Back Conditions Flashcards
Subtopics: approach- back pain, approach: inflammatory conditions of the spine; approach: degenerative spine deformities
SPINAL DEFORMITIES AND DEGENERATION
Spinal deformities occur in either the sagittal or coronal plane. Define both:
- Coronal plane imbalance
- Sagittal plane imbalance
Coronal plane imbalance
- Lateral deviation of the normal vertical line > 10 degrees
Sagittal plane imbalance
- Radiographic sagittal imbalance of > 5 cm
SPINAL DEFORMITIES AND DEGENERATION
T/F The patients who typically present with spinal deformities/ imbalances are patients in the 60s, more so in females
False
Male= female, 60s .
SPINAL DEFORMITIES AND DEGENERATION
Locate idiopathic scoliosis vs degenerative scoliosis
SPINAL DEFORMITIES AND DEGENERATION
Idiopathic scoliosis = thoracic spine
Degenerative scoliosis = lumbar spine
SPINAL DEFORMITIES AND DEGENERATION
- Describe the pathoanatomy of degenerative scoliosis
- List 4 conditions that may contribute to loss of sagittal plane balance.
Degenerative scoliosis results from the asymmetric degeneration in joint space and/or facet joints in the spine.
- OA
- Pre-existing scoliosis
- Iatrogenic instability
- Degenerative disk disease ( group of conditions in which disk material is displaced into the spinal canal»_space; protrusion/ herniation/ sequestration)
SPINAL DEFORMITIES AND DEGENERATION
True or false: Worse prognosis in spinal instability is seen in the following patients:
- Depleted ability to compensate (e.g. retroverted pelvis and obliterated lumbar lordosis)
- Obliquity as L/S junction
- Severely positive sagittal balance
True
SPINAL DEFORMITIES AND DEGENERATION
Progression of spinal deformities depend on the curve magnitude and additional risk factors. Elaborate on these.
Curve magnitude
- Curve < 30 degrees»_space; rarely progresses
- Curve > 50 degrees»_space; likely to progress.
Risk factors
- Pre-existing rotational changes
- Intercrestal line below L4-5
SPINAL DEFORMITIES AND DEGENERATION
List 5 types of spinal deformities
- Idiopathic (residual, d/t untreated adolescent idiopathic scoliosis)
- Degenerative (de novo, d/t degeneration)
- Post-traumatic
- Iatrogenic
- Paralysis
SPINAL DEFORMITIES AND DEGENERATION
List and explain the 3 main symptoms these patients present with.
- Low back pain (most common)
- Caused by spondylosis OR micro/macro instability OR discogenic pain.
- More severe than the general population. - Neurogenic claudication
- Pain in lower extremities and buttock not relieved by sitting/ forward flexion. Caused by spinal stenosis on the concave side of the curve. - Radicular leg pain and weakness.
- Caused by foraminal and lateral recess stenosis. Worse in concavity of the deformity where there is vertebral body rotation/ translation.
SPINAL DEFORMITIES AND DEGENERATION
List 3 main findings on physical exam
- Deformity
- Rigidity
- Radiculopathy on neurological exam
SPINAL DEFORMITIES AND DEGENERATION
List and account for imaging modalities needed in spinal instability.
- Whole spine AP + lat and bending x-ray
- CT scan
- CT myelogram
- MRI (if lower extremity pain and possible nerve compression )
- Dexa scan - to identify bone density for surgical planning
SPINAL DEFORMITIES AND DEGENERATION
Treatment: non-operative
- What is the indication of non-operative Mx?
- List and elaborate on the 4 non-operative modalities of managing spinal deformities.
