SPINE

RUDI FEBRIANTO, MD
Orthopaedic Surgeon RSUP NTB/FK UNRAM

Curriculum Vitae
Nama : Rudi Febrianto Lahir : Sumbawa, 18 Februari 1975 Status : Menikah ( 1 istri, 3 Anak) Pendidikan :

SD 3 Mataram SMP 1 Mataram SMA 1 Mataram Pendidikan dokter FK UI 1993 1999 Pendidikan orthopedi & traumatologi FK UI 2003 2008 Ketua SMF Orthopedi & Traumatologi RSUP NTB/FK UNRAM

Spine Anatomy
33 vertebra : 7 cervical, 12

thoracal, 5 lumbal, 5 sacrum, 1 coccygeus Spinal curves: normal curves - Cervical lordosis - Thoracic kyphosis - Lumbar lordosis - Sacral kyphosis

 Cervical C1-C2: unique bones allow stabilization

of occiput to spine and rotation of head. Motion: rotation and fl exion/extension. Thoracic Relatively stiff due to costal articulations. Motion: rotation. Minimal flexion/extension. Thoracolumbar Facet orientation transitions from semicoronal to sagittal. Segments are mobile. Most common site of lower spine injuries. Lumbar Largest vertebrae. Common site for pain. Houses caudaequina. Motion: fl exion/extension. Minimal rotation. Sacrum No motion. Is center of pelvis

Radiologic Evaluation

Spinal Problem
Stability : stable or unstable? Location : Cervical or Thoracolumbal? Cause :
- Infection - Non-infective inflammatory disease - Tumor - Trauma

Management : - early management

- definitve management

Stability
Stable fracture is one in which the

vertebra component will not be displaced by movement. - Wedge compression fracture Unstable fracture is one in which there is a significant risk of displacement and consequent damage to neural tissue
- Burst compression fracture, Fracturedislocation

Three Column Stabilty Concept

TREATMENT

Objective :

To preserve neurological function

To relieve any reversible neural compression

To restore alignment of the spine

To stabilize the spine

To rehabilitate the patient

SPINAL DEFORMITIES
Scoliosis

- Postural scoliosis - Structural scoliosis Kyphosis

SCOLIOSIS
Lateral curvature of the spine

Postural scoliosis

compensatory to some condition outside the spine, as a short leg, pelvic tilt reversible and curvature without rotation Structural scoliosis irreversible and curvatrue with rotation in the primary curve etilogy : idiopathic (85%), osteopathic, neuropathic, myopathic

Treatment
Aim of treatment are to prevent the progression, to correct and stabilize a more severe deformity Non-operative Spinal braces : curve 20 - 40 and with 2 years age Milwauke brace, Boston brace, TLSO

 Operative

Idiopathic scoliosis with curve more than 40 and more than 10 years old Correction the curvature by combination of spinal instrumentation and spinal fusion.

SPINAL INFECTION
Tuberculosis (Spondylitis TB or Potts

disease) Spine is the most common site of skeletal tuberculosis and the most dangerous.
The most common site are the lower

thoracic and upper lumbar

 Granulomatous inflammation, characteristized by

slowly progressive done destruction

Treatment
General treatment

- Antituberculosis drugs for 9 month 1 years - General rest - Nourishing diet Debridement and stabilisation-spinal fusion after 1 month of drug therapy

Spondylitis TB L2-3 with posterior stabilization

 Surgical Indication

- Neurologic Defisit Acute neurologic deterioration, paraparesis and paraplegia - Spinal deformity with instability or pain - Large Paraspinal abscess - No respone to medical therapy, continuing progression of kyphosis or instabilty

Complication
Potts Paraplegia

- Paraplegia of active disease : develops realtively early, may result either from extradural pressure or from direct involvement of spinal cord - Paraplegia of healed disease : develops late, result either from the gradual development of a bony ridge or from progressive fibrosis. Kyphosis Deformity

