang PG, Goldberg G, Lawrence JP, Hong J, Harrop JS, Anderson DG, Albert TJ, Vaccaro AR. The management of spinal injuries in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis: a comparison of treatment methods and clinical outcomes. J Spinal Disord Tech. 2009;22(2):77–85. doi: 10.1097/BSD.0b013e3181679bcb .
9 Thoracolumbar Spine Trauma
|
Take-Home Message • Know the TLICS. • C ombination of bone, ligament, and neurologic defi cit to defi ne stability of injury and, therefore, operative vs. nonoperative treatment. • Requires bony and soft tissue imaging in conjunction with physical fi nd-ings to accurately defi ne stability. |
Defi nition
• Trauma to the bone, ligament, and nerve structures of the spine
Etiology
• D ifferent mechanism of force applied to the spine from motor vehicle, trauma, falls, penetrating trauma, violence, etc.
• Flexion, fl exion/distraction, axial load, hyperextension, sheer, lateral bending, and rotational forces
Pathophysiology
• As per the defi nition above
• Post-injury infl ammatory change of bone, ligament, and neurologic tissue
• Sometimes leads to neurologic defi cit
Radiographs
• X-ray: defi nes bony injury and overall spinal alignment.
• CT: gives accurate 3-D image of bony injury and facet joint location.
• MRI defi nes neurologic and soft tissue injuries.
Classifi cation
• TLICS classifi cation-point system – 4 points is in between, less than four nonoperative, and more than four defi nitely operative
• Morphology
|
Compression fracture |
1 |
|
Burst fracture |
2 |
|
Translation/rotation |
3 |
|
Distraction |
4 |
• Neurologic involvement
|
Incomplete |
3 |
|
Complete |
2 |
|
Cauda equina |
3 |
• Posterior ligamentous complex
|
Intact |
0 |
|
Injury suspect/indeterminate |
2 |
|
Injured |
3 |
Treatment
• Nonoperative can be observation or bracing, historically burst fractures treated aggressively but many can be treated closed, from the University of Iowa study
Operative
• D epends on pathology, comminution of any burst component, and the need to decompress any neurologic injury.
• Can be anterior, posterior, or combined and possibly staged.
• Goal is to decompress, stabilize the spine, and mobilize the patient.
Complications
• DVT/PE especially with spinal cord injury
• Infection
• Neurologic
• Blindness
• Positional neuropathies
• Decubiti
• Death
Bibliography
1. Cao Y, Krause JS, DiPiro N. Risk factors for mortality after spinal cord injury in the USA. Spinal Cord. 2013;51(5):413–8. doi:1 0.1038/sc.2013.2. Epub 2013 Feb 5.
2 . P atel AA, Vaccaro AR. Thoracolumbar spine trauma classifi cation. J Am Acad Orthop Surg. 2010;18(2):63–71.
3. Weinstein JN, Collalto P, Lehmann TR. Thoracolumbar “burst” fractures treated conservatively: a long-term follow-up. Spine (Phila Pa 1976). 1988;13(1):33–8.
10 Osteoporotic Vertebral Fractures
Take-Home Message
• Most common fragility fracture.
• Multiple fractures are likely.
• No history of trauma always.
• Can affect life expectancy due to pulmonary function defi cits.
Defi nition
• Fracture due to insuffi cient strength of the vertebral body caused by loss of bone density, i.e., osteoid and mineral loss
Etiology
• Vertebral bodies largely cancellous bone and are therefore more susceptible to bone loss.
• Osteoporosis with or without trauma can lead to fracture.
Pathophysiology
• Osteoporosis leading to decrease strength in bone and fracture
• Also changes in structure of bone leading to weakness in the bone
Radiographs
• X-rays may show “codfi sh” vertebra or simple wedging.
• Vertebral bodies may appear with vertical striations.
• CT defi nes bony anatomy of the fracture, whether or not there is burst component.
• MRI defi nes the canal and may show fatty replacement of the marrow.
• DEXA – dual energy X-ray absorptiometry
Classifi cation
• WHO defi nition of osteoporosis is greater than 2.5 deviations below the mean peak bone mass of young adults based on DEXA.
Treatment
• Many patients are asymptomatic.
Nonoperative
• Observation
• Bracing
Operative
• V ertebroplasty – AAOS makes strong recommendation against vertebroplasty because of cement extravasation in the neurologically intact patient.
• Kyphoplasty.
• Decompression and stabilization, hardware, may need cement supplementation.
Complications
• Infection
• DVT/PE
• Neurologic injury
• Chronic pain
• Adjacent segment fractures
Bibliography
1. Link TM. Osteoporosis imaging: state of the art and advanced imaging. Radiology. 2012;263(1):3–17. doi: 10.1148/radiol.12110462 .
2. McGuire R. AAOS clinical practice guideline: the treatment of symptomatic osteoporotic spinal compression fractures. J Am Acad Orthop Surg. 2011;19(3):183–4.
3 . P atil S, Rawall S, Singh D, Mohan K, Nagad P, Shial B, Pawar U, Nene A. Surgical patterns in osteoporotic vertebral compression fractures. Eur Spine J. 2013;22(4):883–91. doi:1 0.1007/s00586-012-2508-4. Epub 2012 Sep 28.
11 Fractures of the Sacrum
Take-Home Message
• This section is for sacral fractures as distinct from fractures of the pelvic ring.
• U-shaped fractures of the sacrum represent a dissociation of the spine from the pelvis.
• T ransverse sacral fractures differ in terms of whether or not they are high or low.
• Neurologic involvement common.
Defi nition
• U-shaped fractures of the sacrum are where proximal sacral segments are no longer connected by bony or soft tissue to the distal ala, lower sacrum, and pelvis; spinopelvic dissociation.
