O&T SC055: Spine Related Pain

Question 1

Spine function

Answer 1

1. Protect spinal cord
2. Transfer loads (through disc, facet joints)
3. Trunk support (through muscle attachments)
4. Motion (flexion / extension, lateral flexion, rotation)
5. Chest wall attachment (e.g. ribs, musculature to maintain respiratory function)

Question 2

Neck / Low back pain

Answer 2

• Low back pain most disabling
• Prevalence up to 83% in one’s lifetime
• Musculoskeletal issues are highest burden in terms of global disease
• 20% patients seen in GP complains of back / neck problems

Back pain:
- Mostly benign
—> 60% subside in 1 week
—> 90% in 6 weeks
—> 95% in 12 weeks
- Variable severity

Question 3

Approach to Back pain

Answer 3

1. Identify cause
2. Rule out sinister condition
3. Localise source of pain by P/E
4. Guide appropriate investigations + treatment

Question 4

***DDx of Back pain

Answer 4

Mechanical pain (97%):
1. Back sprain (>70%)
2. Lumbar disc degeneration
3. Lumbar disc herniation
4. Spondylolisthesis
5. Fracture
- Vertebral body
- Spondylolysis

Non-mechanical (3%):
1. Neoplasia
2. Inflammatory arthritis (AS / Spondyloarthropathy)
3. Infection
4. Non-spinal diseases
- Pelvic inflammatory disease
- Endometriosis
- Nephrolithiasis, Pyelonephritis
- Aortic aneurysm

Common causes:
1. Myofascial sprain
- heals quick ~4 weeks
- by strenuous activity
- avoid provocative activity
2. Facet joint degeneration (back pain + referred pain)
3. Disc degeneration
- outer annulus of disc
- facet joint capsule
- chemical and mechanical irritation of nerve root

Question 5

***History taking of Back pain

Answer 5

1. Onset
   - Acute (<1 month): fracture, infection
   - Subacute (1-2 months): tumour, infection (e.g. TB)
   - Chronic (>3-6 months): degenerative, claudication
2. Radiation / Leg pain
   - Lower back to paraspinal musculature, SI joint, buttocks, posterior thigh
   - Extension below knee —> indicate ***nerve root is involved —> follows dermatome
3. Mechanical vs Inflammatory
   - Mechanical: pain when moving
   - Inflammatory: pain at rest, improve with moving
4. Aggravating factors
   - Heavy exertion, repetitively bending, twisting, heavy lifting
   - Pain on lumbar flexion (disc herniation)
   - Pain on extension and rotation / lateral flexion (facet joint)
   - Pain on walking / leg symptoms (**spinal claudication / **spinal stenosis)
5. Night pain (sinister)
6. Neurological deficit
   - **Claudication distance (indicate severity)
   - **Sciatica (Radicular pain)
   - Numbness
   - Weakness
   - Unsteady gait (in severe motor deficit / cord compression resulting in proprioceptive loss)
   - Sphincter control
7. Constitutional symptoms (fever, weight loss, appetite loss)
8. Previous treatment (e.g. Failed back syndrome: chronic pain following back surgeries)

Other history:
9. Age (inflammatory, sarcopenia)
10. Smoking, DM, Immunosuppression, Drug abuse
11. Malignancy (past / family history)
12. Degree of limitation of pain (work, sleep)
13. Psychological state / emotional distress

**Red flag signs:
Raise suspicion for spine **fracture, **tumour, **infection, **inflammatory disease, **Cauda equina syndrome
- Age <20, >55
- History of trauma
- History of immunosuppression (DM, steroid, drug addict)
- History of malignancy
- Neurological deficit
- Deformity (indicate long standing / severe condition)
- Night / Rest pain

Question 6

Claudication vs Sciatica vs Radiculopathy

Answer 6

Claudication / Neurogenic claudication:
- Usually refer to **Spinal stenosis
- **Pain on extension (↓ canal size + foramina size), **improve with flexion / rest (↑ canal size + foramina size)
- **Upright standing / ***Walk certain distance —> develop burning / numbness / pain in lower limbs —> usually cannot tell exact dermatomal location (usually vague sensation)

(Vascular claudication:
- Calf spasms (vs Burning / Numbness pain)
- Relieved by resting (vs Flexion in neurogenic claudication)
- Atrophic changes in toes, loss of hair
- Loss of pulses)

