Orthopedics Presentation on Spinal Disorders.

1. SPINAL DISORDERS
PRESENTER: Kosgei K. Victor
MBCh.B V
SUPERVISOR: Dr. Muteti E. MBCh.B, Mmed(Ortho), FCS, Spine
Specialist- Moi University-Eldoret, Kenya.

2. Introduction to the Spine
• Made of 33 vertebrae; 7 cervical, 12 thoracic, 5 lumbar, 5
sacral (fused) and 4 coccygeal (fused).
• Vertebrae form a functional column.
• Made of 3 columns:
a. Anterior- ALL & anterior 2/3 of vertebral body
b. Middle- PLL & posterior 1/3 of vertebral body
c. Posterior- pedicles, lamina, spinous processes and
ligaments
• Spinal curves: normal curves
a. Cervical lordosis
b. Thoracic kyphosis
c. Lumbar lordosis
d. Sacral kyphosis
• Functions:
a. Stability, support and movement
b. Haemopoietic function
c. Spinal cord and nerve root transmission

3. Spinal disorders- Introduction
• Spinal disorders can be:
A. Traumatic
B. Non traumatic

4. A. Traumatic Disorders
1. Cervical Spine Injuries
a. Occipito-condyle fracture
• High energy fracture
• Usually associated with skull fractures
• CT scan is essential in diagnosis (likely to be
missed in plain x-ray.
• Rx:
i. Impacted and undisplaced fractures- brace
immobilization for 8-12 weeks.
ii. Displaced fractures- halo vest or operative fixation.

5. b. Occipito-cervical Dislocation
• High energy injury
• Almost always associated with other serious
bone/soft tissue injuries- arterial and pharyngeal
disruptions
• Outcome is often fatal
• Dx: lateral cervical x-ray- tip of odontoid should be
no more than 5mm in vertical alignment and 1mm in
horizontal alignment for the anterior rim of foramen
magnum (distances may be higher in children)
• CT scans are more reliable
• Rx: Immediate reduction (without traction) and
stabilization using halo vest pending surgery
• Surgery- Internal fixation using occipito-cervical
plates and screws
• Halo vest may be retained for 6-8 weeks after
surgery depending on severity.

6. c. C1 Ring Fracture
• Also called a Jefferson fracture
• Caused by a sudden load on the head
• No encroachment on the neuronal canal- no
neurological damage
• Associated with other injuries in the cervical spine in
50% of cases
• Seen on plain x-ray in open mouth view and lateral
view
• Unstable injuries- sideways spreading of lateral
masses more than 7mm in open mouth view- ruptured
lateral ligament
• CT is helpful in defining the fracture
• Rx:
i. Stable- semi-rigid collar or halo vest until the
fracture unites
ii. Unstable-halo vest for several weeks. Persisting
instability on x-ray require C1, C2 fixation and
fusion

7. C2 Pars Interarticularis Fractures
• Hangman’s fracture- Bilateral fractures of the pars Interarticularis of C2 and
C2/3 disc is torn
• Mechanism- extension with distraction
• Neurological damage is unusual
• Stable fractures (<3mm of C2/3 subluxation)- Rx with semi rigid orthosis until
united (usually 6-12 weeks)
• Fractures with more than 3mm displacement may need reduction (without
traction) then held with halo vest until union occurs
• C2/3 fusion is required in persistent pain and instability.

8. C2 Odontoid Process Fracture
• Occur as flexion injuries in young adults after high velocity accidents or severe falls
• Occur in elderly osteoporotic people as a result of low energy trauma in which neck is
forced into hyperextension
• Displaced fracture- dislocation of the atlanto-axial joint in which the atlas is shifted
forward or backward taking the odontoid process with it
• No neurological injury with displacement
• However, cord damage is not uncommon especially in the elderly
Classification- Anderson and D’Alonzo (1974)
Type I
• Avulsion fracture at the tip of odontoid process due to traction by alar ligaments
• Fracture is stable and unites without difficulty
Type II
• Fracture at the junction of the odontoid process and body of axis
• Most common and potentially dangerous
• Fracture is unstable and prone to non union
Type III
• Fracture through body of axis
• Stable and unites with immobilization

9. Clinical Features
• Hx- severe neck strain followed by pain and stiffness due to
muscle spasm
• Neurological symptoms may occur
• Plain x-rays show the fracture
• MRI useful as it may reveal rupture of transverse ligaments
Treatment
Type I
• Immobilization in a rigid collar
Type II
• Undisplaced- held by halo vest, elderly- rigid collar
• Displaced- Reduced by traction then operative fusion of C1/2
Type III
• Undisplaced- halo vest for 8-12 weeks
• Displaced- reduction by halo traction the and immobilization by
halo vest for 8-12 weeks