• Transverse fractures of the sacrum may involve a sacral kyphosis, and stabiliza-tion of the SI joints may be needed as well as sacral laminectomy to decompress canal. Etiology
• Motor vehicle trauma
• Falls
• Insuffi ciency fractures
Pathophysiology
• Axial forces from falls often cause this
• Osteoporosis leading to sacral insuffi ciency fracture
Radiographs
• O ften missed on X-ray, needs high index of suspicion with pelvic pain and perianal sensation changes.
• CT is the best study.
• MRI to look at cauda equina.
Classifi cation
• Know the Denis classifi cation, covered elsewhere.
• Transverse fractures subdivided but this does not direct treatment.
Treatment
Nonoperative
• Simple observation and symptomatic treatment – controversial
Operative
• Lumbopelvic fi xation, triangular osteosynthesis
• Percutaneous fi xation with SI screws of appropriate length or bilateral fi xation, at least two screws to prevent further kyphosis
• Sacral laminectomy
• Bilateral lateral sacral fi xation for some transverse sacral fractures
Complications
• Infection
• Neurologic defi cit
• DVT/PE
• Wound dehiscence
• Chronic pain
Bibliography
1. Fountain SS, Hamilton RD, Jameson RM. Transverse fractures of the sacrum. A report of six cases. J Bone Joint Surg Am. 1977;59(4):486–9.
2 . K önig MA, Jehan S, Boszczyk AA, Boszczyk BM. Surgical management of U-shaped sacral fractures: a systematic review of current treatment strategies. Eur Spine J. 2012;21(5):829–36. doi: 10.1007/s00586-011-2125-7. Epub 2011 Dec 23.
3. Nork SE, Jones CB, Harding SP, Mirza SK, Routt Jr ML. Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma. 2001;15(4):238–46.
4 . R oy-Camille R, Saillant G, Gagna G, Mazel C. Transverse fracture of the upper sacrum. Suicidal jumper’s fracture. Spine (Phila Pa 1976). 1985;10(9):838–45.
Deformity
1 Pediatric-Adolescent Idiopathic Scoliosis
Take-Home Message
• Right thoracic curve common, can be progressive
• Left thoracic curve needs MRI
• Large curves can cause cardiopulmonary compromise
• More common in females
Defi nition
• Lateral curvature of the spine in the coronal plane of unknown cause Etiology
• Unknown
– Family history of fi rst-degree relatives important
• Inner ear problem, proprioceptive cord problem, hormonal
Pathophysiology
• Unknown
• Lateral curvature causes rotational deformity and lends to progression
S. E. Smith , MD
Department of Orthopedics, Front Range Orthopedic Center, 1551 Professional Ln Suite 200, Longmont, CO 80501, USA e-mail: samuel.smith@dhha.org
© Springer-Verlag France 2015 377
C. Mauffrey, D.J. Hak (eds.), Passport for the Orthopedic Boards and FRCS Examination, DOI 10.1007/978-2-8178-0475-0_16
Radiographs
• X-rays: Full-length standing fi lms, fi rst fi lm AP and lateral as there can be sagit-tal plane imbalances as well, protect reproductive organs
• Document Cobb angle and spinal balance, spinal rotation, apical vertebrae, sta-ble vertebra, check clavicle angle (important for determining whether or not to include upper thoracic curve)
• Use fl exibility x-rays to further defi ne curve behavior when deciding on opera-tive treatment
• Check pelvis for Risser grade (0–4)
• MRI for left-sided curves and then look at whole spinal axis
Classifi cation
• King classifi cation – older and less often used at meetings
• Lenke classifi cation – more complex but better able to use for treatment and especially for level selection, takes into account sagittal plane abnormalities in deciding structural nature of the curve
Treatment
Nonoperative
• Observation for small curves and to document progression
• Bracing for curves 25–45°
• Type of brace determined by apex of curve, above T7 need Milwaukee-type brace, otherwise can use underarm orthosis
• Brace wear should be full time, i.e., 23 h out of 24, but there are studies showing that less than full-time wear okay
• Trying to halt progression, duration of brace wear at least 1 year and otherwise until skeletal maturity defi ned by multiple factors
Operative
• Posterior fusion and fi xation
• Anterior fusion and fi xation especially lumbar and thoracolumbar curves
• Combined approaches for more severe or infl exible curves
Complications
• Loss of correction
• Adding on of the curve
• Crankshaft phenomenon in pediatric patients
• Pseudarthrosis
• Infection
• Neurologic injury
• SMA syndrome can cause postop ileus
Special Situations
Infantile idiopathic scoliosis
• Boys are more commonly affected
• Left thoracic curve more common
• Other congenital defects more common
• Curves less than 30° can be observed
• L ook at study by Mehta, Cobb greater than 20°, RVA greater than 20°, and a phase 2 relationship defi ne progression
• Treatment casting, dual growing rods, or VEPTR
Bibliography
1. Lenke LG. Lenke classifi cation system of adolescent idiopathic scoliosis: treat-ment recommendations. Instr Course Lect. 2005;54:537–42.
2. Mehta MH. The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint Surg Br. 1972;54(2):230–43.
3 . W ard WT, Rihn JA, Solic J, Lee JY. A comparison of the lenke and king classifi cation systems in the surgical treatment of idiopathic thoracic scoliosis. Spine (Phila Pa 1976). 2008;33(1):52–60. doi: 10.1097/BRS.0b013e31815e392a .
