B3 L39: Common Spinal Surgeries and Fractures Flashcards
1
Q
What are 3 decompressive surgeries?
A
- Micro-discectomy
- Discectomy (Disc prolapse)
- Laminectomy (Spinal Stenosis)
2
Q
What are 3 elective surgeries?
A
- Decompression Surgery
- Fusion Surgery
- Corrective Surgery –Scoliosis Surgery
3
Q
What are 4 types of traumatic vertebral fractures?
A
- Flexion injury - crush fracture
- Vertical compression - burst fracture
- Flexion + rotation - fracture-dislocation
- Hyperextension - vertebral arch fracture
4
Q
What are the 3 functions of the vertebral disc?
A
- Absorbs compressive forces through the spine
- Allows movement of vertebral bodies on each other
- Prevents wear of the vertebral endplate
5
Q
What are 4 indications for considering surgery on a prolapsed disc?
A
- No improvement with conservative therapy
- An increase in neurological deficit
- Bladder and bowel symptoms suggesting Cauda Equina lesion
- Intractable pain
6
Q
What are 2 indications for disc surgery?
A
- Patients with radiating pain who do not respond to conservative treatment
- Have objective findings consistent with lumbar disc herniation may be considered for elective surgery.
7
Q
What are 3 objective signs for disc surgery?
A
- neurological and neural tension signs
- personality factors
- results of diagnostic tests such as CT Scans, MRI Scans
8
Q
What is a discectomy?
A
Often done in conjunction with partial laminectomy (removal of lamina- get to disc).
Disc excision relieves pain in about 75% of appropriate patients smaller spinal surgery
9
Q
With a discectomy, there are lower rate of return of the physical signs of _____ or loss of _____.
A
weakness; reflexes
10
Q
What is a microdiscectomy?
A
Disc is excised through small incisions under endoscopic control.
11
Q
Why is there a shorter recovery period for a microdisectomy?
A
The recovery period is shorter and surgical trauma minimised (less soft tissue disruption less pain post-op)
12
Q
Why is it important to be aware of patient position 9eg. prone) when in longer spinal surgeries?
A
Close attention for pressure areas (need to be padded if long surgery)
13
Q
Why discectomies seem to be small spinal surgeries, they still have relatively _______ (long/short) recovery periods. In fact, it takes about _______ months to get back to original and full function.
A
long; 8-9 months
14
Q
With age, what happens to the IV disc? List 2 changes and what that causes?
A
With age the IV disc loses
- fluid content
- height
Can bulge into the canal
15
Q
Spinal facet joints can _____ (becomes thin/thicken and enlarge with arthritis and can bulge into the ____.
A
thicken; canal
16
Q
What is spinal stenosis?
A
lead to narrowing of the canal
(With age the IV disc loses fluid content and height and can bulge into the canal)
17
Q
Stenosis can affect the ____ or ______.
A
lateral foramen; central canal
18
Q
Where are 2 places that stenosis can affect?
A
- lateral foramen
- central canal
19
Q
What does the process of disc degeneration look like?
A
20
Q
What are 4 symptoms of lumbar stenosis?
A
- Lower back pain
- Pins and needles or numbness in the legs (neurogenic claudication)
- Cramping in the legs (associated with certain walking distance)
- Leg weakness
21
Q
What is a technique to relive some lumbar stenosis symptoms such as cramping in the legs (associated with certain walking distance)?
A
if forward flex- able to decompress force on spinal cord- able to walk more (relive symptoms) (eg. walk with walker, trolley)
22
Q
What is a laminectomy?
A
Involves removal of piece of lamina to decrease the pressure on the spinal cord or nerve root (spinous process and lamina removed –> decrease pressure –> relieve symptoms )
23
Q
How does having multiple laminectomies affect the vertebrae? Are there any effects of laminectomies on one spinal level?
A
have problems with stability with multiple levels
no stability problems with one level
24
Q
What are 6 complications of decompression surgery?
