SPINE

Examination of Spine SYMPTOMS Pain Sciatica Stiffness Deformity Numbness or paraesthesia Urinary symptoms Other

SYMPTOMS

Pain

Sciatica

Stiffness

Deformity

Numbness or paraesthesia

Urinary symptoms

Other

Examination of Spine Signs with the patient standing Look Skin Shape and posture Feel Tenderness Move Flexion / Extension Rotation / Lateral flexion

Signs with the patient standing

Look

Skin

Shape and posture

Feel

Tenderness

Move

Flexion / Extension

Rotation / Lateral flexion

Examination of Spine Signs with patient lying face downwards Bony outlines Tenderness Sensations and Power Femoral stretch test Signs with patient lying on his back Straight leg raising test (sciatic stretch) Neurological examination of lower limbs Circulation in the limbs Rectal examination

Signs with patient lying face downwards

Bony outlines

Tenderness

Sensations and Power

Femoral stretch test

Signs with patient lying on his back

Straight leg raising test (sciatic stretch)

Neurological examination of lower limbs

Circulation in the limbs

Rectal examination

Cutaneous distribution of nerve roots

Muscle Power Testing (MRC Scale 0 Total paralysis 1 Barely detectable contracture 2 Not enough to act against gravity 3 Strong enough to act against gravity 4 Still stronger but less than normal 5 Full power

0 Total paralysis

1 Barely detectable contracture

2 Not enough to act against gravity

3 Strong enough to act against gravity

4 Still stronger but less than normal

5 Full power

Imaging Plain x-rays AP and lateral views Oblique views PA view of S.I. Joint Computed tomography (with mylography) MR imaging Radioisotope scanning Discography and facet joint arthrography

Plain x-rays

AP and lateral views

Oblique views

PA view of S.I. Joint

Computed tomography (with mylography)

MR imaging

Radioisotope scanning

Discography and facet joint arthrography

Low back pain Lifetime incidence ranges from 60 -80% Most cases resolve spontaneously D/Dx: Simple back pain (non specific low back pain) Nerve root pain Possible serious spinal pathology

Lifetime incidence ranges from 60 -80%

Most cases resolve spontaneously

D/Dx:

Simple back pain (non specific low back pain)

Nerve root pain

Possible serious spinal pathology

Simple back pain Presentation 20 - 50 years Lumbosacral, buttocks and thigh “Mechanical” pain Patient well Specialist referral not required

Presentation 20 - 50 years

Lumbosacral, buttocks and thigh

“Mechanical” pain

Patient well

Specialist referral not required

Treatment for acute low back pain Vast majority improve within 2 months Symptomatic Rx with Aspirin/NSAIDs Bed rest should be limited to 1-2 days ? Corsets, TENS, Traction Exercise - Stretching & range of motion active

Vast majority improve within 2 months

Symptomatic Rx with Aspirin/NSAIDs

Bed rest should be limited to 1-2 days

? Corsets, TENS, Traction

Exercise - Stretching & range of motion active

Chronic low back pain Pain that persists after 3 months < 5% of patients with L.B.P develop Ch.L.B.P Multiple factors Disc, facet joints, annulus fibrosis, ligaments Psychosocial factors Surgery is rarely helpful Functional restoration programme

Pain that persists after 3 months

< 5% of patients with L.B.P develop Ch.L.B.P

Multiple factors

Disc, facet joints, annulus fibrosis, ligaments

Psychosocial factors

Surgery is rarely helpful

Functional restoration programme

Acute disc prolapse Uncommon in very young and the very old Nerve root pain follows the dermatome of the involved nerve Pain is generally worse in the leg than in the back Exacerbation of leg pain by straining, sneezing or coughing Localised neurological signs

Uncommon in very young and the very old

Nerve root pain follows the dermatome of the involved nerve

Pain is generally worse in the leg than in the back

Exacerbation of leg pain by straining, sneezing or coughing

Localised neurological signs

Cauda Equina Syndrome Large midline disc prolapse Compresses several nerve roots Sphincter disturbance Saddle anaesthesia Prompt surgical intervention

Large midline disc prolapse

Compresses several nerve roots

Sphincter disturbance

Saddle anaesthesia

Prompt surgical intervention

Treatment acute disc prolapse Conservative Bed rest for 48-72 hours NSAIDs Epidural steroids 85% relief rate Surgical treatment 10-15% of patients ultimately require surgery More rapid relief but the ultimate end point is the same regardless of treatment

Conservative

Bed rest for 48-72 hours

NSAIDs

Epidural steroids

85% relief rate

Surgical treatment

10-15% of patients ultimately require surgery

More rapid relief but the ultimate end point is the same regardless of treatment

Spinal Stenosis Commonest cause of neurologic leg pain in older patients Symptoms Neurogenic claudication - Vascular claudication Treatment

Commonest cause of neurologic leg pain in older patients

Symptoms

Neurogenic claudication - Vascular claudication

Treatment

Red flags for possible serious spinal pathology Presentation under age 20 or onset over 55 Thoracic pain Past hx of carcinoma, steroids Unwell, weight loss Widespread neurology Structural deformity Abnormal blood parameters