2 Adult Spine Deformity
Take-Home Message
• High complication rate treated operatively
• Nonoperative treatment successful often
• Severe pain and dysfunction attributable to positive sagittal balance
• Diffi cult decision sometimes as to when or when not to fuse to the pelvis
Defi nition
• Scoliosis especially of the lumbar spine caused by asymmetric development of lumbar spondylosis
• May occur in preexisting adolescent idiopathic curve
Etiology
• Degenerative cascade describe by Kirkaldy-Willis which is asymmetric Pathophysiology
• D egenerative cascade leads to disc and facet degeneration, and when this occurs, asymmetrically curve or deformity ensues
• Frequently associated and exacerbated by osteoporosis and associate fractures
• Can occur in preexisting AIS
• When advanced can lead to fl attening of lordosis beyond the ability of the pelvis to retrovert, normal lumbar lordosis roughly equal to pelvic incidence
• Olisthesis, lateral, anterior, or retro often associated
Radiographs
• X-rays: signs of spondylosis, Cobb angle, sagittal plane deformity, olisthesis
• Must get full-length fi lms to evaluate global balance
• CT: defi nes bony anatomy and stenosis, more informative if done with myelo-graphic contrast
• MRI useful to evaluate for stenosis both centrally and in the foramen, radicular symptoms commonly in the concavity of the curve
Classifi cation
• Schwab classifi cation: thoracic, TL/L, double curve, along with a description of the mismatch between the pelvic incidence and the lumbar lordosis as well as the SVA, i.e., the number of centimeters the C7 vertebra is in front of S1
Treatment
Nonoperative
• Exercises, PT
• Manipulative therapy
• NSAIDs
• Avoid opioids
Operative
• Anterior release and reconstruction
• Posterior release and reconstruction
• Have to decide when and when not to fuse to the pelvis
• Osteotomies sometimes employed, Ponte, PSO, VCR
• Combined approaches
Complications
• Infection
• Loss of fi xation, often bone density is poor
• Pseudarthrosis especially L4/L5 and L5/S1
• S moking increases risk of failure of treatment both with respect to pain relief and fusion success
• Neurologic injury
Bibliography
1. Bess S, Schwab F, Lafage V, Shaffrey CI, Ames CP. Classifi cations for adult spinal deformity and use of the Scoliosis Research Society-Schwab Adult Spinal Deformity Classifi cation. Neurosurg Clin N Am. 2013;24(2):185–93. doi: 10.1016/j.nec.2012.12.008.
2 . K otwal S, Pumberger M, Hughes A, Girardi F. Degenerative scoliosis: a review.
HSS J. 2011;7(3):257–64. Epub 2011 Jun 11.
3 Adult Thoracic Kyphosis
Take-Home Message
• Normal kyphosis T2 to T12 20–40°, 45° max
• Normal sagittal balance defi ned by sagittal vertical axis 0–4 cm
• Most of the time will respond to conservative measures
• Patients in positive sagittal balance more at risk for pain and disability
Defi nition
• Abnormal kyphosis caused by degenerative disease or prior Scheuermann’s kyphosis
Etiology
• Prior Scheuermann’s
• Osteoporosis and compression fractures
• Thoracic spondylosis
• Tumor
• Infection
Pathophysiology
• Above issues cause loss of anterior spinal column height
• Gibbus acute kyphosis over short distance from fracture, tumor, or infection
Radiographs
• X-rays: vertebral body wedging caused by trauma or bone destruction from tumor or infection, old Scheuermann’s kyphosis
• Cobb angle: need upright scoliosis fi lms to measure sagittal balance parameters, defi ne bone density
• DEXA scan to measure bone density
• CT: sometimes need this to defi ne bony anatomy
• MRI: prior to surgery to defi ne soft tissues and look at the cord and its relation-ship to the kyphosis, MRI will look at tumor and infection well Classifi cation
None
Treatment
Nonoperative
• NSAIDs
• Hyperextension exercises to strengthen paraspinous muscles
• Modifi cation of activity
Operative
• Anterior/posterior
• Posterior alone with osteotomies
• Combined approaches
• Depends on diagnosis and rigidity of the curve and the degree of sagittal imbalance
Complications
• Complication rate high
• Loss of correction
• Neurologic injury including paralysis
• Proximal junctional kyphosis above the construct
• DVT/PE
• Pseudoarthrosis
• Donor site complications
• Bone graft substitutes and their complications
Bibliography
1 . B ae JS, Jang JS, Lee SH, Kim JU. Radiological analysis of lumbar degenerative kyphosis in relation to pelvic incidence. Spine J. 2012;12(11):1045–51. doi: 10.1016/j.spinee.2012.10.011 . Epub 2012 Nov 14.
4 Other Scolioses
Take-Home Message
• Congenital: hemivertebra and unsegmented bars
• N euromuscular: CP, myelomeningocele, spinal muscular atrophy,
Duchenne’s muscular dystrophy, myelomeningocele
Defi nition
• Congenital: vertebral segmentation abnormalities during gestation
• Neuromuscular: spinal muscular imbalance during growth secondary to neuro-logic abnormality
Etiology
• Congenital: maternal diabetes, Etoh abuse during pregnancy, genetic
• Neuromuscular: variable etiologies
Pathophysiology
• Congenital: hemivertebrae and unsegmented bars
– Other systems involved: genitourinary, cardiac
• Neuromuscular: spine deformity alters sitting or positioning imbalances leading to diffi cult care, pressure sores
Radiographs
• X-rays
Congenital: look for hemivertebra
– Neuromuscular: follow curve progression
• CT: defi ne bony anatomy, diastomatomyelia
• MRI: tethered cord, intradural lipoma, Arnold-Chiari malformations Classifi cation
• None
Treatment
Nonoperative
• Observation
• Do not brace congenital curves
• Can brace neuromuscular curves until surgery appropriate
Operative
• Congenital scoliosis: fi t operation to pathology, most likely to progress with hemivertebra and unsegmented contralateral bar, posterior, anterior/posterior, hemivertebra resection, growing rods, VEPTR
• Neuromuscular: often fuse to the pelvis to control pelvic obliquity
Complications
• Crankshaft phenomenon
• Short stature from fusion in childhood
• Neurologic injury
• Infection
Bibliography
1 . B owen RE, Abel MF, Arlet V, Brown D, Burton DC, D’Ambra P, Gill L, Hoekstra DV, Karlin LI, Raso J, Sanders JO, Schwab FJ. Outcome assessment in neuromuscular spinal deformity. J Pediatr Orthop. 2012;32(8):792–8. doi: 10.1097/ BPO.0b013e318273ab5a .