Sciatica:
- Pain radiating down the leg
- Radicular pain in certain distribution (e.g. calf, foot dorsum)
- A type of radiculopathy

Radiculopathy:
- Pain related to single nerve root —> single dermatome
- Pain on walking / certain positions (e.g. sitting, flexion)
- Indicate ***disc pathology causing spinal stenosis

NB:
1. Can have both sciatica and claudication at the same time in nerve root compression
2. There is NO lumbar myelopathy (∵ cauda equina —> all are nerve roots)

Question 7

***Red flag signs

Answer 7

Raise suspicion for spine **fracture, **tumour, **infection, **inflammatory disease, ***Cauda equina syndrome
- Age <20, >55
- History of trauma
- History of immunosuppression (DM, steroid, drug addict)
- History of malignancy
- Neurological deficit
- Deformity (indicate long standing / severe condition)
- Night / Rest pain

Question 8

***P/E of Spine

Answer 8

Look:
1. Deformity

2. Standing posture
   - Cervical lordosis
   - Thoracic kyphosis
   - Lumbar lordosis
3. ***Listing
   - Herniation lateral to nerve root (compressing on “shoulder” of nerve root) —> lean to contralateral side
   - Herniation medial to nerve root (compressing on “axilla” of nerve root) —> lean to ipsilateral side
4. Muscle atrophy (indicate chronicity ∵ denervation of muscle)
5. ***Modified Schober test
   - Assessment of spine movement (Flexibility)
   - Disc herniation will cause limitation in flexion
6. ***Gait (may indicate cord compression)

Feel:
1. Tenderness
- Muscle
- Spinous process
- SI joint
- Hip

2. Tone (UMN vs LMN lesion)

Move:
1. ROM
- Forward flexion / extension
- Lateral flexion

2. Neurology
   - Motor
   - Sensory
   - Reflex

Special test:
1. **Straight leg raise test / Lasegue test / Bowstring test
- Patient lying supine —> Passive elevate leg in a straight leg —> stretch **sciatic nerve (L4-S3) —> pain (Normal: 70o) (positive: radicular dermatomal pain, same type of pain as patient’s experience, <70o)
—> **Cross straight leg raise test —> lift contralateral normal leg —> pain in problem side (∵ pulling of involved nerve root against axillary / posteromedial compression, negative in shoulder / far lateral compression)
—> **Lasegue test (confirmation test) —> lower leg a bit until no pain —> passive dorsiflex ankle to reproduce pain
—> ***Bowstring test —> gradually flex knee until no pain —> compress on popliteal fossa to reproduce pain (Alternative: 90o flex hip, 90o flex knee, extend knee until pain, drop a bit then compress on popliteal fossa)

2. Femoral nerve stretch test
   - Prone position —> Hip extension —> stretch ***femoral nerve (L2-L4)
3. Circulation (Vascular problems can always mimic spinal problems)

Question 9

***Investigations of Back pain

Answer 9

Infection:
1. WBC
2. ESR (high blood fibrinogen causes RBC to stick to each other) (chronic cause)
3. CRP (6-8 hours after onset of infection) (acute cause)

Burn turnover markers (Malignancy):
4. ALP
5. Globulin
6. CaPO4

Malignancy:
7. Serum protein electrophoresis (Multiple myeloma)
8. Tumour markers (e.g. CEA, CA19.9, PSA)

Imaging
- Treat symptoms not images
- Imaging should be confirmatory tests
- Must explain to patients the reason for MRI

9. X-ray
   - correlation with symptoms
   - positive history
   - malignancy and infection
   - false assurance? (False negative ∵ not completely sensitive to diseases esp. in early stages)
10. CT
    - assess fracture configuration
11. CT myelogram
12. MRI
    - assess disc, soft tissue, canal pathologies
    - nerve compression
    - sinister pathologies (e.g. tumours, infection)
    - confirmation of lesions

Question 10

***Interpret X-ray of Spine

Answer 10

1. Alignment
   AP view:
   - Spinous process (rotation / malalignment, scoliosis)
   - Lateral edge of Vertebral body (laterolisthesis)

