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Spinal Disorders 2017
This document provides an overview of spinal disorders, including: 1. Traumatic spinal disorders like fractures of the cervical spine (C1-C2), thoracolumbar fractures from compression or flexion, and cervical disc herniations. 2. Treatment approaches depending on the stability and neurological involvement, ranging from immobilization to surgical fixation or decompression. 3. A classification system for cervical fractures like Anderson and D'Alonzo for odontoid fractures. 4. Details on mechanisms, clinical features, investigations, and management of specific fractures.
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Spinal Disorders 2017
- 1. SPINAL DISORDERS PRESENTER: KosgeiK. Victor MBCh.B V SUPERVISOR: Dr. Muteti E. MBCh.B, Mmed(Ortho), FCS, Spine Specialist- Moi University-Eldoret, Kenya.
- 2. Introduction to theSpine • Made of 33 vertebrae; 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused) and 4 coccygeal (fused). • Vertebrae form a functional column. • Made of 3 columns: a. Anterior- ALL & anterior 2/3 of vertebral body b. Middle- PLL & posterior 1/3 of vertebral body c. Posterior- pedicles, lamina, spinous processes and ligaments • Spinal curves: normal curves a. Cervical lordosis b. Thoracic kyphosis c. Lumbar lordosis d. Sacral kyphosis • Functions: a. Stability, support and movement b. Haemopoietic function c. Spinal cord and nerve root transmission
- 3. Spinal disorders- Introduction •Spinal disorders can be: A. Traumatic B. Non traumatic
- 4. A. Traumatic Disorders 1.Cervical Spine Injuries a. Occipito-condyle fracture • High energy fracture • Usually associated with skull fractures • CT scan is essential in diagnosis (likely to be missed in plain x-ray. • Rx: i. Impacted and undisplaced fractures- brace immobilization for 8-12 weeks. ii. Displaced fractures- halo vest or operative fixation.
- 5. b. Occipito-cervical Dislocation •High energy injury • Almost always associated with other serious bone/soft tissue injuries- arterial and pharyngeal disruptions • Outcome is often fatal • Dx: lateral cervical x-ray- tip of odontoid should be no more than 5mm in vertical alignment and 1mm in horizontal alignment for the anterior rim of foramen magnum (distances may be higher in children) • CT scans are more reliable • Rx: Immediate reduction (without traction) and stabilization using halo vest pending surgery • Surgery- Internal fixation using occipito-cervical plates and screws • Halo vest may be retained for 6-8 weeks after surgery depending on severity.
- 6. c. C1 RingFracture • Also called a Jefferson fracture • Caused by a sudden load on the head • No encroachment on the neuronal canal- no neurological damage • Associated with other injuries in the cervical spine in 50% of cases • Seen on plain x-ray in open mouth view and lateral view • Unstable injuries- sideways spreading of lateral masses more than 7mm in open mouth view- ruptured lateral ligament • CT is helpful in defining the fracture • Rx: i. Stable- semi-rigid collar or halo vest until the fracture unites ii. Unstable-halo vest for several weeks. Persisting instability on x-ray require C1, C2 fixation and fusion
- 7. C2 Pars InterarticularisFractures • Hangman’s fracture- Bilateral fractures of the pars Interarticularis of C2 and C2/3 disc is torn • Mechanism- extension with distraction • Neurological damage is unusual • Stable fractures (<3mm of C2/3 subluxation)- Rx with semi rigid orthosis until united (usually 6-12 weeks) • Fractures with more than 3mm displacement may need reduction (without traction) then held with halo vest until union occurs • C2/3 fusion is required in persistent pain and instability.
- 8. C2 Odontoid ProcessFracture • Occur as flexion injuries in young adults after high velocity accidents or severe falls • Occur in elderly osteoporotic people as a result of low energy trauma in which neck is forced into hyperextension • Displaced fracture- dislocation of the atlanto-axial joint in which the atlas is shifted forward or backward taking the odontoid process with it • No neurological injury with displacement • However, cord damage is not uncommon especially in the elderly Classification- Anderson and D’Alonzo (1974) Type I • Avulsion fracture at the tip of odontoid process due to traction by alar ligaments • Fracture is stable and unites without difficulty Type II • Fracture at the junction of the odontoid process and body of axis • Most common and potentially dangerous • Fracture is unstable and prone to non union Type III • Fracture through body of axis • Stable and unites with immobilization
- 9. Clinical Features • Hx-severe neck strain followed by pain and stiffness due to muscle spasm • Neurological symptoms may occur • Plain x-rays show the fracture • MRI useful as it may reveal rupture of transverse ligaments Treatment Type I • Immobilization in a rigid collar Type II • Undisplaced- held by halo vest, elderly- rigid collar • Displaced- Reduced by traction then operative fusion of C1/2 Type III • Undisplaced- halo vest for 8-12 weeks • Displaced- reduction by halo traction the and immobilization by halo vest for 8-12 weeks
- 10. Posterior Ligament Fracture •Result from sudden flexion of mid cervical spine • Upper vertebra tilts forward on the one below opening an interspinous space posteriorly • Patient complains of pain and there may be tenderness • X-ray may reveal an increased gap space between adjacent spines • Unstable injury- angulation more than 110, anterior translation of vertebra more than 3.5mm or if facets are fractured and displaced • Stable- semi rigid collar for 6 weeks is adequate • Unstable- posterior fixation and fusion is advisable Wedge Compression Fracture • Result from flexion leading to compression fracture of vertebral body • Middle and posterior elements remain intact and injury is stable • Rx- collar for 6-12 weeks • Axial CT/MRI should be done to identify associated injuries.