2. Hedequist D, Emans J. Congenital scoliosis: a review and update. J Pediatr Orthop. 2007;27(1):106–16.
5 Scheuermann’s Kyphosis
Take-Home Message
• Wedging of three consecutive vertebrae
• Schmorl’s nodes
• Growth abnormality of ring apophysis
• Males more commonly affected
Defi nition
• Kyphosis of the thoracic spine caused by wedging of multiple vertebrae, defi ned radiographically by 5° of wedging over three adjacent vertebrae
Etiology
• Unknown and probably multifactorial
– May be autosomal dominant
Pathophysiology
• T here are abnormalities of the growth plate of the anterior vertebrae represented by the disruption of the ring apophysis, may be a secondary effect to the ring apophysis rather than an intrinsic abnormality
Radiographs
• X-rays: normal thoracic kyphosis 20–40°
• Greater than 45° of thoracic kyphosis is abnormal
• Severe kyphosis greater than 75°
• MRI: sometimes need to identify herniated thoracic disc
Classifi cation
• N eed to distinguish from postural kyphosis which will be fl exible and will correct with improved posture
• No classifi cation but you must be able to defi ne Cobb angle and establish fl exi-bility of the curve
Treatment
Nonoperative
• Observation for progression, like scoliosis progresses with growth
• Bracing can be effective in growing child to prevent further deformity; at one time, it was felt that bracing can improve deformity but no longer believed to be the case
Operative
• Posterior surgery with or without osteotomies, posterior shortening
• Anterior surgery with rods, open or VATS, to release anterior structures
• Anterior/posterior surgery
• Fuse to fi rst lordotic disc
Complications
• MRI preop
• Cord can be draped over kyphosis, beware of anterior lengthening causing neu-rologic defi cit
• Infection
• DVT/PE
• Proximal junctional kyphosis
Bibliography
1. B radford DS, Moe JH. Scheuermann’s juvenile kyphosis. A histologic study. Clin Orthop Relat Res. 1975;110:45–53.
2. M iladi L. Round and angular kyphosis in paediatric patients. Orthop Traumatol Surg Res. 2013;99(1 Suppl):S140–9. doi:1 0.1016/j.otsr.2012.12.004. Epub 2013 Jan 1.
6 Adult and Pediatric Spondylolisthesis
Take-Home Message
• Know Wiltse classifi cation
• Know Meyerding grades
• Dysplastic forms have more risk of neurologic sequelae
Defi nition
• Anterior slippage of typically L5 on S1 caused by instability of the motion segment
Etiology
• Multifactorial
• Isthmic defect most common
• Traumatic pedicle fractures
• Dysplastic facets with stretching or fracture of the pars, posterior elements some-times come forward too
Pathophysiology
• Instability of the motion segment
• Stenosis, central and neuroforaminal depending on type of slip
• Problems with sagittal balance
• Sometimes hyperlordotic lumbar spine in patient with high pelvic incidence
• Sometimes lumbosacral kyphosis with higher slip grades
Radiographs
• X -rays: pars defects, slip, dysplastic changes of facet and remodeling changes of dome of sacrum and trapezoidal shape at L5
• Degenerative slip rarely greater than grade 2, has associated spondylotic change, facet degeneration and subluxation seen
• Review pelvic incidence, pelvic tilt, and sacral slope, and understand pelvic inci-dence is a fi xed number and that sacral slope plus the pelvic tilt equals the pelvic incidence
• CT: better defi nes pars defects, bony stenosis, facet joints
• MRI to look at soft tissue associated with pars defects, neurologic visualization especially foramina
Classifi cation
• W iltse classifi cation: type I – congenital; type II – isthmic; type III – degenerative; type IV – traumatic, acute, usually pedicles are fractured; type V – pathologic
• Meyerding classifi cation based on percentage of slip of L5 on S1, hard to defi ne with dysplastic and remodeling changes
Treatment
Nonoperative
• Most of the time nonoperative therapy is successful
• PT and exercises
• NSAIDs
• Activity modifi cation
Operative
• Depends on pathology
• Dysplastic and remodeling changes may require dome osteotomy and reduction of lumbosacral kyphosis
• D egenerative slip can be approached anterior or lateral alone, front and back or posterior alone with or without cages, may need decompression
• I sthmic slip can also be approached variably depending upon pathology and surgeon preference
• S pondyloptosis: L5 in front of the pelvis may need anterior/posterior surgery with complete L5 removal and reduction and fusion of L4 to the sacrum with fi xation to the ilium
Complications
• L5 root palsies
• Infection
• DVT/PE
• Pseudarthrosis
• Repeat surgery
Bibliography
1. Alfi eri A, Gazzeri R, Prell J, Röllinghoff M. The current management of lumbar spondylolisthesis. J Neurosurg Sci. 2013;57(2):103–13.
2 . L abelle H, Roussouly P, Berthonnaud E, Dimnet J, O’Brien M. The importance of spino-pelvic balance in L5-s1 developmental spondylolisthesis: a review of pertinent radiologic measurements. Spine (Phila Pa 1976). 2005;30(6 Suppl):S27–34.
3. Wiltse LL, Newman PH, Macnab I. Classifi cation of spondylolysis and spondylolisthesis. Clin Orthop Relat Res. 1976;117:23–9.
