Miller-Spine Flashcards
Key aspects of the spine physical examination
Cervical Neurologic Examination
Findings in Cervical Compression
Findings in Lumbar Compression
Lower Extremity Neurologic Exam
Cervical Spine Anatomy
Review Cervical Myelopathy
Spinal cord compromise without reference to specific pathologic entity
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Presenting symptoms can be subtle
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Finger clumsiness, deterioration of handwriting, difficulty in fine motor control of hands, weakness of pinch
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Ataxia with wide-based gait, leg heaviness, and inability to perform tandem walk
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Urinary retention, urgency, or frequency
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Lower extremity weakness (corticospinal tracts) can be associated with worse prognosis.
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Natural history of cervical spondylotic myelopathy is characterized by one of three presentations:
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Stepwise deterioration in symptomatology followed by a period of stability (most common, 65%–80%)
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Slowly progressive decline (over months to years, 20%–25%)
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Rapidly progressive decline (over days to weeks, 3%–5%)
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Physical examination
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Upper motor neuron findings in myelopathy
Myelopathy hand and the finger escape sign (small finger spontaneously abducts because of weak intrinsic muscles)
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Hyperreflexia, Hoffmann sign, clonus, or Babinski sign
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Inverted radial reflex (ipsilateral finger flexion when brachioradialis reflex being elicited)
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Funicular pain—central burning and stinging with or without L’hermitte sign (radiating lightning-like sensations down the back with neck flexion)
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Upper motor neuron findings not always present in all patients
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Upper extremities may have radicular (lower motor neuron) signs along with evidence of distal myelopathy.
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Treatment
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Nonsurgical treatment—NSAIDs, cervical epidural injections, isometric exercises, traction, and occasionally temporary collar immobilization
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Surgical indications—natural history of myelopathy is typically progressive; therefore surgical decompression is frequently indicated.
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Procedures
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Anterior procedures include ACDF versus ACCF or combination (hybrid). Anterior-based procedures are options for patients with either kyphotic or lordotic cervical sagittal alignment.
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Posterior options include laminectomy and fusion versus laminoplasty. Posterior-based options are contraindicated in patients with fixed cervical kyphosis owing to the surgical inability to indirectly decompress the spinal cord.
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Combined anterior and posterior procedures (circumferential surgery). Considered for patients requiring multilevel corpectomy resection with strut reconstructions (highly unstable spine).
Common measurements in C1-C2 disorders
Rheumatoid Cervical Spine
Overview
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Less common owing to improvement and increased use of disease-modifying antirheumatic drugs (DMARDs)
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Patients with rheumatoid arthritis (RA) should undergo flexion/extension radiography before elective surgery.
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When spine is involved, cervical spine, more specifically occipitoatlantoaxial joint (O–C2), is site most commonly affected.
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Atlantoaxial subluxation (AAS)—typically the first manifestation of cervical instability in rheumatoid patient
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Atlantoaxial invagination (AAI)—typically occurs next, after AAS
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Subaxial subluxation (SAS)—usually occurs after AAS and AAI
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Occurs in up to 90% of patients with RA and is more common with long-standing disease and with multiple joint involvement
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Presenting complaints
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Axial neck pain
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Stiffness
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Occipital headaches
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Due to erosion of the C1–2 joint, with subsequent compression of greater occipital branch of C2 nerve
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Results more specifically in pain in posterior aspect of base of skull that is typically relieved with manual traction
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Myelopathy, radiculopathy, or myeloradiculopathy, depending on neurologic structures at risk
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Physical examination
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Subtle signs of neurologic involvement should be sought.
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Neurologic impairment (weakness, decreased sensation, hyperreflexia) in patients with RA usually occurs gradually and is often overlooked or attributed to other joint disease.
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Neurologic impairment with RA has been classified by Ranawat (Table 8.6).
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Imaging
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Radiographic markers are assessed for indications of impending neural compression (Fig. 8.8).
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Anterior atlantodens interval (AADI), frequently referred to simply as atlantodens interval (ADI)
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Posterior ADI (PADI), sometimes also referred to as space available for the cord (SAC)
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MRI
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Cervicomedullary angle (CMA) (Fig. 8.9) is measured by drawing a line along anterior aspect of cervical spinal cord and the medulla.
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Normal: 135–175 degrees
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In patients with progressive superior migration of the odontoid, the CMA decreases owing to draping of the brainstem over the odontoid.
