Common Spinal Disorders Explained

Common spinal disorders explained

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Common spinal disorders explained Andrew D Skyrme, Guy PF Selmon, and Lesley Apthorp Andrew D Skynne, MB BS, BSe (Hons), FRCS (Orth) Orthopaedic Department Eastbourne DGH, Kings Drive, Eastbourne, BN26 2UD, UK

Guy PF Selmon, MB BS, FRCS, FRCS (Tr & Orth) Consultant Orthopaedic Surgeon The Conquest Hospital The Ridge, St Leonards on Sea Hastings, TN37 7RD, UK

Lesley Apthorp, MA MB, BChir, MRCP, FRCR Consultant Radiologist The Conquest Hospital The Ridge, St Leonards on Sea Hastings, TN37 7RD, UK

REMEDICA

Acknowledgments Many thanks to Cannel, Kate, and Hugh for all their support.

Preface Spinal surgery is becoming increasingly specialized \vi.th the development of new techniques and technologies. As such, the majority of new spinal texts are highly complex and difficult to navigate for anyone who is not a spinal surgeon. Common spinal di.~orders explained was written to provide a concise text that includes up-todate information on the majority of spinal disorders in an easy-ta-read format. The book is aimed primarily at medical professionals who are not specialized in spinal surgery, and in particular at orthopedic trainees, primary-care physicians, and allied healthcare professionals such as physiotherapists, chiropractors, osteopaths, and sports physicians.

Each condition has been summarized to allow the reader to be able to use the text as a reference when reviewing a patient with back pain. To provide a more readable book we have deliberately not used multiple references, but have included multiple illustrations and radiographs to aid understanding of the various conditions. Patients are becoming more literate regarding their conditions and, as such, the text can also be used by patients to keep them fully infonned about their particular condition. We hope that you and your patients benefit from Common spinal di.lOrdus explained, and that it helps to improve your ability to diagnose and treat the many spinal disorders you are likely to encounter in the course of your work. Andrew D Skynne, Guy PF Selmon, and Lesley Apthorp

Foreword The greater recognition of spinal disorders and their enonnous implications for healthcare has become an increasing source of concern. However, the last few years have seen a dramatic improvement in our ability to diagnose treatable spinal conditions thanks to the widespread introduction of magnetic resonance imaging, and an improvement in the available treatment options since the development of lle\V technical systems for stabilizing the spine and the introduction of disc replacement. In addition, the use of complex instrumentation has increased dramatically in recent years, and new bone graft substitutes and dynamic fIxation techniques may well become more routine as the years go by. This book is a highly useful source of practical infonnation for any general practitioner or physician who deals with patients with spinal problems In addition, it serves as a useful background to the medical specialties commonly involved in the treatment of spinal problems - notably physiotherapy, osteopathy, and chiropractic therapy - as well as allied disciplines such as pain medicine, and is invaluable to specialists such as rheumatologists who may just wish to update their knowledge of the surgical aspects of spinal management. And while this book is not aimed at the specialist spinal surgeon due to the speed at which new techniques in spinal surgery are evolving, it provides valuable information for orthopedic surgeons or other similar specialists who might encounter spinal problems from time to time The authors of Common spinal di.~orders explained have succeeded in drawing together a large volume of infonnation covering an extensive range of pathologies affecting the spine. Any bOClk dealing with such a wide therapeutic area requires a clear and organized approach for it to be effective. The dividing up of this book into prudent and clinically applicable chapters provides it with a well-structured framework, ensuring that it is easy to use. Each chapter is dedicated to a specific anatomical area, diagnostic method, or group of disorders, and covers the whole range of possible situations that the physician might have to deal with. Rather than going into specific details about individual prostheses that might or might not be used in spinal surgery, or exploring the more subtle implications of and controversial issues regarding some of the very latest implants and surgical techniques, the authors have decided to deal with the main conceptual points within surgical care. They have skillfully alluded to these in the appropriate context, providing a sound background on which to base funher learning.

The management of spinal disorders involves many different disciplines but the common goal should always be to improve patient welfare. This book is a very valuable text for all those involved in trying to help a group of patients who are all too frequently branded as "just having backache". The economic effects of ill-judged or inadequate management of these problems are very substantia\, and it is impo"ant for all general physicians and specialists dealing with spinal problems to stay up-to-date, be aware of the breadth of the problems they are dealing with, and know the sometimes very serious implications of misdiagnosis. It is very much hoped that those reading this book will be prompted into taking further interest in this diverse and exciting area of clinical practice. Richard Gullan Consultant Neurosurgeon King's College Hospital London, UK

Contents Chapter 1

History and examination

1

Chapter 2

Imaging of the spine

9

Chapter 3

Anatomy of the thoracolumbar spine

15

Chapter 4

Thoracolumbar trauma

21

Chapter 5

Mechanical lower-back pain

31

Chapter 6

Prolapsed thoracolumbar intervertebral discs

39

Chapter 7

Lumbar spinal stenosis

47

Chapter 8

Spondylolisthesis

53

Chapter 9

Spinal infections

59

Chapter 10

Spinal tumors

67

Chapter 11

Inflammatory arthropathies affecting the spine

73

Chapter 12

Disorders of the sacrum and the coccyx

n

Chapter 13

Anatomy of the cervical spine

81

Chapter 14

Cervical spine injuries

85

Chapter 15

Soft-tissue injuries of the cervical spine

95

Chapter 16

Cervical radiculopathy

101

Chapter 17

Cervical spondylosis and myelopathy

105

Chapter 18

The rheumatoid spine

109

Chapter 19

Pediatric spinal conditions

113

Abbreviations

127

Glossary

129

Index

133

Chapter 1 History and examination History ~A

42-year-old man presents to the surgery \vith back pain."

General inquiry v.rhen assessing a patient presenting with back or neck pain it is essential to take a thorough history and examination, as it is usually possible to make an accurate diagnosis or a differential diagnosis based on the findings. The infonnation that should be obtained from the history includes: 1) age, sex, race, and weight

2) past medical history, panicularly any past history of lower-back or neck injuJies 3) level of activity 4) family history 5) social background

Specific history The most common symptoms that patients present with are back pain or neck pain, and as such it is imponant to gain as much infonnation as possible about the nature of the pain to aid in the diagnosis The specifIC points to inquire about include: 1) date: the date of onset of the pain

2) severity: assess the analgesic that the patient is taking, whether the pain wakes the patient at night, and how far the patient is able to walk before he/she has to stop because of the pain 3) site: specifically, ask the patient to put one finger on the most painful spot, and then ask the patient to outline the entire area over which the pain is siruated 4) progress: fmd out whether the pain has improved or deteriorated 5) injury: did the pain coincide with a specific injury, or has there been any injury in the past1 6) occurrence: is the pain constant or intennittent, and are there periods of exacerbation? Constant pain at rest is much more sinister and can represent an underlying infection or tumor 1

History and examination

7) 8) 9)

10)

II)

12)

radiation: does the pain radiate down the patient's legs or anns, indicating nerve roOt compression or radicular symptoms? aggravating factors: is the pain made worse by coughing or sneezing? Again, this indicates radicular symptoms treatment: has the patient tried any specific treatments and, if so, how successful have they been? Find out what, if any, analgesic the patient is taking and whether it alleviates the pain activity: is the patient able to carry out activities of daily living, including washing and dressing him/herselP Inquire whether he/she is able to work and whether he/she has taken any time off work as a result of the back pain quality: is the pain sharp or dull in nature? A deep, gnawing pain that is constant and not relieved by rest or analgesia is highly suggestive of either an infection or a tumor duration: how long does the pain last and when is the pain worse (ie, morning or evening), or is it activity-related?

It is imponant to assess whether or not the patient has any stiffness in the back or neck and specifically ask whether the patient has difficulty bending to put on his!her socks and shoes Patients with neck stiffness often complain of stiffness when l(X)king to either the left or the right, and occasionally when looking up. Constitutional symptoms It is essential to assess the general health of the patient and, specifically, the physician should inquire about: 1) weight: has the patient lost a significant amount of weight, again

2) 3) 4) 5)

2

suggestive of a possible metastatic tumor, or has the patient put on a signifICant amount of weight due to reduced level of activity secondary to back pain? fever, night sweats, and rigors: these are all features of infection malaise, anorexia, and myalgia: these are rather nonspecific symptoms, but again they relate to the patient's well-being lumps: has the patient noticed any lumps in any other areas of the body, which may be suggestive of a malignancy? review of systems: one should assess each of the patient's systems in tum, including: • gastrointestinal tract: has there been any rectal bleeding, dysphagia, vomiting, abdominal pain, alteration in bowel habit, or other symptoms? • urinary tract: does the patient have signs of prostatism, including hesitancy, frequency of micturition, postmicturition dribbling, or hematuria?

Chapter 1

•

respiratory tract: have there been any instances of cough, sputum, hemoptysis, shorrness of breath, or chest pain? • other systems: including breast, thyroid, and skin

Examination Thoracolumbar spine Observation It is important to assess whether or not the patient has a nonnal thoracic kyphosis

and lumbar lordosis Any loss of lordosis may indicate that the patient has spasm in the thoracolumbar muscles. In addition, check whether there is any scoliosis, which is defined as a curvature of the spine associated with a rotational defonnity. Assessment of the paraspinal musculature is essential to see whether there is any wasting or erector spinae, or whether the muscles are in spasm. An obvious rib hump at the thorax is suggestive of a scoliosis. Palpation

Examine for tenderness in the thoracolumbar spine, and whether this is worse over the muscular tissues or over the bony spinous processes. Movement

Assess thoracic rotation and whether this is equal to the right and left. In the lumbar spine, assess flexion and how far the patient is able to reach towards hislher toes. Then, assess extension and lateral flexion. Documentation of any reduction in the range of movement (ROM) is essential to allow one to monitor the patient's progress with treatment. Bear in mind that the ROM often decreases with age; however, a patient with lumbar stenosis may well have excellent flexion, as this tends to maximize the spinal canal dimensions. Extension in these patients is often reduced, as it exacerbates their symptoms. Neurology A careful assessment of the patient's lower limbs should be made, including tone,

power, reflexes, and sensation. Reflexes

• anklejerkSl-2 • knee jerk L3-4

3

History and examination

,

.

, , ,' ,,, ,, : , ',', ' ., ','. , ' ' ,, , , /,' ',', " ' ,~--' /12 L3 L4, ",',' \ " ' , " - - -=.." ...-/' <~,." ," ,,,

-

.

.

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"'p

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,

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L4 L5, 51 Inversion and eversion

Ankle

Figure 1.1, Movemcnts

to

aS5C.5S when examining the thoracolumbar spinc.

Power One should assess the following movements, as seen in Figure L 1:

• hip fle>..ion L2-3 • • • • • • •

hip extension L4-5 knee extension L3--4 knee flexion L5-51 ankle dorsiflexion L4-5 ankle plantar flexion 51-2 inversion of the foot L4 eversion of the foot LS-51

Dermatomes The lumbar and sacral dennatomes can be seen clearly in Figure 1.2.

Cervical spine Inspection The physician should first test for loss of the cervical lordosis and whether or not there is any spasm of the erector spinae muscles, and, at the same time, check for spasm of the trapezius and sternomastoid muscles.

4

Chapter 1

Figure 1.2. lumbar and sacral dcrmalomes.

Palpation

Identify the spot that is most tender in the cervical spine and detennine whether this is located over soft tissue or bone. The trapezius is the most commonly affected muscle in soft-tissue injuries of the cervical spine, followed by the sternomastoid Movement

Specifically test fleAion, extension, lateral flexion, and lateral rotation. Any reduction in the range of movements should be documented accurately. Neurology

Assess the patient·s upper limb neurology including tone, power, reflexes, and sensation. Power

Test the fonowing movements in the upper limb (see Figure 1.3): • • •

shoulder abduction C5 shoulder adduction C6-7 elbow flexion C5-6

5

History and examination

Pronation/supination Elbow

Wrist

Hand (Intrinsic muscles)

Figure 1.3. Segmental innervation of movements of the upper limb.

• wrist flexion and extension (6-7 • • • •

finger fle>..ion and extension (7---8 pronation and supination (6 elbow extension (7-8 small muscles of the hand Tl

Reflexes It is important to assess:

• • •

biceps jerk (5---6 triceps jerk (7---8 brachioradialis (6

Cervical dermatomes The cervical dermatomes are divided by the midaxial line, which runs down the center of the arm and forearm with the hand in the anatomical position. The area occupied by the cervical dermatomes is shown in Figure 1.4.

Special tests There are specific tests (outlined below) related to the neck and back that should be carried out in an effon to aid diagnosis

6

Chapter 1

c,

--I

Figure 104. Cervical dcrmatomcs. Straight leg raise Assess the straight leg raise (5LR) bilaterally and look for symmetry. At the same time, assess whether there is a positive sciatic stretch by dorsiflexing the foot whilst the patient is perfonning a straight leg raise. A positive sciatic stretch test is indicative of radicular symptoms. Femoral nerve stretch This involves the patient lying prone and then extending the hip to see whether this produces radicular symptoms along the distribution of the femoral nerve. Anal tone With lower-back pain and back injuries, it is important to assess anal tone. Any loss of anal tone should alert the clinician to a cord or cauda equina injury. Rarely, the sacral nerve roots 52-4 can be compressed or injured. Perianal sensation Any loss of perianal sensation is highly suggestive of cauda equina syndrome. Bowel and bladder function Assess whether the patient has a disturbed bowel or bladder function, and whether they have a palpable full bladder, which indicates cauda equina syndrome.

7

History and examination

If the patient does have a palpable bladder then, following catheterization, assess the volume of urine that was held by the bladder, as this is an indication of bladder function. Waddell's inappropriate signs It is imponant to consider those criteria that allow the physician to differentiate between true organic pathological symptoms and psychosomatic symptoms: the latter can mimic disease and result in unnecessary investigation. Waddell was the first to describe psychosomatic signs in relation to the lumbar spine and they include: 1) nondennatomal sensory loss

2) pain in the spine with axial loading of the cranium 3) inappropriate SLR, ie, the patient is unable to perform an SLR whilst lying, but they can sit upright with the hips at 90 which is equivalent to an SLR of 90° 4) pelvic rotation produces pain in the lumbar spine. There is no demonstrable rotation in the lumbar spine 5) diffuse tenderness in the mid-thoracic region 6) light touch producing inappropriate pain 0

,

8

Chapter 2 Imaging of the spine Radiological assessment of the spine is an integral part of the thorough investigation of a patient with back and neck pain, or other suspected spinal pathology.

Plain radiographs X-ray films still have a role to play in the imaging of the spinal column, although computed tomography (CD and magnetic resonance imaging (MRl) are now the principal imaging modalities in use. Anteroposterior CAP) and lateral views (with the addition of an odontoid peg view in the neck) are the standard images obtained. They are particularly helpful in assessing trauma, spondylolisthesis, degenerative disease, infection, and tumor, It should be remembered that the views are usually obtained with the patient

supine, ie, nonweight-bearing. Oblique views of the lumbar spine are also helpful in delineating spondylolyses in the area of the pars interarticularis: the classic 'Scottie dog' outline should be seen on these views. However, the radiation dose is significant espedally if oblique or coned-down views are requested. Cervical spine X-ray films of Ap, lateral, and odontoid peg views are shown in Figure 2.1.

(.)~----~(b)'----~"""-

Figure 2.1. Cervical spine x.ray. (a) Anteroposterior; (b) lateral: (c) ooonloid peg view complete \vith lOngue piercing.

9

Imaging of the spine

(.)

Figure 2.2. Thoracic

spinc X-ray (normal). (a) Antcropostcrior: (b) ImeraL Thoracic spine X-ray films (AP and lateral views) are shown in Figure 2.2 Lumbar spine X-ray films (AP and lateral views) are shown in Figure 2.3.

Lower-back pain and X-ray films In the management of patients with lower-back pain (LBP), there is some debate regarding which patients require X-ray films in the acute phase. Generally, patients with straightforward LBp, with or without sciatica, will tend to improve significantly within 6 weeks. These patients do not require X-ray films, but should be reassessed clinically after 6 weeks. Suspicion should be raised in patients who have back pain that occurs in the following circumstances: I) younger (aged

< 20 years) patients

older (aged> 50 years) patients a preceding history of tumor a history of trauma night pain/significant rest pain systemic symptoms 7) atypical or unusual picture

2) 3) 4) 5) 6)

10

Chapter 2

(OJ

Figure 2.3.

Lumbar spine X-ray (normal). (a) Anteroposterior: (b) laleraL

Whilst MRl is the investigation of choice in patients with spinal disorders, X-ray films also have a role to play, particularly in assessing trauma and defonnity. It is helpful to obtain a lateral lumbar spine X-ray film with the patient standing. The radiological appearance of individual pathologies will be described in the relevant chapters

Fluoroscopy Fluoroscopy is mainly used for needle localization during injections, and to confinn the appropriate spinal level dUring surgery. Dynamic imaging, especially of the cervical spine, is occasionally undenaken. This may be panicularly imponant in assessing stability of the cervical spine follOwing soft-tissue injury when plain films appear normal. These films should nonnally be supen1sed by a member of the spinal team.

Myelography This technique involves introducing a low-viscosity, water-soluble medium into the subarachnoid space and taking conventional radiographs. It is not without its complications and has largely been superceded by newer techniques. Myelography is rarely indicated now, although it might still have a role in the investigation of patients who have cardiac pacemakers. I1

Imaging of the spine

• •

Figure 2.4. Bone scan showing multiple metastases

Bone scanning Bone scanning is an effective screening investigation for the spine as it has the advantage of being able to assess the whole skeleton at once. It is particularly helpful in detecting spinal metastases (see Figure 2.4) and locating multifocal primary tumors, and plays a role in assessing infection in the spine, particularly discitis. It can also be helpful in the assessment of patients with spondylolyses: 'hot' scans suggest the lysis may be attempting to heal and surgical intervention can be delayed, and 'cold' scans suggest an established nonunion.

Computed tomography This technique is still widely used and is being developed to give further information about spinal pathology Three-dimensional reconstructions are now more \vi.dely available and can add considerably to the visualization of the problem. a is panicularly useful in assessing bony abnormalities, including trauma. Reversing the gantry of the cr enables spondylolyses to be accurately assessed. a is also helpful for performing guided biopsies of spinal lesions. The radiation involved in a lumbar CT scan is similar to that of a plain lumbar X-ray, although 12

Chapter 2

Figure 2.5. Computed tomography scan of a lumbar burst fmcture.

scatter is significantly less with CT A cr scan of the lumbar spine is shown in Figure 2.5. Both cr and bone scanning involve a significant dose of mdiation to the patient.

Magnetic resonance imaging MRI is becoming more readily available and is the imaging modality of choice for spinal problems in many hospitals. Advantages of this technique include: • soft-tissue resolution • characterization of pathological tissue • lack of radiation There are a few conrraindications to MRI scanning, such as the presence of ferromagnetic aneurysmal clips, cardiac pacemakers, or other recently implanted metal devices. MRI is particularly effective at demonstrating intervertebral disc problems, such as prolapse and degenerative disease. However, it is also well recognized that many asymptomatic patients exhibit spinal abnormalities on MRI, the prevalence of which increases \vith age. Therefore, it is essential that MRI be performed with a specific question in mind. Before considering spinal surgery it is preferable to perform a scan to attempt to correlate the findings with the clinical picture. If there is no identifiable 'target' on an MRI scan, the surgeon \vill not proceed to surgery. Sagittal MRI scans of the cerVical, thoraciC, and lumbar spine are shown in Figure 2.6.

Discography/spinal probe This is a technique that involves placing a needle into a specific disc space under image-intensifier guidance. The main reason for doing this is to try to obtain more information about the disc in question Infection is the main potential complication.

13

Imaging of the spine

(.)

(')

Figure 2.6. Saginal magnetic resonance images of (a) cervical spine; (b) thoracic spine; (c) lumbar spine.

Summary Radiological assessment of the spine is an essential adjunct to the investigation and treatment of spinal disorders. Most of these investigations are likely to be organized by the specialist involved with the case. Investigations should be ordered with a specific question in mind, and findings are usually only significant if they correlate with the patient's symptoms.

14

Chapter 3 Anatomy of the thoracolumbar spine To fully understand the pathology of back complaints it is imponant to have a thorough understanding of the anatomy of the thoracolumbar spine, including the bony and soft-tissue elements of the region: the anatomy can be analyzed to help make a differential diagnosis. The vertebral column fanns the cenrral axis of the skeleton and acts to support the skull and provide attachment for the ribs; it is also attached to the pehis at its lower end. The vertebral column requires both great strength, which is provided by the bony elements, and great flexibility, which is provided by the SofHissue elements including the muscles and ligaments.

Vertebral column anatomy The vertebral column is made up of33 venebrae: 7 in the cervical spine, 12 in the thoracic spine, 5 in the lumbar spine, and 9 that are fused in the sacrum and coccyx The spine consists of a number of curves in the sagittal plane, including a cervical lordosis, a thoracic kyphosis, and a lumbar lordosis. However, anatomical variation does exist and Figure 3.la shows an example of lumbarization, where there are six rather than five lumbar venebrae. Conversely, Figure 3.1 b shows an example of sacralization, where the fifth lumbar venebra is fused to the sacrum, {.)

L

.....----,

Figure 3.1. (a) lumbarization; J (b) sacralization.

15

Anatomy of the thoracolumbar spine

1'1,-Transv&n;e process Pedicle

/ Facet lor rlb head

----"'r"

Inferior articular process Spine

SUperlor anlcular pIOCMS

_,L

Intervertebral loramen

y

---:I-:-~/

Facellor rlb head ~-_ Spinous process

Transv&n;e process Facet lor rlb tubercle Vertebral canal

--::=__

=::::::=~~~~~~~~~....

process Superlor articular

Pedicle __- - - - \ ( Facet lor rlb tlead -

Figure 3.2. Basic vertebral anatomy of a mid·thoracic vertebra. Counting the vertebrae from the last vertebra \vi.th a rib attached allows one to calculate the number. The basic vertebral anatomy can be seen in Figure 3.2. Each vertebra has a body anteriorly, and a neural an:h, which is bound by the pedicle, lamina, and articular facets; the spinous process extends posteriorly, and the transverse process extends laterally.

Bony anatomy Thoracic vertebrae The thoracic vertebrae are characterized by facets on the side of their bodies for articulation with the heads of the ribs (see Figure 3.2). There are also facets on the transverse processes for aniculation \vi.th the rib tuben:les. The spinous processes of the thoracic vertebrae are IOllg and downward sloping, while the articular facets are relatively vertical.

16

Chapter 3

Anterior longitudinal ligament

r--

Posterior longitudinal ligament

Nucleus pulposus Annulus librosus

'WI »

««««(

Ugamentum Ilavum

c=""L

A prolapsed disc

Figure 3.3. Saginal section through the lumbar vertebrae showing a normal and a prolapsed intervertebral disc.

lumbar vertebrae There are five lumbar vertebrae: these are larger in size and more square-shaped than the thoracic vertebrae, and they have horizontal spinous processes. The articular facets of the lumbar vertebrae lie in the sagittal plane.

The intervertebral joints The spinal column is composed of vertebrae, which articulate via intervertebral discs and articular facets posteriorly. The amount of movement between each "motion segment" is small; however, the combined movement of all the motion segments is considerable. The maximum amount of movement occurs at the cervicodorsal and dorsolumbar junctions. As a result these are two relatively common sites of injury. The vertebral bodies are interposed by intervertebral discs: these are extremely strong and consist of a peripheral annulus fIbrosus, which is fIxed to the vertebral body above and below, as seen in Figure 3.3. This diagram also shows the anatomy of a disc protrusion. The annulus fibrosus surrounds the semifluid nucleus pulposus. Disc pathology is one of the common causes of back complaints and must be considered with most diagnoses.

ligamentous attachments The anterior longitudinal ligament extends from the tubercle of the atlas, anteriorly, to the front of the sacrum, distally. It is fInnly attached to the periosteum of the 17

Anatomy of the thoracolumbar spine

vel1.ebral bodies, anteriorly, and also to the intervertebral discs. The posterior longitudinal ligament extends from the back of the body of C2 to the sacral canal. FUl1.hennore, the posterior longitudinal ligament is attached to the posterior aspect of the venebral boclies. The ligamentum flavum derives its name from its characteristic yellow color, which is due to the high content of elastin fibers. It attaches to the front of the upper lamina and the back of the lower lamina of the vertebrae along the length of the spine. The supraspinous ligaments join the tips of the adjacent spinous processes. These ligaments are strong bands of white fibrous tissue that are taut in flexion and lax in extension. The interspinous ligaments are relatively weak and connect the spinous processes along their adjacent borders. The interspinous ligaments are particularly well developed in the lumbar region. There are also intel1.ransverse ligaments that are fairly weak and join the transverse processes along their adjacent borders.