Degenerative Disorders
1 Cervical Spondylosis
Take-Home Message
• Degenerative Cascade
• Degenerative disc changes and facet arthrosis
• Can lead to stenosis
• Changes of aging vs. pathologic change
Defi nition
• Disc degeneration and facet arthropathy leading to a variety of changes which can cause axial and radicular pain can cause neurologic changes
Etiology
• Age related
• Motion and wear and tear over time
• Injuries
• Smoking
• Occupation
• Genetic
S. E. Smith , MD
Department of Orthopedics,
Front Range Orthopedic Center,
1551 Professional Ln Suite 200, Longmont, CO 80501 , USA
e-mail: samuel.smith@dhha.org
© Springer-Verlag France 2015 389
C. Mauffrey, D.J. Hak (eds.), Passport for the Orthopedic Boards and FRCS Examination, DOI 10.1007/978-2-8178-0475-0_17
Pathophysiology
• Degenerative cascade
• DDD with instability, micro or macro
• Annular tearing
• Facet degeneration leading to stenosis
Radiographs
• X -rays: Disc narrowing, endplate sclerosis, marginal osteophytes, uncal hypertrophy, and foraminal narrowing seen on obliques, subluxation
• CT: Defi nes bony anatomy but not good at seeing stenosis unless done with myelography
• MRI: Disc desiccation, foraminal stenosis, central stenosis, disc herniation
• Discography controversial
Classifi cation
• Subjective
• Mild, moderate, severe
Treatment
• Natural history favorable
Nonoperative
• Physical therapy
• Chiropractic care
• Massage
• NSAIDs
• Relative rest
Operative – depends on pathoanatomy
• Decompression
• Fusion
• Instrumentation
Complications
• DVT: PE
• Infection
• Neurologic injury
• Covered in other sections
Bibliography
1 . K elly JC, Groarke PJ, Butler JS, Poynton AR, O’Byrne JM. The natural history and clinical syndromes of degenerative cervical spondylosis. Adv Orthop.
2012;2012:393642.
2 Cervical Disc Herniation
|
Take-Home Message • Typically causes radiculopathy with nerve compression in the foramen, i.e., C6 nerve root in the C5/C6 foramen • Central herniations can cause spinal cord compression and myelopathy • Herniations with axial pain only do not do well with surgery |
Defi nition
• Disruption of the annulus fi brosis of the intervertebral disc leading to displacement of the nucleus pulposus away from the center of the disc
Etiology
• Degenerative cascade
• Microtrauma leading to annular tearing
• Genetic predisposition
Pathophysiology
• Annular tearing as a repetitive phenomenon
• Tears coalesce into a larger annular fi ssure
• Nucleus displaces from the center of the disc into the canal or foramen or both
• Most commonly cause radiculopathy but can cause myelopathy
Radiographs
• Sometimes normal
• Degenerative disc space narrowing sometimes seen
• CT does not show herniation in the cervical spine well
• MRI “gold standard” for diagnosis
• Myelogram/CT for when MRI not possible
Classifi cation
• No accepted classifi cation
Treatment
• Natural history of cervical radiculopathy is favorable
Nonoperative
• Bracing
• Traction: Controversial as to whether it helps or not
• Manipulation
• Medication
• PT
• Spinal injections
Operative
• Anterior cervical discectomy with or without fusion. Most favor fusion to pre-vent collapse of disc into kyphosis
• Fixation vs. stand-alone graft
• Plates or interlocking cages
• Disc arthroplasty
• Posterior foraminotomy avoids fusion and results can be comparable to ACD/ACF and is amenable to less invasive approach
Complications
• Dysphagia
• Aspiration
• Esophageal injury
• I njury to recurrent laryngeal nerve-latest information suggests equal risk from right or left sided approach, review the anatomy as it relates to the aortic arch for the RLN
• Dural tear
• Infection
• DVT/PE
Bibliography
1. Lees F, Turner JW. Natural history and prognosis of cervical spondylosis. Br Med J. 1963;2(5373):1607–10.
2. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg.
2007;15(8):486–94.
3 Cervical Spinal Stenosis
Take-Home Message
• C an be congenital, developmental with degenerative disease, or associated with OPLL
• M ost common source degenerative osteophytes from margins of disc, facet hypertrophy, and degenerative hypertrophy of the uncovertebral “joint”
• Vertebral subluxation a potential factor
• Can cause radiculopathy, myelopathy, or both
Defi nition
• Decreased space for the spinal cord and exiting nerve roots of the cervical spine from a variety of causes
• Congenital stenosis defi ned by Torg ratio or a sagittal diameter of less than 10 mm
• Not everyone with stenosis has symptoms
Etiology
• Degenerative marginal osteophytes and hypertrophy of the abovementioned structures decrease the space available for the cord and nerve roots
– Congenital stenosis can have superimposed degenerative stenosis
• Familial tendency
• Smoking
• Occupational factors
• OPLL ethnic and genetic factors
Pathophysiology
• Degenerative cascade of Kirkaldy-Willis
• OPLL dealt with separately
• C an lead to spinal cord compromise and signs of myelopathy (Hoffman’s, clonus, poor tandem walking, hyperactive refl exes, incoordination )
• Radiculopathy (Spurling’s)
Radiographs
• X-rays: May show osteophytes, deformity, subluxation, and congenital stenosis
• MRI good with canal dimensions and direct visualization of cord and nerve roots • Detects signal change in cord
• Defi nes operative anatomy, limited diagnostically but very useful if used with myelography
Treatment
Nonoperative
• Physical therapy
• Chiropractic care
• NSAIDs
• Opioid therapy for only brief periods
Operative
• Approach depends on specifi c pathoanatomic problems
• Anterior
• Posterior
• Anterior/posterior
• With or without fusion
• ACD/ACF most common procedure and can be single or multiple levels
• Laminoplasty for myelopathy in some cases
• Y ou must correlate symptoms and physical fi ndings to imaging studies, i.e., does the patient have deformity, myelopathy, or radiculopathy? Does the patient need pain relief or prevention of further neurologic deterioration?