Lateral view:
- Anterior longitudinal ligament (spondylolisthesis)
- Posterior longitudinal ligament (retrolisthesis)
- Spinal laminar line
- Spinous process
- Normal curvature of spine (Lordosis, Kyphosis)

2. Bone
   - Size + Height
   - Vertebral body (↑ size from cranial to caudal in lumbar spine)
   - ***Pedicles (erosions may indicate metastasis)
   - Transverse process (attachment of psoas, if psoas pull too hard —> transverse process fracture)
   - Spinous process
3. Collapse
4. Disc space
   - Smooth
   - Largest on L4/5 —> L5/S1 —> L3/4
5. End plates
   - Smooth
6. Foramen (Lateral view)
7. Girdle (SI joint)
   - Erosion / Fusion
   - Sclerosis line
8. Height
9. Iliopsoas shadow
   - Tumour / Abscess / Haematoma can disrupt outline
10. Interarticularis (below pedicle of each level)

Question 11

1. Discogenic back pain

Answer 11

• Back pain caused by disc herniation
• Worse in forward ***flexion postures
  —> Sitting
  —> Bend forward to tie shoes

Pathophysiology of Disc herniation:
Rim lesion
—> Annulus tear
—> Lose ability to absorb shock
—> Shortened disc space
—> Herniated nucleus pulposus
—> Herniated content go into spinal canal
—> Nerve compression + Leg symptoms

Pain caused by:
1. **Biomechanical problems (Modic changes —> instability of spine)
2. **Cytokine release (Inflammatory)
3. ***Ingrowth of nerve and vasculature to the disc after annular tear

Features on X-ray:
- Disc space narrowing

Features on MRI:
- **High intensity zone in disc (inflammatory lesions at anterior / posterior aspect of annulus —> indicate **annulus fissure)
- ***Darker disc (degenerated disc)
- Posterior annulus fissure
- Compression of nerve root

Treatment:
Conservative:
1. Avoid flexion posture
2. Injection of LA in area of annulus tear to reduce pain —> but controversial since puncture can lead to more damage / degeneration of annulus

Surgery:
1. Decompression (RFA to cut away protruded segment of disc —> but do not treat pathology —> if heavy loading again disc can still progress to prolapse)
2. Spinal fusion

Question 12

2. Facet joints

Answer 12

• 2 Facet joints per spinal segment
• Sliding joints with ***lots of nerve fibres (dorsal rami of spinal nerve)

Facet joint arthrosis:
- Pain on **extension
- **Lateral extension for side of facet joint arthrosis
- Indicates overload of facet joints —> part of **Disc degenerative cascade (Disease origin at the **disc —> degeneration of disc —> overload facet joint —> ***spondylolisthesis)
- Bright signal in T2 weighted MRI due to edema

Hypertrophy of facet joint:
- ***Narrowing of intervertebral foramen

Treatment:
1. Back muscle strengthening
2. Facet joint injections of LA / Steroids

Question 13

3. Spondylolysis

Answer 13

***Pars interarticularis defect / fracture —> discontinuation of adjacent vertebra

Clinical features:
1. LBP with insidious onset (can be acute if acute hyperextension (e.g. diving, weight lifting, gymnastic))
2. Radicular symptoms only with **Spondylolisthesis (only in severe case will Spondylolysis develop into Spondylolisthesis) (Pars defect alone does not compress nerve root)
3. **Hamstring spasm (flexed hips + knees)
4. Shortened stride length
5. ***Flattened lordosis

Investigations:
1. X-ray
- Oblique view for “Scotty dog” appearance: break in pars —> break in dog’s neck
2. Single photon emission CT (SPECT): increased radionuclide uptake as stress reaction
3. CT
4. MRI

End-stage degeneration:
- **Spondylolisthesis
—> Radiological instability
—> **Spinal stenosis by kinking centrally / compression by superior articular process impingement at foramen / excessive movement can also cause osteophytes, ligamentum flavum hypertrophy

Treatment:
1. Rehabilitation
- core strengthening to prevent progression

2. Protect in acute cases
   - bracing
   - activity avoidance
   - resume all activities once symptoms resolve
3. Surgery
   - rarely needed
   - stabilise spine
   - high grade slips in adolescents
   - non-union fracture
   - neurological symptoms

Question 14

Spondylolisthesis

Answer 14

Many types / causes:
1. Degenerative of facet joints (elderly)
2. Spondylolysis (younger)
Etc.