- 11. Burst and Compression-flexionFractures Due to axial compression of cervical spine Burst fracture- vertebral body is crushed in neutral position of head Tear drop fracture- antero-inferior fragment of vertebral body is sheared off due to combined compression and flexion There’s risk of posterior displacement of vertebral fragment and spinal cord injury Plain x-ray show crushed vertebral body or a triangular fragment separated from antero-inferior edge of fractured vertebra Traction should be applied immediately CT and MRI should be done to look for retropulsion of bone fragments into spinal canal Rx: i. No neurological deficit- surgical or confinement to bed and traction for 2-4 weeks followed by halo vest immobilization for 6-8 weeks - Halo vest unsuitable in initial Rx because it does not provide axial traction ii. Neurological symptoms- urgent anterior decompression- anterior corpectomy, bone grafting and plate fixations - Sometimes posterior stabilization is needed.
- 12. Fracture Dislocation • Causedby severe flexion or flexion rotation injuries • Inferior articular facets of one vertebra ride forward over superior facets of the vertebra below • Posterior ligaments are ruptured and spine is unstable; often there's cord damage • Lateral x-ray shows forward displacement of a vertebra on the one below of greater than half the vertebra’s antero-posterior width • Displacement must be reduced urgently using skull traction for 6 weeks • MRI should be performed to rule out presence of disc disruption • Collar and halo vest immobilization is advised for further 12 weeks • Posterior open reduction and fusion is advised if closed reduction fails.
- 13. Hyperextension Injury • Causedby acceleration forces • Bone and joint disruptions are rare- strains of soft tissue • Stable in neutral position • Should be held by collar for 6-8 weeks Avulsion Injury of the Spinous Process • May occur in severe voluntary contraction of muscles at the back of the neck • Known as clay- shoveller’s fracture (C7 spinous process fracture) • Immobilized with a collar Cervical Disc Herniation • May cause severe pain radiating to one or both limbs and neurological symptoms • Diagnosis is confirmed by MRI or CT myelography • Paresis may need surgical decompression
- 14. Sprained Neck (Whiplashinjury) • Common following RTAs • Caused by sudden acceleration forces in vehicles without seat headrest followed by recoil in flexion • Women are more affected than male- neck muscles are more gracile • Pathology involves anterior spinal ligament, capsular fibers straining Clinical features • Pain and neck stiffness appear 12-24 hours • Pain radiates to the shoulders associated with headache, dizziness, blurring of vision and paresthesia • Neck muscles are tender and movements are restricted • Neurological deficits are uncommon • X- rays may show straightening of normal cervical lordosis due to muscle spasms • MRI may show disc degeneration
- 15. Grade Clinical Pattern 0No neck symptoms or signs 1 Neck pain, stiffness and tenderness No physical signs 2 Neck symptoms and musculoskeletal signs 3 Neck symptoms and neurological signs 4 Neck symptoms and fracture or dislocation Grading • DDx - Vertebral fracture - Mid cervical subluxation • Rx - Analgesics - Physiotherapy - Osteopathy an d chiropractic treatments- helpful
- 16. Thoracolumbar Fractures Flexion compressionInjuries • Most common vertebral fracture • Caused by severe spinal flexion • Posterior ligaments remain intact • Pain may be severe but fracture is usually stable • Neurological injury is rare • Rx: i. Minimal wedging- bed rest for two weeks until pain subsides ii. Moderate wedging- thoracolumbar brace or cast applied with the spine in extension for 1-2 weeks • If instability persists, surgical fixation is indicated
- 17. Axial Compression orBurst Injury • Severe axial compression may ‘explode’ the vertebral body causing failure of both anterior and middle columns • Posterior column is usually but not always undamaged • Posterior part of vertebral body is shattered and fragments of bone and disc may be displaced into spinal canal • Injury is usually unstable • AP x-rays show spreading of vertebral body with an increase in interpedicular distance • CT scan is essential to see retropulsion of bone fragments into spinal canal • Rx: - No neurological damage- bed immobilization and thoracolumbar brace or cast for 12 weeks - Neurological symptoms- anterior decompression and stabilization