Complications
• Paralysis
• Nerve root injury either directly or indirectly. Traction palsies possible and usu-ally resolve with time
• Esophageal injury with anterior approach
• Recurrent laryngeal nerve injury with anterior approach
• Horner’s syndrome
• Infection
• DVT/PE
• Pseudarthrosis
• If use BMP anteriorly, risk of airway compromise from seroma
Bibliography
1. Emery SE. Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(6):376–88.
2 . F ountas KN, Kapsalaki EZ, Nikolakakos LG, Smisson HF, Johnston KW, Grigorian AA, Lee GP, Robinson Jr JS. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976). 2007;32(21):2310–7.
4 Thoracic Herniated Disc
Take-Home Message
• Very rare
• Often calcifi ed and may only see that on CT, this may indicate adherence of the herniation to the dura
• M ore common at the lower thoracic levels where there is more spinal mobility
Defi nition
• Migration of nucleus pulposus through weakened annulus through microtears of the annulus
Etiology
• Degenerative cascade
Pathophysiology
• As per lumbar herniated disc
Radiographs
• X-rays: Thoracic spondylosis, Schmorl’s nodes
• CT: Calcifi cation of the herniation
• M RI: Shows exact nature of herniation and looks at thoracic roots and the spinal cord
Classifi cation
• Central vs. foraminal
• Myelopathy vs. radiculopathy or combination
Treatment
Nonoperative
• Natural history favorable
• NSAIDs
• Exercise and PT
• Manipulation
• Massage
Operative
• D iscectomy: Anterior, costotransversectomy or lateral approach, may need fusion
• VATS
Complications
• Spinal cord injury
• Dural tear
• Infection, DVT/PE
• Recurrent surgery
• Pneumothorax
• Vascular injury
Bibliography
1 . V anichkachorn JS, Vaccaro AR. Thoracic disk disease: diagnosis and treatment.
J Am Acad Orthop Surg. 2000;8(3):159–69.
5 Lumbar Spondylosis
Take-Home Message
• Degenerative cascade of Kirkaldy-Willis
• Disc degeneration and facet arthropathy
• Can lead to deformity, stenosis, subluxation
• N ot always a cause of symptoms and therefore must correlate history and physical with imaging fi ndings
Defi nition
• D egenerative disc disease and facet arthropathy which can cause axial and referred pain, or disc herniation or stenosis with radiculopathy or neurogenic claudication
Etiology
• Changes of aging vs. pathologic change
• Smoking
• Genetic
• Occupation
Pathophysiology
• Disc degeneration
• Facet arthropathy
• Stenosis
• Deformity
• Causes in some case positive sagittal balance, covered in adult deformity and kyphosis sections
Radiographs
• X-rays: Disc narrowing, endplate sclerosis, subluxation, Schmorl’s nodes, mar-ginal osteophytes, facet hypertrophy/arthropathy, and stenosis
• M RI: Disc dessication, disc herniation, stenosis either central, lateral recess, or foramen or combination
• CT alone can be useful when MRI cannot be done or when bony defi nition important for surgery
• Myelography with CT better at defi ning stenosis
• Discography – controversial
Classifi cation
• Subjective
• Mild, moderate, severe
Treatment
• Natural history favorable
Nonoperative
• Physical therapy
• Manipulation
• Massage
• NSAIDs
• Short-term periods of rest
• Short-term opioid therapy
Operative
• Depends on pathoanatomy and its relationship to history and physical exam
• Ranges from decompression to fusion and from single-level procedure to multilevel procedure
Complications
• Neurologic injury
• Infection
• Blood loss
• Dural leak
• Blindness
• Plexopathy-brachial, lumbar • Major vessel, visceral injury
Bibliography
1. Torgerson WR, Dotter WE. Comparative roentgenographic study of the asymptomatic and symptomatic lumbar spine. J Bone Joint Surg Am. 1976;58(6): 850–3.
6 Lumbar Discogenic Back Pain
Take-Home Message
• Operative treatment controversial
• Confi rming disc as real source of pain diffi cult
• Discography controversial
• Success related to psychosocial issues
Defi nition
• Pain caused by disc degeneration
Etiology
• Degenerative cascade – discussed elsewhere
Pathophysiology
• Chondrocyte degeneration
• Disc desiccation
• Instability
• Infl ammatory cytokines
Radiographs
• X-ray: Marginal osteophytes, disc narrowing, endplate sclerosis, and cyst formation
• Discography: Subjective test and controversial in terms of interpreting disc as source of pain, requires control, and disc injection can induce degenerative change
• CT: Facet degeneration and possible facet source of pain, important if disc arthroplasty is a consideration
Classifi cation
• Modic changes I, II, and III worth knowing but type of changes not defi nitively known to relate to pain and instability
Treatment
• Conservative treatment emphasized
Nonoperative
• NSAIDs
• PT
• Massage
• Manipulation
Operative
• Disc arthroplasty, one level typically, two levels can be done, done to reduce adjacent segment degeneration and further surgery
• Arthrodesis, front alone, back alone, front and back
• Cage placement vs. posterior fusion alone
• Avoid operating on multilevel disease as results are not good
• Consider psychosocial screening in these patients
• Results not as good in workers’ compensation cases
Complications
• Infection
• Chronic regional pain
• Repeat surgery and adjacent segment degeneration
• DVT, PE
Bibliography
1 . D ickerman RD, Zigler J. Re: Carragee EJ, Lincoln T, Parmar VS, et al. A gold standard evaluation of the ‘discogenic pain’ diagnosis as determined by provocative discography. Spine 2006;31:2115–23. Spine (Phila Pa 1976). 2007;32(2): 287–8; author reply 288–9.
2. Maghout Juratli S, Franklin GM, Mirza SK, Wickizer TM, Fulton-Kehoe D. Lumbar fusion outcomes in Washington State workers’ compensation. Spine (Phila Pa 1976). 2006;31(23):2715–23.