Causes: (SpC Revision)
1. Dysplastic (Congenital malformations)
2. Isthmic (i.e. Pars fracture) (Stress fracture in gymnast who arches back a lot, Elongation of pars due to various reasons) (common, can slip >25%)
3. Degenerative (Loss of disc height: usually only minor slip <25%)
4. Traumatic
5. Pathologic (Pagets, Metastatic disease)
6. Iatrogenic (After surgical excision)

Question 15

4. Spinal stenosis

Answer 15

Spinal canal narrowing with possible ***nerve root compression

Causes:
1. IV disc herniation (but with positive SLR test (self notes))
2. Osteophytes
3. Facet joint hypertrophy
4. Ligamentum flavum hypertrophy

Clinical features:
1. **Neurogenic claudication
- **Walking increases severity of burning / aching pain, numbness (dermatomal), paresthesia, subjective / objective weakness
- **Pain on extension (↓ canal size + foramina size), **improve with flexion / rest (↑ canal size + foramina size)
- Burning / Numbness in lower limbs
2. Leg / Back pain
3. **Motor deficit
4. **Sensory disturbance
5. Reflex alterations
6. ***SLR test negative (SpC Revision)
7. Lots of symptoms but no signs on examination (e.g. -ve SLR test) (SpC Revision)

Cauda equina syndrome:
- Severe stenosis
- **Acute LBP
- **Sciatica
- **Saddle paresthesia
- LL weakness
- Gait dysfunction
- **Sphincter incontinence
- Bimodal distribution:
—> Young: Large central disc herniation (after acute trauma)
—> Elderly: Chronic deterioration of spinal stenosis

Treatment:
1. Surgery
- Dural sac + Nerve root decompression —> target cause of stenosis

Question 16

Spinal canal anatomy

Answer 16

Part:
1. Central

2. Lateral recess
   - bound by medial border of facet joint + intervertebral foramen laterally
   - nerve root of **next lower level (aka **traversing nerve root) start to exit
   - compression of nerve roots a level below (L3/4 disc compress L4 nerve root)
3. Foraminal
   - nerve root of ***same level exited

Question 17

5. Sacroiliac joint pain

Answer 17

• Mimic back pain (esp. buttock pain)
• Usually diagnosis of ***exclusion

Treatment:
1. Conservative (Majority)
- Physiotherapy
- Analgesic
- Injection

2. Surgery (Very rare)
   - Fusion

Question 18

6. Ankylosing spondylitis / Spondyloathropathy

Answer 18

• Axial vs Peripheral
• ***Asymmetrical peripheral arthritis
• Affects women as well as men (M>F)
• Familial aggregation
• Association with ***HLA-B27 (not diagnostic)
• Rheumatoid factor ***negative (Seronegative)

Early diagnosis important:
1. **Clinical
2. Radiological (MRI?)
- SI joint eroded —> sclerotic —> fusion
- **Syndesmophytes + ossification of anterior / posterior longitudinal ligaments (caudal to cranial) —> connecting adjacent vertebrae together —> very stiff spine (“Bamboo spine”)
- ***Enthesitis
3. Blood tests

Inflammatory back pain:
- Onset of back pain before 40 yo
- Insidious onset
- Persistent for >=3 months
- Morning stiffness
- Improve with exercise

P/E:
1. **Schober test
- midpoint of PSIS + 10cm above
- bend forward
- normal >5cm increase
2. **Occiput-to-wall test
3. ***Chest expansion

Question 19

7. Global imbalance

Answer 19

Degenerative scoliosis / Adult deformity

Clinical features:
1. Coronal
- Truncal translation, shoulder / pelvis asymmetry
- Rib on pelvis impingement

2. Sagittal
   - Unable to stand upright, forward stooping posture
   - Muscular fatigue and discomfort, decompensation with walking
   - Hip extensor weakness (∵ chronic use to maintain upright posture)
3. Postural imbalance
   - Cone of economy
   —> body can remain balanced in only a narrow range (esp. narrow in spine deformity)
   —> deviation from stable zone
   —> increased muscle / energy use
   —> mechanical disadvantage