- Indicated in coronal curves of < 30 degrees (less likely to progress)
Management:
1. Oral medications - NSAIDS, Amitriptylline
2. Physiotherapy- core strengthening
3. Corticosteroid injections and nerve root blocks - therapeutic and diagnostic
4. Bracing - slows down progression, and increases comfort.
SPINAL DEFORMITIES AND DEGENERATION
Surgical correction has a very high complication rate and includes surgical curve correction with instrumented fusion. List 5 indications for surgery
- Coronal curves > 50 degrees
- Sagittal imbalance
- Curve progression
- Intractable pain or radicular pain that failed nonoperative Mx
- Cardiopulmonary decline
SPINAL DEFORMITIES AND DEGENERATION
The goals of surgery are to restore spinal balance. Sagittal plane balance is the most reliable predictor of clinical symptoms post-op. Surgery aims to relieve pain and obtain fusion.
List 6 complications of spinal surgery in these patients.
- Thromboembolism
- Pseudoarthrosis (most common)
3.Infection - UTI commonest - Neurologic compromise
Pulmonary embolism - Instrumentation problems e.g. loosening or breakage
SPINAL DEFORMITIES AND DEGENERATION
- What is pseudo-arthrosis
- List 4 risk factors
- Def: A condition where a fracture fails to heal and forms a fibrous joint instead (pseudo-arthrosis)
- Age > 55
- Smoker
- Kyphosis and positive sagittal balance > 5cm
- Hip arthritis
OSSIFICATION POSTERIOR LONGITUDINAL LIGAMENT
- This is a cause of cervical myelopathy in which patients?
- The cause is not clear but there are some associated risk factors, list 5.
- Common in Asians (2-3% of the Japanese population), mostly in men in their 50s-60s.
Risk factors:
- Diabetes
- High salt, low meat, low calcium content in diet.
- Obesity.
- Mechanical stress
OSSIFICATION POSTERIOR LONGITUDINAL LIGAMENT
- These patients are often asymptomatic but may have signs or symptoms of myelopathy (as a result of spinal cord compression). List 5 signs.
- What 3 imaging can be used to make the diagnosis?
Cervical myelopathy signs:
1. Unsteady gait
2. Clumsy
3. + Babinski
4. Sustained clonus
6. + Hoffmann sign
7. Brisk reflexes.
Imaging: X-ray: shows ossification of posterior ligament.
CT: look at bony anatomy
MRI: evaluate spinal cord
OSSIFICATION POSTERIOR LONGITUDINAL LIGAMENT
- What are the complications of OPLL?
- Describe the treatment of OPLL
Complications:
1. Recurrence post-surgery
2. Permanent SCI
Treatment:
- Mild sx/sx: observe
- Surgery to decompress the spinal cord and stabilize the spine
RHEUMATOID CERVICAL SPONDYLITIS
Fill in the blanks
RA is an auto-immune disease that affects the (1) ______ joints in 1-3% of the population.
The duration is (2)_____, the pattern is (3)______ and although it commonly affects small joints, it can also affect large joints.
If mostly affects (4)______ (gender) at the ages of (5) _______.
Describe the typical RA X-ray, serology and histology
- synovial
- chronic
- symmetric polyarthritis affecting PIPs, MCPs, wrist
- females
- 40-50 yo
Xray: erosions (marginal)
Serology: positive RF
Histology: proliferative synovitis, fibrinoid necrosis surrounded by a palisade of inflammatory cells.
RHEUMATOID CERVICAL SPONDYLITIS
Pannus formation leads to the destruction of the ligaments and bone leading to instability.
- List the RA manifestations (3 radiological entities), therefore, in the cervical vertebrae
- Describe the Xray findings and 2 other imaging that can be done (& why).
- Atlantoaxial subluxation (unstable c1/c2)
- Basilar invagination (superior migration of odontoid above the foramen magnum)
- Subaxial subluxation
On XRAY:
- Flexion-extension views: ADI > 3.5 mm
- Lateral Xray to assess the basillar invagination and subaxial subluxation > 4mm
Other imaging: CT for bony anatomy and MRI for spinal cord compression
RHEUMATOID CERVICAL SPONDYLITIS
- Describe the symptoms that the pt with RA of the cervical spine will present with (3)
- What complications can we expect with cervical RA?
- Describe the treatment of cervical RA.