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Reduced CMA has an increased association with respiratory dysfunction and sudden death.
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Atlantoaxial subluxation (AAS)
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Typically first stage of cervical spine involvement in the rheumatoid patient
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Occurs in 50%–80% of patients with RA
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Often the result of pannus formation at synovial joints between the dens and ring of C1, resulting in destruction of transverse ligament, dens, or both
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Leads to instability between C1 and C2, with subsequent subluxation
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Diagnosis
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Anterior subluxation of C1 on C2 is the most common finding, but posterior and lateral subluxation can also occur.
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Findings on examination may include limitation of motion, upper motor neuron signs, and weakness.
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Plain radiographs that include patient-controlled flexion and extension views are evaluated to determine AADI as well as PADI.
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Instability is suggested by AADI motion of more than 3.5 mm on flexion and extension views, although radiographic instability in RA is common and not necessarily an indication for surgery.
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PADI less than 14 mm may be more sensitive than AADI measurement for spinal cord compression in patients with RA.
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Surgical indications
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Intractable pain
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Progressive neurologic instability, cervical myelopathy
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Can be due to mechanical instability
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Direct compression by pannus of C2
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Mechanical instability; evaluation of C1–2 motion/relationship
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AADI greater than 9–10 mm
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PADI less than 14 mm
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PADI may be more sensitive for identifying patients at increased risk of neurologic injury
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PADI less than 14 mm usually requires surgical treatment.
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Surgery is less successful in patients with Ranawat grade IIIB neurologic impairment but should still be considered.
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Treatment
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Surgical fixation
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Gallie fusion—mostly of historical significance
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Brooks fusion—mostly of historical significance and rarely used alone
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C1–2 transarticular screw fixation (Magerl)
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Still used but less commonly since advent of C1–2 Harms construct (see later)
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Requires preoperative CT to evaluate position of vertebral arteries
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Requires reduction of C1–2 joint
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Poses increased risk for vertebral artery and C2 nerve injury
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C1 lateral mass—C2 pedicle/pars fixation (Harms construct)
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Lower rate of vertebral artery and C2 nerve injury
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Biomechanically strongest construct of C1–2 fixation techniques
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Does not require reduction of C1–2 joint
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Odontoidectomy
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Should be reserved as a secondary procedure
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Anterior cord compression by pannus often resolves after posterior spinal fusion.
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AAI
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Also known as cranial settling, basilar invagination, cranial invagination, and other names.
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Second most common manifestation of RA in cervical spine
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Occurs in 40% of patients with RA
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Results in cranial migration of the dens from erosion and bone loss between the occiput and C1–2
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Often seen in combination with fixed atlantoaxial subluxation
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Measurements are shown in Fig. 8.8.
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Landmarks may be difficult to identify.
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Ranawat line is most reproducible.
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Diagnosis
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Progressive cranial migration of dens
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Findings on examination may include limitation of motion, upper motor neuron signs, weakness, and, in severe cases, bulbar symptoms.
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Surgical indications
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Intractable pain
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Progressive cranial migration or neurologic compromise may require operative intervention (occiput–C2 fusion).
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Cervicomedullary angle less than 135 degrees (on MRI) suggests impending neurologic impairment.
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Treatment
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Occipitocervical fusion
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Typically from occiput to C2
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Gentle traction to help bring odontoid process out of foramen magnum
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Transoral or retropharyngeal odontoid resection for persistent brainstem compression after occiput–C2 fusion.
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SAS
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Occurs in 20% of cases of RA
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Seen in combination with upper cervical spine instability
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Pathoanatomy
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Pannus formation in uncovertebral joints (joints of Luschka) and facet joints. Subluxation may occur at multiple levels.
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Radiographic markers of instability
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Subaxial subluxation of greater than 4 mm or more than 20% of the body is indicative of cord compression.
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A cervical height index (cervical body height/width) of less than 2.00 approaches 100% sensitivity and specificity in predicting neurologic compromise.
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Surgical indications
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Intractable pain
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Progressive neurologic compromise, cervical myelopathy
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Mechanical instability—subluxation greater than 4 mm
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Procedure
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Posterior spinal fusion with or without decompression
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Fusion to the most distal unstable level.
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Occiput and/or C1–2 joint included if AAI or AAS exists.
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Anterior spinal fusion
May be required to restore sagittal alignment
May be necessary to increase likelihood of fusion on multilevel posterior spinal fusion
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Surgery may not reverse significant neurologic deterioration, especially if a tight spinal canal is present, but can stabilize it.