Presentation under age 20 or onset over 55

Thoracic pain

Past hx of carcinoma, steroids

Unwell, weight loss

Widespread neurology

Structural deformity

Abnormal blood parameters

Spondylolisthesis Forward slippage of one vertebral body on another Causes Congenital Isthmic Traumatic Pathologic Degenerative Treatment

Forward slippage of one vertebral body on another

Causes

Congenital

Isthmic

Traumatic

Pathologic

Degenerative

Treatment

Spondylolisthesis Forward slippage of one vertebral body on another

Forward slippage of one vertebral body on another

Spondylolysis Spondylolisthesis

Discitis

Spinal Deformity Deformity may occur in either coronal or sagittal plane Scoliosis - Lateral curvature of the spine Structural Nonstructural Kyphosis - Sagittal plane deformity in the thoracic or thoracolumbar spine

Deformity may occur in either coronal or sagittal plane

Scoliosis - Lateral curvature of the spine

Structural

Nonstructural

Kyphosis - Sagittal plane deformity in the thoracic or thoracolumbar spine

Scoliosis Idiopathic Scoliosis 80% of all scoliosis Adolescent - age 10 or over Juvenile - age 4 to 9 Infantile - age 3 or under

Idiopathic Scoliosis

80% of all scoliosis

Adolescent - age 10 or over

Juvenile - age 4 to 9

Infantile - age 3 or under

Scoliosis - Cobb angle

Adolescent idiopathic scoliosis Structural scoliosis presenting at or about the onset of puberty and before maturity 80 % of cases of idiopathic scoliosis Mostly (90%) in girls Predictors of progression very young age marked curvature Risser sign

Structural scoliosis presenting at or about the onset of puberty and before maturity

80 % of cases of idiopathic scoliosis

Mostly (90%) in girls

Predictors of progression

very young age

marked curvature

Risser sign

Adolescent idiopathic scoliosis Treatment Prevent a mild deformity from becoming severe Correct an existing deformity Nonsurgical treatment Curves between 20-40 when spinal growth is incomplete Curves > 30 (Risser 2 or less) even if no progression Surgical treatment Curves >40 in skeletally immature Unbalanced curves between 20 - 40 in skeletally immature Curves >50

Treatment

Prevent a mild deformity from becoming severe

Correct an existing deformity

Nonsurgical treatment

Curves between 20-40 when spinal growth is incomplete

Curves > 30 (Risser 2 or less) even if no progression

Surgical treatment

Curves >40 in skeletally immature

Unbalanced curves between 20 - 40 in skeletally immature

Curves >50

Congenital scoliosis Due to congenital anomalous vertebral development Hemivertebrae Wedged vertebrae Fused vertebrae Absent or fused ribs Treatment Early fusion in progressive curves

Due to congenital anomalous vertebral development

Hemivertebrae

Wedged vertebrae

Fused vertebrae

Absent or fused ribs

Treatment

Early fusion in progressive curves

Congenital Hemivertebra

Neuromuscular scoliosis Causes Poliomyelitis Cerebral palsy Syringomyelia Friedrich’s ataxia Muscular dystrophies Typical paralytic curve is long, convex towards the side with weaker muscles

Causes

Poliomyelitis

Cerebral palsy

Syringomyelia

Friedrich’s ataxia

Muscular dystrophies

Typical paralytic curve is long, convex towards

the side with weaker muscles

Neuromuscular scoliosis Treatment Mild curves No treatment Moderate curves with spinal stability As for idiopathic scoliosis Severe curves Fitting a suitable sitting support Surgical stabilization of the entire spinal segment

Treatment

Mild curves No treatment

Moderate curves with spinal stability

As for idiopathic scoliosis

Severe curves Fitting a suitable sitting support

Surgical stabilization of the entire spinal segment

Kyphosis Postural (Round back) Compensatory Structural

Postural (Round back)

Compensatory

Structural

Kyphosis Causes Postural kyphosis Postradiation kyphosis Scheuermann’s disease Metabolic disorders Myelomeningocele Skeletal dysplasias Traumatic kyphosis Tumourous conditions Postsurgical Infections

Causes

Postural kyphosis Postradiation kyphosis

Scheuermann’s disease Metabolic disorders

Myelomeningocele Skeletal dysplasias

Traumatic kyphosis Tumourous conditions

Postsurgical Infections

Scheuermann’s disease Excessive thoracic kyphosis (Cobb angle >45° with wedging of 5° or more) of at least 3 adjacent apical vertebrae and vertebral end plate irregularities Aetiology unknown Incidence 1% of general population with slight female dominance

Excessive thoracic kyphosis (Cobb angle >45° with wedging of 5° or more) of at least 3 adjacent apical vertebrae and vertebral end plate irregularities

Aetiology unknown

Incidence 1% of general population with slight female dominance

Scheuermann’s disease

Scheuermann’s disease Treatment Orthotic treatment Skeletally immature - Milwaukee brace (poor compliance) Surgical (rare) Severe deformity in skeletally mature Severe deformity and neurologic signs

Treatment

Orthotic treatment

Skeletally immature - Milwaukee brace (poor compliance)

Surgical (rare)

Severe deformity in skeletally mature

Severe deformity and neurologic signs