Orthopaedics: Spine

Fractures of the Spine

• see Neurosurgery
• 4 main types of fractures (see Table 9)

Table 9. Fracture Type and Column involvement

Cervical Spine

General Principles

• Cl = atlas: no vertebral body, no spinous process
• C2 = axis: odontoid= dens
• 7 cervical vertebrae; 8 cervical nerve roots
• nerve root exits above vertebra (Le. C4 nerve root exits above C4 vertebra)
• radiculopathy = Impingement of nerve root
• myelopathy = Impingement of spinal cord

Special Testing

• Compression test pressure on head worsens radicular pain
• Distraction test: traction on head relieves radicular symptoms
• Valsalva test: Valsalva manoeuvre increase intrathecal pressure and causes radicular pain

 Table 10. Cervical Radiculopathy/Neuropathy

X-Rays for C-Spine

• AP spine: alignment
• AP odontoid: atlantoaxial articulation
• lateral

o       vertebral alignment: posterior vertebral bodies should be aligned (translation >3.5 mm is abnormal)

o       angulation: between adjacent vertebral bodies (> 11 • is abnormal)

o       disc or facet joint widening

o       anterior soft tissue space (at C3 should be =<3 mm; at C4 should be =<8-10 mm)

• oblique: evaluate pedicles and intervertebral foramen
• ± swimmer's view: lateral view with the arm abducted 1800 to evaluate C7-T1 junction if the lateral view is inadequate (must see C7-T1 in all trauma situations)
• ± lateral flexion/extension view: evaluate subluxation of cervical vertebrae

Differential Diagnosis of C-Spine Pain

• trapezial sprain, whiplash, cervical spondylosis, cervical stenosis, rheumatoid arthritis (spondylitis), traumatic injury

Thoracolumbar Spine

General Principles

• the spinal cord terminates at conus medullaris (Ll)
• individual nerve roots exit below pedicle of the vertebra (ie. LA nerve root exits below LA pedicle)

Special Tests

• Straight leg raise (SLR): passive lifting of the leg (30-70°) reproduces radicular symptoms of pain radiating down post/lat leg to the knee, ± into the foot
• Lasegue manoeuvre: dorsiflexion of the foot during SLR makes symptoms worse or, if the leg is less elevated, dorsiflexion will bring on symptoms
• Femoral stretch test: with the patient prone, flexing the knee of the affected side and passively extending the hip results in radicular pain

 Table 11. Lumbar Radiculopathy/Neuropathy

Differential Diagnosis of Bilek Pain

 1. mechanical or nerve compression (>90%)

• degenerative (disc, facet, ligament)
• peripheral nerve compression (disc herniation)
• spinal stenosis (congenital. osteophyte, central disc)
• cauda equine syndrome

 2.others

• neoplastic (primary. metastatic, multiple myeloma)
• infectious (osteomyelitis, TB)
• metabolic (osteoporosis)
• traumatic fracture (compression, distraction, translation, rotation)
• spondyloarthropathies (ankylosing spondylitis)
• referred (aorta, renal, ureter, pancreas)

DEGENERATIVE DISC DISEASE

•  loss of vertebral disc height with age results in:

o       bulging and tears of annulus fibrosus

o       change in the alignment of facet joints

o       osteophyte formation

• can cause back-dominant pain
• management

o       non-operative

o       ––staying active with modified activity

o       ––back strengthening

o       ––NSAIDs

o       ––do not treat with opioids; no proven efficacy of spinal traction or manipulation

• operative - rarely indicated

o       decompression ± fusion

o       no difference in outcome between non-operative and surgical management at 2 years

SPINAL STENOSIS

• definition: narrowing of spinal canal <10 mm
• aetiology: congenital (idiopathic, osteopetrosis, achondroplasia.a) or acquired (degenerative, iatrogenic- post spinal surgery, ankylosing spondylosis, Paget's disease, trauma)
• clinical features

o       ± bilateral back and leg pain

o       neurogenic claudication (see Table 13)

o       ± motor weakness

o       normal back flexion; difficulty with back extension

• investigations: cr1MRI reveals narrowing of the spinal canal, but gold standard = CT myelogram
• treatment

o       non-operative: vigorous PT (flexion exercises, stretch/strength exmises), NSAIDs, lumbar epidural. steroids

o       operative: decompression surgery if conservative methods failed >6 months

MECHANICAL BACK PAIN

• definition: back pain NOT due to prolapsed disc or any other clearly defined pathology
• clinical features

o       dull backache aggravated by activity

o       morning stiffness

o       no neurological signs

• treatment: symptomatic (analgesics, PT)
• prognosis: symptoms may resolve in 4-6 weeks, others become chronic

 LUMBAR DISC HERNIATION

• definition: tear in annulus fibrosus allows protrusion of nucleus pulposus causing either a central, posterolateral or lateral disc herniation, most commonly at LS-Sl > 14-5 > L3-4
• aetiology: usually a history of flexion-type injury which tears the annulus fibrosus allowing for protrusion of the nucleus pulposus
• clinical features

o       –back dominant pain (central herniation) or leg dominant pain (lateral herniation)

o       –tenderness between spines at the affected level

o       –muscle spasm ± loss of normal lumbar lordosis

o       –neurological disturbance is segmental and varies with the level of central herniation

o       –––motor weakness (L4, LS, Sl)

o       –––diminished reflexes (14, Sl)

o       –––diminished sensation (L4, 15, Sl)

o       +ve straight leg raise

o       +ve Lasegue test

o       bowel or bladder symptoms, decreased rectal tone suggests cauda equina syndrome due to central disc herniation - a surgical emergency

• investigations: MRI
• treatment

o       symptomatic

o       –extension protocol (PT)

o       –NSAIDs

o       –90% resolve in 3 months

o       surgical discectomy reserved for progressive neurological deficit, failure of symptoms to resolve within 3 months or cauda equina syndrome due to central disc herniation

SPONDYLOLYSIS

• definition: defect in the pars interarticularis with no movement of the vertebral bodies
• aetiology

o       trauma: gymnasts, weightlifters, backpackers, loggers, labourers

• clinical features: activity-related back pain
• investigations

o       oblique x-ray: "collar" break in the "Scottie dog's" neck

o       bone scan

o       CT scan

• treatment: activity restriction, brace, stretching exercise

 SPONDYLOLISTHESIS

• definition: defect in pars interarticularis causing a forward slip of one vertebra on another usually at LS-Sl, less commonly at L4-5
• etiology: congenital (children), degenerative (adults), traumatic, pathological, teratogenic
• clinical features: lower back pain radiating to buttocks

Table 14. Classification and Treatment of Spondylolisthesis

Class: Percentage of Slip & Treatment

 0-25% Symptomatic operative fusion only for intractable pain

 25-50

 50-75 Decompression for spondylolisthesis and spinal fusion

 75-100

 >100

 Specific Complications

• may present as cauda equina syndrome due to roots being stretched over the edge of LS or sacrum