Neural anatomy The spinal cord travels within the vel1.ebral canal, which is the space bordered by the vel1.ebral body, anteriorly, and the pedicle and lamina, posteriorly. The individual nerve roots travel through the intervertebral foramen, which is the space formed by adjacent pedicles. The dorsal root ganglion is situated within the intervel1.ebral foramen. The spinal cord "proper" usually ends at Ll and this region is called the conus medullaris. Below this level the spinal cord consists of individual nerve roots within the dural sac known as the cauda equina ("horse's tail"), which ends in the filum tenninale at 52.

Muscles of the vertebral column The muscles of the spine work to control vel1.ebral column movement. The flexor muscles lie anterior to the spine and consist of the psoas, longus capitis, and longus colli. These muscles are assisted by the two rectus abdominis muscles, which indirectly act to flex the spine. The extensor muscles lie posterior [0 the spine and are termed "erector spinae". Gassing the extensor muscles as one muscle group, erector spinae, is an oversimplification as they consist of deep and superficial layers; however, the majoIity of clinicians consider the extensor muscles as a single muscle group.

Movements of the vertebral column Fle>..ion and extension are common to all parts of the spine. However, the majority of flexion and extension in the thoracolumbar spine is due to the lumbar spine; 18

Chapter 3

lateral flexion also occurs in the lumbar spine. The main reason for the lack of flexion and extension in the thoracic spine is the combined effect of facet joint alignment and the splinting effect of the thoracic rib cage. As a result, rotation occurs predominantly in the thoracic spine: there is no demonstrable rotation in the lumbar spine.

Summary A basic and correct lmowledge of the anatomy and biomechanics of the spine is fundamental to the understanding of all spinal conditions. This chapter should be used for cross-reference to allow a more detailed appreciation of the various conditions that this book outlines.

19

Chapter 4 Thoracolumbar trauma Injuries of the thoracolumbar spine are relatively common, especially osteoporotic wedge fractures, which are prevalent in the elderly. Back pain secondary to thoracolumbar trauma is also common, and is a potential source of chronic disability. Over 20% of patients with fractures of the thorncolumbar spine will have long-tenn disability as a result of their injury. The incidence of chronic pain has been shown to be the same in patients with injuries treated nonsurgically and those treated surgically_ The exact cause of the pain is not always obvious, but it might be related to defonnity, soft-tissue injury (disc damage in panicular), secondary degenerative changes, or neural compression. A past history of tmuma should be sought at the first consultation.

Etiology Motor vehicle accidents are the most common cause of trauma to the spine. However, falls account for 60% of spinal fracrures in patients over the age of 75 years. The thoracolumbar junction is the most common site for fractures; this is due to the transition between the mobile lumbar and the restricted thoracic spinal segments, The presence of one spinal fracture should aim the clinician to the possibility of funher fractures in other pans of the spine. Approximately 15%-20% of patients sustain neurological injury \'lith thoracolumbar trauma

Neurological sequelae The majority of patients \'lill have no neurological disturbance. However, a small number will be rendered paraplegic at the time of injury and these patients \'lill have no neurological function in their legs, Approximately 80% of patients will recover one root level of function over time. However, there is a group of partial spinal cord lesions from which some meaningful recovery is possible. These lesions are described below. Central cord syndrome

This syndrome is due to trauma in the cervical spine but \vill be discussed here with the other partial cord lesions. It is usually encountered in the elderly. The patient usually already has a narrowed cervical spinal canal and minimal trauma can cause spinal cord injury. The upper limbs are affected more than the lower

21

Thoracolumbar trauma

Dorsal columns (SIHlSory: deep touch, proPfloceptlon, vibration)

Sulcus

Lateral corticospinal tract (motOfj

Co,

"""' Am

...,""

spinothalamic tract {slHlsory: pain and temperature)

VlHltrai spinothalamic tracl (slHlsory: pain and light touch)

Anterior spinal artery venlral corticospinal tract (motOfj

Figure 4.1. Cross section of the spinal cord demonstrating ascending (sensory) and dc.sccnding (motor) tmcts. limbs and there is mixed motor and sensory loss nonsurgical and the prognosis for this syndrome is fair.

Management is usually

Anterior cord syndrome The anterior pan of the cord is affected resulting in motor loss, and loss of pain and tempemture sensation below the lesion. The prognosis for this syndrome IS poor. Brown-Sequard syndrome Hemi-section of the cord results in ipsilateral motor loss, and contralateral pain and thennoanesthesia. The prognosis for this syndrome is usually the best of all of the incomplete lesions. Posterior cord syndrome This is rare and usually only spares a few anterior spinal cord tracts.

A cross section of the spinal cord demonstmting ascending (sensory) and descending (motor) tracts is shown in Figure 4.1. 22

Chapter 4

Differential diagnosis It is usually obvious if there is a significant history of trauma. [t can, however, sometimes be difficult to distinguish between an osteoporotic compression fracture (new or old) and a rumot (usually metastatic). The history is important, but magnetic resonance imaging (MRI), with or without bone scanning and computed tomography (CT) scanning. is ultimately required. Classification Many systems exist to classify these injuries: the most commonly used is the Denis system, although this is thought to be somewhat outdated. More recently the AO (a group of European orthopedic surgeons who are prominent in the management of trauma) classification has gained wider popularity, but it is relatively cumbersome. Denis divided injuries into major and minor groups. Within the majot group he identified four types of injury: 1) compressIOn

2) burst 3) seat-belt type (flo.ion/distraction) 4) fracture/dislocation Treatment Initial treatment of any suspected spinal injuty involves simple tesuscitation and immobilization with appropriate handling and turning. Hypotension should be avoided to reduce the risk of secondary spinal cord insult.

Compression injuries Nearly 50% of all injUries are compression (wedge)-type fractures. These occur as a result of axial loading, combined with either flexion or lateral bending. Diagnosis is made from anteroposterior (AP) and lateral X-rays (see Figure 4.2). Compression injUries are generally stable and the majority can be treated conservatively \vith a shon period of bed-rest followed by mobilization, \vith or without an orthosis. If there is more than 50% venebral body compression, or more than 30 of local kyphosis, there may be damage to the more posterior structures in the spine: it is usually possible to elicit this clinically. Q

Funher investigations, including CT and MRl, help to detennine the extent of the damage. Erect lateral X-rays may also be helpful to demonstrate funher collapse of the fracture when upright. Surgery may be indicated if the fracture is thought to be unstable or if it is associated \vith severe kyphotic defonnity. Surgical options include fIXation from the front and/or the back with or \vithout fusion.

23

Thoracolumbar trauma

Figure 4.2. Lateral X-ray of compression fraerure of ll.

Figur£ 4.3. X-ray showing multiple asymptomatic lumbar spine compression fractures.

Osteoporotic-related spine fractures Osteoporosis is a systemic metabolic disorder resulting in decreased bone mass and an increased incidence of fractures. Primary osteoporosis is an age-related loss of bone mass, whereas secondary osteoporosis is related to an endocnnopathy or other disease state. Vertebral compression fractures in primary osteoporosis are common, since the condition pnmanly affects trabecular bone. Fracture incidence is directly related to bone mass loss and fractures typically affect the midthoradc and thoracolumbar regions of the spine (see Figure 4.3). These fractures may arise with minor rrauma or with no trauma at alL They do not necessarily cause pain and are often diagnosed incidentally. It should be noted that women with a pre-e>.isting vertebral insufficiency fracture are four times more likely to experience a further vertebral fracture. Fracture-Jisk can be assessed by monitoring bone mineral density using dual-energy X-ray abso11'tiometry (DEXA). With osteoporosis, there is no doubt that prevention is better than cure; however, treatment may be required and consists of estrogen replacement, calcitonin, and bisphosphonates. Treatment of the vertebral fractures is usually conservative, although there is ongoing interest in techniques that involve the injection of bone 24

Chapter 4

Figure 4.4. X.ray of burst fracture of Ll. (a) Antcropostcrior: (bl latcraL

cement and other substances into collapsed vertebral bodies (vel1.ebroplasty and kyphoplasty).

Treatment techniques Vertebroplasty is a technique that involves placing a rigid cannula into the vertebral body in question low-viscosity cement is then "injected" into the vertebral body, which sets hard. Thus "stabilization" of the fractured vertebral body is achieved, and this often improves patients' pain. A potential disadvantage of vertebroplasty is that because the cement is being forced into an enclosed space, it can therefore extrude from the vertebral body; the consequences of this can be catastrophic. Kyphoplasty is a slightly newer technique that involves placing a balloon into the collapsed vertebra, which is then inflated. This creates a cavity in the vertebral body and, to some extent, restores the height of the vertebral body. Low-viscosity cement is then introduced into this cavity, with a smaller risk of cement extrusion. The longer-term outcome of these techniques is, as yet, unknown.

25

Thoracolumbar trauma

Figure 4.5. Computcd tomography scans of a burst fracture showing retropulsion of bony fragmcnts into thc spinal canal.

Burst fractures Burst fractures account for -15% of thoracolumbar fractures (see Figure 4.4). They represent significant damage to the structures of the spine, and are often associated with retropulsion of bony fragments into the spinal canal (see Figure 4.5). These injuries require investigation with plain radiographs and CT; MRl may be required in some instances. Lateral erect X-rays may also show funher instability. The mode of treatment depends on several factors, including the neurological status of the patient, the amount of defonnity present, and the extent of spinal canal compromise. It is accepted that the degree of canal compromise does not always correlate with neurological status and there is Significant debate over exactly which patients require surgery, panicularly those with canal compromise. In general, patients who are neurologically intact can be treated conservatively, whilst those with neurological deficit usually undergo surgical stabilization.

26

Chapter 4

Figure 4.6. Magnetic resonance image of a lap-belt injury at Ll: posterior soft-tissue damage can be seen.

Seat-belt type injuries These injuries are rare. They are due to flexion-disrraction forces, and are associated with the use of lap-type seat belts (see Figure 4.6). There are subgroups of injury within this group: some only involve soft tissues and some only involve bone. There is a high incidence of intra-abdominal injuries associated \vith these fractures. Treatment is chosen according to the exact injury and surgery is usually undertaken to produce initial stability and prevent late defonnity. Fracture dislocations These injuries are highly unstable and are usually associated with profound neurological deficit. Treatment usually consists of surgical stabilization, the timing of which is detennined by the overall condition and neurological status of the patient. Urgent reduction and stabilization is indicated in patients with incomplete neurological injuries who have a progressive deficit. In patients with complete neurological deficit, stabilization is usually undertaken to help rehabilitation, ideally in a specialist spinal injury unit. AP and lateral X-ray films of a fracturedislocation of L2 are shown in Figure 4.7,

27

Thoracolumbar trauma

(.)

Figure 4.7. X-ray of fracture dislocation of 12. (a) Anteroposterior; (b) lateraL

Minor injuries Minor injuries include isolated fractures of the transverse processes (see Figure 4.8) and spinous processes, and fractures of the facet joints. The "clay shoveler's fracture" is a reasonably well-known, isolated fracture of the lowercervical or upper-thoracic spinous process. The treatment of this injul)' and other minor injuries is usually conservative.

Complications of thoracolumbar fractures The most common late complications of this type of injury are: I) pam

2) deformity 3) late-presenting neurological deficit Up to 20% of patients sustaining thoracolumbar fractures will become chronically disabled due to pain. The pain can be very difficult to control, and its treatment should be based on the perceived cause, which may not necessarily be the fracture; it may be due to subsequent degenerative change. It is usually necessary to involve the pain clinic in the treatment of patients with chronic pain following trauma. Deformity, when encountered, is usually in the form of kyphosis and can be

28

Chapter 4

Figure 4.8. Anteroposterior X-ray of lumbar spine showing multiple fraclUred transvcrse processes.

associated with progressive neurological deficit. The decision to surgically correct a post-traumatic kyphosis is based on the individual concerned and the disability it causes. Neurological deficits that present late may result from defonnity, secondary degenerative changes, or post-traumatic s}'Iingomyelia. Surgical intervention is indicated according to the degree of disability.

Summary Thoracolumbar injuries are relatively common. The majority are compression fractures and can be treated conservatively. Initial rest followed by mobilization is adequate for most people. Extension braces are used in some centers. Patients with pain that does not settle with appropriate conservative treatment should be referred for assessment. More severe spinal injuries are usually seen in hospital initially, and then referred to the appropriate team. Surgery is usually indicated in patients with neurological deficits or in those with grossly unstable injuries. in patients who are paraplegic, stabilization of the spine is undertaken early to facilitate nursing and to prevent late defonnity and chronic pain.

29

Chapter 5 Mechanical lower-back pain Epidemiology In industrialized countries, the lifetime prevalence of lower-back pain (LBP) exceeds 70%, and, in 2000, almost half the adult population of the UK (49%) reponed LBP lasting for at least 24 hours. LBP is the most common cause of activity limitation in those aged < 45 years. Thousands of days are lost from work each year as a result of LBP and enonnous sums of money change hands as a result of personal injury claims. for these reasons the economic impact of patients with LBP is enonnous, and their suffering is significant. It has been estimated that in 1992-1993 there were about 7 million visits to general practitioners for back-related problems in the UK these were mostly LBP.

Etiology One of the main difficulties in the management of people with LBP is the fau that the exact causes of nonradicular (axial), mechanical LBP are not completely understood. Various authors have speculated about likely pain sources, but as yet the~ is no widespread agreement. With no consensus on etiology, treatment options are numerous and sometimes speculative. Broadly speaking, any structure in the lumbar spine that has pain receptors can cause LBP. The most common theories on etiology of LBP are concerned with: 1) facet joints

2) intervenebral discs 3) lumbar instability

Facet joints Nerve fibers have been identified in the capsules of facet joints and, therefore, degeneration in these joints has been put forward as a cause of back pain. Patients with abnormal facet joints can derive benefIt from local anesthetic injections into these joints Some studies have shown that spinal fusion procedures can have a benefIciallong-tenn effect on patients with a good response to injections. However, these findings are by no means universal.

31

Mechanical lower-back pain

Intervertebral discs The nerve supply to the intervertebral discs and the immediately adjacent tissue is well understood. Both the posterior longitudinal ligament and the posterior fibers of the annulus fibrosus are well innervated, and stimulation of these structures causes typical symptoms in a significant number of patients. Degeneration in these structures is common and is likely to be responsible for many of the symptoms seen in patients with LBP. However, magnetic resonance imaging (MRl) scans show that asymptomatic people can, and often do, have degenerate discs. Some studies suggest that up to 40% of asymptomatic people over 40 years of age have degenerate discs, which is pan of the normal aging process, Lumbar instability Many surgeons are of the opinion that abnormal movement between two or more adjacent vertebrae, caused by degeneration in the spine, is responsible for LBP. The exact source of the pain is poorly understood. Spinal fusion has been suggested as treatment for this condition, the theory being that symptoms will resolve by eliminating abnonnal, painful movement. However, it is diffIcult to prove that abnonnal movement is taking place. In addition, there is no correlation between a solid spinal fusion and relief of symptoms, and pseudoarthroses (where bony fusion is not achieved) are not necessarily associated with poor outcomes. Muscle-related pain Paraspinal muscles have also been implicated as a cause of LBp, and many people believe that muscle tears and sprains are a common cause of discomfort. Myofascial pain syndrome can occur and is characterized by the presence of specific trigger points that can be palpated to produce symptoms. it is also possible that deconditioned spinal extensor muscles can cause chronic pain due to muscle fatigue. Psychological factors Without doubt, there are other important factors related to back pain in some individuals. These have to be addressed to decide on the best treatment options for a given patient. Financial gain and cultural belielS are known to be important factors. Ongoing litigation and compensation claims can influence patients' symptoms and these have to be explored. Back pain is now so common that it is widely accepted by society, the work place, and by governments. Advertisements in the media are constantly reminding the public not to suffer in silence if back pain has started as a result of an accident in which they were not at fault. This may well overshadow the patients with genuine back symptoms \vith genuine causes. Referred pain It is important to establish whether back symptoms are due to a primary spinal condition or to a condition unrelated to the spine. This should be possible from

32

Chapter 5

Figure 5.1. Di.scogram: a method of

Figure 5.1. Sagitlal magnetic resonance

localizing pain via "stimulation" of the disc concerned.

image of degenerate (black) l5-Sl disc.

a careful history and a thorough examination. Unrelated spinal conditions that can cause back pain include: 1) peptic ulceration

2) 3) 4) 5) 6)

pancreatitis pyelonephtitis pelvic inflammatory disease prostate disorders aortic aneurysms

Diagnosis 1) plain X-ray fIlms

2) discography (can be effective to localize pain via "stimulation" of the disc concerned) (see Figure 5.1) 3) MRl (see Figure 5.2) The indications for plain X-my films as part of the investigation of patients with LBP are discussed in Chapter 6. Although the role of discography is widely contested. it is generally agreed that it is indicated in patients with predominantly LBP for whom spinal fusion is being considered. it helps to localize the level (or levels) involved through symptom reproduction. MRl is now wi.dely available and is commonly used as an adjunct to discography. As previously mentioned, asymptomatic people may

33

Mechanical lower-back pain

have abnormal discs, and this can be shown on MRl. Computed tomography is usually not requin:d in the investigation of patients with LBP who have had MRl scans.

Psychological testing Psychological tests an: important in assessing likely treatment outcome, irrespective of the underlying spinal condition. There are a number of questionnaires available that help to provide psycholOgical profiles on patients; their use is essentiaL

Treatment Nonsurgical The majority of patients who experience an episode of acute LBP will have resolution of their symptoms whether they seek treatment or not. Treatment is therefore conservative, and it is important that the patient should understand this. It is important to exclude a nonspinal cause for pain as early as possible. Nonsurgical treatments include: 1) short-tenn bed rest (24-48 hours)

2) nonsteroidal anti-inflammatory drugs 3) muscle relaxants (short-tenn if possible) Treatment should be followed by a period of exercise. Extended bed-rest should be avoided as this can result in muscle deconditioning and abnonnal illness behavior (the patient begins to ~act out" an illness when there may be nothing acrually wrong). No exercise program has been devised that will benefit all patients, so each patient should be given a program that is tailored to his;her response to various exercises: extension and/or flexion exercises are commonly used. There is no documented evidence to support the use of traction. Several studies have also shown that there is little evidence to support the use of transcutaneous electrical nerve stimulation ([ENS) machines, although they appear to be of benefit to a significant number of patients. Corsets are thought to lead to lumbar musculature deconditioning. Chronic LBP usually provides the biggest treatment challenge, and the involvement of "back schools" and the local pain clinic are essential. Most clinicians involved in the management of back pain also support any other modes of treatment that the individual might find helpful, such as chiropractics and osteopathy. Epidural injections

A significant number of patients with both leg and back pain caused by disc disease have a good response to an epidural injection of local anesthetic and a long-acting steroid. Short-term relief is experienced in 60%-85% of patients, but this falls to about 40'*. after 6 months Up to three injections can be administered over a period

34

Chapter 5

of 3 or 4 days, which decreases the volume of a given injection. The injections are placed either directly around the cauda equina in a "lumbar epidural", or they can be placed through the sacral hiatus in a "caudal epidural". The complications are rare but include epidural abscess fonnation, which can be a disaster It should be pointed out that there have not been any randomized, controlled clinical trials conducted that indicate that epidural steroids are beneficial. Facet joint injections This is a technique that can be conducted with the patient awake. Needles can be accurately placed into degenerate facet joints. Local anesthetic and steroids can then be infiltrated. These treatments are associated with very few side effects and, despite the fact that evidence for their benefit is largely anecdotal, this technique is commonly perfonned. Discography This technique involves needle localization in the disc at the appropriate level. It can be used to evaluate symptom reproduction: if local anesthetic is infiltrated during the procedure, patients' symptoms may also disappear for a short time, again indicating that the level is symptomatic. There is evidence that approximately one third of patients will have long-tenn relief from their symptoms, although the technique is primarily an investigation and not a treatment.

Surgical There is considerable controversy regarding the precise indications for surgical intervention in patients with LBP Spinal fusion is the most common procedure perfonned, but even this has not gained wi.despread acceptance in the surgical community; this is partly due to the lack of randomized, prospective trials published in the literature. Long-tenn results on other techniques, including stabilization of the lumbar spine (without fusion) and heat treaunent of the discs (intradiscal electrothennal therapy), are awaited. A recent study has indicated that the latter is of no proven benefit. Before considering using these techniques, con",ervative treatment should have been exhausted, and significant pain and disability should still exist. Ongoing litigation should be a relative contraindication to surgery. Patients should have been thoroughly investigated with MRI and discography. Surgical techniques include: 1) posterior fusion \vi.th autogenous bone graft (\vi.th or without the use

of supplementary instrumentation) 2) interbocly fusion (ei.ther posterior [posterior lumbar interbocly fusion, PUF, see Figure 5.31 or anterior [anterior lumbar interoody fusion, AUF, see Figure 5.4]) 3) combinations of anterior and posterior techniques

35

Mechanical lower-back pain

(.)

Figure 5.3. X-ray of postcrior lumbar intcrbody fusion and pedide scrcwaugmcntation. (a) Antcropostetior: (b) lmeral.

The addition of spinal instrumentation, (ie, screws, rods, and plates) increases the rates of fusion. Some improvement in pain and function is seen in approximately 75% of patients who undergo surgery, but complete pain relief is rare. Patients should be made aware of these outcomes before contemplating surgery, and the final decision to undergo an operation should be made by the patients themselves Other surgical techniques

All other surgical procedures focus on nonfusion techniques. 1) Disc replacement surgery. Although the concept of lumbar disc

replacement is not new, there has been renewed interest in it recently. In an effort to try to avoid fusion in discogenic back pain, disc replacement involves the insertion of a disc prosthesis that allows movement at the level concerned. It requires a wide anterior approach to the lumbar spine and entails all of the potential problems associated with that approach. Long-tenn outcome is awaited. There are also disc replacements available for the cervical spine, although their use is limited at present.

36

Chapter 5

Figure 5.4. X-ray of anterior 15-5 I fusion. (a) Anteroposterior: (b) lateraL

2) Dynamic stabilization techniques There are several systems available that restrict and modify the movement of an abnormal lumbar spine. Some of these involve the placement of pedicle screws, which are then connected up with strong cord. Others involve the use of interspinous process spacers. These are both relatively new techniques and there are no long-term data available in the literature on their use.

Summary LBP is extremely common. It is not always possible to identify the exact cause, although there are several structures, including muscle, that are often to blame. Sinister causes of back pain and nonspinal causes should be considered and excluded as soon as possible. Most investigations are likely to take place after a period of conservative treatment to which the patient has been unresponsive. Analgesia, rest, and early mobilization are effective treatments for the majority of patients. Exercises should be tailored to the individual. Complementary medicine provides help for a significant number of patients. Surgery is reserved for those

37

Mechanical lower-back pain

whose symptoms are unrelenting despite extensive conservative treatment. Patients must be made fully aware of the potential risks and expected benefits of all procedures, and, ultimately, the decision to proceed must be made by the patient. Fusion procedures have been the most common surgical intervention for back pain, and it remains to be seen whether other procedures can produce better results in the long tenn.

38

Chapter 6 Prolapsed thoracolumbar intervertebral discs Disc structure and degeneration intervertebral discs are composed of two distinct parts: a supportive outer annulus

fibrosus and a gelatinous inner nucleus pulposus. They are anchored to the vcnebme above and below via canilagenous end-plates. In nonnal discs, water is an important component of the nucleus: however, water content diminishes with age, leading to disc degeneration. The process of aging of the spine has been divided into three distinCl stages: 1) instability and annular tears, which tend to occur in a younger age group (20-40 years) 2) internal disc disruption, which occurs in an older age group (40-60 years) 3) stabilization and ankylosis, which tend to occur in patients aged> 60 years

Whilst this may not always be helpful in a given patient, it highlights the fact that the spine of a 70-year-old looks significantly different to that of a 15-year-old, as one would expect. Given that all spines wear over time, it is not clear why some patients develop prolapsed intervenebral discs (PlVDs) and others do not. it is also not clear why some patients are symptomatic and others are not. Different spinal levels degenerate at different rates. PlVD is usually a condition of young and middle-aged people, typically those in their third or founh decade of life. The [\VO basic clinical signs of degenerate discs are lower-back pain (LBP) and symptoms suggestive of nerve root compression. Although discs can be degenerate with no evidence of nerve root compression, these discs can be a source of back pain. Nerve root compression can occur with discs that protrude, extrude, or become sequestrated (Figure 6. I). Thoracic disc prolapse is very rare; by far the most common prolapse site is the lumbar spine, with L4-5 being the most frequent location, followed by L5-S 1 and L3-4. Most discs tend to herniate posterolaterally Under these circumstances the

39

Prolapsed thoracolumbar intervertebral discs

~,

Postlll1or longitudinal -----.... ligament

.

