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TEXT PATRICK MCKENNA ▸ Consultant Spinal Surgeon ▸ Fellowship trained ▸ Scope of work PATRICK MCKENNA ▸ Wrong job THE SPINAL BIT ▸ www.spinaldoctor.co.uk BONY ANATOMY OUTLINE ▸ Anatomy of the spine VERTEBRAL COLUMN 15 15 20 30 20 20 ▸ Cervical Spine: ▸ Lordotic curvature ▸ Neuroanatomy ▸ Greatest ROM ▸ The Normal Spine ▸ Most vulnerable to injury ▸ Trauma ▸ Degenerative conditions of the spine ▸ Clinical assessment ▸ Thoracic Spine: ANATOMY OF THE SPINE ▸ Spinal emergencies ▸ Greatest protection ▸ Least ROM ▸ Lumbar Spine: ▸ Balance between protection/ROM TEXT VERTEBRAL COLUMN: MAJOR SUPPORTING LIGAMENTS VERTEBRAL COLUMN: MAJOR SUPPORTING LIGAMENTS FUNCTIONS OF THE SPINE ANTERIOR LONGITUDINAL LIGAMENT POSTERIOR LONGITUDINAL LIGAMENT ▸ Transmits weight of the trunk to the lower limbs ▸ Surrounds/protects spinal cord ▸ Attachment point for the ribs and muscles of neck and back ▸ Anterior Longitudinal Ligament – runs vertically along anterior surface of vertebral bodies ▸ Neck - Sacrum ▸ Attaches strongly to both vertebrae and intervertebral discs (very wide) ▸ Prevents back hyperextension ▸ runs vertically along posterior surfaces of vertebral bodies ▸ Narrower, weaker ▸ Attaches to intervertebral discs ▸ Prevents hyperflexion VERTEBRAL COLUMN: SUPPORTING LIGAMENTS VERTEBRAL COLUMN: SUPPORTING LIGAMENTS LIGAMENTUM FLAVUM POSTERIOR LIGAMENTS BONY ANATOMY ▸ strong ligament that connects the laminae of the vertebrae ▸ Interspinous ligament ▸ body ▸ Protects the neural elements and the spinal cord ▸ Supraspinous ligament ▸ Intertransverse ligament ▸ Stabilizes the spine to prevent excessive vertebral body motion ▸ weight bearing 85% ▸ Vertebral arch ▸ formed by pedicle and laminae ▸ Forms the posterior wall of the spinal canal with the laminae ▸ 2 pedicles ▸ Stretches with forward bending / recoils in erect position BONY ANATOMY ▸ anterior ▸ posterior part ▸ Strongest of the spinal ligaments CLINICAL ANATOMY CLINICAL ANATOMY ▸ 2 laminae BONY ANATOMY BONY ANATOMY CERVICAL VERTEBRA ▸ Transverse Processes: ▸ Project laterally from each pedicle-lamina junction ▸ Attachment site for intrinsic ligaments and muscles ▸ Spinous Processes: ▸ Prominent posterior projections ▸ Attachment site for intrinsic ligaments and muscle BONY ANATOMY BONY ANATOMY BONY ANATOMY Lumbar vertebra BONY ANATOMY BONY ANATOMY BONY ANATOMY FACET JOINTS PARS INTERARTICULARIS INTERVERTEBRAL FORAMEN ▸ Articulations between superior articular facet (bottom vertebrae) and inferior articular facet (above vertebrae) ▸ Area between the superior and inferior facets ▸ Space where spinal nerve roots exit the vertebral column ▸ Common site for stress fractures (lumbar spine) ▸ Size variable due to placement, pathology, spinal loading, and posture ▸ Contribute to ROM ▸ ↓ Weight-bearing stress through vertebral body and disc ▸ Synovial joints ▸ Spondylolysis - refers to the defect (black arrows) present when the pars interarticularis (green arrow) is fractured BONY ANATOMY BONY ANATOMY VERTEBRAL ANATOMY THORACIC VERTEBRA ▸ Can be occluded by arthritic degenerative changes and spaceoccupying lesions (tumors, spinal disc herniations) BONY ANATOMY THORACIC ARTICULATIONS Costovertebral joint Costotransverse joint ▸ Articulation between vertebral bodies and ribs ▸ Superior and Inferior Costal Facets BONY ANATOMY BONY ANATOMY BONY ANATOMY SACRUM SACROILIAC JOINT SIJ ▸ Curved, triangular shaped ▸ Between the sacrum (base of the spine) and the ilium of the pelvis ▸ 5 fused vertebrae ▸ Strong, weight bearing synovial joints (2) ▸ Fixes the spinal column to the pelvis ▸ Stabilizes the pelvic girdle ▸ Covered by 2 different kinds of cartilage ▸ Sacral surface (hyaline cartilage) ▸ Iliac surface (fibrocartilage) ▸ Functions: ▸ Shock absorption (spine) ▸ Allows the transverse rotations (lower extremity) to be transmitted up the spine. ▸ Motions: ▸ limited BONY ANATOMY BONY ANATOMY BONY ANATOMY SACROILIAC LIGAMENTS SACROILIAC LIGAMENTS COCCYX ▸ Posterior Sacroiliac Ligament: ▸ Anterior Sacroiliac Ligament: ▸ Forms the