What is the cervicomedulary angle and what does it mean
an angle less than 135 degrees on MRI suggests impending neurologic impairment
what is the cervical height index?
Diagram of the cervical nerve root orientation
Diagram of the lumbar nerve root orientation
Anterior soft tissue shadows normal numbers for trauma evaulation:
6mm C2
20mm C6
Review the ASIA classification
Review incomplete spinal cord injuries
Central cord syndrome
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Most common incomplete spinal cord syndrome
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Typical mechanism is hyperextension with preexisting canal stenosis.
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Cord is compressed anteriorly by osteophytes and posteriorly by the infolded ligamentum flavum.
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Cord is injured in the central gray matter, resulting in proportionately greater loss of motor function to upper extremities than to lower extremities.
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The upper extremity is affected more than the lower extremity.
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Variable sensory sparing
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The prognosis is good for the recovery of ambulation, but the patient is less likely to recover upper extremity function.
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Anterior cord syndrome (spinothalamic tract injury)
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The second most common incomplete cord injury
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No typical mechanism for injury
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Direct compression to anterior spinal cord
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Less commonly, vascular injury to anterior spinal artery, or spinal cord ischemia (e.g., anterior spinal artery, artery of Adamkiewicz)
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Damage is primarily in the anterior two-thirds of the cord.
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Loss of motor response, pain reception, and temperature reception below the level of injury
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Patients demonstrate greater motor loss in the legs than the arms.
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Preservation of posterior/dorsal column; vibration sensation, proprioception, and deep pressure sensation intact
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The prognosis for motor recovery is poor.
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Brown-Séquard syndrome (spinal cord hemisection)
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Typical cause is penetrating trauma.
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Ipsilateral loss of motor and loss of position/proprioception function on the side of injury
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Contralateral loss of pain and temperature to the side of injury (usually one to two levels below the insult)
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Best prognosis for recovery of ability to walk (90%)
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Posterior cord syndrome
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Very rare; least common incomplete spinal cord pattern
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Injury to posterior/dorsal column—loss of proprioception, vibrator sensation, and deep pressure sensation
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Preservation of anterior column; motor response, pain reception, and temperature reception intact
Review the safe zones for halo pin placement:
Adults: 4 pins at 6 to 8 inch-lb pressure; children: 8 to 10 pins at 2 inch-lb pressure
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Complications—pin loosening, pin infection, pressure sores, nerve injury, dural penetration
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Gardner-Wells (GW) tongs
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Can be used more acutely to realign the spine in the patient with a displaced fracture with or without neurologic injury
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Pins parallel to the external auditory meatus approximately 1-cm above pinna
What are the absolute contraindications to giving high dose steroids for a spinal cord injury
Penetrating spinal wounds, particularly gunshot wounds
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Injury more than 48 hours old
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Peripheral nerve injuries such as brachoplexopathy, stingers, root level injuries, cauda equina
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Pregnancy
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Age younger than 13 years
key facts about rehab after spinal cord injury
Functional level determined by both sensory and motor level as dictated by
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Most distal intact functional sensory level and
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Most distal motor level where motor grade is 4 or greater
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Respiratory function by level of cord injury
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C1–2 injury
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Vital capacity only 5%–10% of normal
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Ventilator dependence
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Cough absent
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C3–5 injury
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Vital capacity 20% of normal
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Cough weak and ineffective
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Lower cervical and upper thoracic injury
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Vital capacity 30%–50% of normal
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Cough weak but may be effective
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T11 injury and below
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Respiratory dysfunction minimal
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Vital capacity near normal
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Cough strong
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Mobility and function determined by highest motor level
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C3 or above—respiratory dependent
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C4—transfer dependent
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C5—transfer assist
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C6—independent transfers
Activities of daily living
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C6—independent grooming and dressing; can operate flexor hinge wrist-hand orthosis
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C7—able to use knife to cut food
key testable components about a syrinx
Introduction
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Confluent collection of abnormal CSF within the spinal cord
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In regard to orthopaedic spine, most common etiology is posttraumatic syrinx and secondary to herniated disc.
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Other primary causes of spinal syringomyelia include postinflammatory, arachnoid abnormalities (arachnoid cyst), tumor, and idiopathic.
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Syringomyelia can also be related to abnormalities of the foramen magnum: tonsillar descent (Chiari malformation), arachnoid veil with fourth ventricle outlet obstruction.