Treatment:
1. Surgery

Question 20

8. Osteoporotic vertebral fracture with non-union

Answer 20

History:
- May not have injury —> ∵ Fragility fracture in osteoporosis
- An episode of sudden increase in back pain
- Gradual decreased mobility

Clinical features:
1. No pain —> Increasing pain on posture change —> Pain decrease after settling
2. Usually fracture can heal —> but with non-union —> big gap —> instability —> **neurological symptoms
3. Neurological symptoms
4. **Kummel’s disease
- 6-8 weeks after vertebral collapse —> osteonecrosis of remaining posterior body (∵ lack of blood supply) —> further collapse due to weakened bone —> sudden deterioration of neurology (∵ instability causing nerve compression)

X-ray:
1. **Decreased vertebral height
2. **Intra-vertebral lucency
3. Provocative radiograph: Opening up on extension (Vacuum sign) —> instability
4. Provocative test: Marked pain

MRI:
1. Fluid signal inside vertebra —> ∵ accumulation of fluid in non-union space

Treatment:
1. Conservative
- If only collapse
- Symptomatic relief —> Fracture usually heals

2. Surgery
   - Neurology —> Decompression
   - Instability —> Stabilise (posterior fixation feasible) —> Cement injection
   - Deformity (usually kyphotic) —> Correction (to avoid imbalance)

Difficult in osteoporosis:
1. Multiple fractures
2. Poor recipient bone for fusion
3. High non-union rate
4. Stress riser after stabilisation (adjacent level fractures + collapse ∵ implant are rigid)
5. Elderly with co-morbidities

Question 21

9. Metastatic spinal tumour

Answer 21

Clinical features:
1. Rest / Constant pain
2. Constitutional symptoms
3. History of malignancy

X-ray:
- Destruction not evident until after 30-50% of cancellous bone destroyed
- **Winking owl sign (classical finding on AP, erosion of pedicles —> **asymmetrical collapse)

Treatment:
1. Understand the pathology
- Tumour type
- Prognosis
- Organ involvement
- **Adjuvant options available to patient? —> if yes than separation surgery may be needed to facilitate adjuvant therapy
- **Potential targeted therapies (histological diagnosis): EGFR, TFF-1

2. Surgery
   - Palliative decompression
   - Tumour debulking
   - Separation surgery (separate tumour from spinal cord to allow stereotactic body RT —> avoid radiation neuritis)
   - En bloc excision (in single level involvement with high life expectancy)

Question 22

10. Infection

Answer 22

Indications for surgery:
1. **Neurological compromise
2. Abscess
3. Biopsy for uncertain diagnosis
4. Disease progression, uncontrolled symptom
5. Late **deformity and ***instability due to bone erosion (relative)

Aims:
1. **Pathology for specimen
2. **Abscess drainage
3. ***Debridement of dead tissue
4. Stabilisation

TB vs Pyogenic infections:
- More indolent, slow growing
- Less prominent clinical symptoms initially
- More bone loss
- ***Subligamentous spread (e.g. spread along underneath posterior longitudinal ligament to other levels) (Pyogenic infection: can break through ligament —> cause abscess)

(From JC Surgery: Spinal infections
Causative agents (most common —> least common):
1. Bacterial
2. Mycobacterial
3. Fungal
4. Parasitic

Pathologies:
1. **Spondylodiscitis (Most common, infection of **Vertebral body + Disc space)
2. **Spondylitis (TB)
3. **Paraspinal abscess (e.g. Psoas abscess, Abscesses at paraspinal muscles)
4. ***Epidural abscess (cause neurological deficits)
5. Discitis (Children)
6. Facet joint septic arthritis)

Question 23

General management of Back pain (SpC Revision)

Answer 23

1. Analgesia
2. Physiotherapy
   - Mobilisation + Exercise (Hydrotherapy)
   - Education
   - Physical modalities
   —> Traction
   —> USG
   —> Interferential
   —> Heat
3. Surgery
   Indications:
   - Loss of bladder / bowel control
   - Progressive neurological deficit
   - Persistent pain despite conservative treatment

Techniques:
- Discectomy alone
- Posterior fusion
- Instrumentation
- Decompression

Question 24

DDx of Neck pain

Answer 24

• Axial neck pain (midline, focal tenderness in C-spine) vs Radicular neck pain (radiation, nerve root involvement)
• Radiation (dermatomal)
  —> Occiput (may cause dizziness)
  —> Periscapular
  —> Upper limb