Non-infection Inflamatoy Disease

Degerative Disc Disease

Herniation of intervertebral disc

Spinal Stenosis Segmental instability

Degenerative Disc Disease

The spinal structures most affected by

degenerative disease are

Intervertebral discs Articular facet joints

These conditions are similar to osteoarthritis

and degenerative disease of the spine, which is often referred to as osteoarthritis of the spine, or spondylosis Occurs at all levels of the spine Asymptomatic degeneration in majority of the population

 Symptoms Low back pain and/or buttocks pain If leg pain also exists, there is likely an additional cause, eg, HNP. Diagnosis Patient examination CT/MRI

 Nonoperative care

Rest for acute, low back pain

NSAID medication Physical therapy Exercise/walking Low-impact aerobics Trunk strengthening

Surgical care Failure of nonoperative treatment Minimum of 6 weeks Fusion Removal of disc and replacement with bone graft, or a cagefilled bone graft, or a bone graft substitute Arthroplasty Articulating disc replacement

Segmental Instability
Spondylolisthesis forward shift of the spine in relations to the vertebra segment immediately below Spondylolysis defect in one or both side of the neural arc of lumbar vertebra Spondyloloptosis completely dislocation

Spondylolisthesis
Usually occur in lumbar spine,

paricularly in L5-S1 Type : - Spondylosis spondylolisthesis - degenerative spondylolisthesis - Traumatic spondylolisthesis - Congenital spondylolisthesis

 Gradation of spondylolisthesis
Meyerdings Scale
Grade 1 = up to 25% Grade 2 = up to 50% Grade 3 = up to 75% Grade 4 = up to 100% Grade 5 >100% (complete dislocation, spondyloloptosis)

 Symptoms
Gradual onset of low back pain that aggravated by standing, walking, running and relieved by lying down Nerve root irritation that cause sciatica

 Nonoperative Care Rest NSAID medication Physical therapy Steroid injections

Surgical care Failure of nonoperative treatment Decompression and fusion

Instrumented Posterior approach With interbody fusion

Spinal Stenosis
A bony narrowing of the spinal canal

Bony narrowing may be congenital or may be

acquired

 Central stenosis Narrowing of the central part of the spinal canal Foraminal stenosis Narrowing of the foramen, resulting in pressure on the exiting nerve root

Far lateral recess

stenosis
Narrowing of the

lateral part of the

 Nonoperative care Rest NSAID medication Physical therapy

Exercise/walking

Steroid injections

Surgical care Failure of nonoperative treatment

Minimum of 3-6 months duration

Decompression
Bone removal to widen area Laminectomy Foraminotomy High success rate May require adjunct fusion

to address instability

Herniation of intervertebral disc

The progressive degeneration of a disc,

or traumatic event, can lead to a failure of the annulus to adequately contain the nucleus pulposus Herniation of intervertebral disc is not synonimus degeneration disc disease, but may be complication of degerative disc disease Most common sites is L4-5, L5-S1, and L3-4

 Varying degrees Disc bulge

Mild symptoms
Usually go away with nonoperative treatment

Rarely an indication for surgery

Extrusion (herniation)
Moderate/severe symptoms
Nonoperative treatment

 Posterolateral

herniation: nerve root compression cause sciatica Medline herniation : cauda equina compression cause cauda equina syndrome

 Cauda Equina Syndrome symptoms : Bilateral leg pain Loss of perianal sensation Paralysis of the bladder Weakness of the anal sphincter

Surgical intervention in these cases is urgent

 Nonoperative Care Initial bed rest Nonsteroidal anti-inflammatory (NSAID) medication Physical therapy
Exercise/walking

Steroid injections

Surgical care Failure of nonoperative treatment

Minimum of 6 weeks in duration

Can be months

Discectomy Removal of the herniated portion of the disc Usually through a small incision

Spinal Tumor
Most spinal tumor are metastase and

malignancie 20 40% primary spinal tumors are benign Typically, benign lesion are in posterior elements, and most anteriorly located lesions are malignant

Posterior Element Tumor

Osteoid Tumor

Osteoblastoma
Osteochondroma Aneurysma bone cyst

Vertebral Body Tumors

Hemangioma

Eosinofilic Granuloma
Giant cell tumor Primary Malignat tumor

- Osteosarcoma - Ewing Sarcoma - Multiple myeloma Metastatic tumor - Breast, lung, prostat, kidney, GIT, and thyroid cancer