.

, .-

Nuclear matlll1a1

. ~.

DEGENERATE DISC

PROTRUSIONS

~

. A. ~;

"~ "g=~,~

Postlll1or longitudinal Posterlor longitudinal ligament

~.

Nuclear material

EXTRUDED

I SEQUESTRATED

" ~

.

~

Figure 6.1. Schematic dIm\~ng of pathological disc nomenclature. Reproduced \\~th permission from the American Academy of Onhopaedic Surgeons (Wiltse LL Lumbosacral spine reconstruction In Orlltopal'dic Knowledge Updall'. Chicago: American Academy of Orthopaedic Surgeons, 1984, p. 247).

L4 vertebra

L4 root

L5 mot

'--

Figure 6.2. Schematic representation of nerve root locations. Ikproduced L5 vertebra with permission from Elsc\~er (Weissman BN, Sledge CB Onltofll'dic Radiology. Philadelphia' --' \VB Saunders, 1986, p. 283).

discs tend to exert pressure on a specific nerve root, which causes sciatica. Sciatica is the specific tenn used to describe pain that radiates down the back of the leg and below the knee in a myotomal distribution; it is usually exacerbated by stretching the sciatic nerve Prolapsed discs tend to impinge upon the nerve root corresponding to the lower vertebra at a given level, eg, an L4-5 prolapse usually causes L5 nerve root compression. Discs can also prolapse centrally to produce

Chapter 6

bilateral leg symptoms or, if the fragments are large enough, cauda equina syndrome. Finally, discs can prolapse laterally, which can result in the root of the upper vertebra becoming compressed at a given level (Figure 6.2).

Symptoms and signs Typically, patients with PIVDs will have both leg and back pain, with leg pain being their chief complaint. Patients often relate its onset to a specific incident, but have usually had intennittent back pain for some time. Their pain is exacerbated by heavy lifting and prolonged bending. In patients with minimal leg pain, true nerve root compression due to a prolapsed disc is much less likely. Patients who present with predominant back pain are much less likely to have a surgically significant prolapsed disc, but they may well have degenerate disc disease. Leg pain is usually intennittent and relieved by rest, but it is made worse by coughing and sneezing [n some cases there may be associated muscle weakness or sensory loss, or both; these will usually be limited to the level involved. The clinical findings may well vary according to the timing of the examination (Thble 6.1). [n the acute phase. lumbar paraspinal muscle spasm is common, with associated loss of the lumbar lordosis. Sciatic stretch testing should be strongly positive and "cross over" pain is not uncommon (straight leg raising of the "nonnal" leg causes pain in the contralateral leg and this is usually highly significant). Any neurological deficit \vill vary according to the level involved. Nerve root involved

Disc level usually responsible

Motor deficit

Sensory deficit

Reflex lost

L2

L1-2

Iliopsoas weakness

Mid thigh

None

L3

L2-3

Hip adductors and quadriceps

Distal thigh

None

L4

L3-4

Tibialis anterior

AnteromediaJ calf and knee

Knee jerk ,

L5

L4-S

Extensor hallucis longus

Anterolateral calf and dorsum of fool

Diminished knee jerk

51

LS-$1

Gastrocnemius complex

Sole of fool and lateral border of foot

Ankle jerk

Table 6.1. Symptoms and signs associated with prolapsed imcrvcrlebral discs affecting nerve roots U-5 and 51.

41

Prolapsed thoracolumbar intervertebral discs

Figure 6.3. Magnetic resonance image of large central prolapsed lumbar disc. (a) Sagittal: (b) axial. arrow shows disc causing almost complctc llallening of cauda cquina.

Cauda equina syndrome The cauda equina is the collection of lumbosacral nerve roots that continues from the spinal cord Occasionally, a massive disc prolapse can cause pressure on the entire cauda equina, leading to: 1) severe back pain

2) 3) 4) 5) 6)

bilateral leg pain wealmess in both legs bladder dysfunction (usually incontinence) bowel dysfunction with loss of anal tone saddle anesthesia/paresthesia

Patients \vi.th cauda equina syndrome should be examined for any sensory or motor neurological deficit, including a rectal examination to assess anal tone and perianal sensation. Bladder dysfunction usually presents as incontinence. Retention of urine is often a sign of significant pain. Urgent magnetic resonance imaging (MRI) is required and prompt surgical decompression is suggested if the diagnosis is confirmed in order to avoid long-term neurological deficit. Sagittal and axial MRIs shmvi.ng large central disc prolapse are illustrated in Figure 6.3.

Investigations Plain X-ray films The role of plain radiographs in the initial investigation of patients with back and leg pain is conrroversial Plain anteropostetior and lateral X-ray films of the lumbar

42

Chapter 6

Figure 6.4. Magnetic

~sonance

image of prolapsed L4-S disc. (a) Sagittal: (b) axiaL

spine probably do not contribute to initial patient care and are therefore not usually required in the acute stages of symptoms. X-rays should be ordered if symptoms do not settle or if there is any suspicion about the etiology of the pain.

Magnetic resonance imaging MRl remains the investigation of choice in the assessment of patients with back pain and suspected PIVD. A potential problem of MRl is its ability to demonstrate abnonnalities that may be un~lated to the patient's symptoms. Nonnal aging of the spine produces degenerate discs on MRI that frequently do not cause symptoms. The most imponant aspect is to correlate the scan findings to the symptoms of the patient, Sagittal and axial MRI scans of a prolapsed L4-5 disc are shown in Figure 6.4. Neurophysiological studies These can be used to differentiate peripheral neuropathies from spinal nerve root entrapment, and they can be particularly helpful in distinguishing carpal runnel syndrome from cervical spine problems.

Treatment Conservative The majority of patients with acutely prolapsed discs can be managed conservatively as most will have improved significantly by 6 weeks, The initial treatment consists of:

43

Prolapsed thoracolumbar intervertebral discs

1) bed rest (24-48 hours)

2) anti-inflammatory drugs and analgesia if required 3) muscle relaxants Alxlominal and lower limb exercises should be commenced when comfort allows, under the guidance of the physiotherapist if possible. Back education at "back school" is proving popular and may get people back to work sooner. Patients should avoid activities that exacerbate their symptoms such as lifting and prolonged bending. it is often a question of trying to fmd the best remedy for the individual patient: moclification of the patient's lifestyle may well be required. The majority of patients' symptoms will settle within 6-8 weeks of starting conservative treatment. Epidural injections

These injections can be used in the acute stage of disc prolapses and in some cases can defer the need for surgery Nerve root injections

Using the image intensifier, nerve root injections can target individual nerve roots. These blocks can be both diagnostic and therapeutic. They are day case procedures and have few associated risks. Up to 50% of patients with leg pain resulting from nerve root impingement will have long-term benefit from these injections. They are particularly effective for far-lateral disc prolapses. Chemonucleolysis (chemical dissolution of the disc)

The lytic enzyme chymopapain has been used extensively for chemonucleolysis in the past: it acts to reduce the size of PIVDs. There have been significant side effects, such as transverse myelitis and other neurological problems, and its use is currently limited. It may be beneficial in younger patients to avoid spinal surgery, but it is rarely used now.

Surgery Indications for surgery include: 1) cauda equina syndrome

2) 3) 4) 5)

progressive neurological deficit failure of conservative treatment appropriate MRI findings a patient with leg pain as the predominant symptom

In patients with signs and symptoms of nerve entrapment (predominant leg pain and paresthesia in dermatomal distribution), surgery to decompress the entrapped 44

Chapter 6

root should be performed. The removal of a prolapsed disc can usually give a 90% chance of improvement to patients who have leg pain as their main symptom. Once the decision to operate has been agreed by aU involved, it is important to perform the appropriate operation. Discectomy is the most common operation performed; this can be open or percutaneous, and with or withom a magnification aid. Patients should be warned that the operation is unlikely to help their back pain. [n patients who have leg pain and back pain of equal intensity, and in whom there is radiological evidence of a prolapsed degenerate disc, it may be more appropriate to perform a discectomy l\fith a fusion procedure such as posterior lumbar interbody fusion. In these patients it is often helpful to perform preoperative discography. Urgent discectomy is indicated for patients with proven cauda equina syndrome. Vlhichever method is used for isolated discectomy, patients are usually able to go home within 24-72 hours Depending on the patient's occupation, it is usually necessary to have at least 6 weeks off work. It should be noted that the long-term (5-year) outcome for patients with PIVD is the same whether they are treated conservatively or surgically. However, the surgical group may have a more rapid initial improvement Complications of disc surgery These are seen in up to 10% of patients and they include: 1) increasing LBP

2) 3) 4) 5)

scar tissue formation, leading to further nerve root compression recurrent prolapsed disc superficiaVdeep infection nerve root damage

Exacerbation of LBP can occur as a result of ongoing disc degeneration. Treatment is conservative in the first instance, bm some form of fusion or stabilization may ultimately be required. Recurrent disc prolapse is also seen and must be differentiated from scar tissue formation as the treatment is often different; MRI (using gadolinium) is used to differentiate between the [\vo conditions. Recurrence of symptoms is often a significant problem and the exact cause must be identified. Recurrent spinal surgery is not usually as successful as the primary procedure, and the patient must be made aware of this if further surgery is considered.

45

Prolapsed thoracolumbar intervertebral discs

Thoracic disc disease Thoracic disc disease is extremely rare and its incidence is approximately 0.5% of all disc prolapses. Pain is usually a characteristic symptom, with unilateral or bilateral weakness and/or numbness also reported. Bowel or hladder dysfunction (or sometimes both) is occasionally reponed. The diagnosis can be confinned with MR!. The usual treaunent is surgical excision via either a costotransversectomy or an anterior transthoracic approach. Thoracoscopic techniques have been developed, but they are not yet widely used.

Summary Lumbar disc herniations are common and typically cause symptoms in people aged 30-40 years, Classically, patients present with sciatica and varying degrees of back pain. The most common levels to be affected are L4-5 and L5-5 I, causing L5 and 51 r(X)t compression, respectively; the exact signs and symptoms will depend on the level involved. The majority of patients with confirmed disc prolapse are treated conservatively. Discectomy is indicated in cases refractory to conservative treatment. Referral is recommended for patients whose symptoms do not settle with appropIiate conservative treatment, in patients with progressive neurological deficits, or in those in whom the diagnosis is in doubt. Patients with suspected cauda equina syndrome should be referred urgently.

46

Chapter 7 Lumbar spinal stenosis Introduction Spinal stenosis is defined as narrowing of the spinal canal or the neural foramina It can occur in any part of the spine but this chapter will concentrnte on the most common area, the lumbar spine. Spinal stenosis can cause pressure to develop on any of the following structures: 1) the spinal cord (although the cord itself ends at the level of the

body of Ll)

2) the cauda equina 3) individual nerve roots

Spinal stenosis can therefore produce either back or leg symptoms, or both, However, cauda equina and nerve root compression can occur without producing symptoms. This highlights the existing uncenainty as to the exact etiology of spinal stenosis. With aging, spinal degeneration leads to abnormal spinal motion, which may compound the compression. This can lead to the stan of clinical symptoms of spinal stenosis. An absolute stenosis is defmed as a midsagittal anteroposterior CAP) lumbar canal diameter of s 10 mm (in most patients this should be > 11.5 mm, see Figure 7.1).

"-

/'

//

~(f'~ "

~

~ ~y Figure 7.1. Line drawing of superior aspect of mid-lumbar vcrtebra. Arrow indicates midsagittal anteropostcrior canal diameter

47

Lumbar spinal stenosis

('I

(OJ

)~ \

Q

1 ) "".:

V

)~

//~

-

V

Figure 7.2. (3) Line drawing of mfoillumbar canaL (b) line drawing of lalcrallumbar recess encroachment.

Central stenosis causes pressure on the thecal sac. Lateral stenosis compromises the individual nerve roOt either in the subfacetal area or in the intervertebral foramen (see Figure 7.2).

Classification Spinal stenosis can be either congenital or acquired. The congenital group includes idiopathic narrow canals and developmental disorders such as achondroplasia: the acquired type is much more common. Ibtential compression can arise as a result of: 1) osteoanhritic facet joints

2) 3) 4) 5) 6) 7)

ligamentum flavum hypenrophy degenerate bulging intervertebral discs osteophyte fonnation spondylolisthesis spinal trauma Paget's disease

However, it is often a combination of several of these factors With progressive disc and facet degeneration, the spine often becomes less stable in the first instance and this may worsen the stenosis (Figure 7.3),

Symptoms and signs Symptoms of lumbar spinal stenosis usually start in the sixth or seventh decade, although congenital cases usually start earlier. ~Spinal claudication'" is the classic presentation of this disease.

48

Chapter 7

1·1 ..........,

fbi

Figure 7.3. X.ray of degenerate lumbar spine. Cal Anleroposlerior Carrow shows osteophyte): (b) lateral (while atTow shows reduced disc height, blue atTow shows osteophyle, dashed arrow shows reduced size of rool canal).

This can consist of: 1) leg pain associated with exercise or extension of the lumbar spine,

2) 3) 4) 5)

including standing "heaviness" in the legs neurological distUlbances in the legs occasional urinary dysfunction back pain

Vascular claudication The symptoms of lumbar spinal stenosis need to be distinguished from those of vascular claudication: this should be possible from the history and examination Classic spinal claudication produces pain that is worse when walking downhill and is albiated when sitting or bending forward (this increases the diameter of the spinal canal and therefore its capacity). Vascular dauclicants have pain that is worse when walking uphill. Time to relief of pain is usually quicker in vascular

49

Lumbar spinal stenosis

(OJ

Figure 7.4. (a) Saginal magnetic resonance image shmving multiple level lumbar canal stenosis. (b) Axial magnetic resonance image shQl.\~ng multifactorial lumbar canal stenosis.

claudication. vascular claudicants tend not to have neurological symptoms. Smoking and other tisk factors for vascular disease should be assessed. Examination of these patients is frequently unremarkable, although they may have neurological defICits. As part of the examination, fIXed flexion deformity of the hip must be excluded as this can lead to increased lumbar lordosis. Assessment of peripheral pulses is mandatory.

Investigations Routine investigations should include: 1) plain AP and lateral X-rays of the lumbar spine and pelvis

2) magnetic resonance imaging (MRI) (Figure 7.4) or computed tomography (CT) scan depending on availability 3) flexion/extension views, which can be helpful if instability is suspected It should be possible to make the diagnosis clinically and MRI scans should be reserved for those for whom surgery is planned. Sometimes CT scans are performed after myelography; this can give useful infonnation on facet joint hypertrophy and the presence of osteophytes.

Treatment The etiology of spinal stenosis is poorly understood. Severe neurological deterioration is rare in patients treated nonoperatively. The decision to operate is not necessarily based on a specific neurolOgical defiCit, but on a decrease in the

50

Chapter 7

patient's quality of life as a result of an increase in his!her symptoms, Surgery cannot routinely be expected to reverse these deficits.

Conservative therapy This will help a significant number of patients. It should include: 1) education: avoid standing and extension of the lumbar spine

2) reassurance 3) analgesia 4) epidural steroids The role of epidural steroid injections remains controversial as there have been no randomized, controlled trials concentrating on their use in spinal stenosis alone But they do provide relief of leg pain for a significant number of patients and are relatively safe.

Surgery if the patient's quality of life is deteriorating and the MRI findings match the symptoms and signs, surgery should be considered. Decompressive laminectomy is the procedure of choice for most patients it is essentially an operation to relieve symptoms in the legs and not an operation designed to improve back pain, although this does sometimes occur: the patient should therefore be made aware that the operation might not resolve back pain. If there is an associated structural deformity, such as a degenerative scoliosis or spondylolisthesis, a fusion procedure with or without instrumentation should be considered. Outcome is predominantly related to patient selection. Most patients would choose to have the same operation again in similar circumstances. There are newer techniques available that place spacers between the spinous processes of adjacent vertebrae in an effort to distract the two vertebrae and hence increase the diameter of the spinal canal. They do not require the spinal cord to be opened at surgery. The long-term outcome of these techniques is awaited.

Summary Spinal claudication as a result of spinal canal stenosis presents most commonly in patients aged 60-70 years and should be differentiated from vascular claudication by history and examination Referral is usually necessary in patients with progressive neurological deficits and symptoms that do not settle with conservative treannent. In patients with appropriate MRl findings, surgery in the form of decompressive laminectomy is sometimes necessary in resistant cases. In singlelevel surgery, about 80% of patients will get relief of their claudicant symptoms fusion is not routinely performed unless there is additional pathology present in the spine.

51

Chapter 8 Spondylolisthesis Introduction Denved from the Greek words

~spon~r,

meaning spine, and

~Oli.~lhesi.~",

meanmg

slippage, spondylolisthesis refers to the slippage of one vertebra and the spinal column above on the vertebra below This usually occurs at the LS-S 1 or L4-5 levels.

Classification The classification of spondylolisthesis is paramount to understanding and diagnosing the condition. The most widely accepted classification (see Figure 8. I), divides the disease into: 1) dysplastic

2) isthmic a) lysis of the pars

b) attenuation of the pars c) acute fracture of the pars 3) degenerative 4) traumatic 5) pathologic

Isthmic

DeglHleratlve

Traumatic

Pathologic

Figure 8.1. Classification of lumbar spondylolisthesis.

53

Spondylolisthesis

Figure 8.2. A dysplastic spondylolisthesis

Figure 8.3. An isthmic spondylolisthesis

with> 75% slip and rounding of the body of the sacrum due to an abnonnality of the 51 facet.

with a clearly visible pars defect (arrow).

Dysplastic spondylolisthesis This is a congenital abnonnality of the upper sacrum or the arch of L5 occurring specifically at the facet joints of LS-51 (see Figure 8.2). it is associated with L5 spina bifida occulta in all cases. The disease is twice as common in females as males and presents in patients under 20 years old. The patients often complain of hamstring spasm and, less commonly, of leg pain and altered gait. Patients may present with symptoms of sciatica or even cauda equina syndrome. Isthmic spondylolisthesis In this type of spondylolisthesis. the lesion is in the pars interanicularis and may either be a stress fracture of the pars. an elongation of the pars, or lysis of the pars (see Figure 8.3). Patients between 5 and 18 years of age are the most commonly affected and may have a positive family history. L5-51 is the level most commonly affected. There is a higher incidence of this disorder in young females, gymnasts, trampolinists, and fast bowlers (that is, people who undergo repetitive hyperextension injuries, causing lysis of the pars at L5-51).

54

Chapter 8

Figure 8.4. A degmerative sfXlndylolisthcsis at L4-5. \\~th a Grade I slip.

Figure 8.5. A magnetic resonanee image of a degenerative spondylolisthesis at the less common level of 15-51, \\~th obvious degeneration of the dises above.

Degenerative spondylolisthesis Degenerative spondylolisthesis is due to chronic instability of a motion segment, \vith degeneration of the facet joints. It is primarily seen in women over the age of 40 years and over 90% of cases occur at the L4-5 level (see Figures 8.4 and 8.5). The symptoms of degenerative spondylolisthesis are: back pain, unilateral nerve root compression including sciatica, and spinal claudication. The slip is usually less than 30% and self-limiting. Traumatic spondylolisthesis Traumatic spondylolisthesis usually occurs through the pedicle and not through the pars. It is associated with high-energy injuries such as falls from a height, sponing injuries, or road traffic accidents. Pathological spondylolisthesis This occurs most commonly in patients with metastatic malignancy, rheumatoid anhritis, tuberculosis, or occasionally Paget's disease. These patients are invariably older and display all the other features of a systemic disease

55

Spondylolisthesis

Clinical signs The clinical signs associated with spondylolisthesis are: I) age: dysplastic or isthmic types occur in childhood or adolescence, 2) 3) 4) 5) 6) 7) 8) 9)

degenerative types occur in the elderly lower-back pain (LBP), especially in the young patient nerve root compression gait abnonnality kyphosis palpable step in the vertebral column hamstring tighmess scoliosis with or without spasm loss of lumbar lordosis

Investigations Plain X-rays are the initial investigation in most patients, followed by computed tomography (CD or magnetic resonance imaging (MRl), if indicated. The degree of slip is divided into the following grades depending on the percentage of vertebral body overlap measured on the lateral radiograph of the lumbosacral spine (see Figure 8.6 and lable 8. I). Grade

Percentage of vertebral body overlap

I

<25%

"III

25%-49% 50%-74%

IV

75%-99%

V

100% (spondylolisthesis}

Table 8.1. The "degree of slip",

,,,, ,,

,

%SIlP=~Xl00=50 Figure 8.6. Pcrcentage slip.

56

Chapter 8

Treatment Children and adolescents The younger a child is, the greater his/her risk of suffering a slip progression. Females are four-times more likely to suffer slip progression than males. If the slip is less than 25%, keep the patient under review and monitor the situation both clinically and radiographically. If the slip is less than 50%, restrict the sporting activity of the patient, as these slips are usually isthmic spondylolistheses, with lysis of the pars All patients with a spondylolisthesis of greater than 25%, or those in the high-risk category (including females, those with spina bifida, and those with wedging of the body of l5), should be referred for an onhopedic or spinal opinion. Adults Conservative treatment is the most common form of therapy for adult spondylolisthesis. Patients with a symptomatic spondylolisthesis of greater than 25% should be referred for a spinal opinion. Patients with radicular pain (sciatica) or spinal claudication should be managed symptomatically, and, if their symptoms do not reduce, then referral to a spinal team would be appropriate.

Summary Spondylolisthesis is a condition of slippage of one venebra on another and can occur at any age. Patients can present with LBp, sciatica, hamstring tightness, or spinal stenosis. The management of spondylolisthesis is divided by age: children and adolescents require close monitoring and should be formally assessed by a spinal surgeon, whereas adults can usually be managed in the community as they tend to have a much more benign condition requiring conservative symptomatic therapy.

57

Chapter 9 Spinal infections Introduction Infection in the spine can be classified by the anatomical site of origin of the infection and the organism responsible for the infection. The most common infections of the spine include: 1) pyogenic vertehral osteomyelitis

2) disc space infection 3) spinal tuberculosis 4) abscess fonnation: epidural and paravertebral Each of these infections occurs predominantly in certain subgroups of the population, which aids in the diagnosis of the disease.

Pyogenic vertebral osteomyelitis This fann of osteomyelitis accounts for approximately 4% of all cases of osteomyelitis, and the most common mechanism of infection is by hematogenous spread. infection can also spread from surrounding tissues, or may occur following invasive spinal procedures. The most common sites include: 1) lumbar spine (60% of cases)

2) thoracic spine (30%) 3) cervical spine 00%)

Staphylococcus aureus is the most common infecting organism, followed by streptococci and enterobacter Etiology Vertebral osteomyelitis occurs more frequently in the following patient groups: 1) olde!; debilitated patients: the mean age of occurrence is 60 years old. However, there is bimodal age distribution \vith peak incidences at ages

1-15 years and 50--80 years 2) intravenous drug addicts

59

Spinal infections

3) males (twice as frequently as in females) 4) patients \vith diabetes mellitus The patient may present following a history of a urinary tract, respiratory tract, or skin infection, or following invasive surgery

Pathogenesis The initial site of infection is the vertebral endplate, where there is an end-arterial circulation. As a result, the infection spreads from the endplate across the disc space and into the adjacent endplate of the vertebrae above or below. There is also an anastomosis, which facilitates the spread of infection between the vertebrae The most common site of infection \vithin the spine is the anterior column: the posterior arches are less frequently affected. Clinical features The clinical features of vertebral osteomyelitis include: 1) unremitting spinal pain in 90% of patients

2) pain that is unrelieved by rest. This is extremely unusual \vith lower back pain. so therefore it is important to consider the diagnosis of spinal infection with any patient that presents \'lith unremitting pain that is not relieved by rest 3) constitutional symptoms: anorexia, weight loss, fever 4) tenderness, muscle spasm, reduced range of movements 5) neurological deficit in 30%-40% of patients 6) progressive kyphosis of the spine

Diagnosis The follO\ving investigations can be performed to assist diagnosis of vertebral osteomyelitis: 1) raised erythrocyte sedimentation rate and C-reactive protein (eRP) level

2) equivocal white cell count 3) radiographs: the radiographic changes of infection are often subtle in the early stages, and difficult to diagnose (see Figure 9.1). The radiographic changes include: a) disc space narrowing (after 2 weeks) b) osteopenia and erosion of vertebral endplates (after 6 weeks) c) reactive sclerosis (after 8 weeks) d) paraspinal swelling with the possible loss of psoas shadows (after 10 weeks) e) possible vertebral fusion (after 6 months)

60

Chapter 9

t·)

)')

Figure 9.1. Plain X-rays of thoracolumbar discitis (al Anteroposterior: (b) lateraL

Figure 9.2. Magnetic resonance image showing collapse of two lumber vertebrae with obliteration of the disc space (arrow) and posterior canal intrusion.