Common causes:
Mechanical:
1. Degenerative disc / facet
2. Nerve compression
3. Cervical instability (inflammatory / congenital)
4. Soft tissue injury

Non-mechanical:
1. Inflammatory arthritis
2. Neoplastic

Question 25

***P/E of Cervical spine

Answer 25

Look:
1. Head + Neck posture (e.g. torticollis, protracted / retracted head posture)
2. Muscle wasting
- Shoulder (deltoid, rhomboid, trapezius)
- Back
- Scapular
3. C-spine (Front + Lateral)
- Front: Lateral deviation
- Lateral: Lordosis

Feel:
1. ***Tenderness along C-spine
- Spinous process
- Paraspinal muscles
- Compression of hyoid bone (C3 vertebra), thyroid cartilage (C4/5 vertebra), cricoid ring (C6 vertebra), carotid tubercle of C6 vertebra —> may elicit tenderness in cervical spine
2. Stepping
3. Shoulder problem? (Neck pain may mimic shoulder problem)

Move:
1. ROM
- Flexion / Extension
- Lateral flexion
- Rotation
2. Shoulder examination

Neurological exam:
1. **Motor
- Myotomes
- Muscle power (apart from active movement against resistance / gravity, MUST also have **full ROM)

2. ***Sensory
   - Dermatomes
   - ASIA Sensory 3 point scale (Pinprick + Light touch)
   —> 0: Absent
   —> 1: Different compared with face
   —> 2: Normal
   —> Total sensory index score: 112 (56 per side)
3. Dexterity (Fine motor functions of hands)
4. Coordination
5. ***Proprioception (Romberg’s test)
6. ***Gait
7. ***Sphincter

Special tests:
1. Alignment
2. **Lhermitte sign
- flexion of neck —> cervical instability (e.g. C1/2 subluxation) —> **cord compression —> sharp radiating symptoms down all 4 limbs
3. **Spurling test (~ Straight leg raise test in Lumbar spine)
- lateral flexion + extend + axial compression on head to narrow foramen —> **radicular pain
4. **Cervical myelopathy signs
- Upper limb: **Myelopathic hand signs
- Lower limb: Spasticity, Clonus, Brisk jerks, Babinski upgoing, Romberg’s test, Gait

Significance:
- Examination provides symptomatic disc level
- Spinal cord ascends during development —> disc lie opposite to cord segment **one lower than root passing them (i.e. L4/5 disc herniation —> compress on L5 nerve root + **L6 cord)

Question 26

Dermatomes and Myotomes

Answer 26

Dermatomes:
- C4: Shoulder
- C5: Lateral elbow
- C6: Thumb
- C7: Middle finger
- C8: Little finger
- T1: Medial elbow / axilla

Myotomes:
***C3-5: Diaphragm

C5: Elbow flexors (Biceps)
C6: Wrist extensors (Extensor carpi radialis)
C7: Elbow extensors (Triceps)
C8: Finger flexors (Long flexors of digits: DIP flexion)
T1: Intrinsic hand muscles (Finger abductors: ADM)

L2: Hip flexors (Iliopsoas)
L3: Knee extensors (Quadriceps)
L4: Ankle dorsiflexors (Tibialis anterior)
L5: Long toe extensors (Extensor hallucis longus)
S1: Ankle plantar flexors (Gastrocsoleus)
S2: Anal sphincter

Question 27

Investigations of Neck

Answer 27

1. Blood tests
2. X-ray
   - Oblique views (for ***Neuroforamen)
3. Myelograthy (rare now)
4. CT (fracture)
5. MRI
   - cord compression
   - disc herniation
   - structural pathologies