Treatment
Irradiation

indication : pain, slowly progressive neurological symptoms in the presence of a radiosensitive tumor, spinal canal compromise Instability is a relative contraindication, because of the potential collapse and progression of deformity that could occur with tissue necrosis Operative Indication : decompression and stabilization, radioresistan tumor

Spinal Trauma
Cervical injury

- Jeffersons fracture - Odontoid fracture - Hangmans fracture - Subaxial cervical fracture Thoracolumbal injury - Compression fracture wedge and burst fracture - Fracture dislocation

Cervical Injuries
Cervical spine

injuries must be suspected in patient with : unconscious maxilofacial trauma neck pain

Cevical
C1 Fracture

(Jeffersons Fracture)

Sudeen load on the top of head Usually no neurologis damage

 C2 fracture (odontoid

fracture)

Uncommon Flexion injury after high-velocity or severe fall Neurological symptoms occur in about 20% cases

 Fracture of pedicle

C2 (Hangmans Fracture) Associated with C2/3 facet dislocation, need open reduction and stabilization.

 Lower Cervical Injury (Fracture from C3

C7) Wedge fracture Posterior ligament injury Burst fracture Hiperextension injury Fracture-dislocation Tear drop injury Subaxial cervical fracture

Tear drop fracture C7

Fracture Dislocation C7 T1

Thoracic & Lumbar injury

Relatively common, particularly in

thoracolumbar region Most common fracture are compression fracture, wedge and burst. Less common but more serious are fracture-dislocation.

Wedge Compression Fracture

Vertebral body

crushed anteriorly, posterior ligament remain intact. Stable injuries Clinically symptoms relative mild, but may be there is local tenderness

Burst Compression Fracture

Failure of both anterior

and middle column Posteior column and intervertebral disc may be displaced into spinal canal. May be stable but usually unstable Neurologic defisit (+) unstable ]]

Fracture-Dislocation
Segemental

displacement All three column distrupted, posterior ligament torn, posterior facet joint fracture, and spinal column dislocated. Completely unstable

Management
Early management

Rescucitation (Airway & cervical control, Breathing, Circulation) Immobilization (Rigid Collar Neck, Long Spine Board) Neurologic Assesment Inj. Methylprednisolone 30 mg/kgBB bolus, and 5,4 mg/kgBB/hour for 23 hours.

 Definitive Management

1. Cervical Spine

-Cervical collar

- Halo ring - Fixation

2. Thoracolumbal - Bed rest

- Brace - Decompression and stabilization

Subaxial Cervical Spine Injury Classification System (SLIC)

Injuries descriptors:

Spinal level

Injury morphology (major component) Osseous injury description

Fractures or dislocations of transverse processes, pedicles, endplates, superior and inferior articular processes, lateral masses, facet joints, laminae, spinous processes

Status of DLC (major component) with descriptors

Neurological examination (major component)

Confounders (preexisting cervical disease)

Subaxial Cervical Spine Injury Classification System (SLIC)

Components Morphology No abnormality Compression Burst Distraction Rotation/translation Disco-ligamentous complex (DLC) Intact Indeterminate Disrupted Neurological Status Intact Root injury Complete cord injury Incomplete cord injury Continuous cord compression in setting of neurological deficit Points 0 1 +1 = 2 3 4 0 1 2 0 1 2 3 +1

Subaxial Cervical Spine Injury Classification System (SLIC)

Score interpretation Treatment option

1-3 nonoperative 4 nonoperative/operative 5 operative

Realignment Neurological decompression Stabilization

 Fracture dislocation

C7-T1 with decompression and posterior stabilization

 Nama : Rudi Febrianto Lahir : Sumbawa, 18 Februari 1975 Status : Menikah ( 1 istri, 3 Anak) Pendidikan :

SD 3 Mataram SMP 1 Mataram SMA 1 Mataram Pendidikan dokter FK UI 1993 1999 Pendidikan orthopedi & traumatologi FK UI 2003 2008 Ketua SMF Orthopedi & Traumatologi RSUP NTB/FK UNRAM

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