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Principle of the spine disorders

Dr. Rendra Leonas,SpOT, FiCS, (k) spine, M.Humkes Depart. Orthopaedic Rs. Moh Hoesin Palembang

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Outline of Presentation

1
2 3

Anatomy and Physical examination

Diagnosis Treatment

Conclusion

Introduction : Incidence

Treatment difficult
multiplicity of factors involved. Pain generators elusive Diagnostic imaging frequently inconclusive.

Introduction :
Anatomy of the spine

Lumbosaral

Protection
Support Mobility

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Anatomy and Physiology

33 bones comprise the spine

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Function
Skeletal support structure Major portion of axial skeleton Protective container for

spinal cord

Vertebral Body
Major weight-bearing component Anterior to other vertebrae components

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Anatomy and Physiology

Characteristic of the Vertebrae Cervical
C-1 & C-2 no vertebral body Support head Allow for turning of head Vertebral body size increase inferiorly they become

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Anatomy and Physiology

Characteristic of theVertebrae Lumbar spine has strongest and largest weight bearing of the body Sacral & Coccyx vertebrae are fused No vertebral body

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Anatomy and Physiology Components of Vertebrae

Spinal Canal
Opening in the vertebrae that the spinal cord passes through

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Pedicles
Thick, bony structures that connect the vertebral body to the spinous and transverse processes

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Anatomy and Physiology Components of Vertebrae

Laminae

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Posterior bones of vertebrae that make up foramen

Spinous Process
Posterior prominence on vertebrae

Intervertebral Disks
Cartilagenous pad between vertebrae Serves as shock absorber

Transverse Process
Bilateral projections from vertebrae Muscle attachment and articulation location with ribs

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Intervertebral Disc

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nucleus pulposus annulus fibrosus hyaline cartilage end plates

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Facet Joints
Act to limit shear and torsion
motions between vertebrae Orientation of facet changes along length of spine Cervical : couple lateral bending and torsional motion Thoracic : coronal plane orientation of joint surfaces Lumbar : sagital plane orientation of joint surfaces Facets carry 10-20% of compressive load in upright standing, >50% of anterior shear load in forward fexion

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SPINAL CORD
Only 2% of human CNS, but innervate almost all

areas of the body Caudal two-third of the CNS, From for.magnum to IV disc L1 L2 43-45cm length + 25cm fillum terminale with mean caliber of 10 mm, 30 gr weight Protected by vertebral canal with 2 enlarged zones (cervical & lumbar) and narrowing at the level of thoracic spine

SPINAL CORD

31 medullary segments 31 spinal nerve

roots : 8C, 12T, 5L, 5S, 1Co Radix dorsalis & ventralis enlargement : spinal ganglion fuse n.spinalis out intervertebral foramina ventral ramus & dorsal ramus Unequal growth of spinal cord and vertebral canal direction & length of spinal nerve roots vary according to level of emergence

SPINAL CORD BLOOD SUPPLY

1 anterior and 2
posterior spinal arteries Ant. spinal artery Gray Matter Post .spinal artery White Matter Venous drainage ant & post spinal veins

Anatomy and Physiology

SPINAL NERVES 31 pairs of spinal nerves :
8 cervical 12 thoracic 5 lumbar 5 saccral 1 coccygeal

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Each has both motor and sensory fibers

Motor fibers = anterior or ventral root Sensory fibers = posterior or dorsal root
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SPINAL NERVES

C1 : exits between
atlas & occipital bone C2-C7 : exit above corresponding C vert. C8 : exit between vert. C7 and Th1 Thoracic, lumbar, sacral nerves exit below the corresponding vert.

SPINAL NERVES

Segmental control of upper limb movements

SPINAL NERVES

Segmental control of lower limbs movements

OVERVIEW

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LOOK
inspection

FEEL
palpation

MOVE
active & passive movements LOGO

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EXAMINATION : STANDING

Look :
bruise hematom wound : gun shoot wound stab wound
Deformity

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EXAMINATION :STANDING Feel :

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Tenderness: may be bony, intervertebral or

paravertebral Bony prominence or steps spinous processes

using C7 &/or L4-5 as landmarks

facet joints
approx. 2cm lateral to spinous processes

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EXAMINATION : STANDING

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Feel :
assess alignment, mobility & tenderness of: transverse processes of vertebrae lateral to spinous processes

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EXAMINATION :STANDING Feel :

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Tenderness: may be bony, intervertebral or

paravertebral Bony prominence or steps spinous processes

using C7 &/or L4-5 as landmarks

facet joints
approx. 2cm lateral to spinous processes

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EXAMINATION : STANDING

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Feel :
assess alignment, mobility & tenderness of: transverse processes of vertebrae lateral to spinous processes

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Signs of nerve root compression

Standard full neurological examination of both lower limbs :

tone, power (MRC grading) sensation (light touch, pinprick & proprioceptive if indicated) reflexes (physiologic and patologic) an anatomical distribution [dermatome(s) or myotome(s)] LOGO

Neurological Examination

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Objectives :
Determine if defect is present Localize the level of the deficit