chief bond of union between the bones ▸ Connects the anterior surface of the lateral part of the sacrum to the ilium ▸ Upper part: (short PSL) ▸ Nearly horizontal in direction ▸ Ilium to upper sacrum ▸ Consists of 4 (in some cases 3 or 5) vertebrae fused together ▸ Attachment site for muscles of pelvic floor and sometimes portions of gluteus maximus ▸ Lower part: (long PSL) ▸ Oblique in direction ▸ Lower sacrum to PSIS THE DISC DISCS INTERVERTEBRAL DISCS ▸ Nucleus Pulposus: Core ▸ Gelatinous, acts like a rubber ball (enables spine to absorb compressive forces) ▸ 60-70% water ▸ Annulus Fibrosus: Outer rings ▸ Multilayered fibers (cross from opposite directions) ▸ Rings absorb compressive forces themselves DISCS DISCS INTERVERTEBRAL DISCS INTERVERTEBRAL DISCS ▸ Intervertebral Discs: ▸ Functions: ▸ 23 intervertebral discs ▸ Shock absorbers ▸ No disc between skull and C1 or between C1-C2 ▸ walking, jumping, running ▸ Discs are thickest in the lumbar vertebrae and cervical regions (enhances flexibility) ▸ Allow spine to bend ▸ At points of compression, the discs flatten out and bulge out a bit between the vertebrae DISCS MUSCLES INTERVERTEBRAL DISCS ERECTOR SPINAE ▸ Iliocostalis: ▸ Intervertebral Discs: Dehydration Process ▸ Collectively, the discs make up about 25% of the height of the vertebral column ▸ Nucleus pulposus becomes dehydrated during course of day ▸ Flattens out (height is 1-2 centimeters less at night than when we awake in morning) ▸ Aging Process = Permanent dehydration (ages 40 – 60) ▸ Iliocostalis Lumborum ▸ Iliocostalis Thoracis ▸ Iliocostalis Cervicis ▸ Longissimus: ▸ Longissimus Thoracis ▸ Longissimus Cervicis ▸ Longissimus Capitis ▸ Spinalis: ▸ Decreased ROM ▸ Spinalis Thoracis ▸ Narrowing intervertebral foramen ▸ Spinalis Cervicis ▸ Spinalis Capitis MUSCLES NEURO TRANSVERSO SPINAL MUSCLES LUMBAR AND SACRAL PLEXUS ▸ Lumbar: ▸ Deep intrinsic layer ▸ Formed by 12th thoracic nerve and L1L5 nerve roots ▸ Fibers run from 1 transverse process to the spinous process superior to them ▸ Innervation: ▸ Anterior and medial muscles of thigh ▸ Group formed by: ▸ Semispinalis ▸ Multifidus ▸ Rotators NEUROANATOMY NEURO NEURO LUMBAR PLEXUS LUMBAR AND SACRAL PLEXUS ▸ Dermatomes of medial leg and foot ▸ Femoral Nerve – formed by branches of L2, L3, L4 nerve roots ▸ Obturator Nerve – anterior branches of L2, L3, L4 NEURO SACRAL PLEXUS ▸ Sacral: ▸ Formed by L4, L5 and lumbosacral trunk ▸ Innervation: ▸ Muscles of buttocks, posterior femur, and lower leg ▸ Sciatic Nerve – gives rise to ▸ Tibial nerve ▸ Common peroneal nerve NEURO TEXT SACRAL PLEXUS SAGITTAL BALANCE ▸ harmony between the gravity line and the spinal plumb line NORMAL SPINAL BALANCE ▸ when out of balance ▸ c7 plumb line runs anterior to the gravity line ▸ fighting to keep balances ▸ compensation ▸ symptoms TEXT TEXT TEXT SAGITTAL BALANCE SAGITTAL BALANCE SAGITTAL BALANCE KYPHOSIS KYPHOSIS ▸ pelvic incidence ▸ lumbar lordosis ▸ sacral slope ▸ pelvic tilt AETIOLOGY ▸ Tumour ▸ Degenerative ▸ Iatrogenic ▸ Congenital ▸ failure of formation ▸ failure of segmentation KYPHOSIS CLINICAL ASSESSMENT ▸ Postural ▸ combined ▸ post- laminectomy ▸ post-radiation ▸ history ▸ examination ▸ imaging ▸ Infective ▸ TB ▸ Sherman’s disease ▸ Traumatic KYPHOSIS KYPHOSIS KYPHOSIS POSTURAL DEGENERATIVE CHANGE CONGENITAL ▸ Parents concerned with postural roundback deformity ▸ age ▸ Clinical gentle rounding of the back rather than gibbus ▸ hereditary ▸ Xray required to rule out Sheurman’s or Congenital ▸ moulding associated with BMD ▸ disc degeneration ▸ sagittal imbalance ▸ physiotherapy ▸ spinal muscular weakness and attenuation ▸ failure of sagittal compensatory mechanisms KYPHOSIS KYPHOSIS KYPHOSIS SCHEUERMANN’S DISEASE SURGERY SURGERY KYPHOSIS KYPHOSIS KYPHOSIS COSMESIS TRAUMATIC KYPHOSIS INSUFFICIENCY FRACTURE ▸ 3 consecutive VB ▸ 5 degrees ▸ ?lumbar ▸ without neurology ▸ presentation ▸ compression fracture ▸ examination findings ▸ distraction/ Chance fracture ▸ investigation ▸ bone or ligamentous ▸ ?biopsy/screen ▸ management ▸ mobilise if stable ▸ brace if necessary ▸ vertebrolasty/kyphoplasty ▸ surgical stabilisation and correction KYPHOSIS KYPHOSIS KYPHOSIS VERTEBROLASTY/ KYPHOPLASTY COMPRESSION FRACTURES FIXATION ▸ Type A fractures ▸ posterior open ▸ Sagittal balance ▸ >30 degrees (?20) ▸ Surgical correction be required ▸ Monitor ▸ ?brace ▸ uss fracture fixation KYPHOSIS KYPHOSIS FIXATION FIXATION ▸ Posterior percutaneous fixation ▸ anterior column reconstruction ▸ low morbidity ▸ low physiological hit ▸ early mobilisation ▸ powerful restoration of sagittal balance ▸ direct decompression ▸ early stability ▸ physiologically demanding KYPHOSIS KYPHOSIS X-CORE DESIGN TEXT ▸ Cylindrical cages ▸ Strut graft ▸ TCP ▸ Mesh ▸ Stackable carbon fibre KYPHOSIS THORACOTOMY ▸ Major procedure ▸ Shark bite ▸ Lung deflation ▸ Chest drain ▸ Complications ▸ Pain TEXT TEXT TEXT ANTERIOR SUPPORT VERSUS POSTERIOR ONLY CORPECTOMY TECHNIQUE TIPS ▸ Better maintenance of alignment ▸ Access to pathology ▸ Coagulation of segmentals ▸ Reduced collapse ▸ Decompression of cord ▸ Extrapleural ▸ Small approach with limited comorbidity TEXT RETRACTOR PLACEMENT ▸ Perpendicular ▸ Clear position proven orthogonally ▸ Use the retractor as a guide to perform corpectomy TEXT TIPS ▸ Bold removal seems to reduce blood loss ▸ AP flouroscopy to burr down to the pedicle medial wall ▸ See the cord laterally first KYPHOSIS CORPECTOMY ▸ What supplemental fixation? ▸ Hyperacute surgery - ?blood loss diminished with MIS techniques MISS NH POST TRAUMATIC KYPHOSIS AND SAGITTAL IMBALANCE TRAUMA ASIA SCALE ASIA SCALE TRAUMA TRAUMA WITH NEUROLOGICAL DEFICIT TRAUMA TRAUMA MANAGEMENT OF SPINAL CORD INJURY MANAGEMENT OF SPINAL CORD INJURY ▸ HOSPITAL MANAGEMENT ▸ NGT to suction ▸ Immobilization ▸ Prevents aspiration ▸ Rigid collar ▸ Decompresses the abdomen (paralytic ileus is common in the first days) ▸ Sandbags and straps ▸ Spine board ▸ Foley ▸ Urinary retention is common ▸ Log-roll to turn ▸ Methylprednisolone (Solu-Medrol) ??????? ▸ Prevent hypotension ▸ Only if started within 8 hours of injury ▸ Pressors: Dopamine, not Neosynephrine NEUROLOGICAL EXAMINATION TIME! ▸ Exclusion criteria ▸ Fluids to replace losses; do not overhydrate ▸ Cauda equina syndrome ▸ Maintain oxygenation ▸ O2 per nasal canula ▸ If intubation is needed, do NOT move the neck ATLS ▸ GSW ▸ Pregnancy ▸ Age <13 years ▸ Patient on maintenance steroids TRAUMA SPINAL COLUMN INJURY WITH NEUROLOGICAL DEFECIT ▸ Functional spinal unit TRAUMA TRAUMA INSTABILITY INSTABILITY ▸ Clinical Instability ▸ physiological loads - those which are incurred during normal activity ▸ the loss of the ability of the spine under physiological loads to maintain its pattern of displacement so that there is no initial or additional neurological deficit, no major deformity, and no incapacitating pain ▸ incapacitating pain - unable to be controlled by nonnarcotic drugs ▸ incapacitating deformity - gross deformity that the patient finds intolerable ▸ How do we decide on whether a fracture is unstable? TRAUMA TRAUMA TRAUMA DECIDING ON STABILITY COLUMNS STABILLITY ▸ discuss with spinal surgeon ▸ HOLDSWORTH ▸ AO classification ▸ mechanism of injury may suggest for further imaging ▸ DENIS ▸ plain radiographs may suggest need for further imaging ▸ MRI ▸ If fails trial of mobilisation, i.e. clinically unstable, leave for a few days and try again ▸ spinal board unnecessary ▸ if fails after a few days, diagnosis is instability ▸ indication to consider fixation TRAUMA TEXT STABILITY ▸ thoracolumbar injury classification and severity scale ▸ Approximately 50% of flexionextension motion occurs at occiputC1. ▸ Approximately 50% of rotation occurs at C1-C2. CERVICAL SPINE FRACTURES ▸ Lesser amounts of flexion-extension, rotation, and lateral bending occur segmentally between C2-C7. TRAUMA TRAUMA TRAUMA CERVICAL SPINE ANATOMY CERVICAL SPINE ANATOMY C1 CERVICAL SPINE ANATOMY C2 ‣ Atypical cervical vertebra C2 (axis) ‣ Odontoid process or dens ‣ Vertebral canal/foramen ‣ Facet joints Occipital condyles ‣ Transverse process Foramen magnum ‣ Transverse foramen ‣ Bifid spinous process ‣ Lamina TRAUMA