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Degenerative thoracolumbar spine Flashcards

Discogenic back pan herniated thoracic disc herniated lumbar disc synovial facet cyst Lumbar stenosis

1
Q

What is discogenic back pain?

A
  • Back pain associated with disc degeneration
  • controversy over acceptance of cause of isolated back pain
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2
Q

What are the signs and symptoms of discogenic back pain?

A
  • Axial loading back pain without Radicular symptoms
  • Pain excerbated by
    • ​Bending
    • sitting
    • axial loading

Signs

  • Straight leg raising negative
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3
Q

What investigations are useful in dx discogenic back pain?

A

Xrays

MRI

  • degenerative disc without significant stenosis/herniation

Provocative Discography

  • studies shosn can lead to accelerated disc degeneration and herniation, loss of height and endplate changes
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4
Q

What is the tx of discogenic back pain?

A

non operative

  • NSAIDS, physical therapy , lifestyle modifications
    • tx of choice in majority without neurology

Operative

  • Lumbar Discectomy w fusion
    • controversial
  • Lumbar total disc replacement
    • single level disease with disease free facet
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5
Q

What is the epidemiology of thoracic disc herniation?

A
  • Uncommon
  • makes up to 1% of herniated nucleus pulposa
  • most seen 40-60 years
  • As disc desiccates less likely to actually herniate
  • location
    • usually involves middle- lower levels
    • T11-T12 most common
    • 75% disc occur T8-T12
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6
Q

What are the risk factors for thoracic disc herniation?

A
  • Scheuermann’s disease
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7
Q

Describe the types of herinated thoracic disc?

A

BY herniation

  • Bulging nucleus
    • annulus intact
  • Extruded disc
    • thru annulus by confined to Post LL
  • Sequestrated
    • Disc material free in canal

By Location

  • Central
  • Posterolateral
  • Lateral
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8
Q

What are the symptoms thoracic disc herniation?

A

Symptoms

  • Pain
    • axial back or chest pain- most common
    • thoracic radicular pain
      • band pain around course of intercostal n
    • arm pain
  • Neurology
    • Numbness, parathesia, sensory changes
    • Myelopathy
    • Paraparesis
    • Bowel/ bladder changes- 15-20%
    • sexual dysfunction
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9
Q

What are the signs of thoracic disc herniation?

A
  • localised thoracic tenderness
  • root symptoms
    • dermatomal sensory changes- parathesia/dysesthesia
  • cord compression & findings of Myelopathy
    • weakness / mild paraparesis
    • abnormal rectal tome
  • UMN signs
    • Spascitity
    • Hyperreflexia
    • sustained clonus
    • positive Babinski sign
  • Gait changes
    • wide based
  • Horner’s syndrome
    • seen with HNP T2-T5
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10
Q

What investigations are useful in thoracic disc herniation?

A

xrays

  • lateral radiographs
    • disc narrowing
    • calcifications (ostephytes)
  • MRI
    • most useful and dx
    • disadv high false positive rate at asymptomatic individuals
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11
Q

What are the tx for thoracic disc herniation?

A

Non operative

  • Activity modification, physical therapy, symptomatic tx
    • majority of cases
    • immobilisation & short term rest
    • analgesic
    • progressive activity restoration
    • injections for radiculopathy
    • majority improve non op

Surgery

  • Discectomy with possible hemicorpectomy or fusion
    • ​minority of pt
    • myelopathic findings, progressive
    • persistent and intolerable pain
    • debate regarding transthoracic /costotranvserectomy approach
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12
Q

What are the surgical techniques for disectomy of thoracic spine?

A
  • Transthoracic discectomy +/- fusion
    • best approach fo rcentral disc
    • complx- intercostal neuralgia
    • ca be done video assisted surgery
  • Costotransversectomy +/- fusion
    • lateral herniated discs
    • extruded or sequestrated discs
    • some studie suggest anterior or lateral costotransversectomy is better
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13
Q

What is the epidemiology of lumbar disc herniation?

A
  • 95% involve L4/5 or L5/S1
    • most common L5/S1
  • peak incidence 40-50 years
  • only 5% become SYMPTOMATIC
  • male 3: 1 female
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14
Q

What is the pathoanatomy of lumbar disc herniation?