A
- Neural tissue damage
- Infection in disc space
- error in diagnosis
- RSD (CRPS)
- wound infection
- pulmonary complications.
25
What are 2 complications of micro discectomy? How does that affect post-operatively?
1. inadequate decompression
2. dural tearing
longer period resting in bed symptoms
cracking headache in sitting (CFS leak)
26
What are 8 Post Operative Management Discectomy and/or Laminectomy?
1. Circulo-Respiratory Exercises commenced Day 0
2. Neurological checks daily if indicated (normal feeling at cheek or forehead- becomes baseline)
3. Log Roll for comfort only (no physiological reason- no structural loss)
4. Day 0- 1 exercises - Neural mobilisations, Transversus and Multifidus Activation
5. SOOB as pain allows (regular changes in position (equal time in sitting, lying and standing)
6. Mobilise Day 0-1 on Drs orders, initially on rollator and progress quickly to single stick or independently on stairs.
7. Back education and ergonomic advice
8. OPD referral for muscle stability, neural mobilisation progression
27
What are 5 criteria for discharge for a Discectomy and/or Laminectomy?
1. Independently mobile on stairs
2. Independent with HEP
3. Aim for D/C often Day 0 or 1 for discectomy and laminectomy will vary depending on number of levels
4. Outpatient appointment considered (usually 2 weeks) to progress exercises
5. Referral letter required
28
What are 3 main indications for spinal fusion surgery?
1. Instability - Segmental instability secondary to spinal degeneration, degenerative disc disease, traumatic unstable (trauma--\> fracture --\> instability) fractures, fracture dislocations and spondylolistheses
2. Congenital or acquired or deformity - scoliosis, kyphosis, kyphoscoliosis and spondylolisthesis
3. Other conditions may Osteomyelitis (infections), TB, primary or secondary neoplasms (cancer)
29
What are 2 examples of Fusion Techniques?
1. Posterior Lumbar Fusion (example diagram) 3
2. Anterior Lumbar Interbody Fusion
30
What are the functions/purpose of TED stocks? What will they help to avoid?
TED stockings- increase venous return (keep circulation moving) Eg. avoid DVT
31
Bone Grafts are used in conjunction with _____ type procedure
fusion
32
How are bone grafts done?
Involves inter-transverse arthrodesis and is indicated for many primary fusion procedures in the lumbo-sacral spine
33
What are the 2 bones areas that are suitable for bone grafts to be done?
1. Spinous processes
2. Iliac crests
34
Why are iliac crests suitable for bone grafts to be done on?
* has a good axis, not a lot of structures around
* is tri-cortical
35
Corticocancellous and cancellous bone graft from the\_\_\_\_\_\_ are firmly packed into the area bridging decorticated surfaces between levels
illiac crests
36
What are the 3 disadvantages of bone graft alone described by Krag?
1. Bone graft unable to correct spinal deformity
2. No early control of motion
3. Pseudoarthrosis occurs with unacceptable frequency.
37
What do disadvantages of bone graft lead to?
to the evolution of internal fixation devices for lumbar and lumbo-sacral spinal fusion
38
What are 4 forms of bone grafting with a posterior lumbar fusion?
1. autogenous bone chips
2. autogenous bone block
3. bone or composite allografts, o
4. a combination of these procedures
39
What are 9 complications with bone grafts?
1. Blood loss
2. epidural bleeding
3. end plate bleeding
4. neural bleeding
5. intra abdominal vessel injury
6. graft repulsion
7. pseudoarthresis
8. instability
9. infection
40
What occurs in a posterior lumbar fusion? How is it done?
* disc removed
* cage replaced disc space --\> pack bone graft into cage
* posterior pedicle screws into pedicles of spine connected with rods - keeps spine stable
41
What occurs in an anterior lumbar fusion?
* Replaced discs P
* lacement of bone graft or bone graft with an anterior interbody cage within the disc space
* Through the abdomen into the disc space
42
What are 4 indications for an anterior lumbar fusion?