- 18. Jack-Knife Injury • Combinedflexion and posterior distraction may cause mid lumbar spine to jack-knife at an axis anterior to the vertebral column • Seen in lap seat belt injuries • Unstable in flexion, though neurological damage is uncommon • X-rays show transverse fractures in the pedicles or transverse process • Lateral view shows opening of disc space posteriorly • Heals rapidly and requires 3 months in a body cast and well fitting brace
- 19. Fracture Dislocation • Segmentaldisplacement may occur with various combinations of flexion, compression, rotation and shear • All three columns are affected and spine is grossly unstable • Often associated with neurological damage • X-rays show fractures through the vertebral body, pedicles, articular processes and laminae • Varying degrees of subluxation or bilateral dislocation • Associated fractures of transverse processes of ribs • CT is helpful in demonstrating degree of spinal occlusion • Fracture dislocation without neurological deficit- surgical stabilization • Fracture dislocation with partial neurological deficit- surgical decompression and stabilization • Fracture dislocation with paraplegia- shorten hospital stay, rehabilitate and reduce painful deformity
- 20. Non-Traumatic Disorders Scoliosis • Lateralcurvature of the spine • Postural scoliosis- deformity is compensatory or secondary to some condition outside the spine such as short leg or pelvic tilt. Curvature disappears when patient sits • Structural scoliosis- non correctable deformity of the affected segment • Spinous processes swing towards concavity of the fracture and transverse processes rotate posteriorly • Ribs on the convex side swing out producing a rib hump • Deformity is liable to increase throughout the the growth period • Types: • Idiopathic- infantile or juvenile • Osteopathic/congenital • Neuropathic • myopathic
- 21. Clinical Features • Deformityis the presenting feature • Pain is a rare complain- alert for neural tumors • Family history is common • Associated with abnormalities during childbirth or pregnancy • Spine is deviated from midline Treatment • Non operative • Exercises • Bracing- Milwaukee and Boston braces • Operative • Indications- rapidly deteriorating and cosmetic (deformities >300 ) • Methods - Harrington system - Rod and Sub laminar wiring - Cotrel dubousset system
- 22. Kyphosis • Excessive thoraciccurvature- hyper kyphosis, kyphos, gibbous • Caused by sharp posterior angulation due to localized posterior collapse or wedging of one or more vertebrae • May result from congenital, fracture or spinal tuberculosis Postural Kyphosis • Associated with other postural defects like flat feet • Voluntarily corrected by posture training and exercises • Compensatory kyphosis due to other deformities- usually increased lumbosacral lordosis Structural Kyphosis • Fixed and associated with changes in shape of vertebrae • Children- congenital vertebral defects, skeletal dysplasia such as achondroplasia and in osteogenesis imperfecta • Older children- tuberculous spondylitis • Adolescence- Scheurmann’s disease • Adults- ankylosing spondylitis, TB spondylitis, spinal trauma or childhood disorder • Elderly- osteoporosis • Treatment- dependent on the cause
- 23. Tuberculosis • Most commonsite of skeletal tuberculosis • Account for 50% of all musculoskeletal TB Pathology • Blood borne infection settles in vertebral body adjacent to intervertebral disc • Bone destruction and cessation with infection spreading to adjacent disc space • Paravertebral abscess may form and then track along muscle plane and involve sacroiliac or hip joint or along the psoas muscle to the thigh • Gibbous (kyphos) develop as vertebral body collapse into each other • Risk of cord damage due to pressure by the abscess, granulation, sequestra or displaced bone or ischemia from spinal artery thrombosis • With healing vertebrae re-calcify and bony fusion may occur • Resultant kyphosis risk to cord compression
- 24. Clinical Features • Longhistory of ill health and backache • Gibbous formation is dominant • Concurrent pulmonary TB common in children under 10 years • Spinal movements are restricted • Children under 10 years usually develop pigeon chest (pectus carinatum) • Sensory/motor changes may occur in lower limb • MRI and CT scan are suitable in investigation- can point out abscesses cord compression, vertebral fractures • Other tests- ESR- raised - Montoux- positive - Needle biopsy- limited to no neurological symptoms • DDx- malignancies- metastases - Pyogenic infections - Hydatid disease Treatment • Objectives- eradicate or arrest disease - prevent/correct deformity - Prevent or treat complication • Pharmacology- anti-TBs for six months • Surgical- drainage and stabilization of vertebra