Include :
Sensory Motor Reflex LOGO

Neurological Examination

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Sensory examination
Explain, eyes closed Examine : touch, 2 point discrimination,
proprioceptive. Sensory dermatomes, compare each opposite

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Sensory Dermatome

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Muscle Power Grading

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0 - complete paralysis 1 - flicker of contraction possible 2 - movement is possible when gravity is

excluded 3 - movement is possible against gravity 4 - movement is possible against gravity + some resistance 5 - normal power

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Neurological Examination

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Motor examination
Muscle grading Compare each side

Cervical :
Scapular Deltoid & Biceps C4 C5

Wrist extension & supination

Wrist flexion & Pronation

C6
C7

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Neurological Examination

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Motor examination Lumbo-sacral Hip flexor L 1,2,3

Hip extensor Knee flexor Knee extensor Ankle flexor Ankle extensor S1 L 4,5, S1,2 L 2,3,4 S1 L5

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Reflexes

Biceps

Triceps

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Brachioradialis Hoffman

TEST
SLR : sitting & supine

PROVOCATIVE TESTS Add your company slogan COMMENTS

Must produce radicular symptom in the distribution of the provoked root, for sciatic nerve , that means pain distal to knee

Lasgue's sign

SLR radiculopathy aggravated by ankle dorsoflexion

Contralateral SLR

Well-leg SLR puts tension on involved root from opposite direction

Kernig's test

The neck is flexed chin to chest. The hip is flexed to 90, and then the leg is the extended similar to SLR; radiculopathy is reproduced

Bowstring sign

SLR radiculopathy aggravated by applying pressure over popliteal fossa.

Femoral stretch test

Prone patient; examiner stretch femoral nerve roots to test L2-L4 irritation

Nafziger's test

Compression of neck vein for 10 s with patient lying supine ; coughing then reproduces radiculopathy

Milgram's test

Patient raises both legs off the examining table and hold this

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position for 30 s; radiculopathy maybe reproduced

Trauma (fractures) Infections Iatrogenic causes Degenerative chances Neoplasma Congenital

Occupational risks :
Repetitive forward bending bending and twisting Frequents lifting on the job whole body fibration (WBV) ; energy delivered to the body

Phychosocial factors

 History Physical examination Laboratory finding Imaging :

- Plain x-ray
CT MRI

Pain Numbnes Claudicatio Paralysis Paresthesia Deformity

 Based on :
Etiology
Congenital Infection Neoplasm Trauma Degenerative Others

Demands
Age Job Socioeconomic condition etc

 Conservative :

Medication Physical therapy External supports Simple operative, single or in combination : Complex :
Disectomy Facetectomy, etc Decompression Fusion, etc

Operative

Spinal trauma

Introduction
50 % associated with other injuries suspect if mutiple trauma or head injuries more common traffic accident, falls, sport inj principle management accord ATLS and
using collar and long spine board

transf patient inline traction and log rolling

Clinical evaluation

Secondary survey from head to toe History of trauma and neurologic status at
the time accident Palpation any tenderness and bruising or gap between two spinous proc Neurologic evaluation incl rectal examination, perianal sensation, bulbous reflex

INTRODUCTION
The cervical column is
extremely vulnerable to injury

Function:
Movement - flexion, extension, lateral bending and rotation Attached at the cephalic aspect - the skull and its contents

INTRODUCTION
Injury - when loads
exceed the ability of the supporting structures to dissipate energy

Mainly hyperextension:
older patients with spondylolytic disease younger patients with congenitally narrowed spinal canals

INTRODUCTION
Jefferson & Meyer identified
C2 and C5 as the two most common areas of cervical spine injury

Produce neurological damage

in approximately 40% of patients

10% of traumatic cord injuries

have no obvious radiographic evidence of vertebral injury

SPINAL TRAUMA
Definition: injury has occurred
to any of the following structures: Bony elements Soft tissues Neurological structures

Two concerns of spinal

trauma: Instability of the vertebral column Actual or potential neurological injury

SPINAL INSTABILITY
Definition: Loss of normal
relationship between anatomic structures with a resulting alteration of natural function: Spine can no longer carry normal loads

Permanent deformity may occur resulting in severe pain Potential for catastrophic neurological injury

MECHANISM OF INJURY
Understanding details of the
injury aids in diagnosis

Spinal trauma patients may

have injury to other anatomic structures, impeding neurologic evaluation

If possible, question witnesses

for additional details

CLASSIFICATION OF FRACTURES
Stable and Unstable
Stable
Spine can withstand physical loads No significant displacement or deformity to bone or soft tissue

Unstable
Spine may not be able to carry normal loads Most likely have significant deformity and pain Potential for catastrophic neurologic injury

DENIS CLASSIFICATION METHOD

Used to grade thoracolumbar
and cervical fractures

Based on 3-column theory of

the spine:
Anterior = ALL and anterior 2/3 of vertebral body/disc Middle = posterior 1/3 of vertebral body/disc and PLL Posterior = pedicles, lamina, facets, post. Ligaments

Middle column is key to

stability

Magerl Classification
Thoracolumbar fractures

Three types of fractures

based on mechanism of failure:
Type A = compressive loads Type B = distraction forces Type C = multidirectional forces with translation