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Differentiating syringomyelia from hydromyelia
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Hydromyelia—confluent CSF cavity within spinal cord that is a remnant of central canal of spinal cord
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Typically considered a normal variant
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Spinal cord typically not expanded by hydromyelia and therefore not associated with symptoms and not considered a pathologic entity
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Differentiating syringomyelia from spinal cord edema
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Spinal cord edema is increased fluid that is interstitial, and not a confluence of fluid.
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Edema can be secondary to spinal cord contusion or tumor-associated cyst.
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Presentation
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Variable but typically due to the etiology of the syrinx and its associated pathophysiology
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Symptoms associated with partial CSF obstruction (e.g., tussive headaches, strain-related activities)
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Symptoms related to brainstem compression (e.g., swallowing difficulty, voice changes, nystagmus, ataxia, sleep apnea)
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Symptoms related to syringomyelia (e.g., sensory loss [upper greater than lower typically], upper extremity weakness, hand and upper extremity atrophy, gait impairment, lower extremity spasticity, bowel and bladder dysfunction, dysesthetic pain)
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Imaging
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MRI is method of choice
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Does not disrupt CSF dynamics
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T1-weighted image demonstrates intramedullary fluid-filled cavity.
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MRI with gadolinium necessary to rule out possibility of associated spinal tumor.
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T2-weighted images may help identify anatomic detail such as septa in the subarachnoid space.
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CT myelogram
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May have a role in determining obstructive arachnoid disease
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In these cases, performing myelography puncture at C1–2 rather than using lumbar route may allow for pooling of the contrast at the level of the web.
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This pooling may not be seen if contrast is introduced from the lumbar route, because the obstructive subarachnoid web acts as a one-way valve.
C1 injury
A sum of 6.9 is indicative of injury
C2 Odontoid Fractures
Type I—avulsion of alar ligaments from the tip
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Type II—fracture at the base of odontoid
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Type IIA—comminuted fracture of the base of odontoid
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Type III—fractures that extend into the body of C2
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Treatment
Operative indications—based on risk of development of nonunion. Risk factors for nonunion in type II
Displacement greater than 5 mm
Posterior displacement
Age greater than 40 years
Delayed treatment
Angulation greater than 10 degrees
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Type I—immobilization in rigid cervical orthosis
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Type II and IIA
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Nondisplaced—immobilization in rigid cervical orthosis (controversial)
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Displaced types II and IIA fractures are generally considered to require operative treatment because of the high rate of nonunion with nonoperative treatment.
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Type III—typically high incidence of union; most heal in rigid external cervical orthosis. Operative treatment considered if initial displacement greater than 5 mm.
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Procedures
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Posterior C1–2 fusion
Direct osteosynthesis—anterior odontoid screw (Fig. 8.33)
Fracture must be reducible. Nonreduced fracture is a contraindication to anterior odontoid screw.
Fracture geometry must be favorable: anterior superior to posterior inferior (posterior oblique pattern) (Fig. 8.34)
This procedure is associated with a higher failure rate than posterior fusion but theoretically preserves atlantoaxial motion.
Complications
Overall nonunion rate for type II: approximately 32%
Patients older than 80 years do poorly whether treatment is operative or nonoperative.
Airway problems postoperatively or with halo vest immobilization
C2 Body Fracture:
Hangmans
Type I—minimally displaced fracture of the pars secondary to hyperextension and axial loading (<3 mm displacement, no angulation)
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Type IA—same as type I except fracture lines are asymmetric
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Type II—displaced fractures (>3 mm) of the pars, with subsequent flexion after hyperextension and axial loading
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Type IIA—flexion without displacement; care must be taken not to mistake this for a type I fracture, which represents total disc avulsion, because traction may worsen a type IIA fracture.
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Type III—bilateral pars fracture with bilateral facet dislocations (rare)—mechanism is flexion-distraction followed by hyperextension
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Treatment
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Type I—rigid cervical orthosis
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Type II—operative; typically C1–2 fixation or direct osteosynthesis
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Type IIA—halo vest or surgery (no traction)
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Type III—generally operative, usually C2–3 fusion (may require C1–3 fixation, depending on comminution of pars and quality of fixation into C2)
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Complications—vascular injury; vertebral artery injury is rare but increasingly diagnosed by MR angiogram.