TRAUMA TRAUMA CERVICAL SPINE ANATOMY C1/2 ARTICULATION C1/2 ARTICULATION BONY ALIGNMENT The odontoid process of the axis (C2) extends cranially to form the axis of rotation with atlas (C1) TRAUMA ▸ alignment ▸ C1-C2 segment ▸ The primary motion at the C1-C2 joint is rotation TRAUMA TRAUMA SOFT TISSUE TRANSVERSE AND ALAR LIGAMENTS ▸ Nasopharyngeal space (C1) - 10 mm (adult) ▸ Transverse ligament of the atlas is a thick, strong band, which arches across the ring of the atlas, and retains the odontoid process in contact with the anterior arch of C1. ▸ Retropharyngeal space (C2-C4) 5-7 mm ▸ Retrotracheal space (C5-C7) - 14 mm (children), 22 mm (adults) ▸ Extremely variable and nonspecific ▸ The alar ligaments connect the sides of the dens to tubercles on the medial side of the occiptal condyle. ▸ ‘Check’ side-to-side movements of the head when it is turned. TRAUMA TRAUMA TRAUMA UPPER CERVICAL PARAMETERS OCCIPITAL CONDYLE FRACTURE ATLANTOOCCIPITAL DISSOCIATION ▸ 2% of all cervical fractures. ▸ Disruption of the cranial vertebral junction. ▸ Hypoglossal nerve injury. ▸ Subluxation or complete dislocation of occipto-atlantal facets. ▸ TYPE 1 – STABLE ▸ Mechanism poorly understood ▸ Severe flexion or distraction injury. ▸ Comminution of occipital condyle. ▸ Typically fatal. ▸ TYPE 2 – STABLE BC/OA >1 ANTERIOR SUBLUXATION ▸ Can be very difficult to diagnose. ▸ Basillar skull fracture with occipital condyle involvement. ▸ Calculation of Powers ratio ▸ Normal ratio = 1 ▸ TYPE 3 – UNSTABLE ▸ Ratio > 1 is suggestive of anterior dislocation. ▸ ALWAYS CONSIDERED UNSTABLE. ▸ Avulsion of alar ligament with tip of condyle ▸ Halo ineffective longterm, once patient stable then fusion. TRAUMA TRAUMA TRAUMA ATLAS (C1) FRACTURES JEFFERSON FRACTURE JEFFERSON FRACTURE ▸ Mechanism of injury is axial compression +/-extension force. ▸ C1 ring fracture classification – anatomical location and fragments. ▸ Diagnosed typically on plain radiography. ▸ Odontoid peg view ▸ STABLE ▸ Posterior Arch # ▸ First described in 1920. ▸ Widened predens space. ▸ Transverse process # ▸ Most common C1 fracture. ▸ Neurological deficits uncommon. ▸ Simple Lateral Mass # - STABLE ▸ UNSTABLE ▸ Anterior arch # ▸ Comminuted lateral mass # ▸ Three-Four Part Burst # (JEFFERSON) ▸ Usually bilateral breaks in ant/ post arches. ▸ Vertical compression/ axial load injury. ▸ Widened lateral masses of C1 on open-mouth odontoid view. ▸ Associated with: ▸ Fractures of C7 (25%) ▸ Fractures of C2 pedicle (15%) ▸ Extraspinal fractures (58%) TRAUMA C1 FRACTURE MANAGEMENT ▸ Isolated posterior arch or anterior arch ▸ Cervical Orthosis 8 weeks. ▸ Comminuted & Jefferson # ▸ If ADI>4mm or offset >7mm transverse ligament gone. ▸ If intact Orthosis. ▸ If gone traction, reduction and Halo Vest. ▸ Flexion Extension views at 3-4 months ▸ If signs of instability, then fusion TRAUMA TRAUMA ATLANTAXIAL ROTATORY SUBLUXATION INJURY? TRAUMA TRAUMA TRAUMA DISRUPTION OF THE TRANSVERSE LIGAMENT DISRUPTION OF THE TRANSVERSE LIGAMENT ODONTOID PEG FRACTURE ▸ CT scanning to categorise injury types ▸ Incidence: 6% of cervical spine fractures. ▸ Transverse Ligament (Primary) and Alar Ligament (Secondary). ▸ Flexion injury mechanism. ▸ Diagnosis on lateral radiographs ▸ Constraints to anterior displacement of C1 on C2. ▸ Can occur with atlas # or atlanto-axial subluxation. ▸ TYPE 1 – Disruption in substance of TL – ▸ Normal ADI < 3mm. ▸ If >4mm and dens intact – transverse ligament injury. ▸ Associated with atlas fractures (8%). ▸ C1/C2 arthrodesis. ▸ TYPE 2 – Avulsion # of insertion on lateral mass. ▸ Flexion Mechanism in majority of cases. ▸ 74% success rate with trial of rigid immobilisation TEXT TRAUMA TRAUMA ANDERSON D’ALONZO ODONTOID PEG FRACTURE INJURY? TRAUMA TRAUMA TRAUMA TRAUMATIC SPONDYLOLISTHESIS OF C2 / HANGMAN’S FRACTURE HANGMAN’S FRACTURE INJURY? ▸ Type I STABLE (5-8%) ▸ Avulsion of tip of odontoid ▸ ? – treat in orthosis. ▸ Type II UNSTABLE (54-67%) ▸ # through base of odontoid at junction with body of axis ▸ Complication: non-union, esp if >60yrs,displaced and angulated. ▸ Management – Immobilisation vs Anterior screw fixation. ▸ Type III RELATIVELY STABLE(30-33%) ▸ # through body of axis–Prognosis: good with high rate of union. ▸ Halo traction / Halo vest immobilisation. ▸ Described by Schneider in 1965. ▸ Usually through fall or RTA. ▸ type 1 - stable ▸ <3mm displaced no angulation ▸ type 2 - potentially unstable ▸ Neurological injury unusual ▸ High ratio of spinal canal diameter to cord diameter. ▸ Fracture line through neural arch. ▸ Stress concentrated through here. ▸ Classification scheme by Levine and Rhyne ▸ Based on anatomic factors and mechanism. ▸ >3mm displacement with angulation ▸ type 3 -unstable ▸ disc distraction injury ▸ type 4 - highly unstable ▸ facet fracture dislocation TRAUMA TRAUMA TRAUMA UNILATERAL FACET JOINT DISLOCATION INJURY? BILATERAL FACET DISLOCATION ▸ Distractive Flexion Injury. ▸ Distractive Flexion Injury. ▸ Diagnosis confirmed on plain radiographs ▸ Lateral: Anterior subluxation of one vertebrae by 25% at affected level. ▸ Anterior dislocation of one vertebral body by 50% on lateral view. ▸ Facet may be ‘perched’ or dislocated. ▸ UNSTABLE. ▸ Stable if anterior displacement on lateral less than ½ width of VB. ▸ 40% have a disc injury. ▸ Only 30% associated with neurologic defect. ▸ Neurologic deficits common ▸ Seen in up to 85% ▸ Treatment – Achieve anatomic alignment and restore stability. ▸ Closed reduction and immobilisation. ▸ Closed reduction and immobilisation is feasible. ▸ If not possible – then open reduction with fusion ▸ However early fusion recommended as high percentage of late instability. CES CES ▪ Two case presentations. ▪ Thirty-six year old female – Retail manager. th ▪ Private referral to physiotherapy – 25 June 2009. ▪ Back pain and left sided sciatica for 4-5 weeks. ▪ Discussion about Cauda Equina Syndrome. ▪ Associated numbness in leg and genitalia. ▪ ‘When I laugh and cough I wet myself’. ▪ Had attended A/E Dept at RBH twice over a two week period in the middle of June 2009. CAUDA EQUINA SYNDROME ▸ Reassured, analgesia, has a referral to Spinal clinic at end of August 2009. ▪ Patient self funds for MRI. CES CES CES ▪ Review by same physiotherapist (1st July 2009) – MRI results noted and faxed to GP, who planned to forward to surgeons. ▪ Urgent Left L5/S1 Microdiscectomy (10 July 2009) ▪ Then seen by different physiotherapist (9th July 2009). ▪ “Sensation in leg improving” th ▸ Large Disc Fragments removed ▪ Mobilising on ward independently ▪ Discussed with Mr. Mckenna ▸ review in clinic at RBH the following day. ▸ plan for admission and surgery. th ▪ Seen in clinic 27 July 2009 ▸ Persistent symptoms of incontinence, left leg pain and numbness. CES CES CES st ▪ Revision Decompression L5/S1 (1 August 2009). ▪ 30 year PhD student. ▪ Developed back pain and left sided sciatica in August 2009. ▪ Persistent numbness across left buttock /leg and perineal region. ▪ Episodic incontinence of bowel and bladder. ▪ Altered sexual function ▪ Referred to Professor Fowler at Queens’ Square, London ▸ To help manage residual neuro-urological symptoms. CES CES ▪ History as noted ▪ Seen in the spinal clinic on 13 November 2009. ▸ Positive left SLR, power of grade 4 for EHL. th ▸ Remains insensate but continent of urine. ▸ Numbness down left leg and left perineal/saddle region. ▸ Altered sexual function. ▸ Examination finding not really changed. ▪ Diagnosis of Cauda Equina Syndrome. ▪ Emergency MRI of Lumbar spine. ▪ Urgent spinal clinic review to be arranged. ▪ Surgical decompression of cauda equina within 4 hours of clinic review. CES TEXT ▪ No clear definition. ▪ Structure at the lower end of the spinal column of most vertebrates – resembles a horse’s tail. ▪ Complex of clinical symptoms and signs that results from the dysfunction of multiple sacral and lumbar nerve roots in the lumbar vertebral canal. ▪ Spinal cord stops development in infancy while the vertebral bones continue to grow. ▸ In adults spinal cord ends at L1/L2 vertebral level. ▪ Incidence of 1 in 33000 to 1 in 100 000. ▪ Term reserved when there is: ▪ GP refers the following day to