spine conference

1. UC Spine Conference
• Upper Chesapeake Medical Center
• Friday February 2nd, 2018

2. 56 year old man chronic midthoracic
Back pain 3 months PT/NSAID/brace,
possible infection of the spine
SH: truck driver, smoker
Year : 2010

3. 30% involvement 8% THA

7. Causes:
1. Not fused in disease process
2. Trauma
3. Fatigue fx

12. Initially patient did very well but he returned 6 months post op
with axial central
Back pain with normal xrays.

14. • Rheumatoid spondylosis
• Rheumatoid arthritis of the spine
• Marie Strumpell Disease Adolph Strümpellof Germany in 1897 and Pierre Marie of France in
1898
• Bekhterev’s Disease neurophysiologist Vladimir Bekhterev of Russia in 1893
• Pelvospondylitis ossificans/spondylosis
• ankylopoietica
Nomenclature

15. Epidemiology
•M:F 2:1
•North America 1-2 per 1,000
•Never in aboriginal populations of Australia

16. World wide incidenc

17. Seronegative Spondyloarthropathy
RF, Anti-cyclic citrullinated peptide (anti-CCP) antibody testing is particularly useful in the diagnosis of rheumatoid arthritis,
with high specificity, presence early in the disease process,
• Ankylosing Spondylitis
• Reactive Arthritis (Reiter’s)
• Psoriatic
• Enteropathic (IBD)
• Undifferentiated Spondyloarthropathy

18. Radiographic features
• Squaring vertebra
• Bridging syndesmophytes
• Bamboo spine

20. Early Clinical Features
• Inflammatory back pain
insidious dull migratory LBP deep B
buttock, >3mo, improves with exercise
worse with rest, second half of night
pain get up and walk around
• Morning stiffness more than
30 mintues
• Response to NSAID
• <45 years old with normal
MRI

21. Chronic LBP with Clinical Features
make Dx Likely:
1. Sx<45 years of age
2. Dactylitis, enthesitis
3. Nongranulomatous Acute anterior uveitis
4. FH 15-20%
5. HLA B27
6. Sacroiliitis/spondylitis
7. Proximal aortic disease, MV, conduction, aortitis
8. Inflammatory Bowel Disease
9. Pulmonary Fibrosis

22. HLA-B271973
• 90% of AS express HLAB27
• 8% who do NOT have AS
express HLAB27
• If you have HLAB27, 2%
probability of signs and
symptoms AS

23. • Population or Disease Entity
HLA-B27 –Positive
•
Healthy whites 8%
Healthy African Americans 4%
Ankylosing spondylitis (whites) 92%
Ankylosing spondylitis (African Americans) 50%
Reactive arthritis 60-80%
Psoriasis associated with spondylitis 60%
IBD associated with spondylitis 60%
Isolated acute anterior uveitis50%
Undifferentiated spondyloarthropathy20-25%

24. Rib expansion < 2.5cm

26. Modified NY Criteria for AS 1984
• Clinical (at least one)
• LBP and stiffness >3 months improved by exercise worse with rest
• Stiff spinal motion
• Chest expansion stiffness
• Radiographic
• Sacroiliitis bilateral grade 2-4 unilateral 3-4
• 0=nl, 1=suspicious, 2=minimal 3=moderate,4=fusion

27. MRI
• STIR: subchondral bone marrow edema, periarticular erosions (active)
• T1 spin:subchondral fatty marrow infiltration (chronic)

28. DDX sacro-iliitis
• Usually bilateral and symmetrical
• inflammatory bowel disease
• Crohn's disease
• ulcerative colitis
• ankylosing spondylitis
• enteropathic arthritis
• hyperparathyroidism : not a true sacroileitis but can mimick appearances
• osteitis condensans ilii :
• multi centric reticulohistiocytosis
• Whipple disease 1
• Usually bilateral but asymmetrical
• gout
• psoriatic arthritis
• reactive arthritis (Reiter syndrome)
• osteoarthritis
• relapsing polychondritis
• Behcet disease
• rheumatoid arthritis
• sacroiliitis circumscripta
• Usually unilateral
• neoplastic destructive process
• infective
• pyogenic septic arthritis
• tuberculous sacroileitis
• brucellosis 2,3
• Traumatic arthritis

30. Medical treatment
• NSAID: short/long acting, Cox2
selective
• TNF inhibitors such
as etanercept, infliximab,
adalimumab , golimumab,
certolizumab
• TNF contraindications: infection, TB,
CHF, Lupus, MS, Cancer
• Bisphophonates for osteoporosis
• Not helpful: steroids, methotrexate

31. 1.3% annual incidence of fx
78% cervical, 12% thoracic, 9% lumbar, 1% sacral
8% multiple fractures
FRACTURES

33. 1/4/2012 ER for SOB
2 years postop

34. 1/16/2015
ER CT for hypoxia
5 years postop

35. 12/2/17
64 year old back pain LE weakness loss of urine
HPI: chronic LBP, 4 day h/o increasing lower extremity weakness, could not walk
Day prior to admission, numb from groin to toes.
Index surgery 7 years ago

37. T8

38. T7T8

46. 25

49. spondylodiscitis 1. AREA NOT FUSED YET
2. TRAUMATIC FRACTURE
3. FATIGUE STRESS FX

51. RISK FACTORS
•Metabolic
•Smoking (40%)
•Infection
•Excessive motion
•Non-instrumented
•Allograft
•L5S1
•Hip arthritis

52. NON UNION
PSEUDARTHROSIS
DIAGNOSIS
• XRAY: implant failure,
fusion mass, flex/ext,
halo sign
• CT: thin cut with recon
• MRI: coronal recon
• Ultrasound ?
• NUCLEAR MED: poor

53. Bone Graft
• Iliac crest
• Local
• Allograft: structural,
morselized
• BMP
• DBM
• Ceramic: tricalcium
phosphate and corraline
hydroxyapatitie

54. Causes of pain recurrence following spinal
fusion surgery
• Non-union
• Adjacent
segment
degeneration:
disc, facet,
stenosis,
instability
• Pain generator
not included in
fusion
• Pain generator
not in spine

66. Retrospective single 2 level psf 21 years Hopkins
Smoking: wound infections, sepsis, prolonged intubation,. Delayed wound healing
outcome variables: complications or non-union
18% smokers
obesity was the single significant risk factor for complications
no difference for single level fusion
2 level fusion: smokers 29% nonunion, nonsmokers 10%

68. Retrospective AS pseudarthorsis 12 patients, posterior based debridement of nonunion
Transpedicular or transforamenal bone grafting, Qingdao University China, 4 points above
And below, laminectomy if there is a deficit, iliac crest,
Fatigue fx?,

73. 60 year old woman C5 quadriplegia,
h/o emergent intubation 2 months prior,
c6c7 acdf one month prior

79. CERVICAL NONUNION WITH
IMMEDIATE POSTOP CT TO ASSESS
CSF LEAK INTRAOP

82. thanks