Subtypes delineate
stability

AO CLASSIFICATION

CERVICAL TRAUMA
Craniovertebral Junction Fractures Occipito-Atlantal dislocation
Rare Fatal brainstem compression All ligaments
Disrupted

Atlanto-occipital
Fracture

CERVICAL TRAUMA
Craniovertebral Junction Fractures There are reports of patients surviving
Need to fix ligamentous healing in halo vest unpredictable Traction contraindicated Good cervico-occipital fusion posteriorly Avoid smoking and NSAIDs

CERVICAL TRAUMA
Craniovertebral Junction Fractures

C1 fractures:
1. Posterior arch fracture 2. Lateral mass fracture 3. Burst fracture (Jefferson fracture)

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Jeffersons fracture:
53% have associated cervical injuries especially at C2
Sometimes without neurological deficit

CERVICAL TRAUMA
Craniovertebral Junction Fractures

C1 fractures:
Most can be treated with immobilization in a rigid cervical orthosis or a halo vest Isolated posterior arch fractures - stable injuries can be treated in a cervical collar for 8 to 12 weeks

CERVICAL TRAUMA
Craniovertebral Junction Fractures

C1 fractures:
If loss of reduction occurs at C2 fracture stabilisation later when the C1 ring has healed If lateral mass displaced > 7mm halo traction until reduction is achieved

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Rotatory subluxation
C1-2:
Often missed until later Torticollis Wink sign on open mouth view CT helpful

CERVICAL TRAUMA
Craniovertebral Junction Fractures Fielding and Hawkins:
A, Type Isimple rotary displacement without anterior shift; odontoid acts as pivot B, Type IIrotary displacement with anterior displacement of 3 to 5 mm; lateral articular process acts as pivot C, Type IIIrotary displacement with anterior displacement of more than 5 mm D, Type IVrotary displacement with posterior displacement.

CERVICAL TRAUMA
Craniovertebral Junction Fractures Rotatory subluxation of C1-2:
Acute
Reduce closed with halo traction Then apply halo vest

Chronic
Open reduction posteriorly

CERVICAL TRAUMA
Craniovertebral Junction Fractures Occipital condyle fractures:
Rare Lower cranial nerve palsies, eg. Hypoglossal Treat in a halo-vest If instability seen in dynamic x-rays then C0C2 fusion

Anderson and Montesano

CERVICAL TRAUMA
Fractures of Odontoid
Process:
Type 1 fractures at tip Type 2 fractures at waist Type 3 fractures at base Types 2 and 3 are not stable

CERVICAL TRAUMA
Craniovertebral Junction Fractures Dens fractures:
Type 2 commonest 36% non-union rate 68% healing in halo-vest 98% healing with C1-2 fusion

Anderson and D'Alonzo

Type 3 90% union rate Degree of initial displacement important:

> 5mm higher non-union

CERVICAL TRAUMA
Craniovertebral Junction Fractures Magerl and Seemann:
98% fusion rate compared to 86% using wires and autograft 4.1% vertebral artery injury

Transarticular Screw Fixation

CERVICAL TRAUMA
Craniovertebral Junction Fractures Etter et al:
92.3% fusion rate 17% major complication rate

Anterior Screw Fixation

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Hangmans fracture
Involves C2 Sudden hyperextension of head and neck forces vertebrae against spinal cord Complete neurological loss can occur

CERVICAL TRAUMA
Craniovertebral Junction Fractures Hangmans fracture:
Type I fractures are minimally displaced caused by hyperextension and axial loading with failure of the neural arch in tension Because ligamentous injury is minimal - stable - heal with 12 weeks of immobilization in a rigid cervical orthosis

Levine and Edwards

CERVICAL TRAUMA
Craniovertebral Junction Fractures Hangmans fracture:
Type II fractures have more than 3 mm of anterior translation and significant angulation The C2-3 disc may be disrupted Treatment - application of skull traction through tongs or a halo ring with slight extension of the neck over a rolled-up towel

Levine and Edwards

CERVICAL TRAUMA
Craniovertebral Junction Fractures Hangmans fracture:
Type IIA fractures are a variant of type II fractures severe angulation between C2 and C3 with minimal translation A more horizontal than vertical fracture line through the C2 arch Treatment is application of a halo vest with slight compression

Levine and Edwards

CERVICAL TRAUMA
Craniovertebral Junction Fractures Hangmans fracture:
Type III injuries combine a bipedicular fracture with posterior facet injuries Severe angulation and translation of the neural arch fracture and an associated unilateral or bilateral facet dislocation at C2-3 Commonly require surgical stabilization

Levine and Edwards

Imaging

Depend on clinical finding (pain and

deformity)

After patient hemodynamic stabile X ray ap and lateral view in the cervical
must incl C1-C7 (swimmers position or open mouth) , thoracolumbar junction

Ct scan or MRI can be obtained

Case 1

Male, 34 y.o MVA Incomplete spinal

cord injury + Mild HI

Case 2

Male, 80 y.o MVA No neck pain No deficit neurologic Mild HI

 Swimmer view

 Axial CT Scan

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