A
  • Recurrent Torsional strain leads to tears in OUTER ANNULUS
  • leads to herniation of NUCLEUS PULPOSIS
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15
Q

What is the prognosis of lumbar disc herniation?

A
  • 90% of pts will have improvements of symptom within 3 months with non op care
  • Size of herniation decreases over time ( reabsorbed)
    • Sequestered disc herniation- greatest degree of spontaneous reabsorption
    • Macrophage phagocytosis is mechanism of reabsorption
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16
Q

Can you describe/draw the anatomy of the interverbral disc?

A
  • Annulus fibrosis
    • type 1 collagen, water, proteogylcans
    • extensibility & tensile strength
    • high collagen/ low proteogylcan ratio
  • Nucleus Pulposus
    • Composed type 2 collagen,water, proteoglycans
    • Compressibility
      • low collagen/high proteoglycan
      • Proteogylcan interact w H20 & resist compression
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17
Q

Can you describe the nerve root anatomy?

A

key difference between cervical and lumbar spine is

  • Pedicle/ nerve root mismatch
    • C spine C6 n root travels Under C5 pedicle ( mismatch
    • L spine L5 n root travels under L5 pedicle ( match)
    • Xra C8 nerve root ( no C8 pedicle) allows transition
  • Horizontal (cervical) vs Vertical ( lumbar) anatomy of n
    • vertical lumbar root a paracentral & formainal disc will affect different n roots
    • Horzontal cervical root a central & foraminal will affect same n
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18
Q

Can you classify the herniation of the lumbar disc?

A

By location

  • Central prolapse
    • assoc back pain only
    • can cause Cauda equina
  • Posterolateral ( paracentral)
    • most common 90-95%
    • PLL is weakest here
    • affects transversing n root
      • at L4/5 affects L5
  • Foraminal ( far lateral)
    • less common 5-10%
    • affects exiting n root
      • at L4/5 affects L4
  • Axillary
    • Can effect exiting and descending roots

BY anatomy

  • Protrusion
    • Eccentric bulding annulus fibrosis intact
  • Extrusion
    • Tear in annulus, disc herniated thru but continous with disc space
  • Sequestered
    • disc material thu annulus & no longer continuous with disc space
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19
Q

What are the symptoms of lumbar disc herniation?

A
  • Axial back pain
    • discogenic/mechanical
  • Radicular pain
    • worse with sitting coughing, improves with standing
  • Cauda equina syndrome 1-10%
    • bilateral leg pain
    • saddle anaesthesia
    • LE weakness
    • bowel/bladder dysfunction
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20
Q

What are the signs of lumbar disc herniation?

A
  • Motor exam
    • Dorsiflexion weakness- L4/5
    • EHL weakness L5
    • Hip abduction weakness- L5
    • Ankle plantar flexion weakness S1
  • provocation tests
    • Straight leg weakness
    • Lesegue sign- SLR aggrevated by forced ankle dorsiflexion
  • Gait analysis
    • Trendelenberg gait
      • gluteus medius weakness - L5
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21
Q

What imaging is useful in dx in lumbar disc degeneration?

A

Xrays

  • may show lordosis, loss of height, spondylosis

MRI

  • without gadolinium
  • highly specific and sensitive
  • dx from synovial facet cysts
  • high rate of abnormal findings in normal people
    • pt with pain >1 month not responding non op tx
    • red flags
      • infection- iv du, fever, chills
      • tumour- hx cancer
      • trauma
      • cauda equina- bowel/bladder changes
  • MRI With gadolinium for revision surgery
    • distinguish post surgical fibrosis ( enhances) vs recurrent herniated disc (doesn’t enhance)
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22
Q

Describe the tx of lumbar disc herniation?

A

non operative

  • rest. PT, anti-inflammatory
    • 1st line
    • 90% improve within 3 month
    • bed rest then progressive activity
    • extension exercises, pilates
    • nsaids, ,muscle relaxants, oral steriod taper
  • Selective root corticosteriod injections
    • 2nd line in medication fails
    • epidural vs selective nerve block
    • Long lasting improvement in 50%( surgery90%)
    • Best in pts with extruded discs

​​Surgery

  • Laminotomy and discectomy ( microdiscectomy)
    • ​for persistent disabling pain after 6wks non op
    • progressive & significant weakness
    • cauda equina syndrome
  • Far lateral microdiscectomy
    • for far-lateral disc
    • utilises paraspinal approach of wiltse
    • avoids injury to lamina or facet joints
    • complx- injury to dorsal root ganglia->dysesthesias.- abnormal sensation
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23
Q

What are the outcomes of surgery cf non op tx?