61

Spinal infections

4) magnetic resonance imaging (MRO is now the imaging modality of choice and is very sensitive in differentiating nonnal tissue (see Figure 9.2). Gadolinium enhancement increases the sensitivity 5) blood cultures, aspiration of infection, and open biopsy Treatment Any patient with a suspected spinal infection should be referred for a specialist opinion. Thereafter, the treatment includes the isolation of the infecting organism to allow appropriate antibiotic therapy. The patient is usually subjected to a period of bed rest, followed by mobilization in a thoracolumbar orthosis. Some patients require surgical intervention, the indications being: 1) systemic symptoms despite appropriate antibiotic therapy

2) 3) 4) 5) 6)

biopsy for diagnosis and culture severe pain that is refractory to analgesia abscess fonnation vertebral collapse and progressive kyphosis neurological deficit

Antibiotic therapy should be continued for approximately 12 weeks and monitoring of the inflammatory markers is mandatory. Surgical therapy may also include the radical debridement of the infected tissue and stabilization of the vertebral column. This can be done via many approaches, including the retroperitoneal, transthoracic, and transabdominal options.

Disc space infection Disc space infection is relatively uncommon and occurs in children and adults The anatomy of the pediatric intervertebral disc differ:s from that of the adult in that it has a vascular supply and, as such, can be a site of hematogenous infection. In adults, the disc is relatively avascular and therefore intervertebral disc infection is usually a result of secondary invasion from vertebral osteomyelitis, or follOwing invasive therapy such as disc surgery or spinal injection. Again, the most common infecting organism is S. aureu.~, accounting for over 70% of infections. Pediatric infective discitis The average age at presentation is 2-6 years, with boys and girls affected in equal number:s. The child often has back pain that has been present for many weeks. As a result, the child is often irritable, reluctant to walk, and may have a reduced range of movement in the spine. However, children can present with referred symptoms, including abdominal pain, hip pain, knee pain, or generalized constitutional symptoms

62

Chapter 9

Figurt~

9.3. Adult infective discitis with disc space obliteration.

Investigations should include erythrocyte sedimentation mte and CRP levels, blood cultures, and white cell count, all of which may be mised. The pathognomonic mdiographic changes include disc space naITO\ving, which becomes apparent at approximately 14 days, and endplate erosion. The most common site is L4-5 (40% of cases). The infection is almost always at one level. Emher investigation includes MRl or isotope bone scans. The treannent for acute childhood discitis is similar to that of venebml osteomyelitis: bed rest and spinal immobilization \vith a thomcolumbar onhosis, as well as appropriate antibiotic thempy. In most cases, the condition is self-limiting and responds well, so surgery is rarely indicated.

Adult infective discitis Infective discitis in adults has a similar history to venebral osteomyelitis. The patient may well have had recent disc surgery or spinal injection therapy. The patient presents \vith severe unremitting back pain and constitutional symptoms. The inflammatory markers remain raised. However, mdiographic changes may not occur for many weeks. Figure 9.3 clearly shows an aggressive example of adult di.scitis following disc surgery. The treatment of adult infective discitis consists of bed rest, bracing, and antibiotic thempy; it is best to culrure the organism prior to the commencement of antibiotic thempy to enable prescription of the most appropriate antibiotic.

63

Spinal infections

Figllr£ 9.4. Cervical

tuocrculosis with almost complete loss of C4 anterior body.

Spinal tuberculosis (Pott's disease) The most common extrapulmonary location of tuberculosis (TB) is in the spine. TB is extremely common in the third world; however, the World Health Organization has confirmed its increasing incidence in developed countries,

Pathophysiology The infection may spread by direct invasion from the lung into the thoracic vertebrae, or by hematogenous spread. The infection originates in the metaphysis of the vertebral body and spreads under the anterior longitudinal ligament, causing destruction at several contiguous levels. Skip lesions occur in approximately 15% of patients and abscess formation occurs in 50% of patients. The infection leads to progressive kyphosis as more vertebrae are destroyed (see Figure 9.4), The infection does not destroy the disc, but the disc does become sequestered. The infection can involve all three columns of the spine as a result of its propensity to spread, Clinical features The differentiating features of spinal TB and pyogenic osteomyelitis are outlined below: 1) multiple-level disease involving all three columns

2) propensity for abscess formation

64

Chapter 9

3) 4) 5) 6)

insidious onset progressive kyphosis sequestered disc rather than disc destruction spreading along fascial planes

Diagnosis The investigation of spinal TB involves all the imaging modalities previously mentioned, including computed tomography (CT) scans. However, a chest X-ray might reveal the primary source since approximately two-thirds of patients have an abnonnal chest X-ray. Treatment The treatment of spinal tuberculosis involves multiple drug therapy, which should be continued for I year. Treatment for less than 6 months has been shown to result in failure to control infection. Surgical treatment is only indicated when: 1) there is progressive kyphosis

2) 3) 4) 5)

more than 50% of the vertebral body is destroyed there is neurological compromise (Pott's paraplegia) the patient fails to respond to medical therapy abscesses fonn

Abscess formation Abscess fonnation can occur with any of the previously mentioned spinal infections (see Figure 9.5). However, paraspinal and epidural abscesses can also occur as solitary events. The patient usually presents with a history of back pain, constitutional symptoms, and infection in the spine, urinary tract, respiratory tract, or skin, or an infection following surgical intervention. The epidural abscesses often produce back pain in association with radicular pain. However, the paraspinal abscesses may have a delayed presentation. In the thoracic spine, the abscess may present with a subcutaneous mass along the erector spinae. or anteriorly along the tibs. In the lumbar spine, the paraspinal abscesses may track along the psoas into the groin or into the other retroperitoneal structures Treatment The treatment of spinal abscesses involves appropriate antibiotic therapy and isolation of the organism. However, surgical therapy is almost always indicated, as antibiotic penetration into abscess cavities is notoriously poor.

65

Spinal infections

Figure 9.5. Magnetic resonance image of abscess formation (arrow).

Summary When considering a patient with back pain, always consider and actively exclude a spinal infection. Any patient who presents with unremilling back pain and constitutional symptoms such as anorexia, weight loss, and fever, should be investigated for spinal infection or metastatic disease. All patients require referral to the local spinal, orthopediC, or neurosurgical center where appropriate imaging is available. The refeffill of these patients should be on an urgent basis and any patient who presents with neurological deficit should be seen in the local unit within hour:s. Antibiotic therapy, bed rest, and spinal orthoses are the main treatments for spinal infections, and inflammatory marker:s are useful devices for monitoring the response to treatment.

66

Chapter 10 Spinal tumors Introduction Tumors of the spine are an extremely serious, albeit uncommon, cause of back pain. Tumor:s are divided into benign and malignant lesions. Metastatic malignant tumors are the most common type of tumor in the spine: primary spinal tumors account for less than 2% of all tumors and 20%-40% of these rumors are benign. v.rhen reviewing a patient with back pain, it is important to actively exclude the diagnosis of a tumor as a cause by the process of history, examination, and investigation. This chapter will deal \vith the most common spinal rumors and the salient features in the history and examination that will enable you to make the correct diagnosis and aid referral of the patient,

Benign tumors Benign spinal tumors commonly occur in younger age groups, between 5-40 years old. Therefore, with any young patient who presents with an onset of back pain that does not have an obvious cause, always consider the diagnosis of benign tumors. The most common benign tumors are described below.

Osseous lesions Osteoid osteoma A slow-growing lesion with no malignant potential. Osteoblastoma Occurs in people aged 20-30 years old; this lesion is generally larger in size than an osteoid osteoma. Osteochondroma A benign cartilaginous lesion often occurring at the end of long bones; it is slow growing and possibly multiple. Multiple osteochondromas are often inherited and are known as "multiple hereditary exostoses".

Chondral lesions Giant cell tumor A slow growing and locally aggressive tumor, most commonly found in the sacrum.

67

Spinal tumors

Figure 10.1. Hcmangioma of l3 vcrtcbral body. Aneurysmal bone cyst

A locally invasive tumor, most commonly found in the lumbar and sacral spine. Eosinophilic granuloma and hemangioma

Most commonly found in the thoracic spine, involving the anterior portion of the vertebral body (see Figure 10. I).

Clinical presentation Over 80% of patients with benign tumors present with back pain Pain may be isolated to the lower back or can include radicular symptoms The pain is constant and unaffected by posture or activity, The pain does not respond to conventional treatment and the patients are often in pain at night. This presentation in a pediatric patient should alert the clinician to the possibility of a benign tumor. Pain that is relieved by aspirin therapy is almost diagnostic of an osteoid osteoma. Benign tumors may be asymptomatic, or patients may also present \vith: I) neurological symptoms in 35% of cases: weakness, sensory loss,

2) 3) 4) 5)

68

and cord compression scoliosis that is painful and progresses rapidly with or without an associated kyphosis reduced range of movement secondary to pain a palpable lump torticollis

Chapter 10

Investigation Any young patient who presents with the above symptoms should undergo a thorough investigation, including measurement of: complete blood count, erythrocyte sedimentation rate, serum calcium, bone profile, prostate specific antigen, electrolytes, and histocompatibility leukocyte antigen B27. Radiographic investigation should include plain films, as the benign tumors often have characteristic features that include: 1) osteoid osteoma and osteoblastoma: sclerotic lesions often seen in

the pedicle 2) aneurysmal bone cysts and giant cell tumors: expansile and lytic 3) hemangiomas: increased thickening of the venical venebral trabeculae and expansion of the bocly Patients should also receive a bone scan to screen the rest of the skeleton, followed by further imaging of the lesion, with either computed tomography (CD or magnetic resonance imaging (MRO.

Treatment All patients with a diagnosis of a spinal tumor should be referred for a specialist opinion and funher management. This often includes a needle biopsy under CT guidance to aid diagnosis. Lesions that are symptomatic often require en bloc resection and more aggressive tumors need wide resection. Tumors that present with neurological deficit should be referred urgently to a surgical spinal unit. Treatment regimens consist of a combination of surgery, radiotherapy, and occasionally chemotherapy.

Malignant tumors Malignant tumors of the spine are much more common in adults, and the lesions can be divided into two categoIies: metastatic deposits and pIimary tumors.

Metastatic deposits Metastases account for the majority of malignant spinal tumors (see Figure 10.2) and some 80% of these deposits are in the anterior column, The most common site is the thoracic spine (60% of cases) and in 10% of cases patients \vill develop neurological symptoms. The majority of patients (80%) have a survival time of less than I year following the diagnosis of spinal metastases. The malignancies that are most likely to metastasize to the spine include those of the breast, lung, prostate. thyroid, and kidney.

69

Spinal tumors

Figure 10.2. Magnetic resonance image showing multiple metastases in the thoracic spine _ _J from a lung primary.

Primary malignant tumors of the spine The most common primary malignant tumors of the spine include: 1) myeloma: malignant tumor derived from plasma cells, occurring

2)

3) 4) 5) 6)

predominantly in patients over 40 years old chordoma: a tumor of notochordal remnants, 50% of which occur in the sacrum. Males are predominantly affected and the rumor is locally invasive. A mass is felt on digital rectal examination osteosarcoma: this can be a primary rumor or secondary to Paget's disease, bone infarct, fibrous dysplasia, irradiation, or chondrosarcoma chondrosarcoma: tumor occuning in 30---60 year olds, often with a long history of pain osteoblastoma neurofibroma with malignant change

The most common malignant primary rumor in the spine in children is neuroblastoma. Presentation Over 60% of patients with malignant tumors in the spine present with back pain that is unremitting and unrelieved by rest, sleep, or significant analgesia. The patients often have radicular symptoms, and a significant proponion (about 5%) will develop cord compression. The patients will also present with the systemic symptoms of the primary tumor and general constirutional symptoms.

70

Chapter 10

Physical signs In over 60% of cases, patients have muscle weakness and a significant percentage have abnonnal neurology. A small percentage of patients have paravenebral muscle spasm and a mass may be palpable. A significant number will have some tenderness. Girdle pain in particular is impo"ant as this is often a feature of incipient cord compression. Diagnosis The following investigations can be perfol11led to assist diagnosis of primary malignant tumors of the spine: 1) routine blood tests, including a full blooo count to look for anemia

2) 3) 4) 5) 6)

7) 8)

related to chronic disease serum electrophoresis, to aid in the diagnosis of myeloma liver function, clotting, and calcium tests to check for liver deposits liver ultrasound to look for metastases digital rectal examination to palpate for a chordoma plain X-rays: it is wOl1hwhile noting that changes are only seen on plane radiographs when at least 50% of the vel1ebral body has been destroyed \\'hen looking at the anteroposterior X-ray, look for loss of the pedicular outline; and on the lateral X-ray, check for maintenance of vertebral body height. The tumor tends not to cross the intervenebral disc space, which differentiates it from infection MRl or CT scan. MRI is the imaging modality of choice as this gives better soft-tissue resolution CT-guided biopsy to allow a histological diagnosis

Treatment The treatments for malignant spinal tumors are pain relief, initial steroid therapy, radiotherapy, chemotherapy, and surgical treatment. The indications for surgical treatment include: 1) pain that is unrelieved by analgesia

2) a pathological fracture 3) neurological defIcit 4) patients with a survival time of > 10 weeks

Summary The diagnosis of malignant spinal tumors is made by a thorough history, examination, and investigation. The history will often arouse suspicion and a diagnosis of spinal tumor should be considered in any patient who presents with pain that is relentless, is refractory to analgesia, is not relieved by rest or sleep, 71

Spinal tumors

and is located in the spine. The other principal diagnosis is infection, and the salient features for differentiation are that infection results in fever, rigors, nausea, vomiting, and sweating. Spinal tumors can be associated with weight loss, muscle weakness, and the symptoms of the primary rumor. Any child that presents with back pain must be investigated for spinal neoplastic lesions, as should any patient with an atypical history. All patients require referral to a specialist neurosurgical, orthopedic, or spinal unit. Any patient who presents with neurological compromise must be referred urgently (within hours).

72

Chapter 11 Inflammatory arthropathies affecting the spine There are many inflammatory conditions that can affect the spine. Some, such as ankylosing spondylitis and rheumatoid arthritis, are reasonably common. Olhers, such as diffuse idiopathic skeletal hyperostosis and Reiter's syndrome, are very rare.

Ankylosing spondylitis This chronic inflammatory condition has a prevalence of about 0.2% and is more common in men than in women. There is an imporrant genetic component to the disease: over 90% of sufferers are human leukocyte antigen (HLA)-B27 positive. The underlying pathological process is synovitis associated with destruction of articular cartilage. There is also inflammation of the fIbro-osseollS junctions, especially the intervertebral discs. initially, there is localized bone erosion with granulation tissue fonnation: this is subsequently replaced by fIbrous tissue, which is then ossified This causes ankylosis of the joint.

Signs and symptoms Signs and symptoms of ankylosing spondylitis include: 1) lower-back pain (LBP) and stiffness (especially limited extension),

which is often worse in the morning 2) sacroiliac pain and tenderness 3) hip and shoulder pain and stiffness

Investigations Radiologically, the follOwing first changes are usually seen in the sacroiliac joints: 1) erosions and "blurring" of the sacroiliac joint

2) 3) 4) 5) 6) 7) 8)

loss of sacroiliac joint space (see Figure 11.1) ~squaring" of vertebral bodies loss of cervical and lumbar lordoses thoracic kyphosis marginal syndesmophyte formation ~bamboo spine" (see Figure 11.2) destructive arthritis of peripheral joints

73

Inflammatory arthropathies affecting the spine

Figure Il.l.

Sacroiliac X-ray showing oblitcration of thc joint space.

Treatment Treatment is conservative in the vast majority of people, and consists of advice on posture and prescription of anti-inflammatory dmgs. Referral to a rheumatologist is recommended. Surgery is only considered if there are severe defonnities or if there is evidence of cervical instability. Atlantoaxial subluxation can occur, panicularly if the rest of the neck is fused. This should be treated with stabilization, panicularly if there is evidence of spinal cord compression. Patients with severe cervical kyphosis have difficulty looking ahead and can be offered osteotomy. There are, however, significant risks associated with this procedure, including massive hemorrhage and damage to the spinal cord and nerve roots. The C7-TI level is usually chosen for the osteotomy. Severe lumbar kyphOSis can also be corrected with osteotomy, the usual site being L2. Patients known to suffer from ank}'losing spondylitis who develop acute back or neck pain should be assumed to have suffered a new fracture until proven otherwise. [f a fracture is diagnosed, immobilization is required and surgical fusion is often undenaken to ensure union of the fracture.

Rheumatoid spondylitis The majority of patients with rheumatoid anhritis will have spinal involvement, invariably the cervical spine (see Chapter 18).

Sacroiliac pain Pain arising from the sacroiliac joint often manifests itself as LBP and buttock pain; examination should reveal whether or not the joint itself is responsible for the pain. Medial stressing of the joints usually elicits pain in a diseased joint. Causes of pain

74

Chapter 11

Figure 11.2.

Anteropostcrior lumbar spinc X-my showing "bamboo spinc' include degenemte change (the most common cause), ankylosing spondylitis, and the other spondyloatthropathies discussed below. Referred pain is often felt in the sacroiliac area Bone scanning is helpful in highlighting pathology, but is not able to distinguish between the arthropathies. Diagnostic injections using image intensification can also be therapeutic.

Diffuse idiopathic skeletal hyperostosis Also known as Forestier's disease or abbreviated to DiSH, this is a similar condition to ankylosing spondylitis in that ossification occurs in the anterior longitudinal ligament. Similar changes in the sacroiliac joint are often seen it is not an inflammatory disease. it is usually only seen in older men who present with back pain. Osteophyte fonnation in the cervical spine can lead to dysphagia. which occasionally requires surgery in the fonn of osteophyte excision. Defonnity is not usually severe and treaunent is supportive.

Reiter's syndrome This syndrome is a combination of arthIitis, urethIitis, and conjunctivitis and can also have lumbosacral involvement. Patients with Reiter's syndrome can present with LBp, which may be due to spondylitis or sacroiliitis. The sacroiliitis is usually unilatemL The treatment of spinal problems associated with Reiter's syndrome is conservative.

75

Inflammatory arthropathies affecting the spine

Psoriatic spondylitis Up to 20% of patients with psoriasis will develop spinal involvement. Patients usually have symptoms similar in magnitude to Reiter's syndrome. Some, however, have severe involvement that can mimic ankylosing spondylitis. Treatment is conservative, consisting of analgesia, rest, and physiotherapy.

Inflammatory bowel disease and spondylitis Patients suffering from Crohn's disease and ulcerative colitis are also known to suffer from spondylitis and sacroiliitis, These patients tend to have a similar disease to ankylosing spondylitis and those with severe disease are invariably HlA-B27 positive. Colectomy does not alter the course of the spondylitis.

Beh<;:et's syndrome This is a multisystem, chronic recurrent disease that is very rare, Patients can develop sacroiliitis and spondylitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) help with analgesia.

Summary The spine is a common site for the manifestations of inflammatory arthropathies. The most common disorders are rheumatoid anhritis and ankylosing spondylitis. Patients often complain of back and neck pain and stiffness. Referral should be made to either a rheumatologist or the local spinal unit, as both are likely to be involved in the long-tenn management of these patients. The treatment, however, is conservative in the vast majority of cases, consisting of: 1) NSAIDs 2) rest

3) analgesics 4) physiotherapy 5) advice on posture Surgical management of patients with ankylosing spondylitis is an extremely complex and difficult undertaking. Referral to a specialist spinal unit is essentiaL

76

Chapter 12 Disorders of the sacrum and the coccyx The sacrum The sacrum is composed of five fused vertebrae (see Figure 12. I). There are usually fOUf pairs of foramina anteriorly and posteriorly, the appropriate sacral nerve o.iting through the anterior foramen. The sacral canal finishes caudally with the sacral hiatus, through which caudal epidurals are administered. These are highvolume injections of local anesthetic and steroid mixed with saline that diffuse around the cauda equina.

Sacroiliac pain Sacroiliac pain has been discussed previously (see Chapter 11). Degeneration can occur in the joint and should be treated conservatively. Seronegative spondyloarthropathies should be excluded.

/"

7

~

rQ)

oL"",

0

00

\~

U (o~

/

,,0-

~

'\

:

"

Lateral pan, upper surface Pelvic sacral foramen

/

Lateral pan Site 01 fUsion

(}-J

-f!-

"",-

vertebral

"",'M

Facet lor

-'"

Figure 12.1. line drawing of the anterior aspeet of the sacrum.

77

Disorders of the sacrum and the coccyx

Figure 12.2. lateral X-ray of a transverse fracture of the sacrum.

Fractures of the sacrum Fracrures of the sacrum usually occur with pelvic fractures as a result of high-energy injuries. In the elderly, spontaneous fractures can occur due to osteoporosis. Up to half of patients with sacral fractures will sustain neurological injuries. Examination of these patients should include assessment of sphincter function and pertanal sensation. Fractures are best assessed radiologically with X-rays (see Figure 12.2) and computed tomography (CT) scans. Isolated fractures without neurological deficit can be treated conservatively \vith mobilization as pain allows. More significant injuries may reqUire a longer pertod of bed rest. Severe neurological deficits may require early surgical intervention. in the longer tenn, these injurtes may cause patients to suffer chronic lower-back pain (LBP) due to degenerate change in the sacroiliac joints. Arthrodesis of these joints is sometimes indicated in patients \vith refractory pain.

Chordomas Chordomas are the most common type of tumor to affect the sacrum and are malignant. Patients usually present with insidious LBp, which is unremitting. Rectal examination reveals more than half of these tumors, and CT and magnetic resonance imaging confinn the diagnosis. Treatment consists of radiotherapy and surgery Recurrence is common, but radical surgical excision is usually considered worthwhile.

78

Chapter 12

The coccyx The coccyx consists of four fused vertebrae and fOnTIS the lowest part of the spine it can be injured following a direct blow and is sometimes fractured. Fractures of the coccyx are treated conservatively with analgesia and a protective pillow.

Coccydynia Coccydynia is a condition characterized by chronic, disabling pain in the coccyx Sitting is particularly uncomfonable. it is possible to demonstrate radiological instability of the coccyx in up to 50% of patients. The instability is usually posterior subluxation or excessive flexion \vith sitting, Conservative treatment should be tried initially; if analgesia and protective pillows do not help, manipulation under anesthetic and injections of local anesthetic and steroid can be tried. A proportion of patients \vill not have any significant improvement from this, in which case the only option is coccygectomy. This procedure has not gained lvidespread popularity due to JXXlr results and significant potential wound healing problems. However, a recent srudy has shown that in properly selected patients (with radiological evidence of instability), coccygectomy produces good results Surgery should be avoided in patients with associated LBP and pain not localized to the coccyx.

Summary Injuries to the sacrum and coccyx are common. Most sacral fractures are a result of high-energy trauma, and a neurological deficit is seen in approximately half of patients. Treatment is generally conservative. The treatment of coccydynia is not straightforlvard and results are not always g1X)d. Resistant pain localized in the coccyx can be treated with coccygectomy, although patient selection seems to be the most important predictive factor in outcome.

79

Chapter 13 Anatomy of the cervical spine The cervical spine is made up of seven vertebrae with the upper two being markedly different from the lower five. The normal alignment is that of lordosis.

C1 (atlas) and C2 (axis) These [\VO venehme have special modifications to allow significant movement, particularly head rotation and nodding. The atlas (CI, see Figure 13.1) consists of two large lateral masses joined by a short anterior arch and a longer posterior arch. The lateral masses articulate superiorly with the occipital condyles of the skull and inferiorly with the axis (e2, see Figure 13.2). The axis has a large spinous process and the dens (odontoid process), which is a vertical extension [rom the body of the axis. This aniculates with the anterior arch of the atlas The weight of the skull is transmitted through the more laterally based atlantoaxial joints.

Anterior 'Uberc,e~~;f~~~~fl~~~""~'''''~'~'~=:"

Outline 01 dens

Outline 01 transv~:.;;.~ ...~~~~

IIgamltl11 of atlas

, , .

Face! for dens

,,

•

";.--~-

.

--'1- ll"ansverse p~

Foramen lransversa~um

Superior articular lacet

::;::::::::;:-S:£~

Groove lor Ver1llbral artery and suboccipital nerve

Posterior arch

Posterior tubercle

-~. . . <.r

Figure B.l. line drawing of the first cervical vcmbra (Cn, the atlas.