- 25. Pyogenic Osteomyelitis • Uncommon-diagnosis usually delayed • Risk groups- elderly, chronically ill and immunosuppressed Pathology • Staph. Aureus is responsible for 50-60% • Immunosuppressed patients- E. coli, Pseudomonas • Sources of infection- hematogenous, inoculation • Infection begins at vertebral end plates with spread to disc and adjacent vertebra • Can also spread along anterior longitudinal ligament and into paravertebral tissues • Spinal canal involvement (epidural abscess)- surgical emmergency
- 26. Clinical Features • Localizedpain associated with muscle spasm and restricted movements • Point tenderness over affected area • History of invasive procedure or distant infection • Pyrexia and tachycardia may be present • X-ray- loss of disc height, irregular disc space, erosion of vertebral end plate • Radionuclide scans- increased activity at site • MRI- characteristic changes in vertebral end plates disc and paravertebral tissues • Needle biopsy- culture and sensitivity • Other test- ESR, CRP and antistaphyloccocal antibodies Treatment • Bed rest, pain relief • Iv antibiotics • Operative- indications- poor response to conservative Rx, presence of neurological signs and need to drain abscess
- 27. Discitis • Infection limitedto intervertebral disc • Due to direct inoculation following discography, chemonucleolysis or discectomy • Vertebral end plates rapidly attacked and infection spreads into vertebral body • Tenderness over affected disc • ESR is elevated • Children- infection assumed to be blood borne • X-ray features same as pyogenic spondylitis • Rx- broad spectrum antibiotics
- 28. Intervertebral Disc Degeneration •Major cause of chronic backache • Age related- 50% occur in 50+ years • Disc gradually dries out with ageing • Nucleolus pulposus changes for turgid gelatinous bulb to brownish dissociated structure • Annulus fibrosus develop fissures parallel to the vertebral end plate and herniations of nuclear material squeeze through the fissures • Disc cells then die at an increased rate • Glycosaminoglycans production is diminished leading to poor water retention and drying off • Usually asymptomatic • Pain is secondary to effects of disc prolapse • X-rays- flattening out of disc space and osteophyte formation • MRI- bulging of annulus fibrosus • Rx-asymptomatic- no treatment • Symptomatic- management of secondary effects
- 29. Intervertebral Disc Prolapse •Physical stress is the probable cause • May also result from hydrophilic disturbance of nuclear material • Protrusion- posterior bulging of disc with intact annulus • Extrusion- fibrocartlaginous material released posteriorly due to rupture of annulus • Sequestration- part of nucleus may separate and lie freely or move into the intervertebral foramen • Large central rupture may cause compression of Cauda equine • Postero-lateral rupture compresses nerve root proximal to point of exit • Major cause of acute back pain • Sciatica- pain in buttocks and posterior thigh and calf due to nerve root compression • Paresthesia, numbness and weakness are common signs • Back pain and sciatica made worse by coughing • Cauda equine compression may cause urinary retention and perineal numbness • X-rays- narrow disc, osteophytes • CT and MRI are more reliable
- 30. Treatment • Heat andanalgesics soothe • Exercise strengthen muscles • Principles- rest, reduction, removal and rehabilitation • Rest- patient kept in bed with hips and knees slightly flexed • Reduction- continuous bed res for 2 weeks may reduce prolapse • Epidural injection of corticosteroid and local anesthesia may help • Chemonucleolysis- dissolution of nucleus pulposus using a proteolytic enzyme (chymopapain) • Removal- indications 1. Cauda equine compression syndrome 2. Neurological deterioration 3. Persistent pain and sciatic tension • Operative methods- laminotomy and micro discectomy • Rehabilitate-isometric exercises
- 31. Features of CaudaEquina Syndrome 1. Bladder and bowel incontinence 2. Perineal numbness 3. Bilateral sciatica 4. Lower limb weakness 5. Crossed straight leg sign
- 32. Chronic Back PainSyndrome • Self perpetuated • Accompanied by non- organic physical signs 1. Pain and tenderness of bizarre degree of distribution 2. Pain on performing impressive but non-stressful movements 3. Variations in raising the leg while distracting patient attention 4. Sensory and motor function do not fit the physiological patterns 5. Over determined behavior during physical examination • However, pathologies should be excluded before making this diagnosis
- 33. Thank you… Questions/comments References 1. Apley’ssystem of orthopedics and fractures 9th edition 2. Netters concise atlas of orthopedic anatomy