A
  • 70% improvement in back pain
  • neurological recovery less predictable
    • 50% motor/sensory recovery
    • 25% reflex recovery

good outcome

  • if leg pain chief complaint
  • positive straight leg raise
  • weakness correlates with n root impingment seen on MRI
  • married status
  • no workers compensation

Bad outcome

  • workers compensation
  • less relief from symptoms & less improvement in qulaity of life
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24
Q

What are the complications of lumbar spine surgery?

A
  • Dural tear- 1%
    • if have at time of surgery preform water tight repair
  • Recurrent Herniated nucleus pulposus
    • can tx non op
    • outcomes for revision discectomy = primary
  • Discitis- 1%
  • Vascular catastrophe
    • break thru ant annulus- injury aorta/vena cava
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25
Q

What is synovial facet cyst?

A
  • A rare cause of spinal stenosis in lumbar spine
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26
Q

What is the epidemiology of synovial facet cyst?

A
  • Rare
  • location
    • usually Lumbar spine
    • 60-90% at L4-L5 level
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27
Q

What is the pathophysiology of synovial facet cyst?

A
  • Trauma
  • Microinstability of the facet leading to
    • extruded synovium thru joint capsule
    • myxoid degeneration of collagen tissue
    • proliferation of fibroblasts with increased hyaluronic acid production
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28
Q

What are the associated conditions of synovial facet cyst?

A
  • Degenerative Spondylolisthesis
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29
Q

What are the signs and symptoms of synovial facet cyst?

A

Symptoms

  • Mechanical back pain
  • Radicular symptoms- leg pain
  • neurogenic claudication - buttocks/leg pain on walking

Signs

  • May see nerve root deficit at associated spinal levels
30
Q

What imaging is helpful in dx of synovial facet cyst?

A
  • Radiographs
    • Ap, lateral , flexion, extension of spine
    • usually normal
    • look foe segmental instability
  • MRI
    • significiant leg pain
    • best seen on T2 axial/sagittal images
31
Q

What is the tx for synovial facet cyst?

A

Non operative

  • NSAIDs, rest immobilisation
    • mild symptoms
  • CT guided aspiration- technically challening and not usually effective

Surgery

  • Laminectomy with decompression
    • for symptomatic intraspinal synovial cysts
    • high incidence of back pain & cyst formation at 2 years
  • Facetectomy and instrumental fusion
    • significant symp failed non op mx
    • first line of surgical tx
    • lowest risk of persistent back pain & reoccurrance of cyst formation
32
Q

What are the complications of synovial facet cyst?

A
  • Cyst reocurrance
    • high incidence with resection alone
    • facetectomy and fusion
33
Q

What is lumbar spine stenosis?

A
  • **Reduction in dimensions of central or lateral lumbar spine canal **
  • caused by
    • bony structures
      • Facet Osteophytes
      • Uncinate spur ( posterior vertebral body ostephytes)
      • Spondylolithesis
    • Soft tissue structures
      • _​_Herniated/bulging discs
      • hypertrophy/ buckling of ligmentum flavum
      • synovial facet cysts
34
Q

What is the classification of lumbar spine stenosis?

A

By aetiology

  • Acquired
    • Degenerative/Spondylotic change- most common
    • Post surgical
    • Traumatic - vertebral fractures
    • Inflammatory- ankylosing spondylitis
  • Congenital
    • short pedicles with medial placed facets= achondroplasia
35
Q

What is the anatomical classification of lumbar spine stenosis?

A
  • Central stenosis
    • cross sectional area <100mm2 or <10mm AP diameter on axial CT
    • thecal sac compressed
    • presents with non specific root compression or symptoms of lower nerve root (at L4/5- L5 effected)
  • Lateral recess stenosis
    • assoc with facet joint arthropathy adn osteophyte formation
      • overgrowth of superior articular facet
      • sympt of lower nerve root (L5 at L4/5)
  • Foraminal stenosis
    • secondary to disc protrusion, ostephytes, disc collapse
    • presents w higher n root (L4 at L4/5)
36
Q

What are the sign and symptoms of lumbar spine stenosis?