81

Anatomy of the cervical spine

Dens

¢c~\ Impression lor alar ligament Face! for anterior an:h of atlas Foramen transversarlum Facet lor Interior an:h of atlas

"'" -1'ventral lip --'/- / Transverse process Inferior articular process

Spinous process lamina

Figure 13.2. Line drawing of the second cervical vertebra «(2), the axis

Ligaments of the axis and atlas There are a number of strong ligaments that altach to the axis, atlas, and the base of the skull (see Figure 13.3); these are described below: Crucifonn ligament

The crucifonn ligament consists of [\VO pans: the longitudinal band, which joins the axis to the foramen magnum, and the transverse band, which lies behind the dens and holds it in place. [f the transverse band is damaged, the dens can dislocate backwards and cause fatal pressure on the medulla oblongata. Apical ligament

This ligament attaches the tip of the dens to the anterior aspect of the foramen magnum. It is a relatively weak ligament. Alar ligaments

The alar ligaments are a pair of ligaments that also attach the tip of the dens to the foramen magnum and limit rotation of the head. They are much stronger than the apicalligamem. Tectorial membrane

The tectorial membrane extends upwards as a continuation of the posterior longitudinal ligament. It attaches to the anterior margin of the foramen magnum.

82

Chapter 13

Apical ligament Odontoid peg

o Spinal cord

Transverse band 01 cf\Jcllonn ligament

Figure 13.3. line drawing of ligaments around the odontoid peg_

C3-7 The rest of the cer.ical vertebrae share similar characteristics (see Figure 13.4). They all have foramina in the transverse processes that transmit the venebral artery. They also have bifid spinous processes, except for the seventh venebra. This often has a prominent non-bifid process that is obvious in most people and is called the venebra prominens.

Ligaments of the cervical spine All the venebrae are linked by the strong antertor longitudinal ligament and the slightly weaker postertor longimdinal ligament. The postertor ligament is shaped like an hourglass. Its wider pan is located at the level of the discs and, because it is weakest here, accounts for the fact that most disc prolapses occur here. There are supponive ligaments, called interspinous and supraspinous ligaments, that run between the laminae and between the spinous processes

Muscles of the neck A large mass of mainly extensor muscles run up the back of the neck. Some muscles in this group have specialist actions for panicular head movements This large mass of muscles is often given the collective name of "erector spinae".

83

Anatomy of the cervical spine

Foramen transversar1um

""'"

Ant&rlor tubercle

,,~_

Posterior tubercle

~~ ~~~ """"

Superior articular

~

->

';--::::::;,;~_/'~ ....

__ """~"

Inferior anlcular process

Spinal canal

Bilid spinous process

Raised lip on upper surface 01 body Ant&rlor tubercle 01 transverse process,,-"<'"

SUper10r venebral notch

'-~,;::;:=--superlor anlcular

~

process

""'" +.

Spinous process

Sulcus for ventral ramus 01 spinal nerve Posterior rubercle 01 transverse process

Inlerior articular surface

Figure 13.4. Line drawing of a lypical mid-cervical vertebra

Movement Flexion, extension, and lateral flexion all take place in the cervical spine. Head movement takes place at the atlamoaxial join!. Rotation of the atlas (and hence the head) occurs around the dens of the axis Nodding movements take place at the atlamo-occipital joint.

84

Chapter 14 Cervical spine injuries Introduction Cervical spine inJurtes are considered separately to those affecting the rest of the spine; the unique anatomy of the craniocervical junction results in unique biomechanics and injury patterns, The radiological assessment of the cervical spine requires three X-rays: a lateral view (which must include the upper pan of the body of Tl), an anteroposterior (AP) view, and an oclontoid peg view. [t is important never to rely on a single view of the cervi.cal spine, as this only detects approximately 80% of injuries The sensitivity is increased to approximately 90% when three views are taken, and to 98% when computed tomography (CD is used. The incidence of a second fracnlre in the cervical spine has been reponed as being as high as 50% and the incidence of noncontiguous fracnlres as high as 15%. In vie\v of this, it is essential to image the entire cervical spine.

Radiological assessment Lateral view The lateral view must include the occiput to the first thoracic vertebra (see Figure 14.1a), It is important to look for smooth lines along the: I) anterior border of the vertebral bodies

2) posterior border of the vertebral bodies 3) laminae 4) spinous processes Each venebra should be assessed individually for a break in the cortical outline, and vertebral body height should be assessed for wedge fractures. The facet joints should all be in line, and the distance between the odontoid peg and the anterior arch of the atlas should be approAimately 2-3 mm: in a child, this space is often 4 mm. it is important to assess whether there is any soft-tissue swelling anteriorly. As a general rule, there can be 5--8 mm of soft-tissue shadowing in the upper four cervical vertebrae, and up to 10-15 mm in the lower three cervical vertebrae. Any disruption of the alignment or vertebral structure most likely indicates the presence of a fracture.

85

Cervical spine injuries

(0)

(oj , - - - - - - - - - - ,

Figure 14.1. (3) Lateral X-ray of the cef\~calspine. including the occiput and the first thoracic vertebra. (b) Anteroposterior X-my of the cervical spine. (c) Odontoid peg \~ew of the cervical spine.

Anteroposterior view When kXlking at an AP mdiogmph. assess the distance between the spinous processes and whether the processes are in line. Any disruption would imply

86

Chapter 14

cervical injury. In addition, check the symmetrical alignment of the facet joints on both sides of the spine as well as the vertebral bocIy height, as seen in Figure 14.1 b. Odontoid peg view The ocIontoid peg view is taken \vith an open mouth and should illustrate the odontoid peg sitting symmetrically bet\.veen the lateral masses on (1, with a symmetrical (1-2 relationship, as seen in Figure 14. Ie. It is also possible to assess the relationship between (1 and the occipital condyles: the lateral border of the (1 lateral mass should line up with the outer aspect of the body of (2, and any overlap between these two structures should alert the clinician to a (1 ring disruption

Further imaging techniques Oblique views These are useful for looking at individual aspects of the vertebrae, including: the neural foramen, pedicles, laminae, tral1S\'erse processes, and facet joints, Computed tomography CT can detect more than 95% of cervical spine fractures and is the imaging modality of choice for most injuries. Magnetic resonance imaging MagnetiC resonance imaging (MRI) is indicated where the clinidan suspects injury to the cervical cord or a prolapsed intervertebral disc with subsequent neurology. MRI is mandatory for patients with signs of cord injury. Flexion extension radiographs Vlhen plain radiographs do not reveal a fracture but the patient complains of significant neck pain, flexion extension views will provide a source of dynamic imaging. This should be done under strictly controlled circumstances and the patient should be advised to flex the spine and stop if any neurological symptoms arise. Under no circumstances should the clinician actively flex the patient's cervical spine, as this may result in a cord injury in the unstable spine. Be aware, however, that a patient with an acute injUry will be reluctant to move his;1ler cef\ical spine because of the pain.

Atlanto-occipital dislocation This is an extremely rare and often fatal injury that occurs as a result of significant force. The injury is predominantly ligamentous and so a bony fracture may not be seen. Therefore, assess the congruency of the occiput on (I; any disruption of this configuration should be treated with extreme caution.

87

Cervical spine injuries

(.)r-"..-----------,

Figure 14.2. X.ray ofJcffcrson fracturc. (a) Odontoid peg view: arrows show abnormal overlap of (1-1 facet joints duc to a (1 fracture; (b) lateral vicw.

C1 injuries Fracrures of the atlas are typically the result of axial compression of the spine in either flexion or extension. Approximately 15% of these injurtes are associated with significant head and neck trauma. Because of the large space available in the neural canal, these ir~uries are not typically associated with neurological deficits. The incidence of noncontiguous fracrures On the presence of a ( I fracture) is about 30%, so it is imponant to exercise caution when assessing the rest of the cervical spine There are five fracture patterns described for the C1 venebra, which include: l) posterior arch fracture

2) 3) 4) 5)

bur:st Oefferson) fracture anterior arch fracture transverse process fracture comminuted fracture

The most common fracture is the bilaternl posterior arch fracture, followed by the Jeffer:son fracture, which is a potentially unstable bilaternl fracture of the anterior and postertor arch. The diagnosis of a Jefferson fracture is extremely difficult on plain films and the most useful view is the ocIontoid peg view (see Figure 14.2, on which the dissociation of the Cl-2 articulation can be seen clearly). cr is much more .sensitive and shows the fracrure clearly (see Figure 14.3). Management of (1 fractures usually includes a halo vest to immobilize the spine for approximately 12 weeks.

88

Chapter 14

Figure 14.3. CompUlcd tomography scan of aJdfcrson fracture.

Atlantoaxial subluxation Atlantoa>..ial subluxation may occur as an isolated event, or in combination with a fracture of the atlas or odontoid peg. Rupture of the transverse ligament may occur in isolation and would result in atlantoaxial instability. The lateral radiograph is the best method of assessing this injury and. in panicular, this view shows the characteristic increase in the distance between the odontoid peg and the anterior arch of the atlas. A distance of >4 mm should alert the clinician to the presence of this injury,

C2 fractures Fractures of the odontoid peg can be extremely difftcult to diagnose and are usually missed because of inadequate imaging of the cenkal spine. Patients who present with considerable neck pain follo\ving road traffic accidents or falls (especially in elderly patients) require careful examination of the odontoid peg. At least 20% of patients with an odontoid peg fracture have an associated cenkal spine fracture. Odontoid peg fractures have been classified by Anderson and D'Alonzo into three types (see Thble 14.1, Figure 14.4, and Figure 14.5). Type I and type 1lI injuries can usually be managed with an onhosis, such as a halo vest. Type II fractures. however, have a high rate of nonunion and, as a result, many surgeons prefer internal ftxation with either an antetior screw through the odontoid peg or (1-2 fIXation. The only other imponant injury at (2 is the traumatic spondylolisthesis of (2 (hangman's fracture, see Figure 14.6). This occurs when there is a fracture through the pars interanicularis of (2 bilaterally, with separation of the anterior and posterior elements, OassicaUy, the injury is sustained with hyperextension and axial distraction, although the injury can occur with flexion.

89

Cervical spine injuries

Odontoid peg fracture Type I

Rare injuries: essentially avulsions of the tip of the odontoid peg by the apical ligament (see Figure 14.4)

Type II

The most common fracture: occurs through the base of the odontoid peg. These fractures are unstable, with a high rate of nonunion (see Figure 14.5)

Type III

This type of fracture extends through the body of C2

Table H.1. Classification of odontoid peg fractures.

-,•

~

JJ;

",-'

d ~

.,.J ~

.t ~

.' Figure 14.4. Avulsion fracture of the odontoid peg (type O.

..

~"~""

Figure 14.5. Fracrure through the base of the ocIontoid peg (type 10.

Injuries of the subaxial cervical spine These injuries can be divided into: 1) unilateral facet dislocation

2) 3) 4) 5) 6)

bilateral facet dislocation spinous process avulsion compression fractures burst fractures teardrop fractures

Facet joint subluxations These injuries are the result of dislocarion of either a single or bilateral facet joint due to disruption of the ligamentous tissues. The usual mechanism is one of posterior distraction, combined with cervical spine fie>..ion. A unilateral facet dislocation is characterized by an - 25% anterior slip of the vertebral body above Oil the caudal vertebra below (see Figure 14.7), [n contrast, bilateral facet joint dislocations result in more than 50% translation between the two vertebrae.

90

Chapter 14

Ib) . . . . . . .~---

Figure 14.6. (a) Fracture of pedicle of (2 (hangman's fracture) (arrow) and JXlslcrior arch fracturc of (L (b) A displaced hangman's fracture ((2) (arrow).

'--

Figure 14.7. Unilateral facel --' dislocation of (6(1.

91

Cervical spine injuries

Figure 14.8. Fracture dislocation of the cervical spine.

The anterior radiograph might also show a degree of rotational malalignment with an asymmetric relationship of the facet joints or even Widening of the interval between the spinous processes. With facet joint subluxations, CT scanning is mandatory to assess for associated spinal injuries. Any patient who presents with neurological injury should undergo MRl scanning for imaging of the cord. Very rarely, patients present with complete fracture dislocation, as seen in Figure 14.8; this patient died days after the injury due to respiratory complications. Note the Signal change within the cord extending up as far as the C2-3 junction; this leads to paralysis of the diaphragm These patients often die at the scene of the accident as a result of their injUries. Spinous process avulsion Avulsion fractures can occur through the laminae, articular, or spinous processes. They are typically due either to axial compression of the extended spine or to flexion, as seen with the clay shoveler's fracture of the lower cervical spinous process. Compression fractures Compression fractures classically involve the anterior column with loss of vertebral body height. Careful analysis of the lateral radiograph \vill allow the clinician to measure the percentage collapse of the venebral body, and compression of more than 50% should be considered an unstable fracture. Careful analysis of the middle column is important \vith this injury to assess whether there is any retropulsion of the posterior aspect of the vertebral body into the neural canal. Such a fracture would then be classified as a burst fracture. Analysis of the AP radiograph would reveal that the facet joints are asymmetrical; any asymmetry should alert the clinician to the possibility of a burst fracture.

92

Chapter 14

('J

Figure 14.9. CompUlcd tomography scan of burst fracture of a ccrvical vencbra. (a) Anteroposterior: (b) lateral

Burst fractures Burst fractures are the result of axial compression with flexion and resulting posterior displacement of the middle column into the neural canal. This is seen on the lateral radiograph, while the AP radiograph will show widening of the pedicles. Again, funher imaging is mandatory with the burst fracture and should include CT or MRi (see Figure 14.9). Patients with less than 25% loss ofvenebral body height and nonna! neurology can be successfully managed conservatively in an onhosis. Patients lvi.th more than 50% loss of venebral body height may well require operative fIxation. Teardrop fractures This fracture classically occurs due to signifIcant axial compression when the neck is in the flexed position. This often results in significant spinal cord injury and spinal column instability. The injury results in a fracture of the distal, anterior comer of the vertebra, producing the so-called "teardrop fragment". The teardrop fracture also causes considerable injury to the intervertebral disc and the posterior elements and should therefore be considered an unstable injury. Funher imaging is mandatory and these injuries often require stabilization.

Summary The diagnosis of cervical spine injuries can often be difficult, especially when considering a polyrrauma patient. Any patient who presents with signifIcant head and neck trauma or unexplained neck pain should be assumed to have a cervical spine injury until proven otherwise. Thorough radiographic examination of the cervical spine is mandatory and should include imaging from the occiput to the upper body of Tl. Three radiographs should be taken, including a lateral, an Ap, and an odontoid peg view. The lateral X-ray provides the most useful infonnation.

93

Cervical spine injuries

If there is a suspicion of a cervical spine fracture then the patient should receive funher radiographic examination with either a cr or an MRl scan. There is no place for complacency with cervical spine injuries and the patient needs thorough assessment and documentation of neurological status. Patients who have a proven cervical spine fracture need careful analysis of the rest of the spine because the incidence of funher injury or fracture is significant. All cervical spine injuries require referral to either an onhopedic or spinal team for funher assessment and management.

94

Chapter 15 Soft-tissue injuries of the cervical spine Introduction Soft-tissue injuries of the cervical spine are common and are frequently associated with road traffic accidents. The collection of symptoms is often called a "whiplash" injury, a term coined by Harold Crowe in 1928

Mechanism of injury The cervical spine undergoes a combination of hyperextension and hyperflexion in comhination with a distraction force (see Figure 15.1), usually caused by a rear-end collision in a road traffic accident. As yet no satisfactory pathology has been discovered, but this does not mean that there might not be damage to the end plate zone.

Figure 15.1. The mechanism of sofl-tissue injuries of the cervical spine (whiplash injuries) at time of impacL

95

Sott-tissue injuries of the cervical spine

Symptom

Occurrence

Neck pain

95%

Occipital headache

70%

Shoulder pain Lower-back pain

35% 35%

Upper-limb pain (with or without numbness)

10%

Vertigo, auditory disturbance, facial disturbance

5%

Table 15.1. Symptoms and prevalence of soft-tissue injuries of the cervical spine.

Symptoms The most common symptoms are sho\V!1 in lable 15.1. The predominant feature of whiplash injury is neck pain that radiates lO the occiput, into both shoulders, and frequently into the interscapular region. The symptoms usually develop over the first 24 hours following the accident, although - 25% of patients develop SymplOms more than 48 hours after the accident.

Examination Inspection Inspection might reveal a loss of lordosis and also spasm of the paraspinal muscles, including the trapezius and erector spinae. Palpation Palpation often reveals tenderness in the trapezius muscle (unilateral or bilateral), which radiates to the: 1) tip of the shoulders

2) occiput 3) interscapular region The bony spinous processes are often nontender.

Range of movement Examination often reveals reduced movements in flexion, extension, lateral flexion, and lateral rotation. [t is useful to document the findings lO monitor recovery with time. Back pain Apprm..i mately 20%-40% of patients will present with thoracolumbar back pain, and about half of these will consider the back pain to be worse than the neck pain.

96

Chapter 15

Other symptoms The common symptoms reponed include headaches, dizziness, auditory symptoms, dysphasia, and visual disturbance. The patient essentially develops a disorder of spatial equilibrium, which has been postulated to be muscle spindle driven.

Neurology The patient should be carefully assessed for abnonnal neurology, including: tone, power, reflexes, and sensation in both upper and lower limbs. Any abnonnal neurological signs are a poor prognostic indicator and these patients tend to have prolonged symptoms.

Functional assessment f'atients with whiplash and lower~back injuries often complain of functional disability and, again, it is useful to document the disability. The functional assessment can be broken down into activities of daily living, occupation, hobbies/activities, domestic activities, and psychological symptoms. Activities of daily living These include washing, dressing, and raising the

anTIS

above the head.

Occupation f'atients often have to take a period of time off work following their injury. When they return to work, they should return on light duties to prevent any exacerbation of their symptoms, Hobbies/activities it is imponant to document all of the hobbies and activities that the patient enjoyed prior to the injury and to assess the extent to which each has been affected Domestic activities Another key functional assessment is whether or not the patient is able to do general household chores, including cleaning, gardening, and home improvement Psychological symptoms Many patients complain of psychological symptoms that have developed as a result of the injury. These symptoms are often more prominent in patients whose symptoms have been present for a considerable period of time. The clinician should assess for a change in mood state and whether the patient has become depressed, has experienced alterations to sleep and concentration patterns, and whether there have been any emotional changes. A significant percentage of patients complain of anxiety whilst driving if the injury was sustained in a car accident.

97

Sott-tissue injuries of the cervical spine

Group A (12%)

Full recovery occurs within 2 weeks

Group B (48%)

Mild symptoms persist for more than 2 months

Group C (28%)

Little or no improvement occurs after 2 months and ttle patient often complains of symptoms that inteliere with work, hobbies, and activities

Group D (12%)

These patients have severe symptoms that persist and often result in job loss

Table 15.2. Degrees of severity of soft-tissue injuries

to

the

cen~cal

spinc.

Prognosis Vlhen assessing patients \\~th soft-tissue injuries to the neck it is useful to be able to fonn a reasonable prognosis. The follo\\~ng factors have been shown to correlate with a poor prognosis: 1) abnonnal neurology at time of presentation

2) cervical spondylosis: pre-existing degenerative changes in the neck 3) abnonnal cervical lordosis at time of presentation The follO\ving factors have NOT been shown to correlate with prognosis: 1) speed of impact

2) litigation: a study by Norris et al. [I] suggests that litigation has little influence on symptoms 3) seat belt use: seat belt use does not correlate with outcome; but \vithout a seat belt, the incidence of other skeletal injuries increases significantly Studies by Hohl et al. [2J revealed that most patients reach their final level of symptoms within 2 years of the injury. Approximately 10% of patients will suffer from long-tenn symptoms that significantly interfere with their lives. At least 60% of patients' symptoms will resolve almost completely, and another 30% of patients will have moderate symptoms that persist for many years. Four degrees of severity of soft-tissue injuries of the cervical spine have been recognized by Gargan and Bannister (see Thble 15.2) [3J.

Treatment The treatments advised for soft-tissue injuries of the neck include the following therapies:

Rest Most patients are advised to rest their neck for the week following the injury to prevent any funher exacerbation of their symptoms.

98

Chapter 15

Nonsteroidal anti-inflammatory drugs f'atients often benefit from regular anti-inflammatory analgesia as the injury predictably results in a degree of inflammation in the cervical soft tissues. Physiotherapy f'atients often benefit from early physiotherapy. However, there have been no randomized controlled trials to prove this. Physiotherapy can often improve a patient's range of movement by using a combination of exercises, manipulation, and ultrasound therapy. There is certainly good evidence in the physiotherapy literature to conclude that deep friction massage and ultrasound increase the blood flow to the local area, which is of obvious benefit to injured tissues. Patients often require a protracted course of physiotherapy and, once discharged, should continue their exercises at home. Chiropracty/osteopathy ?atients often self-refer to chiropractors or osteopaths in an effort to alleviate their symptoms. Again, there has been no proven benefit of the therapy received from a physiotherapist, a chiropractor, or an osteopath, However, it is worthwhile trying an alternative therapy if one of the others does not work Neck support The use of a soft cervical collar is contentious and has not been proven to benefit the patient. Despite this, a significant percentage of patients report that the use of a soft collar in the immediate postaccident state often SUppol1S the neck and provides a degree of symptom relief. This is undoubtedly due to the fact that the neck collar takes some of the strain off the cervical musculature. Surgical referral There is a significant disparity in the percentage of patients referred for a surgical opinion in the USA and in the UK. The referral rate in the UK is much lower than that in the USA, which is surprising considering the spectrum of injury is the same Surgery is only of benefit when there is a proven pathology within the cervical spine, such as the traumatic prolapse of an intervertebral disc. it should, however, be stressed that traumatic disc prolapse is very rare following a whiplash injury

Summary Whiplash injury is extremely common and is increasingly a cause of litigation. The symptoms are predictable and early treatment with rest, analgesia, and physiotherapy is often beneficial. A significant percentage of patients \vill continue to expertence symptoms for many years; abnormal neurology at the time of injury, pre--existing cervical spondylosis, and an abnormal cervical lordosis have been associated with poor outcome follmving a whiplash injury,

99

Sott-tissue injuries of the cervical spine

References L Norris SH, \Vall L The prognosis of neck injuries resulting fmm rcar-cnd vehicle collisions.J Bonejoint Swg Br 1983:65'60&-1 L 2. Hohl M. Sofl tissue ncck injuries-a revicw Rev Chir Olthop Rqxmmia Appar MOl 1990:76(SuppL 1)'15-25. J. Khan S. Cook), Gargan M e! at. A symptomatic c1a'isilicmion of whiplash injury and the implications for trearrnenLJ Orthop Med 1999:21:22-5.

100

Chapter 16 Cervical radiculopathy Introduction Cervical radiculopathy occurs when a cervical nerve root is compressed in the neck (see Figure 16. I). This is usually as a result of degenerative disease causing either a prolapsed disc or a spondylitic spur of bone. The fonner is more common in patients under 50 years old and the latter in patients over 50 years old. Both have roughly

equal incidence. The nerve roots are usually compressed at the entrance or just medial to the intervenebral foramen. The typical cervical prolapsed disc lies laterally.

Incidence It has been estimated that the average incidence of cervical radiculopathy is 16-200 per 100,000. it is much more common in middle.aged patients and

slightly more frequent in women than men. The most commonly affected nerve roolS are (6 and (7 corresponding to pathology at the C5-6 and (6-7 levels. Cervical myelopathy (compression of the cervical spinal cord, usually secondary to degenerative disease) is more common in the elderly. Body of VllItebra Foramen

(~~~~~,:ranSVersar1um

5~;~~~1t;~:=i-~ t •

nelVe root

Emerging Facet joint

Bifid spinous process

Figure 16.1. Schematic representation of a cross section of midcervical spine

101

Cervical radiculopathy

Nerve

Motor deficit

Sensory deficit

Reflex

involved

Disc level usually responsible

C3

C2-3

None usually

Posterior neck and ear

NM'

C4

03-4

None usually

Base of neck to tip of shoulder

NM'

C5

04-5

Deltoid

Upper lateral

Biceps

~ot

'0"

~

C'

C5-<;

Biceps and wrist extensors

Lateral forearm

Brachioradialis (and biceps)

C7

C6-7

Triceps and finger extension

Middle linger and posterior ><mIh">d

Triceps

C8

C7-T1

Long finger flexors

Ulnar aspect of hand

May lose IJiceps

T1

T1-2

Small muscles of hand

Ulnar aspect of forearm

-

Table 16.1. Ncrvc roots involved in radiculopathy and

~sulting

motor and sensory deficits.