Surgical Techniques of C1-C2 Fusion
C1–2 modified Gallie fusion
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Autograft iliac crest placed over C2 spinous process and against posterior arch of C1
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Held in place by sublaminar wire under arch of C1 and under spinous process of C2 (total of one sublaminar wire)
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C1–2 Brooks fusion
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Two separate iliac crest autografts placed between C1 and C2
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One sublaminar wire is placed on either side (total of two sublaminar wires).
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C1–2 transarticular (Magerl) screws
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Preoperative CT scan to assess for location of vertebral artery at C1–2 junction is imperative.
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Adequate intraoperative radiographs are required, or the technique should not be used.
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Cannulated screw is placed under fluoroscopic guidance over a guidewire.
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Screw is placed through the C1–2 facet joint (transarticular), thereby coupling C1–2.
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C1 lateral mass–C2 pedicle (Harms) screws
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C1 screws are placed through the lateral masses. Starting point of the screw is the center of the lateral mass.
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C2 screws are placed traditionally as pedicle screws. In the case of aberrant vertebral artery a shorter, more straight-ahead pars screw can be used in C2 instead.
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Complications
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Vertebral artery may be injured as it runs in the transverse foramen of C2 or as it lies on the superior aspect of C1 in the groove/sulcus of the vertebral artery.
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C2 (greater occipital) nerve lies just dorsal to the C1–2 joint. Injury can result in numbness in the posterior aspect of the skull.
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Neurologic injury
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Dural leaks
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Nonunion/malunion
Review the SLIC
Based on three separate injury axes
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Fracture morphology
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Discoligamentous complex (DLC) integrity
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Neurologic status
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Scoring
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Each axis considered an independent determinant for prognosis and management
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Each axis receives numerical score, with increasing severity receiving a higher numerical value
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No set value defined as requiring surgical treatment; however, higher numerical values suggest increased need for operative intervention
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Treatment goals
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Address neurologic deficits.
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Typically, approach is selected according to location of compression.
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Anterior cervical discectomy and/or corpectomy for anterior compression
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Posterior laminectomy for posterior compression
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Restoring spinal alignment can help through indirect decompression.
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Achieve immediate stability and long-term fusion. Approach varies depending on injury pattern and presence of associated neurologic instability.
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Restore spinal alignment.
What is the Allen-Ferguson sub-axial classification system?
Based on position of the head and neck at the time of injury (flexion/extension) and the mode of failure (distraction/compression) (Table 8.11)
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Compressive flexion
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Distractive flexion
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Compressive extension
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Vertical compression
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Distractive extension
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Lateral flexion
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Decision for surgery using mechanistic classification can be difficult, but general considerations include:
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Patient with associated neurologic instability
Disruption of PLC
Fracture dislocations and distractive flexion injuries (jumped facets)
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Burst fracture without neurologic injury and with intact PLC and acceptable alignment can be considered for treatment with external immobilization (controversial).
Special Considerations of jumped facet joints
what tumors should you consider pre-op embolization for
Thyroid and Kidney tumors
Review metastatic lesions of the spine
Metastasis—the most common tumors of the spine, spreading to the vertebral body first and later to the pedicles
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Diagnosis
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History of cancer
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Breast, lung, thyroid, renal, gastrointestinal, and prostate metastases are the most common tumors to metastasize to bone.
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Lymphoma, myeloma
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Recent unexplained weight loss
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Night pain
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Age older than 50 years
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Examination—careful physical and neurologic examinations vital
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Imaging
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Should include plain radiographs of entire spine
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MRI with gadolinium of suspected levels; may require imaging of entire neuraxis
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CT scan of chest, abdomen, and pelvis can help identify possible primary lesion.
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Bone scan can assist in assessing for primary lesion and remote sites of involvement (but results can be negative in up to 25% of cases).
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Percutaneous biopsy of spinal lesion may avoid surgical open biopsy and can confirm diagnosis.
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Treatment
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Regardless of surgical or nonsurgical intervention, treatment should include multispecialty involvement.
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Nonsurgical treatment
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Nonoperative treatment should be considered for tumors that are radiosensitive, chemosensitive, or hormonally responsive.
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Radiosensitivity varies among primary tumor types, but newer techniques have made traditionally radioresistant tumors radioresponsive.
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Surgical intervention along with adjuvant radiation and/or chemotherapy should be considered for patients with mechanical instability or evolving/progressive neurologic deficit.
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In the case of epidural spinal cord compression, radiation therapy should be combined with direct surgical decompression for the best clinical outcomes.