A

Symptoms

  • Back pain
  • referred buttock pain
  • Claudication
    • pain worse with extension- walking/standing
    • pain RELIEVED with FLEXION- sitting/leaning
  • Leg pain - unilateral
  • weakness
  • bladder disturbance
    • recurrent UTI- 10% due to autonomic sphincter dysfunction

Signs

  • Kemp sign
    • Unilateral radicular pain from foraminal stenosis made worse by extension of back
  • Straight leg raises- usually negative
  • Valsalva test
    • radicular pain not worsened by valsalva- unlike herniated disc
37
Q

Can you describe the differences between neurogenic claudication and vascular claudication?

A
  • Neurogenic
    • postural changes- yes
    • walking upright- causes symptoms
    • standing stationary- causes symptoms
    • sitting- relieves symptoms
    • stair climbing - up easier- back flexed
    • stationary bicycle- relieves symp= back flexed
    • pulses- normal
  • Vascular
    • postural changes- No
    • walking upright- causes symptoms
    • Standing stationary- relieves
    • sitting- relieves
    • stairs- down easier- back extended
    • stationary bicycle- causes symptoms
    • pulses- abnormal
38
Q

What investigations aid in dx of lumbar spine stenosis?

A

Xrays

  • Standing ap and lateral
    • non specific degenerative change- disc space narrowing, osteophyte formation
    • degenerative scoliosis
    • degenerative spondylolithesis

MRI

  • central stenosis with thecal sac <100mm2
  • obliteration of perineural fat adn compression of lateral recess foramen
  • facet/ligamentum hypertrophy

Ct Myelogram

  • more invasive than MRI
  • may see
    • central and lateral neural element compression
    • bony anomalies
    • bony facet hypertrophy
39
Q

What is the tx of lumbar spine stenosis?

A

Non operative

  • oral medication, PT, corticosteriod injections
    • first line
    • steriod injections- epidural/transforaminal effective and may obviate need for surgery

Operative

  • Wide pedicle to pedicle decompression
    • for persistent pain for 3-6/12 w non op
    • progressive neurological deficit
    • improved pain and function at 4yrs cf non op
    • failure= recurrent disease above/below decompression level
  • Wide pedicle to pedicle decompression with instrumental fusion
    • ​presence of segmental instability-isthmic spondylolithesis,degen spondylolothesis, degenerative scoliosis
    • instablilty = complete laminectomy +/- removal of >50% facets
40
Q

What are the complications of lumbar spine stenosis?

A
  • Increase with age, blood loss and levels fused
  • Major Complx
    • Wound infection- 10%
      • tx with surgical debridement & irrigation
    • Pneumonia
    • Renal Failure
    • neurologic deficits
  • Minor Complx
    • UTI 34%
    • Anaemia requiring transfusion
    • Confusion
    • Dural tear
      • assoc csf leak
      • tx with percutananeous fibrin glue, epidural blood patch or re op if no improvement
    • Failure for symptoms to improve
41
Q

What is the post important pre op prognostic factor in a pt with lumbar spine stenosis who is going to undergo decompression?

A
  • Comorbid medical conditions
42
Q

What are the outcomes of surgery for lumbar spine stenosis?

A
  • The Spine Patient Outcomes Research Trial (SPORT) is a multi-center randomized controlled trial (RCT) comparing surgical and non-surgical treatment for patients with lumbar disc herniations, lumbar spinal stenosis, and degenerative spondylolisthesis. Results of the randomized cohort were disrupted by a high cross-over rate between the surgical and nonsurgical groups. Therefore, they conducted “as-treated” statistical analysis as a prospective cohort study (non-randomized). Based on the as-treated analysis, two year and four year results for spinal stenosis show improved clinical outcomes in pain and function cf no op.
  • Weinstein et al spine 2010
43
Q

What is degenerative Spondylolithesis?

A
  • A slippage of one lumbar vertebra on another but not due to a defect in the pars
  • an absent in pars defect differentiated this from Adult isthmic spondylolithesis
44
Q

What is the epidemiology of degenerative spondylolithesis?