7 Lumbar Herniated Disc
Take-Home Message
• Know traversing vs. exiting nerve root
• T ypical posterolateral HNP affects traversing root, e.g., L4/L5 HNP causes L5 symptoms and signs
• Foraminal HNP affects exiting root, e.g., L4/L5 HNP causes L4 root compression
• Natural history of lumbar HNP is favorable
• L arge numbers of people have asymptomatic HNP, must correlate symptoms and signs
Defi nition
• Migration of nucleus pulposus through weakened annulus through microtears of the annulus
Etiology
• Part of the degenerative cascade
• Genetics
• Smoking
• Working or driving in an environment where patient is exposed to vibration, controversial
• Repetitive labor
Pathophysiology
• Microtears of the annulus
• Torsional strain
• Disc desiccation
Radiographs
• X-rays: May be normal or show signs of lumbar spondylosis
• CT: May show displacement of disc but does not defi ne type of herniation
• CT/myelography: More defi nitive in showing nerve root or thecal sac displacement
• M RI: Disc desiccation, defi nes protrusion vs. extrusion vs. sequestration, shows cauda equina well
Classifi cation
• Disc protrusion with displaced disc material and canal or foraminal encroach-ment but with intact annulus, disc edge distance less than the base distance
• Disc extrusion through annulus and disc edge distance is more than the base distance
• Disc sequestration is when displaced nucleus has separated from the main disc Treatment
• N atural history favorable within 6 weeks to 3 months from the onset of symptoms
• NSAIDS, PT, massage, manipulation
• Discectomy: Open vs. minimally invasive, operating microscope
• Fusion not necessary in vast majority of cases, true even with the fi rst recurrence
• Cauda equina with central HNP, may consider fusion, not always necessary to treat cauda equina as emergency but this is controversial
Complications
• Dural tear
• Discitis which is not always infectious
• Nerve root injury
• Recurrent HNP
• Chronic regional pain
• Vascular and visceral injury from violating annulus anteriorly
Bibliography
1. Kostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986;68(3):386–91.
2 . L ee JK, Amorosa L, Cho SK, Weidenbaum M, Kim Y. Recurrent lumbar disk herniation. J Am Acad Orthop Surg. 2010;18(6):327–37.
3. Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, Herkowitz H, Hilibrand A, Albert T, Fischgrund J. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2008;33(25):2789– 800. doi: 10.1097/BRS.0b013e31818ed8f4 .
8 Lumbar Spinal Stenosis
Take-Home Message
• Verbiest – the fi rst clinical description
• End result of the degenerative cascade
• Know sites for stenosis
• Can cause neurogenic claudication as distinct from vascular claudication
Defi nition
• Reduced dimension of the spinal canal by bony and ligamentous degenerative hypertrophy
• Stenosis can be central, lateral recess, or neuroforamen
Etiology
• Degenerative cascade causing bony and ligamentous hypertrophy secondary to instability
Pathophysiology
• Cartilage degeneration leading to loss of disc height, facet instability, and reac-tive hypertrophic change in nature’s response to instability
• Canal dimensions decrease in size and volume
Radiographs
• X-rays show signs of spondylosis discussed elsewhere
• May show olisthesis, deformity or both
• CT shows bony canal and is enhanced by myelography
• MRI: Shows canal best, T1 to look at epidural fat and neuroforamina, T2 gives myelogram effect
Classifi cation
• Subjective: Mild, moderate, severe
Treatment
Nonoperative
• Observation
• NSAIDs
• Physical therapy and fl exion exercises
• Manipulation
• Epidural steroid injections – mostly temporary relief
• Opioids for short-term pain control
Operative
• Lumbar decompressive laminectomy is mainstay
• Open or less invasive
• May have to do fusion with instability or deformity, covered elsewhere
Complications
• Infection
• DVT/PE
• Failure of pain relief
• Adjacent segment degeneration
• Blood loss
• Dural leak
• Neurologic injury
• Instability or progression of deformity
Bibliography
1 . V erbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br. 1954;36-B(2):230–7.
2. Weinstein JN, Tosteson TD, Lurie JD, Tosteson A, Blood E, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976).
2010;35(14):1329–38. doi: 10.1097/BRS.0b013e3181e0f04d .
Miscellaneous
1 Diastematomyelia
Take-Home Message
• Strong association with congenital scoliosis
Defi nition
• Longitudinal cleft of the spinal cord
Etiology
• Abnormality of congenital fetal development
Pathophysiology
• Longitudinal cleft that can fi x the cord as the spine grows causing neurologic defi cit, similar to a tethered cord
Radiographs
• Ultrasound – in utero.
• X-rays may show widening of the pedicles.
• CT/myelography can best detect bony diastema.
• MRI defi nes neurologic anatomy.
S. E. Smith , MD
Department of Orthopedics, Front Range Orthopedic Center, 1551 Professional Ln Suite 200, Longmont, CO 80501, USA e-mail: Samuel.smith@dhha.org
© Springer-Verlag France 2015 405
C. Mauffrey, D.J. Hak (eds.), Passport for the Orthopedic Boards and FRCS Examination, DOI 10.1007/978-2-8178-0475-0_18
Treatment
Nonoperative
• Observation
Operative
• Surgery to resect and repair
• Must deal with diastema operatively if also doing deformity correction
Complications
• Dural leak
• Retethering of neurologic structures
Bibliography
1 . C heng B, Li FT, Lin L. Diastematomyelia: a retrospective review of 138 patients. J Bone Joint Surg Br. 2012;94(3):365–72. doi: 10.1302/0301-620X.94B3.27897.
2 Myelomeningocele
Take-Home Message
• Higher neurologic levels more likely to cause scoliosis
• Pressure ulceration from sitting imbalance
• Can have neurologic progression from tethered cord
• Urosepsis common
Defi nition
• Failure of the tissue closure causing midline defect
Etiology
• Multifactorial
– Diabetes
– Folate defi ciency during pregnancy
Pathophysiology
• Midline defect that is sometimes just the bone, sometimes the bone and menin-ges, and sometimes the bone, meninges, and neural elements
Radiographs
• X-rays: Monitor her spinal deformity especially.
