Common spinal problems for students

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Common spinal problems for students

  1. 1. Common spinal disorders and General principles of spinal surgery For the medical students Daniel Chan FRCSEd FRCSOrth Consultant spinal surgeon, PEOC, RD & E
  2. 2. Assessment   History, physical examination, simple investigation, special investigation Mechanical presentation: Axial pain    Exclude fractures, tumours and infection Red flags Yellow flags  Neurological presentation        Spinal cord Cauda euina Nerve roots Document the deficit Duration of the deficit Rapidity of progression Deformity :local, regional, global   Coronal balance Sagittal balance
  3. 3. Non spinal conditions       CVA Gillain Barre Transverse myelitis Amyotrophic neuralgia MS Vascular     dissecting aneurysm Saddle embolism Peripheral nerve palsies Herpes zoster
  4. 4. Surgical principles  Decompression  Stabilisation       Pathology Direct Indirect    In situ Correction of deformity Combined When, how, why      Degenerative Inflammatory Neoplastic Infective Traumatic Congenital developmental
  5. 5. Degenerative L4/5 Disc herniations
  6. 6. Indications for Surgery-Absolute   Acute cauda equina syndrome - emergency Progressive neurological deficit – urgent
  7. 7. Acute cauda equina syndrome    LBP Root Compression  Motor / sensory  Uni- / Bilateral Sphincter Disturbance Motor Do a rectal examination and record it Anal Tone   Urinary Retention  Residual volume Sensory  “Saddle” numbness  No sensation with bladder tuck      CESI vs CESC (Reflexes) (SLR)
  8. 8. Central L4/5 Disc Prolapse Needs emergency surgery
  9. 9. Indications for Surgery-Relative   Natural history favourable: 90% settle over 3 months Failure of appropriate time and conservative treatment     Unremitting leg pain in appropriate distribution Nerve tension signs (SLR limited by leg pain) Imaging confirmation    6-8 weeks done at time when surgery is contemplated When patient accepts risk to reward ratio Recurrent attacks of leg pain
  10. 10. Lumbar Microsurgery
  11. 11. Degenerative  Spinal stenosis
  12. 12. Spinal Stenosis        Elderly patient Leg pain: radicular or claudicating Paraesthesia “Paralysis”: jelly legs Unusual to have acute deficit…usually additional PID, synovial cyst or pin hole stenosis Cervical spondylosis and extension injury = central cord syndrome Tandem stenosis
  13. 13. Limited segmental decompression  Technique of LSD
  14. 14. Degenerative  Degenerative spondylolisthesis
  15. 15. Degenerative spondylolisthesis
  16. 16. Degenerative scoliosis
  17. 17. Degenerative scoliosis
  18. 18. Degenerative scoliosis
  19. 19. Degenerative scoliosis
  20. 20. Pars interarticularis Spondylolysis: The Scotty Dog Spondylolytic spondylolisthesis
  21. 21. Spondylolytic spondylolisthesis
  22. 22. Cervical Radiculopathy Signs     Shoulder abduction sign  Rests arm on head – reduces nerve root tension and empties epidurals Holds head tilted to opposite side  Opens foramen C7 pain  Tend to pronate forearm when describing the pain unlike C6 and CTS Extension narrows foramen  Helps distinguish from muscular neck pain and shoulder pathology
  23. 23.  C5   C6   Carpal tunnels syndrome C7 C8   Turner Parson’s syndrome (Neuralgic amyotrophy) Thoracic outlet syndrome C8/T1  Pancoast tumours
  24. 24. Cervical Radiculopathy 4. Acute – Soft Disc Chronic – Hard Disc Disc Height ↓ - foraminal compression Facet - foraminal compression  MRI Gold Standard 1. 2. 3.   CT bony pathology and foramens    Compression in 20% of asymp pts 45 deg to sag plane Dynamic fluoroscopy for stability Myelography - rarely
  25. 25. Natural History  Favourable         Lees 1963 51pts 2-19yrs FU 45% single episode no recurrence 30% mild Sx 25% persis / worse Sx No progression to myelopathy 75% recovers 90% recovers over 3 to 6 months Epidemiology of cervical radiculopathy A population-based study from Rochester, Minnesota, 1976 through 1990 Kurupath Radhakrishnan1 2 * William J. Litchy1 W. Michael O'Fallon3 ,,, , and Leonard T. Kurland2
  26. 26. Separate the woods from the trees     Look for signs of myelopathy Clumpsy arms/hands and legs Spastic Upper motor neurone signs!!
  27. 27. Acute cord compression cervical disc herniation Needs emergency / urgent surgery
  28. 28. Myelopathic Symptoms          Subtle / varied presentation Pins & needles / numbness in hands Stiff hands and reduced dexterity Balance problems / recurrent falls Stiff legs that tire easily Shooting sensations through body Spontaneous twitching / jerking limbs Bowel or bladder disturbance (uncommon) Pain is not a common symptom