A
  • More common in
    • Africans
    • Diabetics
    • women >40 yrs
    • x8 more common in women
      • increase in ligamentous laxity related to hormonal changes

location

  • x5 more common at L4/5 ( cf isthmic L5/S1)
45
Q

What are the risk factors for developing degenerative spondylolithesis?

A
  • Sacralization of L5 ( transitional L5 vertebra)
  • Sagitally orientated facet joints
46
Q

Describe the pathoanatomy of degenerative spondylolithesis?

A
  • Forward subluxation (intersegmental instability) of vertebral body is allowed by
    • Facet joint degeneration
    • Facet joint sagittal orientation
    • Intervertebral disc degeneration
    • Ligamentous laxity ( hormone changes)
  • Degenerative cascade involves
    • disc degeneration -> facet capsule degeneration and instability
    • microinstabilit-> further degeneration-> macroinstability & anterolithesis
    • instability worsens with sagittally orientated facets that allow forward subluxation
47
Q

What are the neurological symptoms caused by?

A
  • Central and lateral recess stenosis
    • degeneration slip at L4/5 will affect L5 n root in lateral recess
    • caused by slippage, hypertrophy of ligamentum flavum, encrochment of spinal canal of osteophytes from facet arthrodesis
  • Foraminal Stenosis
    • ​degenerative slip at L4/5 affect l4 n root
    • vertical foraminal stenosis
      • loss of disc height
      • osteophytes from poastlat corner pushing nerve root up against inferior surface of pedicle
    • anteriopost foraminal stenosis- loss of post/anter ior area
    • degenerative changes of superior articular facet and post vertebral body
48
Q

Name the classification of degenerative Spondylolithesis?

A

Myerding

  • Grade 1 = <25%
  • Grade 2 =25-50%
  • Grade 3= 50 to 75%
  • Grade 4 = 75-100%
  • Grade 5= spondyloptosis- all the way off

Grade 3 and above are rare in degenerative spondylolithesis

49
Q

What are the signs and symptoms of degenerative spondylolithesis?

A

Symptoms

  • mechanical back pain
    • most common pc
    • relieved with rest and sitting
  • Neurgenic claudication & leg pain
    • buttock & leg pain
    • relief by sitting
    • not relieved by standing in 1 place
    • unilat/bilateral
  • Cauda equina
    • rare

Signs

  • L4 root involvement - foramen L4/5
    • weak quads ( sit to stand manover)
    • weak ankle DF ( heel- walk exam)
    • decrease patellar reflex
  • L5 root involvement
    • weakness ankle dorsiflexion ( heel-walk exam)
    • weakness EHL
  • Provocation
    • PT walks until symptoms start then stands
    • if resolves = vascular
    • if sits and resolves = neurogenic
50
Q

What imaging is useful in dx of degenerative spondylolithesis?

A

Xrays

  • Weight beaing ap, lateral neutral, lateral flexion, lateral extension
    • slip evident on lateral xray
    • flexion/extension view
      • instability= 4mm translation or 10o angulation of motion cf adj motion segement

MRI

  • pt with perisitent pain, failed non op tx
  • best for inv of impingment of neural elements -t2 weighted sagittal best

Ct

  • Identify any bony pathology
  • useful when MRI CI- pacemaker!
51
Q

What is the tx of degenerative spondylolithesis?

A

Non operative

  • PT & NSAIDS
    • most pt tx non operatively
  • Epidural steriod injections

​Surgery

  • Lumbar wide decompression with Posterolateral instrumented fusion​
    • laminectomy/wide decompression + foraminotomy
    • worse outcome in smokers
    • better with pedicle screws and athrodesis
    • 79% satisfactory outcome
    • cauda equina syndrome
    • progressive motor deficit
    • in persistent and incapacitating pain failed 6 mo non op
  • Posterior lumbar decompression alone
    • only in medically frail pt who won’t tolerate time for fusion
    • 69% satisfied, 31% poregressive instability
  • Anterior lumbar interbody fusion (ALIF)
    • for revision cases with peudoarthrosis
  • Reduction of lithesis is limited in adults
52
Q

What are the complications of surgical decompression ands fusion on degenerative spondylolithesis?