1. Symptomatic post traumatic kyphosis with or without neurological sequelae
2. Painful lumbar spine degenerative scoliosis with disc disease
3. Repair of failed posterior fusion technique
4. High grade spondylolisthesis
43
An anterior lumbar interbody fusion is a newer surgical technique that involves the placement of bone graft or bone graft with an anterior interbody cage within the \_\_\_\_\_. The most efficient way to place this is through the _____ into the disc space. Most commonly, persons who have undergone this fusion are able to return to their activities much _______ (more/less) rapidly
disc space; abdomen; more
44
What is the plating technique?
Vertebral bodies plated together with screws.
45
What is the disadvantage of the plating technique?
screws can become loose and back out
46
Why is the anterior lumbar fusion more sturdy than the posterior lumbar fusion?
* Cage is more stable that posterior- doesn't have mental at back- needs to be sturdier
* Pack with bone graft for fusion process
47
When is bracing required? When is it not?
Bone grafting alone requires bracing by way of hip spica or TLSO, whereas IF may or may not require bracing depending on the stability gained by the procedure
48
What are 8 post operative management techniques of a lumbar fusion?
1. Circulo Respiratory maintenance commenced day 0
2. Daily neurological checks
3. May not tolerate sitting for long periods
4. Log Roll
5. Exercises to commence day 1 including UL and LL
6. ROM exercises, neural mobilisation exercises
7. Multifidus and Transversus activation
8. Mobility commencing Day 1-2
49
What are the 4 criteria for discharge post lumbar fusion surgery?
1. Independently mobile on stairs
2. Independent with HEP
3. Aim for D/C approx Day 2-3. Out Patient appointment arranged (usually 2 weeks) to progress exercises.
4. Referral letter required
50
What are the main complications of the lumbar fusion surgery apart from generic risks of surgery and risk of neural damage? What can this lead to?
The fusion of one or more spinal levels can lead to the transfer of abnormal stresses at the spinal levels directly above and below those being fused.
This can lead to instability and associated symptoms at these levels
51
What is a current/future trend for treatment?
Artificial Disc Replacement
52
What are 3 factors which must be considered in the design and implantation of an effective disc prosthesis?
The device must:
1. maintain the proper intervertebral spacing
2. allow for motion
3. provide stability.
53
Placement of the artificial disc must be done in such a way as to avoid the destruction of important spinal elements such as the _____ and \_\_\_\_
facets; ligaments
54
An artificial disc must exhibit tremendous \_\_\_\_\_\_. It has been estimated that over the \_\_\_\_\_–year life expectancy of the artificial disc, there would be over 106 million cycles of strides or bends.
endurance; 50
55
Scoliosis surgery is a type of _____ surgery.
corrective
56
What is scoliosis?
a lateral or sideways curve in the spine that is apparent when viewing the spine from behind
57
Is scoliosis common?
Commonly occurring (up to 50% of the population) and generally does not require any treatment
58
Is scoliosis functionally or structurally caused?
Cause unknown although more common in females (~90%), and strong familial trends
59
What are 5 types of scoliotic or kyphotic deformity?
1. postural
2. ideopathic
3. osteopathic
4. neuropathic or
5. myopathic.
60
Which is the most common type of scolioses?
idiopathic
61
What are 3 factors that treatment depends on?
1. degree of deformity (The curve is often referred to as the Cobb Angle)
2. curve progression
3. functional disability (Sig Resp compromise with curves \>60°).
62
What is the management of scoliosis with a cobb angle (curve) of \<15 degrees?
No treatment indicated although advice on exercise, muscle strengthening, posture, ergonomics and ? strapping may be useful
63
What is the management of scoliosis with a cobb angle (curve) of 15-30 degrees?
* Bracing shown to be effective in stopping the progression of the curve in 80% patients until skeletal maturity.