Symptoms:
1. Cervical myelopathy
2. Neck pain and stiffness
3. Occipital headaches
Complications:
1. Progression of neurology with sudden paralysis
2. Pseudoarthrosis secondary to fibrosis
3. Failure to improve symptoms
Treatment:
1. Rx the RA
2. Surgical spinal decompression and stabilization e.g. C1/2 fusion/ occiput/c2 fusion
ANKYLOSING SPONDYLITIS
Describe the:
- Pathogenesis:
- Serology & genetics:
-Joints targeted: - Typical patient
- Pathogenesis»_space; autoimmune
- Serology & genetics»_space; seronegative, HLA-B27 +ve
-Joints targeted: SI joints, spinal joints, symphysis pubis - Typical patient: men, 3rd decade of life
ANKYLOSING SPONDYLITIS
- What is the diagnostic criteria of AnkSpond? (3)
- List 3 Orthopaedic manifestations of Ank Spond (4)
- DX CRITERIA:
- Bilateral sacroiliitis
- Uveitis
- HLA-B27 +ve - ORTHOPAEDIC MANIFESTATIONS
- BIlateral SI joint inflammation
- Progressive kyphotic deformity
- Cervical spine fractures
- Large joint arthritis
ANKLYLOSING SPONDYLITIS
- Describe how the patient presents to you (symptoms and signs)
- You are now examining this patient. What will you find?
- You highly suspect Ank Spond. What investigations will you do? (Labs, Imaging)
Symptoms: (1) The pt will complain of lumbosacral pain and stiffness that is worse in the mornings. They may or may not have thoracic/ cervical pain later in life. (2) They may have loss of horizontal gaze and (3) Shortness of breath from the kyphosis.
Signs: (1) Limited chest wall expansion (2) Decreased spine motion (3) Kyphotic spine motion (chin-on-chest deformity). Other joints may also be stiff.
Investigations: Labs: HLA-B27 and ESR
Imaging: Standing full AP and lateral x-ray (marginal syndesmophytes, anterior and posterior longitudinal ligaments ossification, SI joint sclerosis/ fuzziness. Later»_space; bamboo spine)
CT if suspect fractures of the spine. MRI»_space; detects inflammation in early disease and sees epidural hemorrhage in spinal fractures. Bone scan» shows inflammation of the SI joint.
ANKYLOSING SPONDYLITIS
- List 3 of complications of Ank Spon
- Broadly describe the management of ank spond
- Fractures, degeneration (OA), Stiff spine
- Non-op: NSAIDS, cox-2 inhibitors, physiotherapy, biologicals, surgery (Mx of fractures, joint fusion/ osteotomies to decrease kyphosis)
DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS (DISH )
- This is a very common cause of back pain and spinal stiffness, more in men > 50 yo. Describe the typical pathology
- It is more common in the thoracic > cervical> lumbar spine. List 3 commonly associated risk factors
- Pathology: non-marginal syndesmophytes at least 3 successive levels.
- Gout, Hyperlipidaemia, Diabetes
DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS (DISH)
- Patients are often asymptomatic. Symptoms will be determined by where the lesion is. Explain.
- Describe findings on Xray, bone scan.
- Why would you do an MRI/CT?
SYMPTOMS
- Pts are often asymptomatic. May complain of mild back pain or stiffness. If in the cervix: pain and stiffness, stridor, hoarseness and sleep apnoea.
- Decreased ROM»_space; may have a myelopathy
ON XRAY:
- non-marginal syndesmophytes, preservation of joint space.
BONE SCAN
- Increased uptake
CT/MRI»_space; if pt had trauma and you suspect a fracture.
DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS (DISH )
- Describe the treatment of DISH
- T/F: Complications of DISH include heterotopic ossification after hip surgery and mortality after trauma.
- TREATMENT:
Medical» NSAIDS, Biphosphonates
Non-medical» Braces, physio, activity modification, spinal decompression and stabilisation if myelopathy.