A
  • Dural tear
  • Pseudoarthrosis ( CT better thna MRI to detect failed arthrodesis)
  • Surgical infection
    • irrigation & debridment-usually metal work retained as fusion aids stability, increasing and aiding arthrodesis
  • Adjacent segmental disease - 2.5%
    • fusions up to L1-3 > risk cf fusion L4 & L5
53
Q

Summarise what degenerative spondylolithesis is?

A
  • Degenerative spondylolisthesis is the combination of spinal stenosis with intersegmental instability of the vertebrae.
  • It most commonly affects L4/5 disc space, causing neurogenic claudication and rarely, cauda equina syndrome.
  • Initial treatment is non-operative and includes physical therapy, pain control and injections.
  • If non-operative measures fail, surgical management includes posterior decompression with fusion of the unstable segments with or without instrumentation.
54
Q

What is the evidence for surgical tx in degenerative spondylolithesis cf non op?

A
  • Weinstein et al (SPORT) NEJM 2007 showed patients with degenerative spondylolisthesis treated with surgery had greater improvement in pain and function through 4 years compared to those treated nonoperatively.
  • Herkowitz JBJS am 1991et al found patients who had had a concomitant spinal arthrodesis, compared to those who had decompression alone, had improved outcomes with respect to relief of pain in the back and lower limbs.
  • Fischgrund et al spine 1997 shows that in patients undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of pedicle screws may lead to a higher fusion rate.
55
Q

Describe adult isthmic spondylolithesis?

A
  • Spondylolithesis in an adult caused by a defect in the pars interarticularis (spondylolysis)
56
Q

What is the epidemiology of adult isthmic spondylolithesis?

A
  • Spondylolysis seen in 4-6% of population
  • Increased prevalence in sports that involve Repetitive Hyperextension - gymnasts, weightlifters

location

  • 82% occur L5/S1
    • due to forces at lumbar spine being greatest at these levels adn the facet more coronal
  • only 11% L4/5
57
Q

What is the pathopysiology of adult ischmic spondylolithesis?

A
  • Foraminal stenosis
    • At L5/S1 ->L5 nerve root impingment
    • hypertrophy fibrous repair from pars defect
    • uncinate spur formation of post L5 body
    • Bulging L5/S1 disc
  • Lateral recess stenosis
    • facet arthrosis
    • hypertrophic ligamentum flavum
  • Central stenosis
    • rare as slips normally grade 1/2
58
Q

What is the prognosis of adult ischmic spondylolithesis?

A
  • Relatively few patients 5% with spondylolysis will develop spondylolithesis
  • Slip progression > in Females
  • Slip progression usually occurs in adolscece post puberty
59
Q

What is the classification system of adult ischmic spondylolithesis?

A
  • Wiltse and Newman
  • Type 1 - dysplastic- a congential defect in pars
  • Type 2
    • A-Isthmic- pars fatigue fx
    • B- Isthmic- pars elongation ( multiple healed fx)
    • C- Isthmic- acute pars fx
  • ​Type 3
    • Degenerative, facet instability wout pars fx
  • Type 4
    • Traumatic, acute post arch fx other than pars
  • Type 5
    • Neoplastic- pathological destruction of pars
  • DON’t forget Myerding for amount of displacement
60
Q

What are signs and symptoms of adult isthmic spondylolithesis?

A

Symptoms

  • Axial back pain
    • most common, vary intensity
  • leg pain
    • L5 radiculopathy
  • neurogenic claudication
    • caused by spinal stenosis
    • buttock & leg pain worse w walking
    • rare
  • Cauda equina
    • rare because slip rarely progress beyond grade 2

Signs

  • L5 radiculopathy
    • weakness ankle dorsiflexion/ EHL
61
Q

What imaging is useful?

A

Radiographs

  • AP, lateral , oblique and flexion-extension
  • lateral -see spondylolithesis and pars defect
  • flex-exten : instability 4mm translation/ 10o angulation of motion cf adjacent motion segment
62
Q

What is pelvic index- how can it be measured?