10. Posterior Ligament Fracture
• Result from sudden flexion of mid cervical spine
• Upper vertebra tilts forward on the one below opening an
interspinous space posteriorly
• Patient complains of pain and there may be tenderness
• X-ray may reveal an increased gap space between adjacent spines
• Unstable injury- angulation more than 110, anterior translation of
vertebra more than 3.5mm or if facets are fractured and displaced
• Stable- semi rigid collar for 6 weeks is adequate
• Unstable- posterior fixation and fusion is advisable
Wedge Compression Fracture
• Result from flexion leading to compression fracture of vertebral
body
• Middle and posterior elements remain intact and injury is stable
• Rx- collar for 6-12 weeks
• Axial CT/MRI should be done to identify associated injuries.

11. Burst and Compression-flexion Fractures
Due to axial compression of cervical spine
Burst fracture- vertebral body is crushed in neutral position of head
Tear drop fracture- antero-inferior fragment of vertebral body is sheared off
due to combined compression and flexion
There’s risk of posterior displacement of vertebral fragment and spinal cord
injury
Plain x-ray show crushed vertebral body or a triangular fragment separated
from antero-inferior edge of fractured vertebra
Traction should be applied immediately
CT and MRI should be done to look for retropulsion of bone fragments into
spinal canal
Rx:
i. No neurological deficit- surgical or confinement to bed and traction for 2-4
weeks followed by halo vest immobilization for 6-8 weeks
- Halo vest unsuitable in initial Rx because it does not provide axial traction
ii. Neurological symptoms- urgent anterior decompression- anterior
corpectomy, bone grafting and plate fixations
- Sometimes posterior stabilization is needed.

12. Fracture Dislocation
• Caused by severe flexion or flexion rotation injuries
• Inferior articular facets of one vertebra ride forward
over superior facets of the vertebra below
• Posterior ligaments are ruptured and spine is unstable;
often there's cord damage
• Lateral x-ray shows forward displacement of a vertebra
on the one below of greater than half the vertebra’s
antero-posterior width
• Displacement must be reduced urgently using skull
traction for 6 weeks
• MRI should be performed to rule out presence of disc
disruption
• Collar and halo vest immobilization is advised for
further 12 weeks
• Posterior open reduction and fusion is advised if closed
reduction fails.

13. Hyperextension Injury
• Caused by acceleration forces
• Bone and joint disruptions are rare- strains of soft tissue
• Stable in neutral position
• Should be held by collar for 6-8 weeks
Avulsion Injury of the Spinous Process
• May occur in severe voluntary contraction of muscles at
the back of the neck
• Known as clay- shoveller’s fracture (C7 spinous process
fracture)
• Immobilized with a collar
Cervical Disc Herniation
• May cause severe pain radiating to one or both limbs
and neurological symptoms
• Diagnosis is confirmed by MRI or CT myelography
• Paresis may need surgical decompression

14. Sprained Neck (Whiplash injury)
• Common following RTAs
• Caused by sudden acceleration forces in vehicles without seat
headrest followed by recoil in flexion
• Women are more affected than male- neck muscles are more
gracile
• Pathology involves anterior spinal ligament, capsular fibers
straining
Clinical features
• Pain and neck stiffness appear 12-24 hours
• Pain radiates to the shoulders associated with headache, dizziness,
blurring of vision and paresthesia
• Neck muscles are tender and movements are restricted
• Neurological deficits are uncommon
• X- rays may show straightening of normal cervical lordosis due to
muscle spasms
• MRI may show disc degeneration

15. Grade Clinical Pattern
0 No neck symptoms or signs
1 Neck pain, stiffness and tenderness
No physical signs
2 Neck symptoms and musculoskeletal signs
3 Neck symptoms and neurological signs
4 Neck symptoms and fracture or dislocation
Grading
• DDx
- Vertebral fracture
- Mid cervical subluxation
• Rx
- Analgesics
- Physiotherapy
- Osteopathy an d chiropractic treatments- helpful

16. Thoracolumbar Fractures
Flexion compression Injuries
• Most common vertebral fracture
• Caused by severe spinal flexion
• Posterior ligaments remain intact
• Pain may be severe but fracture is usually stable
• Neurological injury is rare
• Rx:
i. Minimal wedging- bed rest for two weeks until
pain subsides
ii. Moderate wedging- thoracolumbar brace or cast
applied with the spine in extension for 1-2 weeks
• If instability persists, surgical fixation is indicated

17. Axial Compression or Burst Injury
• Severe axial compression may ‘explode’ the vertebral body
causing failure of both anterior and middle columns
• Posterior column is usually but not always undamaged
• Posterior part of vertebral body is shattered and fragments of
bone and disc may be displaced into spinal canal
• Injury is usually unstable
• AP x-rays show spreading of vertebral body with an increase
in interpedicular distance
• CT scan is essential to see retropulsion of bone fragments
into spinal canal
• Rx:
- No neurological damage- bed immobilization and
thoracolumbar brace or cast for 12 weeks
- Neurological symptoms- anterior decompression and
stabilization