  29. 29. Upper motor neurone signs Lower limbs Upper limbs         Unsteady wide based gait Romberg / Walking Romberg Unable heel toe gait Triangle step test L’Hermittes sign Hyperreflexia  Knee / Ankle Clonus Extensor Plantar Response (Babinski)   Hoffman’s sign Ono 1987  Grip release test  Finger escape sign Hyperreflexia  Inverted Radial Reflex  Scapulohumeral reflex
  30. 30. Natural History - Poor  Clarke 1956     120 pts 75% episodic ↓ 20% slow ↓ 5% rapid ↓  Nurick 1972    Phillips 1973   Symon 1967   67% steady ↓  30% ↑ non surg 50-73% ↑ surg 37% ↑ non surg 57-73% ↑ surg Sampath 2000    Surgery better ↓ neuro Sx and pain ↑ functional status
  31. 31. Spinal infection
  32. 32. Infection
  33. 33. Infection   Pyogenic or TB At risk: i.v drug users  elderly  Immuno compromised  Diabetics  Renal failure  Urological manipulation  Cardiac: SBE  Epidural abscess MRI + Gad  Neurology in cord area needs emergency decompression    Spondylodiscitis  instability and acute deformity
  34. 34. Spinal infection: important lesson       Late diagnosis frequent High index of suspicion Risk factors! Early diagnosis antibiotics alone suffice Late diagnosis with bone destruction leads to spinal deformity and further neurological compromise Difficult surgery then needed
  35. 35. MSCC         Any neurological deficit requires urgent/ emergency MRI Staging for prognosis What is the primary Is it metastatic Is it operable Is it treatable with radio/chemotherapy alone Surgery is palliative Will the patient benefit from surgery
  36. 36. Tumour 59/F Backpain + (L) leg weakness L3 mets with neural compression
  37. 37. Pre op
  38. 38. Pre op Pre embolisation Post embolisation
  39. 39. Intra op
  40. 40. Post op Lateral view AP view
  41. 41. Mechanical low back pain        i.e…..Not infective, metabolic, traumatic, metastatic ?diagnosis Speculative Degenerative discopathy? Facet pain? Segmental pain Specific mechanical pathology:   spondylolytic spondylolisthesis Post surgical destabilisation
  42. 42. Clinical Standards Advisory Group 1994 Red flags         Thoracic pain Fever and unexplained weight loss Bladder or bowel dysfunction History of carcinoma Ill health or presence of other medical illness Progressive neurological deficit Disturbed gait, saddle anaesthesia Age of onset <20 years or >55 years Yellow flags      A negative attitude that back pain is harmful or potentially severely disabling Fear avoidance behaviour and reduced activity levels An expectation that passive, rather than active, treatment will be beneficial A tendency to depression, low morale, and social withdrawal Social or financial problems
  43. 43. Inflammatory - RA
  44. 44. RA
  45. 45. Inflammatory - AS
  46. 46. AS      Prone to fractures Often unstable, fractures like chalk stick Neurological deficit frequent If originally kyphotic, strapping spine board may be dangerous Bamboo spine with fixed kyphosis
  47. 47. Cervical osteotomy - AS
  48. 48. Inflammatory - AS
  49. 49. Trauma Aims of fracture treatment  anatomical reduction alignment  maintain alignment  rehabilitation  Preserve neurological function Tissue healing  bone heals with bone  bone healing may malunite  soft tissue heals with fibrous tissue  fibrous healing remains unstable
  50. 50. Scoliosis Isola instrumentation
  51. 51. Double rod systems : Kaneda
  52. 52. Growing rod     Paediatric down sized implants Instrumentation without fusion Periodic lengthening of rod Allows continuing growth
  53. 53. Growing rod
  54. 54. Summary     Keep it simple Axial pain and stability problem Neurological problem Apply the 2 principles of decompression of neural structures and stabilisation of bony ligamentous structures
  55. 55. Summary      Presents with brachiagia with or without sensory and or motor symtoms Dermatomal distribution identifies level Consider important differentials Favourable natural history favours conservative treatment Response to surgery generally good
  56. 56. My experience     Retrospective 47 patients 72% satisfactory (good/excellent) clinical outcome 97% fusion rate
  57. 57. Investigations  MRI  Other  Bloods   Remember Coag CT myelogram
  58. 58. Radicular Pain  Mechanical  Biological / Chemical   Inflammation    IL-1, IL-6, Sub P, TNF-α blood vessel permeability Oedema of root / DRG Metabolic disorders with neuropathy e.g. diabetes  Increased susceptibility to radiculopathy

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