A
  • Pelvic tilt + sacral slope
  • a line is drawn from the center of the S1 endplate to the center of the femoral head
  • a second line is drawn perpendicular to a line drawn along the S1 endplate, intersecting the point in the center of the S1 endplate
  • the angle between these two lines is the pelvic incidence (see angle X in figure above)
  • correlates with severity of disease
    pelvic incidence has direct correlation with the Meyerding–Newman grade
  • Child 470, adult 570
  • A low PI= low shear forces at lumbrosacral junction and less lumbar lordosis
  • PI greater in pts with spondylolithesis
    *
63
Q

What is pelvic tilt? how can this be measured?

A
  • pelvic tilt = pelvic incidence - sacral slope
  • a line is drawn from the center of the S1 endplate to the center of the femoral head
  • a second vertical line (parallel with side margin of radiograph) line is drawn intersecting the center of the femoral head
  • the angle between these two lines is the pelvic tilt (see angle Z in figure above)
64
Q

What is sacral slope? How is it measured?

A
  • Sacral slope= pelvic incidence- pelvic tilt
  • a line is drawn parallel to the S1 enplate
  • ​a second horizontal line (parallel to the inferior margin of the radiograph) is drawn
  • the angle between these two lines is the sacral slope (see angle Y in the figure above)
65
Q

What is the tx of adult isthmic spondylolithesis?

A

non operative

  • oral medications, lifetsyle modifications, PT
    • most pt tx non op
    • bracing maybe benefit in acute phase

Operative

  • L5-S1 Decompression & instrumented Posterolateral fusion +/- reduction
    • in low grade L4-5 spondylolithesis with persistent and incapacitating pain w failed consx
    • progression of slip/neurological deficit
    • cauda equina
    • improve sagittal balance with reduction
    • risk of stretch injury L5 nerve root
    • PLIF- common, inserts device medial to facets
  • Anterior Lumbar interbody fusion ALIF
    • success to tx low grade isthmic spondylolithesis when radicular symptoms
    • not used in high grade due to translation & angular deformity
    • gd- excellent results at 2years 87-94%
    • thru trans-retropertioneal approach
  • Posterior decompression+ insitu PLIF L4-S1 & posterior strut support
    • high grade spondylolithesis
    • partial reduction better to preserve nerve root L5 than full reduction
66
Q

What are the complications of surgery for adult isthmis spondylolithesis?

A
  • Pseudoarthrosis
  • Dural tear
  • Nerve injury- L5 from reduction-weak EHL, ankle dorsiflexion, therefore aim for partial rather than full reduction
67
Q

What is sacroilitis common in?

A
  • Ankylosing spondylitis
    • ​assoc HLA- B27
    • 1-2% pts will have HLA- B27
  • Reiter’s Syndrome
    • ​oligoarthritis, conjuctivitis, urethritis
  • ​Joint Arthritis
  • common in teen- middle aged
  • Males > females
68
Q

What is the pathophysiology of sacroilitis?

A
  • Trauma
  • infection
  • pregnancy
  • Often from Chronic inflammation of SI joint-> fibrosis and ossification
69
Q

what is the prognosis of sacroilitis?

A
  • depends on cause but most patients will eventually resolve the epidoes and continue without issue
70
Q

What are the signs and symptoms of sacroilitis?

A

Symptoms

  • pain with prolonged standing
  • difficulty climbing stairs
  • generalised back pain
  • weakness from hip musculature on affected side
  • morning stiffness

Signs

  • FABER TEST
    • Pain with FLEXION, ABDUCTION & EXT ROTATION
  • Ankylosing spondylitis
    • spinal flexion deformities
    • starting in T and L spine
71
Q

investigations useful in sacroilitis?

A
  • xrays
    • erosive changes but non specific
    • calcification/sclerosis at SI joint
  • MRI
      • gadolinium
    • T2 show fluid/inflammation at Si joint ?abscess
  • check
  • WBC- usually normal/ elevated
  • ESR?CRP- elevated
  • Blood cultures- posiitve in 50%
  • HLA- B27
  • Rheumatoid factor- neg in ank spon
72
Q

How is sacroilitis tx?

A

Depends on cause

infection

  • IV antibiotics: iv then oral. monitor crp
  • surgery- if abscess large, crp climbing

Trauma/overuse

  • Rest, activity modifications, nsaids, steriod injections
  • most resolve

Pregnancy

  • observe
  • resolves post partum

If ankl spond

  • agressive PT, nsaids, tnf inhibitors

Spine FRCS (20 decks)

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