Signs and symptoms Signs and symptoms of cervical radiculopathy include: l) neck pain (generalized or localized to one side) or shoulder pain

2) root entrapment symptoms including pain and paresthesiae in the foreann and hand 3) restriction of spinal movement Spurling's test can be used to help detennine whether or not the pain is the result of cervical radiculopathy. It involves applying a downward pressure to the head, which is tilted to the affected side and extended, The test is considered positive if there is reproduction of the pain radiating from the neck down the ann. However, it can be negative in chronic cases, The exact neurological findings will depend on the level involved (see Thble 16.l).

102

Chapter 16

Figure 16.2. Axial magnetic resonance image showing a prolapsed intervertebral eef\~eal disc compressing the left seventh cervical nerve root.

Differential diagnosis There are many conditions that can mimic cervical disc disease including: 1) cervical myelopathy

2) 3) 4) 5) 6) 7)

shoulder pathology carpal tunnel syndrome cubital tunnel syndrome (ulnar nerve compression at the elbow) brachial plexus compression, thoracic outlet syndrome intra- or extraspinal tumors epicondylitis or tenosynovitis

Investigations Plain X-rays Plain radiographs might be normal in patients with cervical disc disease, but can also show a wide range of abnonnalities: 1) loss of disc height

2) osteophytes, especially on the superior articular process 3) spondylolisthesis 4) faCel joint degeneration

Magnetic resonance imaging Magnetic resonance imaging (MRl) is the most useful method for imaging herniated discs (see Figure 16.2).

103

Cervical radiculopathy

Treatment Conservative Treatment with anti-inflammatory drugs and a soft collar is effective in up to 90% of cases. The collar is often most useful at night. Treatment should last at least 6 weeks. facet joint injections and cervical nerve root blocks are also helpful in some cases. Physiotherapy is an important adjunct. As a general rule, radiculopathic symptoms improve more than neck pain does. Surgical There are no strict guidelines as to who should undergo surgery. indications include: 1) significant ann pain

2) failure of appropriate conservative treatment 3) progressive neurological deficit 4) appropriate MRI findings The exact operation will depend on the perceived cause and the position of the pathological lesion. Surgeon preference is also important. Both posterior and anterior approaches are available for the cervical spine. The anterior approach is popular at present and will sometimes include a fusion procedure to prevent subsequent kyphotic defonnity. Posterior approaches have gained popularity again, due to the development of microsurgical techniques and the fact that it can be a minimally invasive operation. [t should be remembered that retraction of the spinal cord is not possible and any disc anterior to the cord should be approached from the front. Results are generally good regardless of approach and procedure, with over 80% of properly selected patients having good or excellent relief of their brachialgia: the relief of neck pain is much less predictable.

Summary Pressure on the cervical nerve roots is usually due to prolapsed discs or bony spurs. It classically produces neck pain and upper-limb signs and symptoms corresponding to the nerve root involved. The C7 root is the most commonly affected. Other causes of peripheral nerve entrapment should be excluded. MRI is the investigation of choice. Treatment is conservative for the majority of patients in the fonn of analgesia and physiotherapy. Surgery is reserved for those with persistent symptoms and appropriate radiolOgical findings. Referral should be made if there is any doubt as to the diagnosis and in those whose symptoms do not settle with a course of conservative treatment.

104

Chapter 17 Cervical spondylosis and myelopathy Introduction The tenn "spondylosis" refers to degeneration of the spine; in the neck, spinal degeneration is tcOlled cervical spondylosis. Cervical myelopathy occurs as a result of pressure on the cervical spinal cord, usually due to spondylosis. Neck pain is common in patients with cervical spondylosis.

Etiology of myelopathy Degenerative changes in the neck are common, but not everyone with spondylosis develops myelopathy. Many theories have been proposed but it seems most likely that patients who develop myelopathy have congenitally narrow bony canals. There

is also hypertrophy of the ligamentous structures, which compounds the compression. Movement of the neck can cause further entrapment of the spinal cord and worsening of the symptoms. Other causes include ossification in the posterior longttudinalligament, disc herniation, IXlstenor spurs, and calcification in the ligamentum flavum. Myelopathy may also arise in patients with malalignment of the cervical spine, eg, kyphosis and spondylolisthesis. Patients with tight canals who do nOi have myelopathy are at risk of spinal cord injury from relatively trivial trauma.

Signs and symptoms Patients often have compression of the spinal cord and of individual nerve roots, and will therefore have signs and symptoms of both upper and lower motor neuron lesions: 1) paresthesiae in the hands

2) 3) 4) 5) 6)

difficulty with balance and walking clumsiness of hands utinary incontinence electric shocks in annsJIegs with cenain neck movements (Lhermitte's sign) neck pain is rare in genuine myelopathy

105

Cervical spondylosis and myelopathy

lr is also wOl1h noting that some patients can have rapid neurological deterioration

with no significant neck pain Signs Signs will depend on the level(s) involved: l) muscle wealmess and \\'asting

2) 3) 4) 5)

loss of reflexes at the level of the lesion with exaggerated reflexes below sensory changes below the level of the lesion up-going plantar reflex positive Hoffmann reflex (flicking the top of the flexed middle finger causes the tip of the thumb to flex: often the earliest sign of cord compression)

The most common level for myelopathy is C5-6, then (4--5, largely because the spinal cord expands here.

Partial cord compression syndromes There are several different types of pal1ial cord compression syndromes. These have been discussed in Chapter 4 (Thoracolumbar trauma) and include: l) central cord syndrome (involves injUry to the cervical spine)

2) Brown-Sequard syndrome 3) antenor cord syndrome 4) postenor cord syndrome

Investigations Plain X-rays may show developmental stenosis. which is defined as an anteroposterior diameter of the spinal canal of less than 12 mm (see Figure 17.l). They may also show: l) posterior bony spurs

2) ossification in the posterior longitudinal ligament or the ligamentum flavum 3) calcified disc herniation Magnetic resonance imaging (MRI) scans will show compression more clearly, as well as showing any intrinsic cord damage (see Figure 17.2).

Treatment Conservative The natural history of patients with cervical myelopathy varies: some patients seem to remain much the same whereas others progress There are no prognostic

106

Chapter 17

('J

Figure 17.1. X-ray of degenerative cervical spine. (a) Anteroposterior: (b) lateral, showing 10S5 of disc height and amerior osteophyte formation at C5-6.

Figure 17.2. Magnetic resonance image of degenerate cervical spine at C5-6 and (6-7.

107

Cervical spondylosis and myelopathy

indicators to suggest who will progress and who will not. Patients with minor neurological deficits are amenable to conservative treatment in the form of a cervical collar, nonsteroidal anti-inflammatory drugs. and observation. [t is suggested that patients with a more severe neurological impairment may benefit from earlier surgical intervention.

Surgical Posterior decompression using a laminectomy has been the main treatment in the past, although longer-tenn results indicate that this can cause instability in patients with pre--existing loss of cervical lordosis. Therefore, various techniques are now employed to decompress the spinal canal posteriorly whilst maintaining stability. The anterior approach has also been used extensively. Variations of this technique are now generally used and fusion. using an autologous bone graft, is a routine pan of the procedure.

Summary Degenerative changes in the cervical spine are common, but spinal cord compression leading to myelopathy is much less common. Patients often present with clumsiness in their hands. and signs and symptoms of spinal cord and nerve root compression. MRl is the investigation of choice. Treatment is conservative in the majority of cases and involves analgesia and a soft collar. Those with neurological deficits, particularly progressive ones, should be assessed for surgery, which can be performed either from the posterior or anterior approach. There are small but significant risks associated with surgery that patients should be made aware of. Surgery should halt progression of neurological deficits and, in some cases, can lead to improvement in the patient's symptoms.

108

Chapter 18 The rheumatoid spine Introduction Most patients \vith rheumatoid arthritis will have cervical spine involvement. Pannus formation and synovitis lead to ligamentous, cartilaginous, and bony destruction, which can JXltentiaUy lead to cervical instability. The upper pan of the cervi.cal spine is most commonly involved. Atlantoa.xial instability is the most common problem encountered (50%-80% of cases). The next most common is disease in the occipitoatlantal and atlantoaxial joints, which can cause cranial settling.

Symptoms and signs Symptoms and signs of rheumatoid arthritis in the cervical spine include: 1) neck pain

2) neck stiffness 3) crepitus 4) headache 5) insidious neurological impairment: a) wealmess b) loss of sensation c) hyperreflexia d) boweVbladder disturbance The neurological impairment is often difficult to detect in the early stages and surge!)' is not always successful at reversing neurological deficits Careful neurological examination and appropriate investigation are required. Plain X-rays and magnetic resonance imaging (MRI) are most helpful. [t is possible to make various measurements on the lateral spine X-ray, including the space available for the cord. Such measurements help indicate subluxation and hence potential cord compression.

Atlantoaxial subluxation This is the most common spinal manifestation of rheumatoid arthritis. Pannus causes erosion of the joint between (1 and (2 and destruction of the transverse ligament and sometimes the dens. The atlas can then slip for.vard on (2 causing spinal cord compression. Plain X-rays, including super.'ised flexion---extension

109

The rheumatoid spine

(.)r---------,-

Figure 18.1. X-ray of cervical spine showing atlantoaxial instability. (a) Rcxion (arrow shows increased adanto-dens interval): (b) extension. views, usually reveal the dynamic nature of the problem, and MRl scans provide more detail. There will be an increased atlanto-dens interval and a decreased space available for the corel. Radiographic evidence of instability is common and is not an absolute indication for surgery. However, with large differences in the atlantodens interval on flexion---extension views (see Figure 18.1) and a small space available for the cord, the Jisk of neurological injury is significant and surgery should be considered. ?rogressive instability and neurological deterioration are also indications for surgery. The surgical options include CI-2 fusion and transanicular screw fixation between CI and C2. The latter does not usually require halo vest immobilization postoperatively. If the subluxation is not reducible it might be necessary to remove the posterior ring of CI to alleviate the cord compression and then perform a fusion procedure.

Cranial settling Erosion between the occiput and the CI-2 complex leads to cranial settling. The dens migrates cranially. Progressive migration and neurological deterioration are indications for surgery, which involves fusion of the occiput to C2. Somatosensory evoked potentials can be helpful in investigating these patients. Significant evidence of brain stem compromise may necessitate resection of the dens.

110

Chapter 18

Lower cervical spine involvement Approximately 20% of patients will have rheumatoid manifestations lower down the cervical spine Multiple level subluxation can occur. It is more common in males, those with seropositive disease, those with severe disease, and those with a long history of steroid use Subluxation of more than 4 mm suggests cord compression, particularly if the space available for the cord is less than 13 mm. Fusion should then be considered.

Summary The cervical spine is commonly involved in patients with rheumatoid anhritis. Atlantoaxial instability is the most common manifestation. Patients should be referred to a spinal unit if they develop neurological symptoms and signs. It is also important to review patients who are due to have a general anesthetic for whatever reason. Flexion---extension views should be obtained as the neck may be at risk durtng intubation and it is preferable to !mow about any cervical instability prior to the operation. Surgery may be indicated in patients with progressive neurological deficits or progressive instability. In the functional history and assessment of these patients it can be difficult to distinguish between limitations caused by joint problems and those caused by neurological problems. The treatment for each is likely to be different.

III

Chapter 19 Pediatric spinal conditions Introduction Back pain in children is relatively uncommon, so mallY clinicians do not have much experience in this area. Pediatric spinal conditions are often considered with the adult conditions. However, it is worth considering spinal conditions and back pain occurring in childhood separately to those occurring in adulthood: this allows a differential diagnosis to be made specifically for pediatric patients. Common conditions causing pain in the pediatric spine include: 1) mechanical problems

2) developmental abnonnalities 3) infection 4) tumors 5) psychological causes 6) cervical spinal conditions 7) scoliosis (not typically painful) The process of investigation of childhood back pain should be the same as in the adult, although a more detailed history is required. Children often present with back pain, spinal curvature, or some fonn of abnonnal neurology. \\!hilst taking the history, it is imponant to inquire: 1) about a family history of inherited disorders

2) about the binh of the child (including the methocl and date of delivery) 3) whether the child has developed nonnally to date The taking of the history is othenvise similar to the methocl used for adults and you should inquire how the presenting symptom interferes \vith the child's function. A functional assessment should look at how the problem affects the child's physical activities, including sport, hobbies, and schooling.

Examination Examination of the pediatric spine is again very similar to examination of the adult spine, with a few exceptions. Panicular attention should be paid to any generalized Il3

Pediatric spinal conditions

congenital abnormalities of the limbs, spine, or internal organs. Look carefully for any scoliosis, examining the pelvic and shoulder symmetry in particular The head should be centered over the pelvis and any deviation of the spine from this plane indicates a scoliosis. A full assessment of the range of movement is essential and any limitation in the child's movement is signifICant and often indicative of an underlying spinal pathology. A thorough examination of the child's neurological status is essential, as any abnormal neurology aids in the diagnosis. it is important to look at the chest, to assess whether there is a prominent rib hump, and also look from the side, to see whether there is an exaggeration of the kyphosis as seen in Scheuermann's disease.

Investigation Investigation of childhood back pain includes: routine blood tests, full blood count, erythrocyte sedimentation rate (PSR), C-reactive protein (CRP), and plain radiographs. funher imaging includes bone scan, computed tomograpy (CD, or magnetic resonance imaging (MRI); the child may require sedation or even a general anesthetic for these investigations to be performed. The incidence of back pain in childhood is about 15%. Each of the spinal conditions are discussed in tum below; this includes references to the main adult text.

Mechanical back pain Mechanical back pain is a collective diagnosis for soft-tissue injuries around the thoracolumbar spine. This group of conditions represents a significant pomon of juvenile back pain and so should be included in most differential diagnoses. The child often complains of back pain that is related to activity and further enquiries may reveal that the child is involved in a sport which involves recurrent minor injuries to the back, such as rugby, gymnastics, or jogging Examination will reveal that the spine looks and moves nonnally. However, palpation may well reveal significant tenderness over the soft tissues such as the erector spinae. Management includes symptomatic control with analgesia, physiotherapy, and restriction of the precipitating activity. The pain should settle relatively quickly with these fonTIS of therapy. If it does not, one must consider another diagnosis.

Hemiation of intervertebral discs Herniation of intervertebral discs also comes under the diagnosis of mechanical back pain and the symptoms are extremely similar to those in the adult. This condition is, however, extremely rare in the child or adolescent. The child often presents with lower-back pain with radicular symptoms radiating into the legs. Any child who presents with symptoms of nerve root origin requires further investigation and an appropriate referral to an orthopedic or spinal team.

114

Chapter 19

Developmental disorders Developmental disorders that can give rise to pediatric spinal conditions include: 1) spondylolysis

2) spondylolisthesis 3) Scheuennann's disease

Spondylolysis/spondylolisthesis These are defects of the pars interanicularis and are common causes of back pain in childhood. The child typically presents between the ages of 8-18 years I\fi.th a history of back pain and possibly sciatica. One should enquire as to whether the child is involved in any sports such as cricket or trampolining. Young fast bowlers can develop an acquired fonn of this developmental defect of the pars interarticularis and this should be distinguished from the developmental anomaly. Examination

Examination I\fi.ll typically reveal tenderness in the lower back with or without muscle spasm. The child may have a reduced range of movement and also tighmess of the hamstrings. Spondylolisthesis varies in that there is a bilateral defect of the pars interarticularis, resulting in forward slippage of the cephalad vertebra on the caudad vertebra below. The developmental form of spondylolisthesis is associated I\fi.th an incidence of nerve root compression, so one should actively examine for distal neurology. Investigation

Investigation of spondylolysis or spondylolisthesis is the same in the child as it is in the adult, and includes plain radiographs and CT or MRL The treatment of these conditions in children is essentially conservative and involves restricting the child's activity. Certainly \\fi.th the acquired defects, it is essential that the child discontinue the sport that is precipitating the condition. The child should be referred for physiotherapy to strengthen the back muscles and stretch the hamstrings. Appropriate analgesia and anti.inflammatory medication should be used where appropriate. All children with a known spondylolysis or spondylolisthesis should be referred for an orthopedic or spinal opinion and the team involved will often continue to monitor the child until skeletal maturity. This is done to ensure that if slip progression occurs, it is picked up early. Notably, the following groups of patients have the highest risk of slip progression:

115

Pediatric spinal conditions

1) females

2) 3) 4) 5)

younger patients patients \vith spina bifida patients \vith rounding of the anterior sacrum, seen on plain radiographs patients \vith wedging of L5

Surgical intervention for the child with spondylolisthesis is rare and is carned out when there is > 50% slip or when conservative therapy has failed to resolve the child's symptoms.

Scheuermann's disease Scheuermann's disease is defined as a thoracic kyphosis of more than 45° with ~5" of anterior wedging at three sequential vertebrae, The disease is more common in males and the onset is often just prior to puberty with a presentation in early adolescence. The quoted incidence for Scheuennann's disease IS approximately 3% and there is an autosomal dominant inheritance pattern in cenain families. The cause of Scheuennann's disease is rather ill defined and possible theories include: 1) defect of growth 2) abnonnality of ossification 3) genetic inheritance The presentation is usually one of back pain or a thoracic kyphosis. The child may say that they have a rather humped back that they find unsightly. Examination

Examination reveals hyperkyphosis that is not correctable with hyperextension. As a result the child often has tight hamstrings as well. it is wonh noting that patients with mechanical back pain often present \vith a kyphosis. However, Scheuermann's disease results in a fixed kyphosis that one is unable to correct, whereas mechanical causes result in a flexible or postural kyphosis. Investigation

Investigation includes plain radiographs of the spine that might reveal: 1) thoracic kyphosis

2) 3) 4) 5) 116

anterior wedging at more than two sequential vertebrae disc space naITO\ving end plate irregularities spondylolysis

Chapter 19

6) scoliosis 7) Schmorl's node The most commonly affected level is T7-9, with TlO-Ll being less common.

Treatment Treatment of Scheuennann's disease is usually conservative and consists of: 1) analgesia

2) physiotherapy to strengthen the back muscles and also correct the child's posture 3) bracing: the principle brace used is the modifIed Milwaukee brace. The brace should be worn for approximately 2 years Treatment also depends on the age of the child, the skeletal maturity, and the degree of thoracic kyphosis. A kyphosis of 45"---60" can usually be managed conservatively without bracing as long as there is no evidence of progression of the kyphosis As soon as progression is noted, bracing is essential. The younger patient may also benefit from bracing. If the thoracic kyphosis is more rigid or is refractory to the Milwaukee brace, then serial casting is an option.

Surgery Surgical intervention is indicated for the severe forms of kyphosis that are refractory to conservative therapy or those that are progressive. The surgery often involves posterior fusion with instrumentation. Anterior discectomy and interbody fusion have also been used Children who are less than 12 years old, symptomatic, or with a significant kyphosis require referral to a specialist team for assessment.

Scoliosis A scoliosis is defined as being a lateral deviation of the spine in association with rotation. There are many causes of scoliosis. However, this chapter will only deal with the most common causes. The subject can become extremely complicated so the topic has been deliberately simplified to include the essential details. Most cases of scoliosis are idiopathic; however, the various types include: 1) congenital scoliosis

2) infantile scoliosis (0-3 years old) 3) juvenile scoliosis (4--10 years old) 117

Pediatric spinal conditions

(bIF-...---------,

('1

Figure 19.1. (a) An example of an idiopathic scoliosis. (b) An example of a degenerate

scoliosis for comparison. 4) adolescent scoliosis (> 10 years old): this is by far the most common

cause of scoliosis in the child (see Figure 19.1) 5) neuromuscular causes Scoliosis is most common in girls and those with a positive family history. However, the expression of scoliosis has a variable penetrance. The curve is described according to the apex. The most common curves, in order of incidence, include: 1) right-thoracic curve with apex at T7

2) double curve \vi.th a right-thoracic and a left-lumbar curve 3) left-lumbar curve 4) right-lumbar curve It is wonhwhile noting that left-thoracic curves are extremely rare and require MRI of the cord to exclude abnonnalities such as a syrinx.

Congenital scoliosis This is the most common congenital spinal disorder and is due to anomalies of the vertebral bodies. The anomalies include unilateral unsegmented bars and hemivenebrae. The unilateral unsegmented bar is one of the most common

liS

Chapter 19

variants, which unfonunately has a high incidence of progression. All children with congenital scoliosis require a review by a spinal surgeon and treatment options include bracing for the mild flexible curves. for those children with hemivenehral defects, surgery is often indicated.

Infantile scoliosis Infantile idiopathic scoliosis is diagnosed if a child less than 3 years old presents with a scoliosis of more than 10". Although this disorder is relatively uncommon, when identified it is a significant finding. It is imponant to inquire about the developmental history of the child, including the binh history. Note any other congenital defects and specifically look for flattening of the skull (plagiocephaly) Also check whether there is a thoracic deformity as there is a significant incidence of developmental anomalies of the thorax, which result in reduced lung volume with obvious consequences. The disorder is much more common in males and the majority of the curves are left thoracic. As such, imaging of the spinal cord is mandatory as previously mentioned Examination should include an assessment of the entire child, and specifically look for any abnormal neurology. An assessment of the child's respiratory function should also be earned out in view of the high incidence of cardiopulmonary complications. Treatment can be divided into three groups: 1) curve <25°: these patients can usually simply be observed

to make sure there is no progression of the scoliosis 2) curve 25°-35°: these patients often require bracing or casting 3) curve> 35° with progression: these patients often require subsequent investigation and operative management with instmmentation

Juvenile idiopathic scoliosis Juvenile idiopathic scoliosis occurs between the ages of 3 and 10 years old The most common curve is the right thoracic, followed by the left thoracic. Lumbar curves are extremely rare in juvenile idiopathic scoliosis. Investigation of these children includes plain radiographs and also MRI scanning, to exclude any cord pathology. There is a high risk of curve progression in these children and most require some form of treatment. Bracing is usually the first line of therapy and again the most common brace used is the Milwaukee brace, which should be worn for 23 hours a day The brace should be worn until the curve stabilizes: that is, until progression ceases. It is wonhwhile noting that approximately 50% of patients with juvenile idiopathic scoliosis require surgical intervention and surgery is usually indicated for the more severe, progressive fOnTIS of the disease. 119

Pediatric spinal conditions

Rib hump

/

\

\

'/

I

-+-

Figure 19.2. A child with a scoliosis. Surgical intervention often involves instrumentation with the use of a rod that allows growth of the spine. If possible, delay fusion until after the adolescent growth spun. Curve progression beyond 50" is usually an indication for fusion.

Adolescent idiopathic scoliosis Adolescent idiopathic scoliosis (see Figure 19.1) typically presents between the ages of 10 and 20 years old and represents the most common fonn of childhood scoliosis. There is a 4: 1 female preponderance, and this increases to 10: 1 when the curve is > 30°. The most common curve is the right thoracic (90% of cases), followed by left lumbar, right lumbar, and double curves. Again, any patient with a lefHhoracic curve should undergo MRI of the cord to exclude a syrinx. Examination Examination should include assessment of the degree of scoliosis and whether this is exaggerated in flo.ion. Assess whether the curve is balanced, ie, whether the head is siruated direcdy above the pelvis. Note prominent rib humps and actively look for hamstring tightness Examination of the child standing and with the spine flexed (see Figure 19.2 and 19.3) clearly demonstrates the prominent rib hump. Assess pelvic asymmetry, limb length equality, absence of the umbilical reflex, and any distal neurological deficit.

120

Chapter 19

Figure 19.3. An anteroposterior chest X-ray showing an adolescent right-thoracic scoliosis and prominent rib hump. Investigation

Investigation includes thoracolumbar radiographs and measurement of the Cobb angle (this is the angle measured perpendicular to the end plate of the most tilted vertebra). One should also measure the Risser grading of the child, which relates to the ossification of the iliac crest apophysis. The Risser grading is from 0-5, with grade 0 representing no ossification in the immature patient and grade 5 representing complete ossification in the older child. The relevance of the Risser grading becomes apparent when one considers factors relating to curve progression. Treatment

Treatment includes: 1) observation: for children with <30" curves

2) physiotherapy: this should include muscle strengthening and posture correction 3) bracing: this is usually indicated in the younger patient in an effort to prevent progression of the scoliosis Bracing is recommended for patients wi.th curves between 30" and 45°. The Milwaukee brace is usually required for curves at or above T7, and for curves below T8 one can use the Boston underarm thoracolumbar orthosis. v..'hen prescribing a brace, it is worth stressing to the patient that the brace will not correct the defonnity, it will only prevent curve progression. The patient should be advised that the brace needs to be worn as much as possible to prevent curve progression 121

Pediatric spinal conditions

(.)