* Definite inconvenience to patient as need to be worn 23 hours / day and need to be weaned over long period of time
64
What is the management of scoliosis with a cobb angle (curve) of \>30-40 degrees?
Surgery
65
What is the problem with bracing?
very effective- but is very hard for patients to comply (esp. for 23hrs a day- which is ideal)
66
What are the 3 types of braces for scoliosis?
1. Milwaukee Brace (diagrams top)
2. Boston Brace (diagram middle)
3. TLSO - Thoracic-lumbarsacral orthosis (diagram bottom)
67
What is the function of the brace?
keep the curve from progressing as a child grows
68
When is a Harrington Rod System used?
large curve:
* impacting function
* progressive rate
69
What is the Harrington Rod System?
‘ratcheted rod and hook’ system involving hooks fixated to posterior elements with correcting forces adjusted by movements on a threaded rod. Progressed to combinations of compression and distraction hooks
70
The Harrington Rod System was previously the ‘\_\_\_\_\_\_\_’ for comparison of instrumentation systems - tending to be now outdated
Gold Standard
71
What are the 2 shortcomings of the Harrington Rod System?
1. Lack of rotational stability
2. loosening of hooks
72
What is the disadvantage post operatively for the Harrington Rod System?
Immobilisation on a cast or brace has been recommended for 3-6 months whilst bone fusion solidifies
73
What is the Luque System?
Developed smooth rods configured into different shapes and fixed segmentally with sublaminar wires, providing immediate stability and decreasing the need for post-operative bracing
74
How is the Luque System different from the Harrington Rod System?
H: 1953
L: 1970’s
Worked with poor patients who had travelled long distances making follow-up difficult and post-operative bracing (necessary with the Harrington system) impossible.
75
What is the shortcoming of the Luque System?
Lack of axial stability and neurological complications due to need to thread the wires through the vertebrae and close to the spinal cord
76
What are the 4 systems developed to overcome the shortcomings of the Harrington Rod and Luque systems?
1. Cotrel-Dubousset
2. Dwyer System
3. Zielke System
4. Wisconsin System
77
What is the Cotrel-Dubousset system?
* Incorporates dual rods with hooks distributed along the rods at various sites to achieve segmental stablisation
* Cross linking of rods offers improved rotational stability in axial plane
* The system permits distraction, compression or rotation between the hook sites and emphasizes correcting the scoliotic deformity by de-rotation whilst maintaining normal sagittal contours of the spine.
* Postoperatively - no need for bracing in adolescents but bracing may be indicated for adults with Tx or Lx corrections or double curves
78
What is the Dwyer System?
* Approach is transthoracic on the convex side.
* Discs are removed, staples and screws driven into the vertebral bodies and a Dwyer cable inserted
79
What is the Zielke System?
Modification of Dwyer instrumentation involving thoracolumbar approach, rib dissection, anterior discectomy, and stablisation using threaded rods, screws and bone grafting
80
What is the Wisconsin System?
Includes a square-ended distracted rod on the concave side of the spinous processes and a C-shaped Luque rod on the convex side attached by segmental wires through the bases of the spinous processes
81
What are the 4 Post Operative Presentations after scoliosis surgery?
1. Usually post-operative immobilisation of the spine. This may involve a cast or a Thoraco Lumbo Sacro Orthosis (TLSO).
2. Such an orthosis is worn for 23 hours a day and removed only for hygiene.
3. The indication for these external fixation devices depends factors such as operative technique, stability of fixation and osteopenia.
4. Patient will present supine with bed flat with adequate analgesia
82
Such an orthosis is worn for \_\_\_\_\_\_\_hours a day and removed only for hygiene
23
83
What are 3 indicators for the use of external fixation devices post-scoliosis surgery?
1. operative technique
2. stability of fixation
3. osteopenia.
84
After a scoliosis surgery, patient will present _____ (prone/supine/sidelye) with bed flat with adequate analgesia
supine
85
What are 2 ways that scoliosis surgery can be done?