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Surgical treatment
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Indications
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Progressive neurologic dysfunction that is unresponsive to radiation therapy
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Persistent pain despite radiation therapy
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Need for an open diagnostic biopsy
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Pathologic mechanical instability
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Radioresistant tumor
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Life expectancy should play an important role with regard to whether surgical treatment is performed.
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Techniques
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Vertebroplasty is gaining favor in cases of metastatic disease of the spine (myeloma, breast) without instability or neurologic compromise and represents a minimally invasive alternative to open surgery.
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In cases of neurologic deficit and/or spinal instability, anterior decompression and stabilization (preserving intact posterior structures) may result in recovery of neurologic function.
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Posterior stabilization or a circumferential approach is indicated in cases of multiple levels of destruction, involvement of both the anterior and posterior columns, or translational instability.
Review primary lesions of the spine
Osteoid osteoma (<2 cm in size) and osteoblastoma (≥2 cm in size)
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Diagnosis
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Common in the spine
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May manifest as painful scoliosis in a child
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Pain typically relieved by aspirin and/or NSAIDs
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Osteoblastomas typically occur in the posterior elements in older patients, with neurologic involvement in more than half.
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Imaging
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Bone scan can help localize the level.
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Thin-cut CT can direct surgical excision.
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MRI is sensitive but not specific; surrounding hyperemic soft tissue may be misidentified as an aggressive lesion.
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Treatment
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Scoliosis (lesion is typically at apex of convexity) resolves with early resection (within 18 months) in a child younger than 11 years.
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If there is no scoliosis, aspirin and/or NSAIDs are the mainstay of treatment.
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Surgery is performed if nonoperative treatment fails.
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En bloc resection versus marginal or intralesional excision
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CT-guided radiofrequency ablation (controversial)
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Posterior spinal fusion may be required, depending on extent of resection
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Aneurysmal bone cyst
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Diagnosis
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May represent degeneration of more aggressive tumor
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Manifests during second decade of life
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Arises in the posterior elements, but possibly also involves the anterior elements
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Treatment
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Marginal or wide excision if possible
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Alternatively, curettage and bone grafting
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Radiation therapy if lesion inaccessible
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Hemangioma
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Diagnosis
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Common; typically seen in asymptomatic patients
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Symptomatic patients older than 40 years may seek treatment after small spinal fractures.
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The classic patient with hemangioma has “jailhouse striations” on plain films with spikes of bone on CT.
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Vertebrae are typically of normal size and not expanded (as in Paget disease).
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Treatment
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Observation or radiation therapy in cases of persistent pain after pathologic fracture
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Anterior resection and fusion are reserved for refractory cases or pathologic collapse and neural compression, but massive bleeding may be encountered.
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Eosinophilic granuloma
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Diagnosis
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Usually seen in children younger than 10 years
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More common in thoracic spine
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May manifest as progressive back pain
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Classically, vertebral flattening (vertebra plana [Calvé disease]) seen on lateral radiographs
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Biopsy may be required for diagnosis unless the radiographic picture is classic.
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Treatment
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Symptoms are usually self-limiting.
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Chemotherapy is useful for the systemic form.
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Bracing may be indicated in children to prevent progressive kyphosis.
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Low-dose radiation therapy may be indicated in the patient with neurologic deficits.
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At least 50% reconstitution of vertebral height may be expected.
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Giant cell tumor
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Diagnosis
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Usually seen in the fourth and fifth decades of life
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Destruction of the vertebral body in an expansile fashion
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Treatment
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Surgical excision and bone grafting
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High recurrence rate is reported.
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Radiation therapy should be avoided because of the possibility of malignant degeneration of the tumor.
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Plasmacytoma/multiple myeloma
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Diagnosis
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Shown as osteopenic lytic lesions on radiographs
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Workup includes skeletal survey.
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Lesions are “cold” on bone scans in up to 25% of cases.
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Pain secondary to pathologic fractures
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Increased calcium level and decreased hematocrit levels as well as abnormal protein measurements are common.
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Treatment
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Radiation therapy with or without chemotherapy
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Surgery is reserved for patients with spinal instability and those with refractory neurologic symptoms.
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Chordoma
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Diagnosis
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Slow-growing lytic lesion in the midline of the anterior sacrum or the base of the skull
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May occur in other vertebrae (cervical spine next most common)
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Patient with this tumor may present with intraabdominal complaints and a presacral mass.