Figures 19.4. (a) An example of a neuromuscular scoliosis in a child \l!ith cerebral palsy: note thc severity of the curve and also the considerable length of the curve. (b) The child following instrumented fusion; this halts curve progression and, as can be seen, corrects the deformity to an extent.

4) surgery: this is usually only indicated for curves of >50°. It is wonhwhile considering those patients who have a high risk of curve progression, and these include: a) younger age « 12 years old) b) females c) Risser grade 0-1 (immature skeleton) d) those with curves of > 200 e) those with a thoracic hypokyphosis 122

Chapter 19

Neuromuscular scoliosis Neuromuscular scoliosis is divided into either neuropathic or myopathic causes: the most common scolioses include cerebral palsy (see Figure 19.4), syringomyelia, spinal cord tumor, muscular dystrophy, and arthrogryposis Examination

Scoliosis is a common feature of the neuromuscular disorders, so the spine should always be assessed in these patients The curves differ from the majority of those seen in other fonns of scoliosis in that they: 1) are frequently longer

2) involve a significant portion of the spine 3) are often unbalanced; there is no compensatory curve. This is one of the distinguishing features of patients with idiopathic scoliosis, who often have a compensatory curve. The compensation allows the head to be centered over the pelvis, which is frequently not the case in the neuromuscular disorders 4) are often associated with other skeletal defonnities of the neck and pelvis. All patients with neuromuscular scoliosis should be assessed for respiratory complications, which are relatively frequent. A functional assessment of the patient is paramount and, in particular, one should assess whether the patient is ambulatory or wheelchair bound. If wheelchair bound, then it is important to assess whether the patient can sit unaided Treatment

The treatment of neuromuscular scoliosis includes: 1) observation

2) bracing up until the age of 12 years. The most popular brace used is the Boston brace, as the Milwaukee brace often results in pressure sores 3) surgical fusion. The fusion is often extensive and frequently involves fusion of the spine to the pelvis. The primary goal of treatment is to pro~ide the patient with a stable spine that is relatively balanced 4) supportive therapy. This includes a multidisciplinary team, involving a pediatrician, a spinal surgeon, a physiotherapist, and an orthotist. Genetic counseling should also be made available to these families

123

Pediatric spinal conditions

Infection Infection is a rare but extremely important cause of pediatric back pain. The infective conditions include: 1) pediatric infective discitis

2) vertebral osteomyelitis 3) abscess fonnation These disorders are discussed separately in the chapter on spinal infection. Essentially, any child who presents with constant, deteriorating back pain that is refractory to analgesia and present at rest requires investigation for spinal infection. The child will frequently present with constitutional symptoms, such as anorexia, weight loss, fever, nausea, and vomiting. Examination often reveals extreme tenderness in the back, and spinal movements are severely restricted. All children presenting in this manner require urgent referral to an orthopedic or spinal team and should be investigated by measuring full blood count, erythrocyte sedimentation rate, and C-reactive protein level, and also by spinal imaging. The treatment often includes antibiotic therapy, bed rest, and a spinal orthosis. Operative intervention is usually restricted to those with: 1) abscess fonnation

2) 3) 4) 5)

neurological deficit infection that is refractory to antibiotic therapy biopsy for diagnosis and culture vertebral collapse with progressive kyphosis

Tumors Spinal tumors are a rare cause of pediatric back pain, which often results in misdiagnoses and delayed diagnoses. The most common tumors of the pediatric spine include: 1) osteoid osteoma

2) osteoblastoma 3) aneurysmal bone cyst Osteoid osteomas can be associated with a painful scoliosis in the child, whilst osteoblastomas are frequently linked with neurological involvement as they affect the posteJior column. Aneurysmal bone cysts typically emerge in the older child in late adolescence. The salient features in the history include constant, unremitting back pain that is present at rest. Patients with osteoid osteomas often fmd that aspmn therapy relieves their pain; this is almost diagnostic. Examination often 124

Chapter 19

reveals a significant reduction in the range of movement in the spine, with or without a scoliosis. Children who present in this fashion require an orthopedic or spinal referral urgently for appropriate therapy Surgical intervention is frequently indicated for tumor resection and spinal fusion. Chapter 10 provides more infonnation on this subject.

Psychogenic back pain Very rarely, children present with back pain that is secondary to some fonn of psychological upset, This is essentially a fonn of somatization. However, it is important to actively exclude all other causes of back pain. A thorough history is essential, including past medical and psychiatric history, as is an inquiry as to the child's family life and also the family setup. The child's schooling is also important, so actively inquire about bullying and truancy. An assessment of the child's development, both physically and mentally, is also important. Examination involves observation of the child and hi~er interaction both with the clinician and with the family. A thorough examination of the back is important for excluding all other causes of back pain, and signs of other past psychological insults, such as self-hann or even nonaccidental inJury, should be actively looked for Following a thorough investigation to e.xclude the other causes of back pam, children with psychogenic back pain need psychological counseling and support. It is important to include the family in the treatment to achieve the best results

Torticollis Torticollis is defined as a rotational defonnity of the neck in association \vith a tilting of the head, The most common causes of tonicollis in the child include: 1) congenital muscular torticollis

2) congenital anomalies: a) (1 facet abnonnalities b) Klippel-feU syndrome c) os odontoideum d) atlantoaxial instability or subluxation 3) secondary to upper respiratory tract infection The most common cause by far is congenital muscular torticollis, which is due to scaning and fibrosis of the sternomastoid muscle. The incidence is increased significantly in breech deliveries, Examination of the child reveals that the head is tilted to the affected side and palpation reveals an obvious cord-like sternomastoid muscle, which is usually nontender. X-rays of the neck are nonnal and if any

125

Pediatric spinal conditions

abnormalities are present another diagnosis should be considered. Approximately 10%-20% of these children have developmental dysplasia of the hip, and so a thorough examination of the child is essential to exclude any other pathology. Treatment includes physiotherapy to try to breakdown the scar tissue in the sternomastoid muscle and stretch the tissues on the affected side. The parents need to be advised regarding stretching exercises so that these can be carried out at home. If the deformity persists beyond 12-18 months then surgical release is often required Any child who presents with a torricollis in hi.s}her early years of life requires review by a spinal or orthopedic surgeon to exclude other pathologies.

Summary Back pain in children is relatively uncommon and, as such, presentation of a child with back pain should alerr the clinician to fully examine and investigate the child. The cause is often mechanical and related to some childhood activity; however, it is imperative that the other diagnoses are actively excluded. Any concern regarding the diagnosis should prompt referral to the local orrhopedic team.

126

Abbreviations AUF

anterior lateral interbody fusion

AP

anteroposterior

eRP

C-reactive protein

CT

computed tomography

DEXA

dual-energy X-ray absorptiometry

DISH

diffuse idiopathic skeletal hyperostosis

ESR

erythrocyte sedimentation rate

HLA

human leukocyte antigen

LBP

lower-back pain

MRI

magnetic resonance imaging

NSAlD

nonsteroidal anti-inflammatory drug

PlVO

prolapsed intervertebral disc

PUF

posterior lateral interbody fusion

ROM

range of movement

SLR

straight leg raise

TB

tuberculosis

TENS

transcutaneous electrical nerve stimulation

127

Glossary

CltlVlcal spine

-.... ~

......

"""""" spine

Lumbar spine

, Sacrum

Coccyx

Anlcroposlerior view.

129

Glossary

Cervical

spine

, Lumbar

spine

Lateral view.

130

Glossary

Odontoid IKg view.

131

Index Page numbers in bold refer to figures. Page numbers in ilalic, refer to tablcs.

A abdominal exercises 44 abscess fOlTIlation 65.66 epidural abscess 35, 65 pamspinal abscess 65 pediatric 124 spinal tuhcrculosi;; (Pott's disease) 64,65 treatment 65 absolute stenosis 47 achondroplasia 48 acquired spinal stenosis 4K 49

activities of daily living 97 activity 2 adolescent idiopathic scoliosis sa scoliosis, adolescent idiopathic adolescents, spondylolisthesis treatment 57

adults, spondylolisthesis

m~anncnt

57

aggravating facial'S, history 2 aging 39,47

alar ligaments 82,83 analgesia coccydynia 79 pediatric mechanical back pain 114 pediatric spondylolysis/spondylolisthesis 115 prolapsed thoracolumbar intervertebral discs 44

psoriatic spondylitis 76 Schcucnnann's disease II? spinal stenosis 51 anal tone 7,42 anastomosis 60 anatomy

cervical spine 15,81,81-4,82 coccyx 15,79 lumbar spine IS, 17 sacrum 15,77,77 thoracic spine 15. 16 thoracolumbar spine 15-19 vembroc 16, 16, 16-17 vembral column 15-16 anemia, malignant tumor 71 aneurysmal bone cyst 69, 124 aneurysms, aonic 33 ankle jerk reflex 3 ankle movement/power examination 4,4

133

Index

ankylosing spondylitis 73-4,74, 75 invc.stigations 73 prevalence 73 sacroiliac pain 75 signs and symptoms 73 treatment 74 ankylosis, disc degenerntion 39 annular tears, disc degenerntion 39 annulus fibrosus 17, 17,32,39 anorexia 2,60, 124 anterior arch frncture 88 anterior column 60, 69 anterior cord syndrome 22, 106 anterior disceetomy 117 anterior longitudinal ligament 17-18 cervical spine 83 ossification 75 anterior lumbar interbody fusion (AUF) 35,37 anterior screw, ooontoid peg fracrure 89 anterior transthoracic surgical excision 46 anterior tubercle 81, 84 anteroposterior CAP) plain radiogrnphs 9 burst fractures 93 cen~cal spine injuric.s 85,86,86-7 comprc.ssion injuries 23 facet joint dislocation 92 fracture dislocations 27, 18 spinal stenosis 50 antibiotics 62,63,65,124 anti-inllammatorydrugs 44,74,104,115 AD classification of thorncolumbar trauma 23 aortic aneur~ms 33 apical ligament 82, 83 arthritis 55,75 see a/.ID rheumatoid spine arthrodc.sis 78 arthrogryposis 123 arthropathies, inflammatory 73-0 ankylosing spondylitis .leE ankylosing spondylitis Beh"et's syndrome 76 diffuse idiopathic skeletal hyperostosis 75 inflammatory bowel disease 76 psoriatic spond>1itis 76 Ikiter's syndrome 75 rheumatoid spondylitis 74 sacroiliac pain 74-5 articular cartilage dc.struction 73 articular facets 16, 17,81 articular processes 16, 84 ascending (sensory) tracts 21 aspirin therapy 68, 114

134

Index

atlantoaxial instability 115 atlantoaxial joints 109 atlantoaxial subluxation 89, 109-10, 110 ankylosing spondylitis 74 tonicollis 125 transverse ligament rupture 89 atlamo-dens imerval, atlantoaxial subluxation 110, 110 atlanto-occipital dislocation 87 atlas ((l) 81,81-2 injury 88. 88, 89 ligaments 82, 83 auditory symptoms 96.97 autogenous bone graft 35 autologous bone graft 108 axial compression 92, 93 axial spine compression, atlas injury 88 axis ((2) 81-2,82 injury 89.90,90,91 ligaments 82, 83 B

back pain benign rumor 68 epidural abscess 65 malignant tumor 70 mechanical, pediatric 113, 114 prolapsed thoracolumbar intervertebral discs 41 Scheuemunn's disease 116 soft-tissue injury of cervical spine 96 thoracolumbar trauma 21 ~a alS<) lower-back pain (LBP); mechanical lower-hack pain "back schools" 34,44 balance difficulty 105 "bamboo spine" 73. 75 bcd-rest adult infective discitis 63 compression injuries 23 mechanicallowcr-back pain 34 pediatric infection 114 pediatric infective discitis 63 prolapsed thoracolumbar intervertebral discs 44 pyogenic vertebral osteomyelitis 62 sacrum fracrurcs 78 Beh"ds syndrome 76 benign tumors set: tumors, benign: ~pecifi[ types biceps jerk 6 bifid spinous processes 83, 84 biopsy 12, 71 binh, pediatric spinal conditions 113 bisphosphonates 14 bladder function 7-8, 42, 46

135

Index

body (vertebrae) 16,16,17,81,84 bone cement 24-5 bone graft 35, 108 bone infarct, secondary osteosarcoma 70 bone scanning 12, 12 benign tumor 69 pediatric infective discitis 63 sacroiliac pain 75 bonyabnonnalities 12 bony destruction. rheumatoid spine 109 bony fragment retropulsion 26, 16 bony spurs 106 Boston underarm thoracolumbar orthosis 111,12] bowel function 7,46 brachialgia 104 brachial plexus compression 10] brachioradialis 6 bracing adolescent idiopathic scoliosis 121 adult infective discitis 6] casting, scrial 117, 119 congenital scoliosis 119 halo vest 88,89, 110 infantile scoliosis 119 juvenile idiopathic scoliosis 119 neuromuscular scoliosis 123 $cheuennann's disease 117 see abo Milwaukee brace brain stem compromise, cranial settling 110 breast cancer 69 breech delivery 115 Brown-SCquard syndrome 22,106 burst fractures 15, 16, 26-8, 91 atlas (Cl) injury 88 bony fragment retropulsion 26,16 compUler tomography 26 lateral erect radiograph 26 lumbar spine 13 magnetic resonance imaging 26 plain radiographs 26 scm-belt type injuries 27,17 subaxial cervical spine 93, 93 surgical stabilization 26 bUllock pain 74

C Cl-2 erosion. atlantoaxial subluxation 109 fusion, atlantoaxial subluxation 110 odontoid peg fracture fIxation 89 CI facet joint abnonnality 125

136

Index

0-783,84 (4-5, cervical myelopathy 106 (5-6, cervical myelopathy 106 (6 nerve root. cef\~ca1 radiculopmh}' 10 I (7 nef\'e root, cef\~cal radiculopmhy 10 I (7-Tl, osteotomy 74 calcitonin 14 cardiac pacemakers 11,13 carpal runnel syndrome 43, 103 cartilaginous destruction, rheumatoid spine 109 cartilaginous endplatcs 39 casting, serial II 7, 119 cauda equina 18 compression 47 epidural injections 35 injury, anal lOne examination 7 cauda equina syndrome 42 bladder function 7, 42 discography 45 dysplastic sJXlndylolisthcsis 54 lumbar disc prolapse 40 perianal sensation 7 caudal epidural 35, 77 cemral cord syndrome 21-2,106 central stenosis 48 cephalad vertebra slippage liS cerebral palsy 122, I Z3 cef\~cal collar 99, 108 cervical dermatomes 6, 7 cef\~callordosis IS abnormality 98 ankylosing spondylitis 73 examination 4 laminectomy for cervical myelopathy 108 soft-tissue injury of cervical spine 96 cef\~cal myelopathy 105-8 cef\ical radiculopmhy 101 cef\ical radiculopathy differential diagnosis 103 etiology 105 investigations 106. 107 partial cord compression syndromes 106 signs and symplOms 105-6 treatment 106, 108 cef\~cal nerve root block 104 cervical radiculopathy 101-4 differential diagnosis 103 incidence 101 investigations 103, 103 prolapsed disc 101 signs and synlplOms 102, 102 spondylitic spur of bone 101

137

Index

treatment 104 cervical spinal cord injury 87 cervical spinal cord pressure ~e cervical myelopathy cervical spine anatomy 15,81,81-4,82 anteroposterior view 129 atlas (Cl) .IU alIas (CI) axis ((2) su axis ((2)

0-783,84 carpal runnel syndrome differentiation 43 cervical radiculopathy su cervical radiculopathy examination 4-6. 6, 7 fluoroscopy, dynamic imaging 11 injury ~c cervical spine injuries instability 109 latera! view l30 ligaments 83 magnetic resonance imaging (MRl), sagillal 14 movement 84 muscles 83 odontoid peg view l31 soft-tissue injuries sce soft-tissue injury of cervical spine venebrae 101 cervical spine injuries 85-94 atLlI1tooxial sublwmtion 89 alias (Cl) 88,88,89 axis ((2) 89,90,90,91 radiological assessment 85-7 anteroposterior \~ew 85,86,86-7 computed tomography (CD 85, 87 flexion cxtension radiographs 87 lateral view 85.86 magnetic resonance imaging 87 oblique view 87 odontoid peg view 85, 86, 87 second fracrure incidence 85 soft-tissue swelling 85 subaxial 90-3 burst fracrure 93,93 compression fraclUre 91 facet joint subluxations 90, 91, 92, 92 spinous process avulsion 92 teardrop fracrure 93 wedge fraclUre 85 cervical spondylosis 98, 105-8 cervicodorsal junction 17 chemonuckolysis 44 chemotherapy 69, 71 children su pediatric spinal conditions chiropractic 34.99 chondral lesions 67-8

138

Index

(hondros.arcoma 70 (hordoma 70,71,78 (hyrnopapain 44 day shoveler's [ra(ture 28,92 dini<:al examination sa examination dumsiness, (en~<:al myelopathy 105 Cobb angle 121 (O(<:ydynia 79 (oc<:y~(lOmy 79 (O(gtX 79 anatomy IS, 79 anteroposterior view 129 [ra(ture 79 lateral view 130 (omminUled frao:;:ture 88 (ompensation daims 32,35,98 (OmpresSlon lnJunes nen'e root, pediatri( spondylolisthesis liS subaxial cervkal spine fracture 92 thoramlumbar trauma 23.24 (omputed tomography (CD 9, 12-13, 13 benign tumor 69 biopsy guidance 12 bonyabnomlalities 12 burst [rocllires 26,93 ceni<:al spine injuries 85,87 compression injuries 23 facet joint subluxalions 92 Jefferson [ra(ture 88. 89 lumbar spine burst fracture 13 malignant tumor 71 pediatric spinal mnditions 114 pediatric spondylolysis/spondylolisthesis lIS s.acral chordoma 78 s.acrum fractures 78 spinal stenosis 50 spinal tuberculosis (Pott's disease) 65 spondylolisthesis 56 spondylolysis 12 trauma 12 (on(entration patterns 97 mngenital muscular IOrtimllis 125 congenital pediatric spinal (onditiotlS 114 mngenital smliosis 117,118-19 congenital spinal stenosis 48 mnjun(ti\itis 75 conservative treatment ceni<:al myelopathy 106. 108 ceni<:al radi(ulopathy 104 prolapsed thoracolumbar intervertebral discs 43-4 spinal stenosis 51

139

Index

spondylolisthcsis 57 conus medullaris 18 corsets, mechanical lower-back pain 34 corticospinal tract 11 costotransversectomy 46 cranialsetding 109, 110 C-reactive protein (CRP) pediatric infection 124 pediatric infective discilis 63 pediatric spinal conditions 114 pyogenic vertebral osteomyelitis 60 crepitus 109 Crohn's disease 76 cruciform ligament 82, 83 cubimlrunncl syndrome 103 D decompression cauda equina syndrome 42 ccr\~cal myelopathy lOS entrapped nerve roOl 44-5 prolapsed lumbar disc 41 decompressive laminectomy 51 deep friction massage 99 degenerative spondylolisthcsis 53,53,55,55 Denis system 23 dens (odontoid proccss) 81,81 a1lantoaxialsubluxation 109 cranialselding 110 sec abo ooontoid peg dermatomes ccr\~cal 6, 7 lumbar 5 sacral 5 thoracolumbar spine 4,5 descending (mOlar) lracts 11 development stenosis 106 diabeles mellitus 60 diaphragm paralysis 92 digilal recul examination 71 discectomy 45 discitis .see intervertebral disc space, infection discography cauda equina syndrome 45 fusion 33 mechanicallowcr-back pain 33, 33, 35 prolapscc\ thoracolumbar intervertebral discs 45 discs .IU intervertebral discs disc space ~a interverlebral disc space dizzincss 97 domestic activitics 97

140

Index

dorsal columns 11 dorsal root ganglion 18 dorsolumbar junction 17 dual-energy X-my absorptiomctry (DEXA.) 24 duml s.ac 18 duration, history 2 dynamic stabilization 37 dysphagia 75 dysphasia 97 dysplastic spondylolisthesis 53,53,54,54 E elbow movemcnt/powcr examination 5-6, 6 en bloc rcsection, benign tumor 69 cntrapped ncrve root, dccomprcssion 44-5 cosinophilic granuloma 68 eosinophilic hemangioma 68, 68 epicondylitis \03 epidural abscess 35,65 epidural injections 34-5,44 epidural steroids 51 erector spinae 18,83 examination 4 soft-tissue injury of cervical spine 96 suocutaneous mass 65 tenderness in pediatric mechanical back pain 114 thoracolumbar spine examination 3 erythrocyte sedimentation mte pediatric infection 114 pediatric infective diseitis 63 pediatric spinal conditions 114 pyogenic vertebml osteomyelitis 60 estrogen replacement 24 evoked potentials, cranial settling 110 examination 3-8 anal tone 7 bladder function 7-8 bowel function 7 cervical spine 4-6,6, 7 femoral nerve stretch 7 perianal sens.ation 7 sciatic stretch test 7 special tests 6-8 strnight leg raise ($LR) 7 thoracolumbar spine 3-4,4,5 VlladdeU's inappropriate signs 8 excision 65, 78 exercise 34 extension 3, 16-19 extension braces 29 extensor muscles 18, 32

141

Index

F facet joints alignment in cervical spine injuries 85, 87 as}'mmenieal, compression fractures 92 cervical mdiculopathy 103, 104 compression fractures 92 degeneration 31,54,103 degener
142

Index

discography 33 facel join! degeneration 31 juvenile idiopathic scoliosis 120 lumbar instability 31 mechanieallower-back pain 33,35,36,37 neuromuscular scoliosis 113 pedialric rumors 115 prolapsed thoracolumbar intervertebral discs 45 pyogenic vertebral osteomyelitis 60 rheumatoid spine III Scheuermann's disease 117 spinal stenosis 51 G

gadolinium 45, 61 gail abnormality 54,56 gastrointestinal tract symptoms 2 giant cell rumor 67,69 girdle pain 71 granuloma. eosinophilic 68 groin, subcutaneous mass 65 H halo vest 88,89, 110 hamslring tightness/spasm adolescent idiopathic scoliosis 120 pediatric spondylolysis/spondylolisthesis 115 Scheuermann's disease 116 spondylolisthesis 54,56 hand movementlfXlwer examination 6.6 hangman's fracture 89,91 headache 96.96,97, 109 head nodding 81 head rotation 81 head trauma, alIas (Cl) injury 88 hemangioma. eosinophilic 68 hemivertebrac, congenital scoliosis 118-19 hip deformity 50 dysplasia 116 movement/power examination 4," pain, ankylosing spondylitis 73 hislOry 1-3 constitutional rymplOms 2-3 general inquiry I specific 1-1 Hoffmann reflex 106 human leukocyte antigen (HlA)-B17 posilive 73, 76 humped back, Scheuermann's disease 116 h)'percxtension injuries, repetitive 54 h)'perkyphosis, Scheuermann's disease 116

143

Index

hyperrcflexia, rhcumalOid spine 109 I idiopathic nalTOW canals 48 idiopathic scoliosis 117 see also indil'idlWIIY/15 iliac crest apophysis ossification 121 imaging 9-14 bone scanning 12, 12 compUled tomography (CD see compUled tomography (CD fluoroscopy II magnctic resonancc imaging (MRI) sa magnctic resonance imaging (MRI) myelography II plain radiographs scc plain radiographs immobilization, anky10sing spondylitis 74 infanti1cscoliosis 117.119 infcction 59-66 abscess formation see abscess formation bone scanning 12 classification 59 disc space sa intcrvertebral disc space, infection pediatric 113, 124 pyogcnic vertcbral ostcomyclitis 5<:e ostcom>'Clitis, pyogcnic vertebral spinallUbcrculosis (Pon's disease) sa spinallUbcrculosis (Pon's disease) infcrior articular process 16, 82, 84 inflammatory arthropathies sec arthropathics, inflammatory inHammatory bowel discase 76 instability, disc degcncration 39 imerbody fusion sa fusion (surgical) intcrnal foollion. odontoid peg fracturc 89 intcrspinous ligaments 18,83 intcrspinous process spacers 37 intcrtransvcrsc ligaments 18 intervertcbral discs 17, 17 discectomy 45 discography .see discography height loss, ccrvical radiculopathy 103 herniation 105, 106, 114 magnctic resonance imaging 13 mechanicallowcr-back pain 32 prolapsed .see prolapsed intervcrtebral disc prosthesis 36 replaccment surgery 36 surgery 62 teardrop fraclUre 93 thoracolumbar prolapse sa prolapsed imervertcbral disc, thoracolumbar imcrYCrtcbral disc space infection 62-3 adult infectivc discitis 63, 63 bone scanning 12 disc surgcry, foHO\\~ng 62