A/E - ? Cauda Equina Syndrome ▸ Pain in leg continues but settling. ▸ Anal Tone = Normal ▪ Patient advised to monitor for urinary retention/incontinence. ▪ Wakes up that night with severe left leg pain, numbness around genitalia, insensate of urine. CES ▸ altered sensation : left L4, L5, and perineal area. ▪ Analgesic provisions. ▪ Late October 2009 – flare up of back and leg symptoms. th ▪ Consults Chiropractor on 5 November 2009. ▸ ‘No feeling or pleasure’. ▪ Examination ▪ Improved after 5-6 weeks with medical/conservative measures. ▪ At the base of the Cauda Equina there are approximately 10 nerve pairs ▸ Dysfunction of bladder, bowel or sexual dysfunction ▸ 5 Lumbar. 5 Sacral ▸ Perineal or ‘saddle’ anesthesia ▸ 1 Coccygeal CES CES CES CES ▪ Several theories postulated. ▪ Detrusor and Internal sphincter – Smooth Muscles ▪ Mechanical compression ▪ PARASYMPATHETIC – Via S2, S3, S4 ▸ Cauda equina nerve roots especially susceptible. ▸ Only have single protective layer – Endoneurium. ▸ Promotes emptying of bladder ▪ Ischaemia ▸ Contracts Detrusor and relaxes internal sphincter ▸ relative area of hypovascularity below level of conus ▪ SYMPATHETIC – Hypogastric plexus (T11-L3) ▸ Promotes storage of urine ▸ Relaxes Detrusor and contracts internal sphincter. ▪ Impaired nutrition of neural tissue. ▸ Both via blood supply and diffusion from surrounding CSF. ▪ ‘Closed compartment syndrome’ ▪ Unable to sense bladder as it fills up. ▪ Urinary Retention and Overflow incontinence ▸ Direct mechanical pressure causes intraneural oedema CES CES CES ▪ LUMBARDISCHERNIATION ▪ Tandon and Sankaran described three classical presentations: ▪ BLADDER/BOWEL/SEXUALDYSFUNCTION ▸ Massive central/paracentral ▸ Acutely ▪ PERIANAL/SADDLEANASTHESIA ▸ First symptom of lumbar disc prolapse (TYPE 1). ▸ Late sign of established CES and may indicate poor potential for recovery of normal bladder function. ▸ Endpoint of chronic back pain +/- sciatica (TYPE 2) ▪ Spinal stenosis ▸ Chronically ▪ Tumours ▸ Slow progression eventually leading to visceral impairment and urinary retention (TYPE 3). ▪ Trauma ▪ Infection ▪ Spinal epidural ▪ Spinal haematoma CES ▪ Neurological examination of lower limbs ▪ OTHERS: ▸ Back pain ▸ Sciatica ▪ Two clinical categories : ▸ CESR: Cauda Equina Syndrome with urinary Retention ▸ CESI: Cauda Equina Syndrome Incomplete with urinary retention. CES ▸ Sensory changes in lower limbs and overflow incontinence. ▸ Lower limb weakness symptoms other than ▪ Can be unilateral or bilateral. CES ▪ The need for urgent investigation is vital. ▸ Motor weakness ▸ Sensory deficit ▸ Hyporeflexia, Areflexia ▪ Magnetic Resonance Imaging (MRI). ▪ Remember it is a lower motor lesion. ▪ Perineal sensation – Light touch and pin prick ▪ Anal tone – Tone and voluntary contraction ▪ Bulbocavernous reflex ▪ CT Myelogram if contraindicated. CES CES ▪ Surgical exploration and decompression of any compressive lesions. CES Shapiro S (2000). Medicalrealitiesofcaudaequinasyndromesecondarytolumbardisc. Retrospective review of 44 cases with CES. ▸ Microdiscectomy ▸ Laminectomy Ahn UM et al (2000).Cauda equina syndrome secondary to lumbar disc ▸ Discectomy herniation: A meta-analysis of surgical outcomes. Todd N.V (2005).Cauda Equina Syndrome: timing of surgery probably does influence outcome Meta-analysis of 6 studies reporting the effect of early/late decompression upon the likelihood of recovery of bladder function. Largest meta-analysis of 322 patients with lumbar disc prolapse. ▪ Although the above decision is not questionable, great controversy surrounding overall management remains. ▪ Statistically significant difference in outcomes measures between patients decompressed < 48 hrs to those decompressed > 48 hrs. ▪ The optimal timing of surgery following the diagnosis of cauda equina remains a topic of great controversy. ▪ Repeat analysis by Kohles of Ahn’s meta-analysis showed that intervention less than 24hrs has significantly better outcome than between 24-48hrs. CES CES Qureshi A and Sell P (2007). Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcomes. Prospective longitudinal cohort study of 33 patients. Measures: ODI, VAS for leg/back pain and Incontinence Outcome questionnaire. ▪ Outcomes in patients continent and incontinent of urine at presentation. ▪ Gleave JW and Macfarlane R (2002). Cauda equina syndrome: what is the relationship between timing of surgery and outcome? ▪ Reiterate the need to distinguish between patients with CESR and CESI ▪ Patients treated <48 hrs of onset of are more likely to recover function than those treated beyond (p=0.005). CES ▪ What is a reasonable delay in performing investigation/surgery? ▪ Does it make a difference if it is CESI ? ▸ Improvement in Median VAS scores for leg (p =0.03) and back pain (0.002) ▸ Median score for impact of urological dysfunction on quality of life (p = 0.002), ▸ Satisfaction with current urological symptoms (p = 0.015). ▪ Bladder outcome almost always favourable in patients with CESI that undergo early decompressive surgery. ▪ No statistically significant difference in any of the outcomes measures comparing those that underwent decompression within 24 hrs, 24-48hrs and greater than 48hrs. ▪ However only 50% of patients with CESR will have acceptable bladder function. CES CES ▪ Persistent symptoms of cauda equina have a devastating impact on personal and social life. ▪ Relevant and thorough history. ▪ Major cause of litigation in spinal surgery. ▪ Complete Examination. ▪ NHS Litigation Authority dealt with 107 cases (1997-2006). ▪ Urgent Imaging. ▸ 35% of cases: primary complaint against emergency department. ▸ 52% of cases: primary complaint against inpatient management team. ▪ Should cauda equina syndrome surgical emergency? ▪ Liaise with spinal team early. ▪ Best medical practice is important. ▸ 52% of cases the responsible clinician was in orthopaedics. ▪ Medical Negligence reports will take into account delay in diagnosis and delay to treatment. ▪ Should this be done in the middle of the night? ▪ LACK OF PROOF OF BENEFIT DOES NOT NECESSARILY EQUATE TO PROOF OF LACK OF BENEFIT. DISC HERNIATION HERNIATION HERNIATION HERNIATION DISC HERNIATION WHICH NERVE? ASSESSMENT ▸ http://www.spine-health.com/video/herniated-disc-video ▸ Cervical ▸ History ▸ C5/6 foramen = C6 nerve ▸ exiting only - no traversing nerve ▸ Examination ▸ Lumbar ▸ L4/5 disc - L4 exits ▸ L5 nerve traverses ▸ Investigations HERNIATION RADICULOPATHY RADICULOPATHY CENTRAL DISC HERNIATION NATURAL HISTORY TREATMENT OF BRACHIALGIA: ▸ Cervical • Generally benign, self-limiting conditions. ▸ cervical myelopathy • Few long term sequelae. • Can be very painful and distressing . ▸ Lumbar • Danger of over treatment. • Treatment is a balance between close monitoring of clinical progress and appropriate intervention when required. • Conservative – analgesia and non-steroidals RADICULOPATHY RADICULOPATHY RADICULOPATHY CERVICAL RADICULOPATHY RCT - BMJ. 2009;339:B3883 CERVICAL “NERVE BLOCK” RESULTS OF CERVICAL NERVE BLOCKS 1.5 YEARS N=150 ▸ cauda equina syndrome • Kuijper 250 patients randomised between treatment and no treatment. • Collar 1 or more blocks – 48% better • Short term benefits in treatment group – collar or physio. compared to non-treatment group . • All improved by 6 months – No difference • Physiotherapy Less than 20% needed operations – usually cervical disc replacement. Foraminal injections Steroids and L.A. – x-ray guided. Injection complications – None. Dabasia H and Ramos-Galvez I 2010. RADICULOPATHY RADICULOPATHY RADICULOPATHY CERVICAL DISC HERNIATION SURGICAL TREATMENT OPTIONS ACDF PLATE AND BONE GRAFT • Anterior Cervical Decompression +/- Fusion Size of disc hernia does not correlate with the need for treatment. RADICULOPATHY C5-6 PRESTIGE DISC REPLACEMENT RADICULOPATHY PRESERVATION OF MOVEMENT RADICULOPATHY FDA RCT PRODISC C VS. FUSION • Disc replacement equal or superior to fusion at 2 years. • Similar results for Bryan Disc. • Medtronic Prestige Disc studied . RADICULOPATHY RADICULOPATHY RADICULOPATHY BUT REMEMBER ACD ALONE WORKS POSTERIOR CERVICAL FORAMINOTOMY LUMBAR DISC HERNIATION • Common • Previous