1. One stage (most common)
2. Two stage (for more severe curves)
86
For a patient with severe scoliosis curve, describe the 4 steps for surgery?
1. one stage
2. rest in bed (immobilise)
3. two stage
4. mobilise (have problems with balance)
87
\_\_\_\_\_ education is very important with these patients with severe scoliosis and undergo surgery.
Back Care
88
What are the 4 features of the One stage scoliosis surgery?
1. Immediate commencement of Circulo-Respiratory exercises, with chest care very important due to possible pre-operative respiratory compromise and post-operative altered thoracic biomechanics. Cough may painful therefore support needed.
2. Log Roll
3. Exercises commenced Day 1: UL and LL ROM exercises (avoid pelvic tilt if unstable), Neural Mobility exercises, and Transversus/Multifidus activation. No SLR.
4. Mobilise Day 1-2 on Drs orders with or without bracing. Initially with rollator and progressing quickly to stick and independence as able. Patient may initially have dizziness due to significant blood loss and low Hb, and may have unsteadiness due to altered biomechanics.
89
What is the 2 features of the one stage, 2 features of the second stage in the two stage scoliosis surgery?
Stage One:
1. Thoracotomy incision
2. Anterior discectomy and release of soft tissue +/- bone graft
* Circulo-Respiratory maintenance
* Strict RIB and Log Roll
* No SLR
* Hip/Knee Flexion initially to pelvic tilt progressing to within pain
Stage Two:
1. Insertion of instrumentation 5-7 days later
2. Management then as per one stage operation.
90
What are 3 criteria for discharge post one and/or two stage scoliosis surgery?
1. Independently mobile on stairs
2. Independent with HEP
3. Outpatient appointment arranged (usually 2 weeks) to progress exercises
91
What is the aim of neural exercises post operatively?
relieve pain an symptoms and arising from the surgery and limit scarring in intraneural and extraneural tissues
92
What are the 3 treatment regime to follow post scoliosis surgery?
1. Stage 1 – Large through range Dorsiflexion and Plantarflexion. Hip abduction and adduction, hip rotations in neutral. Progress to PF/DF in small amount of SLR (eg on pillow)
2. Stage 2 – Through range knee extension in some degree of hip flexion. Some patients may tolerate gentle SLR
3. Step 3 – Techniques continued and progressed in increasing amounts of hip flexion
93
The prevention and management of complications associated with fractures applies equally well to ____ fractures as it does to limb fractures. Complications however such as _____ or _______ can potentially be ________ and lead to long term \_\_\_\_\_\_\_.
spinal; neurological impairment; visceral damage; life threatening; disability
94
What is one important factor which which influences the management of spinal fractures?
Whether the fracture is stable or unstable
95
What is vertebral stability?
Ability of spine to withstand load without pain, neurological damage or deformity
96
Unstable fractures carry a ____ (greater/smaller) risk of ______ complications either at the time of injury or at a later stage (not just a point in time- over a period of healing as well (eg. even after 6 weeks- need to remain stable))
neuro
97
50% of vertebral fractures are ______ and \_\_\_\_\_\_\_. In fact, 10% of ___ fractures have another vertebral fracture.
cervical; thoracolumbar; cervical
98
What are 3 mechanisms of injury for a traumatic vertebral fracture?
1. MVA/ MBA (motor vehicle/bicycle accident)
2. Falls (elderly patients)
3. Surf injuries (dive into surf/creek)
99
What are 4 different types of vertebral fractures due to the mechanism of injury?
1. Flexion injury - crush fracture. Stable fractures in the majority of cases but can be unstable if greater than 1/3 loss of vertebral height
2. Vertical compression - burst fracture. Likely to be stable unless greater than 1/3 vertebral height is lost.
3. Flexion + rotation - fracture/dislocation. These injuries are normally highly unstable (high degree of instability with MVA (rolling of vehicle))
4. Hyperextension - vertebral arch fracture. Likely to be unstable if the neural arch has been fractured
100
What is a flexion injury?
crush fracture.