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Physaliferous cells in biopsy specimens
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Treatment
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Surgical excision—treatment of choice (tumor is radioresistant)
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Typically requires resection of sacral nerve roots to achieve margin
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If half of the sacral roots (i.e., all roots on one side) are preserved, patient may still maintain bowel and bladder function.
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High recurrence rate
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Although a complete cure is rare, patients typically survive 10–15 years after diagnosis.
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Lumbopelvic reconstruction is required after surgical resection of sacral lesions.
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Osteochondroma
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Arises in the posterior elements and is frequently seen in the cervical spine
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Treatment is by excision, which may be necessary to rule out sarcomatous changes.
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Neurofibroma
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Benign tumor of neural origin
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Can manifest as enlarged intervertebral foramina seen on oblique radiographs
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Malignant degeneration to fibrosarcoma can occur, which may manifest as new-onset neurologic deficit.
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Malignant primary skeletal lesions
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Diagnosis
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Osteosarcoma, Ewing sarcoma, and chondrosarcoma are uncommon in the spine.
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When they occur they are associated with a poor prognosis.
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Treatment
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Chemotherapy and irradiation are the mainstays of treatment, but aggressive surgical excision may have a role.
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The lesions may actually be metastases, which are treated palliatively.
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Lymphoma
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Can manifest as “ivory” vertebrae
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Usually associated with a systemic disease
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Lymphoma typically treated with radiation and/or chemotherapy
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Surgery typically only necessary if pathologic fracture is present
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Fibrous dysplasia
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At least 60% of patients with polyostotic fibrous dysplasia have spinal involvement, mostly in the posterior elements.
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There is a strong correlation between the presence of a lesion and scoliosis, making scoliosis screening very important in the population with polyostotic disease.
What is vertebrae plana?
l: vertebrae planae), also known as the pancake or silver dollar or coin-on-edge vertebra, is the term given when a vertebral body has lost almost its entire height anteriorly and posteriorly, representing a very advanced compression fracture.
Think EG in children
Review epidural abcess
Note: T1 with gad-the abcess is brighter than csf.
Introduction
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Bacterial infection that results in accumulation of purulent material within the epidural space
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Most abscesses located posteriorly in the thoracic and lumbar spine
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Can frequently extend across multiple segments
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Diagnosis
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History
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Back pain is the most common presenting symptom, followed by neurologic deficit and fever.
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Diagnosis is delayed in half of patients.
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Patients are frequently more systemically ill than patients with osteodiscitis and osteomyelitis.
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Risk factors include IV drug abuse, diabetes, and multiple medical problems.
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Laboratory findings—elevated ESR and CRP values (often more elevated than in osteodiscitis)
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Imaging
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MRI—modality of choice; supplementation with gadolinium allows differentiation between epidural abscess and CSF.
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Abscess and CSF have high signal intensity on T2-weighted images.
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Gadolinium enhances the pus on T1-weighted images, whereas CSF remains low signal.
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Management
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Typically surgical—urgent evaluation and treatment
Laminectomy is performed if the epidural abscess is predominantly posterior.
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If there is concomitant vertebral osteomyelitis, anterior and posterior decompression is performed.
Review spinal TB
Most common extrapulmonary location of tuberculosis
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May be seen in HIV-positive population with a CD4+ counts of 50–200/μL
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Originates in the metaphysis of the vertebral body and spreads under the anterior longitudinal ligament (Figs. 8.23 and 8.24)
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This process leads to destruction of several contiguous levels or results in skip lesions (15%) or abscess formation (50%).
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Diagnosis
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On early plain radiographs, anterior vertebral body destruction with preservation of the disc distinguishes tuberculosis from pyogenic infection.
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About two-thirds of patients have abnormal chest radiographs, and 20% have a negative test result for purified protein derivative of tuberculin or are anergic.
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Severe kyphosis, sinus formation, and (Pott) paraplegia are late sequelae.
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Spinal cord injury may occur secondary to direct pressure from the abscess, bony sequestra, or (rarely) meningomyelitis (poor prognosis).
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Treatment
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Nonoperative—antitubercular therapy is the mainstay of treatment. Frequently, triple and even quadruple therapy is required.
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Surgical indications
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Neurologic deficit
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Spinal instability
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Progressive kyphosis
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Failure of medical management
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Advanced disease with caseation, fibrosis, and avascularity that limits antibiotic penetration
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Procedure
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Radical anterior débridement of the infection followed by uninstrumented autogenous strut grafting (Hong Kong procedure) is the accepted surgical treatment.