RCT showed ACD gave equivalent results to ACDF and had fewer complications. (White et al.) • Posterior surgery reported as successful • Benign course usual – 80-90% settling rapidly. • Minimally invasive techniques. Try nerve blocks or epidurals in refractory cases. • potential for pain and instability (Evidence of temporary benefit). • More proof and comparison with TDR needed. long term results of arthroplasty and meta-analysis suggests superior outcomes with arthroplasty over ACDF Operate when pain persists or when there is deteriorating neurology. RADICULOPATHY RADICULOPATHY TEXT LUMBAR FORAMINAL INJECTION RESULTS OF LUMBAR ROOT BLOCKS N=107, 1YEAR EVIDENCE FOR DISCECTOMY • Lumbar disc prolapse – 64% better 26% ops. • Weber – Surgery better at 1 and 4 years . • Spinal stenosis – 60% better 25% ops. • Far lateral disc – 54% better 46% ops. • Lytic spondylo. - 50% better. 50% ops. • Recurrent disc - 23% better! 61% ops. No difference at 10 years. SPORT trial Weinstein et al Spine 2008 – Surgical treatment improved all outcomes except return to work – Results at 4 years. Peul et al. BMJ – 2008 – Surgery provided more rapid relief but 1 and 2 year outcome similar. Surgery cost effective. RADICULOPATHY STENOSIS MICRODISCECTOMY SPINAL STENOSIS ▸ Presentation ▸ History ▸ Examination ▸ Investigations SPINAL STENOSIS STENOSIS STENOSIS STENOSIS SPINAL STENOSIS SPINAL STENOSIS MRI SPINAL STENOSIS SPORT STUDY • Spine June 2010 Weinstein et al. • Multicentre randomised n = 654 • Operated patients had better function and less pain sustained at 4 years. STENOSIS STENOSIS STENOSIS LAMINECTOMY, LAMINOTOMY OR MICRODECOMPRESSION L4-5 DEGENERATIVE SPONDYLOLISTHESIS THE JOURNAL OF BONE AND JOINT SURGERY (AMERICAN). 2009;91:1295-1304 Surgical Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis Four-Year Results in the Spine Patient Outcomes Research Trial (SPORT) Randomized and Observational Cohorts James N. Weinstein et al. STENOSIS Conclusions: Compared with patients who are treated nonoperatively, patients in whom degenerative spondylolisthesis and associated spinal stenosis are treated surgically maintain substantially greater pain relief and improvement in function for four years STENOSIS STENOSIS PROSPECTIVE TRIAL RESULTS (HERKOWITZ) Excel Good Fair Poor Herkowitz and Kurz JBJS 73-A 1991: 802-808. • 50 patients stenosis and spondylolisthesis. • 63-65Yrs. Laminectomy : 2 9 But : Pseudarthrosis in 36% Did not affect result. 2 • L4/5 in 41, L3/4 in 9. • F.U. 3 years. Fusion & Lam. : 11 13 • 25 laminectomy / 25 laminectomy & fusion. STENOSIS 12 STENOSIS STENOSIS INSTRUMENTED FUSION L4-5 INSTRUMENTED FUSION • Fischgrund et al. (Herkowitz II) Spine 1997 2807-2812. • RCT in 76 patients. • Inter-transverse fusion v Pedicle screws. • Pedicle screws – 76% success – 82% fused. • Inter-transverse- 82% success – 45% fused. • No benefit from higher fusion rate. 1 0 STENOSIS STENOSIS FORAMINAL STENOSIS – LYTIC SPONDYLOLISTHESIS LATERAL INTERBODY FUSION TEXT ▸ TLIF TEXT TEXT TEXT TEXT TEXT TEXT TEXT TEXT TEXT TEXT TEXT TEXT TEXT TEXT PERFECTION! STENOSIS SCOLIOSIS CONCLUSIONS CLASSIFICATION ▸ Congenital ▸ failure of formation or segmentation ▸ Idiopathic • Conservative treatment appropriate initially ▸ infantile, juvenile, adolescent ▸ Neuromuscular • Operations are effective when required. • Monitor clinical progress carefully. SCOLIOSIS ▸ myopathic, neuropathic ▸ Others ▸ NF, trauma, tumour, marfan ▸ Degenerative SCOLIOSIS SCOLIOSIS SCOLIOSIS SCOLIOSIS CLINICAL FEATURES ADAM’S TEST ▸ abnormal lateral curvature >10 degrees ▸ obvious deformity ▸ bend forward ▸ rib hump ▸ scoliometer ▸ vertebral rotation ▸ asymmetry of hips ▸ skin pigmentation ▸ angle of true rotation ▸ congenital abnormalities ▸ scapular level ▸ lower limb length ▸ cardiopulmonary function SCOLIOSIS SCOLIOSIS IDIOPATHIC SCOLIOSIS TREATMENT ▸ 80% of all scoliosis ▸ Bracing ▸ no identifiable cause ▸ Surgical correction using rods and pedicle screws ▸ infantile/juvenile/ adolescent ▸ VEPTR ▸ Magic rods ▸ early / late onset ▸ puberty or lung development ADULT DEFORMITY