18. Jack-Knife Injury
• Combined flexion and posterior distraction may cause mid
lumbar spine to jack-knife at an axis anterior to the vertebral
column
• Seen in lap seat belt injuries
• Unstable in flexion, though neurological damage is
uncommon
• X-rays show transverse fractures in the pedicles or
transverse process
• Lateral view shows opening of disc space posteriorly
• Heals rapidly and requires 3 months in a body cast and well
fitting brace

19. Fracture Dislocation
• Segmental displacement may occur with various
combinations of flexion, compression, rotation and shear
• All three columns are affected and spine is grossly unstable
• Often associated with neurological damage
• X-rays show fractures through the vertebral body, pedicles,
articular processes and laminae
• Varying degrees of subluxation or bilateral dislocation
• Associated fractures of transverse processes of ribs
• CT is helpful in demonstrating degree of spinal occlusion
• Fracture dislocation without neurological deficit- surgical
stabilization
• Fracture dislocation with partial neurological deficit-
surgical decompression and stabilization
• Fracture dislocation with paraplegia- shorten hospital stay,
rehabilitate and reduce painful deformity

20. Non-Traumatic Disorders
Scoliosis
• Lateral curvature of the spine
• Postural scoliosis- deformity is compensatory or secondary to
some condition outside the spine such as short leg or pelvic tilt.
Curvature disappears when patient sits
• Structural scoliosis- non correctable deformity of the affected
segment
• Spinous processes swing towards concavity of the fracture and
transverse processes rotate posteriorly
• Ribs on the convex side swing out producing a rib hump
• Deformity is liable to increase throughout the the growth period
• Types:
• Idiopathic- infantile or juvenile
• Osteopathic/congenital
• Neuropathic
• myopathic

21. Clinical Features
• Deformity is the presenting feature
• Pain is a rare complain- alert for neural tumors
• Family history is common
• Associated with abnormalities during childbirth or
pregnancy
• Spine is deviated from midline
Treatment
• Non operative
• Exercises
• Bracing- Milwaukee and Boston braces
• Operative
• Indications- rapidly deteriorating and cosmetic (deformities
>300 )
• Methods
- Harrington system
- Rod and Sub laminar wiring
- Cotrel dubousset system

22. Kyphosis
• Excessive thoracic curvature- hyper kyphosis, kyphos, gibbous
• Caused by sharp posterior angulation due to localized posterior collapse or
wedging of one or more vertebrae
• May result from congenital, fracture or spinal tuberculosis
Postural Kyphosis
• Associated with other postural defects like flat feet
• Voluntarily corrected by posture training and exercises
• Compensatory kyphosis due to other deformities- usually increased lumbosacral
lordosis
Structural Kyphosis
• Fixed and associated with changes in shape of vertebrae
• Children- congenital vertebral defects, skeletal dysplasia such as achondroplasia
and in osteogenesis imperfecta
• Older children- tuberculous spondylitis
• Adolescence- Scheurmann’s disease
• Adults- ankylosing spondylitis, TB spondylitis, spinal trauma or childhood
disorder
• Elderly- osteoporosis
• Treatment- dependent on the cause

23. Tuberculosis
• Most common site of skeletal tuberculosis
• Account for 50% of all musculoskeletal TB
Pathology
• Blood borne infection settles in vertebral body adjacent to
intervertebral disc
• Bone destruction and cessation with infection spreading to
adjacent disc space
• Paravertebral abscess may form and then track along muscle plane
and involve sacroiliac or hip joint or along the psoas muscle to the
thigh
• Gibbous (kyphos) develop as vertebral body collapse into each
other
• Risk of cord damage due to pressure by the abscess, granulation,
sequestra or displaced bone or ischemia from spinal artery
thrombosis
• With healing vertebrae re-calcify and bony fusion may occur
• Resultant kyphosis risk to cord compression

24. Clinical Features
• Long history of ill health and backache
• Gibbous formation is dominant
• Concurrent pulmonary TB common in children under 10 years
• Spinal movements are restricted
• Children under 10 years usually develop pigeon chest (pectus carinatum)
• Sensory/motor changes may occur in lower limb
• MRI and CT scan are suitable in investigation- can point out abscesses cord
compression, vertebral fractures
• Other tests- ESR- raised
- Montoux- positive
- Needle biopsy- limited to no neurological symptoms
• DDx- malignancies- metastases
- Pyogenic infections
- Hydatid disease
Treatment
• Objectives- eradicate or arrest disease
- prevent/correct deformity
- Prevent or treat complication
• Pharmacology- anti-TBs for six months
• Surgical- drainage and stabilization of vertebra