• M RI: If there is a change in neurologic status with respect to myelopathy, consider tethered cord.
• CT scan: Better defi nition of bony anatomy for spine surgery.
Classifi cation
• Spina bifi da occulta
• Meningocele: Sac does not include neural elements.
• Myelomeningocele: Sac includes neural elements.
• Try to determine neurologic level for prognostic and treatment purposes.
Treatment
• Bracing is not effective but observation can be appropriate.
• W hen spine surgery is indicated, it often requires anterior/posterior approach because posterior arthrodesis is very diffi cult due to defi cient posterior elements.
• As with other neuromuscular deformities, fusion to the pelvis is indicated.
Complications
• Infection risk with surgery high
• Pressure sores
• Failure fi xation, failure of fusion
• Urosepsis
• DVT/PE
Bibliography
1. Keessen W, van Ooy A, Pavlov P, Pruijs JE, Scheers MM, Slot G, Verbout A, Wijers HM. Treatment of spinal deformity in myelomeningocele: a retrospective study in four hospitals. Eur J Pediatr Surg. 1992;2 Suppl 1:18–22.
3 Diffuse Idiopathic Skeletal Hyperostosis
Take-Home Message
• Clinical implications similar to ankylosing spondylitis but it is not infl ammatory
• Causes non-marginal syndesmophytes
• Does not involve facets unlike AS
Defi nition
• Non-marginal syndesmophyte formation over three or more motion segments
Etiology
• Unknown
Pathophysiology
• Ankylosis at the disc
• Pain, stiffness
• Associated at times with stenosis
• Risk of unstable fracture
Radiographs
• X-rays: Syndesmophytes have fl owing appearance.
• Superimposed upon signs of lumbar spondylosis.
• CT: Bony anatomy in cases of suspected fracture.
• MRI and nuclear medicine to check for occult fracture.
• MRI to evaluate associated stenosis.
Classifi cation
None
Treatment
Often associated with poor bone density
Nonoperative
• NSAIDs
• Brace wear
• PT
• Bisphosphonates
Operative
• Stenosis: May need decompression
• Fractures are intrinsically unstable and require surgery most of the time
• May need posterior stabilization alone or combined approach
• Mortality with cervical fractures is high and operative therapy preferred
Complications
• Neurologic injury
• Death
• Risk of heterotopic ossifi cation anywhere in the body
Bibliography
1 . B elanger TA, Rowe DE. Diffuse idiopathic skeletal hyperostosis: musculoskeletal manifestations. J Am Acad Orthop Surg. 2001;9(4):258–67.
4 Ossifi cation of the Posterior Longitudinal Ligament
Take-Home Message
• More common is East Asian populations.
• Can be adherent to dura.
Defi nition
• Ossifi cation of the posterior longitudinal ligament of the cervical spine
Etiology
• Genetics
• East Asian more common
Pathophysiology
• Fibroblastic infi ltration, followed by vascular invasion and ultimately ossifi cation
• Encroaches on the canal and can adhere to dura
• Can cause myelopathy
Radiographs
• Films show degenerative change which is sometimes hard to see and therefore need CT.
• CT defi nes problem and identifi es morphologic type.
• K -line defi nes the size of mass and canal encroachment relative to cervical lordosis.
• MRI shows cord compression and signal.
• PLL very dark on MRI.
Classifi cation
• Single segment
• Multisegmental
• Continuous
• Mixed
Treatment
Nonoperative
• Observation if no neurologic symptoms and canal encroachment minimal
Operative
• If canal encroachment more than 60 % or crosses K-line than myelopathy likely • Anterior
• Posterior – laminoplasty or laminectomy and fusion
• Combined approaches
Complications
• Dural tear
• Paralysis
• Continued progression of myelopathy
• Stiffness even after laminoplasty
• RLN injury
• Esophageal injury
• Nerve root traction injury usually C5
• Postop hematoma
Bibliography
1. An HS, Al-Shihabi L, Kurd M. Surgical treatment for ossifi cation of the posterior longitudinal ligament in the cervical spine. J Am Acad Orthop Surg.
2014;22(7):420–9. doi: 10.5435/JAAOS-22-07-420.
5 Spondylolysis
Take-Home Message
• Isthmic pars fracture without slip
• Can be biologically active or inert
• Does not always cause pain
Defi nition
• Stress fracture without displacement of the pars interarticularis
Etiology
• Genetic predisposition
• Six percent of the population
• Increased risk in gymnastics and football lineman, i.e., whenever hyperextension is emphasized
Pathophysiology
• Pars interarticularis is an area of high stress especially with extension.
• Occurs in 25 % of fi rst-degree relatives.
Radiographs
• May be diffi cult to see on plane fi lms
• Oblique fi lms to look for scotty dog sign
• Bone scan to look for signs of bone turnover – lots of radiation, however
• CT scan may be needed – lots of radiation, however
• MRI to look for bone edema
Treatment
• Depends on activity of defect, i.e., is there potential for healing?
Nonoperative
• Activity modifi cation
• PT with modalities
• Bracing or casting
• NSAIDs
Operative
• Pars repair – ideally in biologically active lesion with no or minimal displacement
• Fusion
Complications
• Failure of healing of pars repair, fusion is the salvage
• Nonunion
• Infection
• DVT:PE
• Nerve injury
Bibliography
1. Menga EN, Kebaish KM, Jain A, Carrino JA, Sponseller PD. Clinical results and functional outcomes after direct intralaminar screw repair of spondylolysis. Spine (Phila Pa 1976). 2014;39(1):104–10. doi: 10.1097/BRS.0000000000000043 .
2. Sakai T, Sairyo K, Suzue N, Kosaka H, Yasui N. Incidence and etiology of lum-bar spondylolysis: review of the literature. J Orthop Sci. 2010;15(3):281–8. doi: 10.1007/s00776-010-1454-4. Epub 2010 Jun 18.