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However, later evidence supports the use of instrumentation if necessary in the presence of spinal tuberculosis.
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Advantages include less progressive kyphosis, earlier healing, and a decrease in sinus formation.
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Adjuvant antitubercular therapy beginning 10 days before surgery has been recommended (controversial) but is not always possible.
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Use of antitubercular medications after surgery is mandatory.
Review Vertebral osteomyelitis
Introduction
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Seen with increasing frequency
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Commonly still associated with a significant (6- to 12-week) delay in diagnosis
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Organism usually hematogenous (S. aureus in 50%–75% of cases)
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Diagnosis
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History and physical examination
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Older, debilitated patients
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IV drug users are at increased risk.
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History of unremitting spinal pain at any level is characteristic, and tenderness, spasm, and loss of motion are seen.
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More common in patients with a history of pneumonia, urinary tract infection, skin infection, or immunologic compromise (transplantation, RA, diabetes mellitus, human immunodeficiency virus [HIV positivity with CD4+ counts <200 cells/μL])
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Fungal spondylitis can be seen in patients with immunologic compromise.
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Neurologic deficits—seen in older patients, patients with infections at more cephalic levels of the spine, patients with debilitating systemic illnesses such as diabetes or RA, and those with delayed diagnoses
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Laboratory findings—elevated ESR, CRP, and WBC count (often high normal or mildly elevated)
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Imaging
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Plain radiographic findings
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Osteopenia
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Paraspinous soft tissue swelling (loss of a psoas shadow)
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Erosion of the vertebral end plates
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Disc destruction (disc space preserved in metastatic disease)
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Bone scanning is sensitive for a destructive process.
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MRI
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Sensitive for detecting infection and specific in differentiating infection from tumor
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Gadolinium enhances MRI sensitivity (Fig. 8.22).
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Tissue diagnosis via blood cultures or aspiration of the infection is mandatory.
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Treatment
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Nonoperative
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After tissue diagnosis, 6–12 weeks of IV antibiotics is the treatment of choice.
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Bracing may be used adjunctively.
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Operative
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Open biopsy is indicated when a tissue diagnosis has not been made.
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Anterior débridement and strut grafting are reserved for refractory cases that are associated with abscess formation or cases involving neurologic deterioration, extensive bony destruction, or marked deformity.
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Posterior surgery is usually ineffective for débridement; posterior stabilization may occasionally be required after anterior débridement and strut grafting.
Osteodiskitis
children more often affected
Osteodiscitis—disc space infection
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Introduction
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Bloodborne infection can primarily invade the disc space in children.
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Staphylococcus aureus is the most common offender, but gram-negative organisms are common in older patients.
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Diagnosis
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Although all age groups are affected, children (mean age, 7 years) are affected more often.
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Presentation
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History—may or may not include recent spinal procedure such as spinal injection
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Inability to walk, stand, or sit
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Back pain/tenderness
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Restricted range of motion
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Laboratory findings—elevated ESR, CRP, and WBC count (often high normal or mildly elevated)
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Imaging
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Radiographic findings
Loss of normal lumbar lordosis—earliest finding
Disc space narrowing
End plate erosion
Findings do not occur until 10 days to 3 weeks after onset, and their absence is unreliable.
MRI with gadolinium is the diagnostic modality of choice.
•
Bone scan may be useful in the diagnosis as well.
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Treatment
Typically medical
Percutaneous biopsy should be obtained if possible.
IV antibiotics should be held until biopsy performed (if possible) to reduce incidence of negative culture results.
Antibiotic therapy should be targeted once culture and sensitivity results are known.
how to differential mets vs osteo in the spine
disk space normal in metastatic disease
disk space disrupted in infection
DISH vs AS vs PLL
inflammatory
what are the biologic or autoimmune medications for AS
TNF-a inhibitors are biological agents approved for 2nd-line treatment of AS. These include etanercept, infliximab, adalimumab, golimumab, and certolizumab pegol, which are all approved for treatment of RA and psoriatic arthritis as well. Additional biological agents unique to RA are IL1 antagonists (e.g. anakinra), B cell inhibitors (rituximab), T cell inhibitors (abatacept), IL6 receptor inhibitors (tocilizumab) and Janus kinase (JAK) pathway inhibitors (tofacitinib).