Stable fractures in the majority of cases but can be unstable if greater than 1/3 loss of vertebral height
101
What is a vertical compression vertebral injury?
burst fracture.
Likely to be stable unless greater than 1/3 vertebral height is lost
102
What is a flexion + rotation vertebral injury?
fracture/dislocation.
These injuries are normally highly unstable
103
What is hyperextension vertebral injury?
vertebral arch fracture.
Likely to be unstable if the neural arch has been fractured
104
What are 2 features of the C1-2 (cervical spine) area?
1. Neural arch
2. Odontoid peg (Dens #)
105
What are 5 features of the C3-7 (Spinal cord greater % of canal) (cervical spine) area?
1. anterior wedge fracture (uncommon but stable)
2. burst fracture (+/-HI, stable if \<1/3 loss of ht)
3. hyperextension (stable in neutral, ALL rupture, oedema may lead to central cord lesion)
4. dislocation & no fracture (unstable with neurological damage)
5. fracture dislocation (extremely unstable, usually cord damage)
106
With a stable cervical vertebral fracture, what is the medical management? Why?
Collar (6/52)
Allow fracture to heal usually use soft collars- avoid pressure (soft tissue) injuries
107
With a stable cervical vertebral fracture, what are 4 physiotherapy management techniques?
1. Systems assessment & maintenance (esp neurological) After 2/7 include hip/knee F to pelvic tilt, bilateral arm exercise (pain limited)
2. Log roll
3. Progress mobility from rollator to pre-morbid level
108
With an unstable cervical vertebral fracture, what is the medical management? Why?
* Skull tongs (skeletal traction) or surgical stabilisation (ORIF+bone graft) +/- Halo-thoracic brace
* Engrit bed or rotabed (pressure area prevention)
109
With an unstable cervical vertebral fracture, what are 3 physiotherapy management techniques?
1. Systems assessment & maintenance (esp neurological)
2. Chest maintenance and or treatment
3. Education
110
What are 3 complications with an unstable cervical vertebral fracture?
1. neurological (after the injury)
2. circulo-respiratory " pressure areas (occiput)
3. infection (post op or at skull tong site)
4. postural hypotension on mobilising, a tilt table may be used once spine has been stabilised
111
How does a Halothoracic vest (Halo) work?
* Immobilises cervical spine
* Pins screwed a few millimetres into skull (screws into the skull (don't screw too far- has a special machine- based on tension to how far to screw))
* Impacts on balance and gait
* Log rolling for in/ out bed
112
What does a misaligned spine look like on an x-ray?
113
What does a corrected- misaligned spine look like on an x-ray?
114
What is the treatment for an unstable thoracolumbar fracture?
commonly associated with paraplegia (ORIF) Usually high energy trauma
115
How is an unstable thoracolumbar fracture caused/mechanism of injury?
flexion results in vertebral body crush fracture, may be pathological (Usually high energy trauma)
116
Thoracolumbar fractures are often stable or unstable?
stable
117
What should be done about the stability of a spine with a thoracolumbar fracture?
Relative rest until pain subsides +/- O Brace (3 pt extension brace)
118
What is the problem with vertebral fractures and their msalignment?
- surgery can fix structural problem (misalignment) - can't fix damage misalignment has done to spinal cord
119
What is the treatment for an unstable lumbar fracture? Why?
risk of paraplegia (ORIF)
120
What is the physiotherapy intervention of a lumbar spine fracture?
* Systems assessment and maintenance (pain Mx)
* Regular neurological assessments
* Log roll (avoid rotation/Flexion)
* Mobilise with aid as required
121
What are 5 important tasks to do to test neurological assessment after a vertebral fracture?
1. Establish baseline of normal sensation
2. Light touch sensation " Sharp/blunt sensation
3. Muscle power within restrictions of fracture stability
4. No resistance in unstable spine due to risk of overflow
5. Reflexes