25. Pyogenic Osteomyelitis
• Uncommon- diagnosis usually delayed
• Risk groups- elderly, chronically ill and
immunosuppressed
Pathology
• Staph. Aureus is responsible for 50-60%
• Immunosuppressed patients- E. coli, Pseudomonas
• Sources of infection- hematogenous, inoculation
• Infection begins at vertebral end plates with spread to
disc and adjacent vertebra
• Can also spread along anterior longitudinal ligament
and into paravertebral tissues
• Spinal canal involvement (epidural abscess)- surgical
emmergency

26. Clinical Features
• Localized pain associated with muscle spasm and restricted
movements
• Point tenderness over affected area
• History of invasive procedure or distant infection
• Pyrexia and tachycardia may be present
• X-ray- loss of disc height, irregular disc space, erosion of
vertebral end plate
• Radionuclide scans- increased activity at site
• MRI- characteristic changes in vertebral end plates disc and
paravertebral tissues
• Needle biopsy- culture and sensitivity
• Other test- ESR, CRP and antistaphyloccocal antibodies
Treatment
• Bed rest, pain relief
• Iv antibiotics
• Operative- indications- poor response to conservative Rx,
presence of neurological signs and need to drain abscess

27. Discitis
• Infection limited to intervertebral disc
• Due to direct inoculation following discography,
chemonucleolysis or discectomy
• Vertebral end plates rapidly attacked and infection
spreads into vertebral body
• Tenderness over affected disc
• ESR is elevated
• Children- infection assumed to be blood borne
• X-ray features same as pyogenic spondylitis
• Rx- broad spectrum antibiotics

28. Intervertebral Disc Degeneration
• Major cause of chronic backache
• Age related- 50% occur in 50+ years
• Disc gradually dries out with ageing
• Nucleolus pulposus changes for turgid gelatinous bulb to brownish
dissociated structure
• Annulus fibrosus develop fissures parallel to the vertebral end
plate and herniations of nuclear material squeeze through the
fissures
• Disc cells then die at an increased rate
• Glycosaminoglycans production is diminished leading to poor
water retention and drying off
• Usually asymptomatic
• Pain is secondary to effects of disc prolapse
• X-rays- flattening out of disc space and osteophyte formation
• MRI- bulging of annulus fibrosus
• Rx-asymptomatic- no treatment
• Symptomatic- management of secondary effects

29. Intervertebral Disc Prolapse
• Physical stress is the probable cause
• May also result from hydrophilic disturbance of nuclear material
• Protrusion- posterior bulging of disc with intact annulus
• Extrusion- fibrocartlaginous material released posteriorly due to rupture of
annulus
• Sequestration- part of nucleus may separate and lie freely or move into the
intervertebral foramen
• Large central rupture may cause compression of Cauda equine
• Postero-lateral rupture compresses nerve root proximal to point of exit
• Major cause of acute back pain
• Sciatica- pain in buttocks and posterior thigh and calf due to nerve root
compression
• Paresthesia, numbness and weakness are common signs
• Back pain and sciatica made worse by coughing
• Cauda equine compression may cause urinary retention and perineal numbness
• X-rays- narrow disc, osteophytes
• CT and MRI are more reliable

30. Treatment
• Heat and analgesics soothe
• Exercise strengthen muscles
• Principles- rest, reduction, removal and rehabilitation
• Rest- patient kept in bed with hips and knees slightly flexed
• Reduction- continuous bed res for 2 weeks may reduce prolapse
• Epidural injection of corticosteroid and local anesthesia may help
• Chemonucleolysis- dissolution of nucleus pulposus using a
proteolytic enzyme (chymopapain)
• Removal- indications
1. Cauda equine compression syndrome
2. Neurological deterioration
3. Persistent pain and sciatic tension
• Operative methods- laminotomy and micro discectomy
• Rehabilitate-isometric exercises

31. Features of Cauda Equina Syndrome
1. Bladder and bowel incontinence
2. Perineal numbness
3. Bilateral sciatica
4. Lower limb weakness
5. Crossed straight leg sign

32. Chronic Back Pain Syndrome
• Self perpetuated
• Accompanied by non- organic physical signs
1. Pain and tenderness of bizarre degree of distribution
2. Pain on performing impressive but non-stressful
movements
3. Variations in raising the leg while distracting patient
attention
4. Sensory and motor function do not fit the
physiological patterns
5. Over determined behavior during physical
examination
• However, pathologies should be excluded before
making this diagnosis

33. Thank you…
Questions/comments
References
1. Apley’s system of orthopedics and fractures 9th
edition
2. Netters concise atlas of orthopedic anatomy