144

Index

osteomyelitis, follo\\~ng 62 pediatric infective 62-3, 124 spinal injection, following 62 narrowing 63. 116 intervenebral foramen 16,18,48 intervencbral joints 17-18 intradiscal e1eCITolhennal therapy 35 intravenous drug addicts 59 irradiation, secondary osteosarcoma 70 isthmic spondylolisthesis 53,53,54

J Jefferson fraclure 88, 88, 89 joints 17-18 ~a alS(J facet joints juvenile idiopathic scoliosis 117, 119-20 K

Klippel-Feil syndrome 125 knee jerk reflex 3 knee mo~ment/power examination 4,4 kyphoplasty 24-5.25 kyphosis ankylosing spondylitis 73, 74 benign tumor 68 cef\~cal myelopathy 105 cef\~cal radiculopathy 104 pediatric spinal conditions 114 posl-lraumatic 29 pyogenic vertebral osteomyelitis 60 spinal tuberculosis 64,65 spondylolisthesis 56 thoracic 3, 15 thoracolumbar trauma. following 28-9 L

Ll, osteotom>' 74 L4-5 facet joints degenerative spond>1olislhesis 54-5,55 pediatric infecrive discitis 63 L5-S] facet join!, dysplastic spondylolisthesis 54, 54 L5 wedging 116 lamina 16,16,81,84 oblique radiograph 87 laminectomy, decompressive 51, 108 lap-belt injury 27,27 lateral conicospinallract 11 lateral plain radiograph 9 cef\ical spine injuries 85,86 compressIon mjunes 23.24 erect, burst fractures 26

145

Index

fracture dislocations 27, 18 spinal stenosis 50 lateral spinothalamic tract 11 lateral stenosis 48. 48 leg pain 41,54 Lhermine's sign 105 ligaments destruction. rheumatoid spine 109 hypertrophy, cervical myelopathy 105 Sf/: abo specific ligamwts ligamentum fiavum 18 calcification 105 hypertrophy 48 ossification 106 limb length equality, adolescents 120 litigation issues 32,35.98 liver function test 71 liver ultrasound, metastases 71 longus capitis 18 longus coUi 18 lordosis 15 Sf/: also cervical lordosis; lumbar lordosis lower-back pain (LBP) ankylosing spondylitis 73 mechanical .let: mechanicallowcr-back pain plain radiographs 10-11 prolapscr\ thoracolumbar intervertebral discs 39 Reiter's syndrome 75 sacral chordoma 78 sacroiliac pain 74 sacrum fractures 78 soft-tissue injury of cervical spine % spondylolisthesis 56 lower-limb assessment 3 lower-limb =rcises 44 lumbar dermatomes 5 lumbar epidural 35 lumbar instability 32 lumbar intervertebral disc prolapse 39-41, 40, 41 lumbar intervertebral disc replacement 36 lumbarization 15,15 lumbar lordosis 15 loss 41,56,73 spinal stenosis 50 lumbar spinal stenosis sa spinal stenosis (lumbar) lumbar spine anatomy IS, 17 aneurysmal bone cyst 68 anteroposterior view 119 burst fraclUre 13 lateral view 130

146

Index

magnetic rC$onance imaging 14 movement 18-19 plain radiographs II, II sa also thoracolumbar spine lumps 2.68.71 sa also abscess formation lung cancer 69 M magnetic rC$onance imaging (MRl) 9. II, 13 abscess formation 66 atlantoaxial subluxation 110 benign tumor 69 bUl'St fracrures 26, 93, 93 cauda equina syndrome 42 cervical cord injury 87 cervical myelopathy 106, 107 cervical radiculopathy 103, 103 cervical spine, sagiltal 14 cervical spine injuries 87 compression injuriC$ 23 contraindications 13 degenerate imcrvenebral discs 32 facet joim subluxations 92 intervcnebral discs 13 juvenile idiopathic scoliosis 119 lumbar spine, sagiltal 14 malignant tumor 71 mechanical lower-back pain 33, 33, 33-4 pediatric infective discitis 63 pediatric spinal conditions 114 pediatric spondylol)'sis/spondylolisthC$is 115 prolapsed thoracolumbar disc surgery 45 prolapsed thoracolumbar intervembral discs 43.43 pyogenic vembral osteomyelitis 61, 62 rheumatoid spine 109 sacral chordoma 78 spinal stenosis 50 spondylolisthesis 56 thoracic disc disease 46 thoracic spine, sagittal 14 malaise 2 malignant tumor'> .Ia tumor'>, malignant manipulation, coccydynia 79 mechanical back pain, pediatric 113, 114 mechanical lower-back pain 31-8 diagnosis 33-4 epidemiology 31 etiology 31-3 beet joints 31 intervcnebral discs 32

147

Index

lumbar instability 32 muscle-related pain 32 prevalence 31 p,,>,chological factors 32 psychological ICSting 34 referred pain 32-3 treatmen! 34-7 discography 35 dynamic stabilization 37 epidural injections 34-5 facet joint injections 35 interbooy fusion 35,36,37 intervertebral disc replacement surgery 36 intradiscal c1ectrothemla1 therapy 35 nonsurgical 34-5 posterior fusion with autogenous bone graft 35 spinal fusion 35 spinal instrumentation 36 stabilization 35 surgical 35-7 metaphysis of vertebral booy 64 metastases 69,70, 71 bone scanning 12, 12 pathological s?Jndylolisthc.sis 55 Milwaukee brace adolescent idiopathic scoliosis 121 juvenile idiopathic scoliosis 119 neuromuscular scoliosis 123 $cheuennann's disease 117 mobilization compression injuries 23 pyogenic vertebral osteomyelitis 62 sacrum fractures 78 mood state change 97 motion segment 17,54 mOlOrvehicie accidents 21. 89, 95 movement ccr\~cal spine 84 cervical spine examination 5,6 pediatric spinal conditions 114. 115 reduced, benign tumor 68 resaicted, cervical radirulopathy 102 soft-tissue injury of cervical spine 96,99 thoracolumbar spine 3,4, 18-19 vertebral column 17, 18-19 multiple drug therapy 65 muscle-related pain 32 muscle relaxants 34,44 muscles 18,83 SEe abo specific mWides muscle weakness, cervical myelopathy 106

148

Index

muscular dystrophy 113 myalgia 2 myelography 11 myeloma 70, 71 myelopathy, cervical see cervical myelopathy myofascial pain syndrome 32 myopathic neuromuscular scoliosis 123 N narrow canals 48, 105 nausea 124 neck muscles 83 neck pain cervical myelopathy 105 cervical radiculopathy 102 cervical spondylosis 105 flexion cxtension radiographs 87 odontoid peg fracture 89 rheumatoid spine 109 soft-tissue injury of cervical spine 96, 96 neck rotation deformity 125-6 neck stiffness 109 neck support 99, 104 needle biopsy 69 necdle localization, fluoroscopy 11 nerve root 18 nerve root compression 47 lumbar disc prolapse 40, 40-1 pediatric spondylolisthesis 115 spondylolisthesis 56 symptoms 39 nerve root entrapment cervical radiculopathy 102 decompression 44-5 differentiation from peripheral neuropathy 43 nerve root injections 44 neural arch 16 neural foramen 87 narrowing see spinal stenosis Oumbar) neurofibroma 70 neurological abnormality/defect pyogenic vertebral osteomyelitis 60 rheumatoid spine 109 soft-tissue injury of cervical spine prognosis 98 thoracolumbar trauma complication 28,29 sa also neurological injury neurological assessment 3 cervical spine examination 5 pediatric spinal conditions 114 thoracolumbar spine examination 3 neurological injury

149

Index

atlallloaxial subluxation 110 thoracolumbar trauma 21-3 sec al~o neurological abnonnality/dcfcct ncuromuscular scoliosis 118, 121, 113 ncuropathic neuromuscular scoliosis 123 ncurophysiological studies 43 night swcats 2 nonsteroidal anti-inl1ammatory drugs (N$AlDs) 34.76.99, 108 nucleus pulposus 17, 17,39

o oblique plain radiographs 9,87 observation adolescent idiopathic scoliosis 111 cervical myelopathy 108 infantile scoliosis 119 neuromuscular scoliosis 123 thoracolumbar spine examination 3 occipital headache 96 occipitoatlantaljoint 109 occupation 97 odontoid peg 83 distance from anterior arch of atlas 85 fracture 89,90,90 Cl-2 fixation 89 plain radiographs 9,85,86,87 odollloid process IU dens (odontoid process); odontoid peg onhosis burst fractures 93 compressIOn lnJunes 23 odontoid peg fracture 89 pediatric infection 114 pediatric infective discitis 63 pyogenic venebral osteomyelitis 62 os odontoideum 125 osseous lesions 67 ossification abnormality 116 osteoarthritic facet joints 48 osteoblastoma 67,69,70, 124 osteochondroma 67 osteoid osteoma 67,69,114-5 osteomyelitis, pyogenic venebral 59-62, 124 clinical fearurcs 60 diagnosis 60-2,61 differentiating features from spinal ruberculosis 64-5 etiology 59--60 pathogenesis 60 treatment 62 osteopathy 34,99 ostcopenia 60 osteophytes

150

Index

cCfvical radiculopathy 103 excision 75 fonnation, spinal stcnosis 48,49,50 osteoporosis 24, 78 osteoporotic compression fracture 23 osteoporotic-related spine fractures 14,24-5 osteoporotic wedge fracIDre 2 I osteosarcoma 70 osteolOmy 74 p Paget's disease 48,55.70 pam pyogenic vertebml osteomyelitis 60 thoracolumbar !rnuma 2K 29 sa (lIS<) speegu: type; pain clinics 34 palpable lump 68, 71 palpable step in vertebral column 56 palpitation examination 3, 5 pancreatitis 33 pannus fomlation, rheumatoid spine 109 paraplegia 21,29 paraspinal abscess 65 paraspinal musculature mechanicall<m'er-back pain 32 spasm 41,71,96 thomcolumbar spine examination 3 parnspinal swelling 60 paresthesia 42,44, 102, 105 pars illlemrticularis defect 115 fracture 89 lesion 54,54 parrial cord compression syndromes 106 pathological sfXlndylolisthesis 53.53,55 pediatric infective discitis 12 4 pediatric spinal conditions 113-26 back pain I 13 birth of child 113 developmemaldisorders 113,115-17 Scheuermann's diseaoe sa Scheuermann's disease spond>1olisthesis 115-16 spondylolysis 115-16 examination 113-14 functional assessment 113 incidence 114 infection 113, 124 intervertebral disc herniation 114 invesrigation 113. 114 mechanical back pain 113, 114

151

Index

psychogenic back pain 113, 125 scoliosis sa scoliosis spinal curvature 113 sfXlndylolisthcsis 57 torticollis 125-6 tumors 113, 114-5 pedide 16,16,84 oblique radiograph 87 sclerotic lesion 69 screws, dynamic stabilization 37 pelvic asymmetry 120 pelvic fractures 78 pelvic inllammatory disease 33 peptic ulceration 33 perianal sensation 7 cauda equina syndrome 42 sacrum fracture;; ?8 peripheral joint arthritis 73 peripheral neuropathy 43 peripheral pulse 50 physiotherapy adolescent idiopathic scoliosis III cervical radiculopathy 104 pediatric mechanical back pain 114 pediatric spondylolysis/spondylolisthesis 115 psoriatic spondylitis 76 $cheuennann's disease II? soft-tissue injury of cervical spine 99 torticollis 126 plagiocephaly 119 plain radiographs 9-11 adolescent idiopathic scoliosis III adult infective discitis 63 anteroposterior (AP) sa anterofXlsterior (AP) plain radiographs atlantoaxial subluxation 109-10, 110 burst fractures 26 cervical myelopathy 106, 107 ccr\~cal radiculopathy 103 Jefferson fracture 88, 88 juvenile idiopathic scoliosis 119 lateral su lateral plain radiograph lower-back pain 10-11 lumbar spine II, 11 malignant tumor 71 mechanicallowcr-back pain 33 oblique 9,87 odontoid peg view 9 pediatric infective discitis 63 pediatric spondylolysis/spondylolisthesis 115 prolapsed thoracolumbar intervertebral discs 42-3 pyogenic vertebral osteomyelitis 50, 61

152

Index

rheumatoid spine 109 s.acrum fractures 78, 78 Scheuermann's disease 116 spinal stenosis 50 spinal tuberculosis (Pon's disease) 65 spondylolisthesis 56 spondylolyses 9 thoracic spine 10 tonicollis 125-6 plantar rellex 106 posterior arch 81 fractufC. atbs ((1) injury 88 posterior cord ~)'lldrome 22, 106 posterior fusion with autogenous bone graft 35 with instrumentation 117 posterior longitudinal ligament 18 cervical spine 83 degeneration, lower-back pain 31 ossification 105, 106 posterior lumbar intetbody fusion (PUF) 35, 36, 45 posterior spurs 105 posterior tubercle 8\,84 posture advice 74 Pott's disease IU spinal tuberculosis (Pon's disease) Pott's paraplegia 65 power examination cervical spine 5-6.6 thoracolumbar spine 4,4 primary spinal tumor 67,69, 70 prolapsed intervertebral disc 17, 17 cervical radiculopathy 101 cervical spine 83 magnetic resonance imaging 87 thoracolumbar 39-46 cauda equina syndrome 41 clinical findings 41 disc degeneration 39-41, 40 disc structure 39-41 investigations 41-3,43 lower-back pain (LEP) 39 lumbar disc prolapse 39-41,40,42 nerve root compression symptoms 39 surgery 44-5 symptoms and signs 41,41 thoracic disc disease 46 thoracic disc prolapse 39 treatment 43-5 prostate cancer 69 prostate disorders 33 protcctive pillow 79

153

Index

pseudoanhroses 32 psoas 18 paraspinal abscess 65 shadow loss 60 psoriatic spondylitis 76 psychogenic back pain 113, 125 psychological counseling 125 psychological faclOrslsymptoms 32.97 psychological tC5ting 34 psychosomatic symptoms 8 pyelonephritis 33 R

radiation. history of 2 radical debridemenl 62 radicular pain benign tumor 68 epidural abscC5s 65 malignant rumor 70 pediatric intervencbral disc herniation 114 radiculopathy, cervical sa cervical radiculopathy radiographs sa plain radiographs radiology sec imaging; specific imaging methods radiotherapy 69,71,78 reactive sclerosis 60 rear-end collision (car accident) 95 rectus abdominis muscles 18 rccUITenl disc prolapse 45 referred pain 32-3, 75 reflexes 3.6, 106 &iter's syndrome 75 renal cancer 69 repetitive hyperextension injuries 54 respiratory [unction 119, 123 respiratory tract infection 125 respiratory tract symplOms 3 rheumatoid arthritis 55 rheumatoid spine 109-11 atlantoaxial subluxation 109-10 cranial sellling 109, ItO lower cervical spine involvement III symptoms and signs 109 rheumatoid spondylitis 74 rib, subcutaneous mass 65 rib hump 114, 110, no, 12\ rib ruberc1es 16 rigors 2 Risser grading 121 rOO, juvenile idiopathic scoliosis 120 rotation, thoracic spine 19 rotational malalignment 92

154

Index

5 sacral canal 77 sacral dennatomes 5 sacral hiatus 35, 77 sacralization 15,15 sacroiliac joints ankylosing spondylitis 73, 74 ossification 75 sacroiliac pain 73,74-5, 77 sacroiliitLs 75, 76 sacrum 77-8 anatomy 15, 77, 77 aneurysmal bone cyst 68 anterior rounding 116 anteroposterior view 129 chordoma 70, 78 fraclUres 78, 78 giant cdllUmor 67 lateral view \30 nerve root injury 7 sacroiliac pain 77 scar tissue, prolapsed disc surgery 45 $cheuennann's disease 114, 115, 116-17 examination 116 investigation 116-17 surgery 117 treatment 117 $chmorl's node 117 sciatica degenerative spondylolisthesis 55 dysplastic s(XlndylolisthC5Ls 54 lumbar disc prolapse 39 pediatric spondylolysis/spondylolisthesis 115 sciatic stretch test 7,41 scoliosis 113, 11 7-23 adolescent idiopathic 118, 120-2 examination 120,110,111 investigation 121 treatment 121-2 benign tumor 68 common curves 118 congenital 117.118-19 idiopathic 117 infantile 117,119 juvenile idiopathic 1 t 7, 119-20 neuromuscular 118. 121, 123 Scheuennann's disease 117 spinal stenosis. associated 51 spondylolisthesis 56 syrinx abnonnality 118 thoracolumbar spine examination 3

155

Index

·Scottie dog" outline 9 seat-belt injuric;; 27, 2.7. 98 self-harm, pediauie back pain 125 sensation loss, rheumatoid spine 109 sensory (ascendingltracts 22 seronegative spondyloanhropathies 77 seroposirive disease, rheumatoid spine III serum electrophoresis 71 severity, history I shoulder movement/power examination 5.6 shoulder pain ankylosing spondylitis 73 cervical radiculopathy 102 soft-tissue injury of cervical spine 96,96 site of pain 1 skeletal hyperostosis, diffuse idiopathic 75 sleep patterns 97 soft collar 99,104 soft-tissue injury of cervical spine 95-100 examination 96-7 functional assessment 97 mechanism of injury 95, 95 neurology 97 prognosis 98, 98 symptoms 96, 96 t~atment 98-9 soft-tissue s,,",'Clling, cervical spine 85 somatosensory evoked potentials, cranial settling 110 spatial equilibrium disorder 97 speed of impact 98 sphincter function 78 spina bifida 54,57,116 spinal canal 84 diameter. cervical myelopathy 106 narrowing .Ia spinal stenosis Oumbar) spinal claudication 48,49-50, S5 spinal cord 18 comprc;;slOn 47,70,71 cross section 12 injury 7,93 spinal curvantre, pediatric 113 spinal extensor muscles 18,32 spinal fusion IU fusion (surgical) spinal immobilization 63 spinal injection 62 spinal instrumentation 36 spinal stenosis Oumbar} 47-51 absolute 47 acquired 48, 49 aging 47 central 48

156

Index

classification 48 congenital 48 definition 47 degenerative scoliosis. assodation 51 etiology 47 investigations 50 lateral 4K 48 lumbar movement 3 midsaginal anteroposterior CAP) lumbar canal diameter 47,47 pressure development 47 spondylolisthesis, associated 51 symptoms 47.48-50 thecal sac pressure 48 treatment 50-1 spinal tuberculosis (Pon's disease) 64,64-5 clinical features 64-5 diagnosis 65 pathophysiology 64 treatment 65 spinothalamic tract 21 spinous processes 16, 16, 17, 82, 84 avulsion 92 cervical spine injuties 86 fractures 28 spondylitic spur of bone 101 s(xmdylitis ankylosing 5ef ankylosing spondylitis Bcru;et's syndrome 76 inflammatory bowel disease 76 psoriatic 76 Reiter's syndrome 75 rheumatoid 74 spondyloanhropathics, seronegative 77 s(xmdylolisthesis 53-7 cervical myelopathy 105 cervical radiculopathy 103 classification 53,53-5,54,55 clinical signs 56 definition 53 investigations 56, 56, 56 lumbar lordosis loss 56 pediatric 115-16 percentage slip 56, 56, 56 spinal stenosis 48, 51 treatmem 57 s(xmdylolysis bone scanning 12 compUled tomography (CD 12 pediatric 115-16 plain radiographs 9 Scheuermann's disease 116

157

Index

spondylosis, cervical 105-8 spon 54,57, 114, 115 Spurling's test 102 stabilization ankylosing spondylitis 74 burst fractures 26 disc degeneration 39 fracture dislocations 27 mechanical lower-back pain 35 pyogenic vel1ebral osteomyelitis 62 teardrop fracture 93 stenosis see spinal stenosis (lumbar) sternomastoid muscles palpitation 5 scaning and fibrosis 125 spasm, examination 4 steroid injection/thempy 71,79 stiffness 2,73 straight leg mise (SLR) 7 subamchnoid space 11 subfacetal area, lateml stenosis 48 subluxation atlantoaxial .IU atlantoaxial subluxation multiple level 111 subaxial cervical facet joints 90,91,92,91 superior articular facet 81 superior articular process 16, 84 superior vertebral notch 84 supraspinous ligaments 18,83 symptoms 2-3 syndesmophyte fOl11lation, marginal 73 synovitis 73, 109 syringomyelia 29, 123 syrinx abnomlality 120

T

17-9, Scheuermann's disease 117 TlO-Ll. $cheuel11lann's disease 117 teardrop fmcture 93 tectorial membmne 81 tenosynovitis 103 the<;al sac pressure 48 momcic kyphosis 3, 15 see abo Scheuermann's disease thomcic outlet syndrome 103 thomcic spine anatomy 15, 16 anteroposterior view 119 defol11lity, infantile scoliosis 119 intervenebral disc disease 46 lateral view 130

158

Index

magnetic rC$onance imaging, saginal 14 metastatic tumors 69 movement 18-19 plain radiographs 10 prolapsed intervenebral disc 39 rotation 3 vembrae 15,16 sa (llw thoracolumbar spine thoracolumbar back pain following cervical injury 96 thoracolumbar spine anatomy 15-19 examination 3-4,4,5 intervcnebral disc prolapse see prolapsed intervenebral disc, thoracolumbar movement 18-19 trauma sec thoracolumbar trauma thoracolumbar trauma 21-9 hack pain 21 burst fracrures sec burst fraclUres chronic pain 11 classification 13 "clay shoveler's fracture" 18 complications of fracture;; 28-9 compression injuriC$ 13, H compression (wedgcl-type fraclUre 23 differential diagnosis 23 etiology 21 extension braces 29 facet joint fracture 28 fracture dislocations 27,28 functional recovery 21 minor injuries 28 neurological sequelae 21-3 osteoporotic-related spine fractures 24,14-5 pain 29 paraplegic 21,29 spinous procC$S fractures 28 transverse processes fraClUres 18,29 treatment 23, 25 thyroid cancer 69 torticollis 68, 125-6 traction )4 transanicular screw fIXation 110 transcutaneous electrical nerve stimulation (TENS) 34 transverse ligament destruction 109 transverse ligament rupture 89 transverse myelitis 44 transverse processes 16,16,81,81,84 fractures 28,19,88 oblique radiograph 87 trapezius 4.5, 96 trauma

159

Index

computed tomography (CD 12 spinal stenosis 48 thoracolumbar see thoracolumbar trauma traumatic spondylolisthesis 53.53,55 (2 89,91 triceps jerk 6 rubcrcle anterior 81, 84 posterior 81, 84 rib 16 rubcrculosis 55 rumors 67-72 benign 67-9,68 clinical prescntation 68 investigation 69 treatment 69 bone scanning 12 ceT\~cal radiculopathy differential diagnosis 103 malignant 67,69-71 diagnosis 71 physical signs 71 presentation 70 treatment 71 neuromuscular scoliosis causc 123 pediatric 113, 124-5 thoracolumbar trauma differential diagnosis 23 see also specific type<;

U ulcerative colitis 76 ultrasound 99 umbilical reflex absence 120 unilateral unsegmented bars, congenital scoliosis 118-19 upper-limb neurological examination 5 upper-limb pain 96 urethritis 75 urinary incontinence 105 urinary tract symptoms 2 V vascular claudication 49-50 ventral corlicospinaltract 22 ventral spinothalamic tract 22 vertebrae analOmy,gcneri! 16,16,16-17 atlas sa atlas (CI) axi.> sa axis ((2) CCT\~cal 15.81. 81-4, 82 sa
160

Index

sacrum 15 thoracic 15,16 ~a alw sf'Ccific ~/!llIal regioll.\ vertebral artery 83 vertebral canal 16, 18 vertebral column anatomy 15-16 anteroposterior view 12.9 instability, teardrop fracture 93 intervenebraljoints 17-18 lateral view 130 ligaments 17-18 see also ~f'Ccifi[ ligaments motion segment 17,54 movement 17,18-19 muscles 18, 83 >ec also individual muscles neural anatomy 18 vertebral endplate pediatric infective discitis 63 pyogenic vertebral osteomyelitis 60 Scheuennann's disease 116 soft-tissue injury of cervical spine 95 vertebral fusion ~ec fusion (surgical) vertebral notch, superior 84 vertebral asteom)'Clitis ~u osteomyelitis. pyogenic vertebral vertebroplasl)' 24-5,25 vertigo 96 visual disturbance 97 vomiting 124 \V \\~ddell's inappropriate

signs 8

walking difficulty 105 water content of intervertebral discs 39 wedge fracture 21. 23. 85 weight 2,60 weight lass 124 wheelchair bound, neuromu~rularscoliosis 123 ·whiplash" injury ICe soft-tissue injury of cervical spine white cell count 60,63 wide resection, benign tumor 69 wrist movement/power examination 6, 6 X X-ray sec plain radiographs

161