Question 28

***Interpret X-ray of Neck

Answer 28

1. Alignment
   - ***Pre-vertebral / Retropharyngeal soft tissue shadow
   —> at C2 level: soft tissue thickness anterior vertebra should be <1/2 width of vertebral body (2-3mm)
   —> at C4 level: soft tissue starts widening (3-4mm) (∵ epiglottis + esophagus)
   —> at C7 level: < entire width of vertebral body
   —> children: “apparent” thicker soft tissue due to cartilaginous bone making vertebral body smaller
   - Anterior longitudinal line
   - Posterior longitudinal line
   - Spinal laminar line
   - Spinous process (AP (rotation / malalignment) + Lateral view)
   - Normal cervical lordosis
2. Bone
   - Size + Height
   - Vertebral body (~ size in all cervical vertebrae)
   - Lateral mass (facet joint in-between)
   - Spinous process
   - Uncovertebral joints
3. Collapse
4. Disc space
   - Smooth
   - Similar size in all cervical levels
5. End plates
   - Smooth
6. **Flexion instability
   - **Anterior Atlantodental interval (AADI): distance between posterior aspect of anterior C1 arch and anterior border of C2 dens —> should be **same in flexion + extension (~4mm)
   - **Posterior Atlantodental interval (PADI): distance between anterior aspect of posterior C1 arch and posterior border of C2 dens (>11mm)
7. Risk factors
   - Developmental stenosis: Pavlov ratio (spinal canal diameter: vertebral body ratio —> usually 1:1)
   - Dynamic stenosis (flexion vs extension): distance between Inferior posterior angle of vertebral body to Superior anterior portion of spinous process at ***a level below (>11mm)

Question 29

1. Disk herniation

Answer 29

• Cervical less common vs Lumbar (∵ less stress)
• Repetitive strain —> nucleus pulposus loses competence —> annular tear —> radial fissures —> nucleus pulposus herniation ***“Soft disk” (Degeneration —> Prolapse —> Extrusion —> Sequestration)

2 mechanisms of radiculopathy:
1. Inflammation of nerve root
- proteoglycans / phospholipase from nucleus pulposus initiates inflammatory cascade
2. Direct compression of nerve root

3 types of compression:
1. ***Intraforaminal
- Motor + Sensory deficit
(- Horner’s syndrome (if compress on sympathetic ganglion))

2. ***Posterolateral
   - Motor-predominant deficit (∵ compress mainly on ventral roots)
3. **Midline
   - **Myelopathy

Question 30

2. Cervical spondylosis

Answer 30

Degeneration of cervical spine (NOT indicate nerve compression)
- Degenerative disk —> Disk collapse —> Uncovertebral joints come into contact + facet joints overload —> osteophytes ***“Hard disk” —> nerve compression

Contact points between cervical spine:
- 2 facet joints
- 2 uncovertebral joints
- IV disc

Facet arthrosis (facet arthropathy):
- Articular cartilage degeneration
- Inflammation
- Synovitis
- Capsular contracture
- Uneven load bearing
- Osteophyte formation
—> ALL can lead to pain

Treatment:
1. Conservative
- Physiotherapy
- Traction
- Muscle strengthening
- Analgesic

2. Surgery
   - No evidence for cervical spondylosis
   - Indications: **Neurology, **Instability, ***Deformity

Question 31

Radiculopathy vs Myelopathy (+ SpC Revision)

Answer 31

Radiculopathy:
- Root compression (LMN)
- Dermatomal (Radiating pain)
- Numbness + Weakness
- Hyporeflexia
- Spurling’s test +ve
- Wax + wane
- Self-limiting (80%), Progression uncommon
- Sensory only

Myelopathy:
- Cord compression (UMN)
- Numbness + Clumsiness + Spasticity
- Hyperreflexia: Clonus / Upgoing Babinski
- Hand signs +ve: 10 second test, Hoffman, Finger escape
- Lower limb involvement
- Downhill course, Slow stepwise worsening
- 3 types of progression: Episodic progression (75%), Steady progression (20%), Rapid deterioration (5%)

Question 32

3. Cervical radiculopathy

Answer 32

• Root irritation
• Compatible spinal level

Clinical features:
- Sharp pain and tingling / burning sensations (Dermatomal)

Causes:
1. **Disc degeneration / herniation
2. **Osteophytes (at uncovertebral joint / facet)

DDx:
1. **Peripheral entrapment syndromes
2. **Rotator cuff / shoulder pathology
3. ***Brachial plexus neuritis
4. Herpes zoster
5. Sympathetic mediated pain syndrome
6. Intraspinal / Extraspinal tumour
7. Epidural abscess
8. Cardiac ischaemia

Investigations:
1. X-ray C-spine (for ***Spondylosis features)
- AP / Lateral: Disc space narrowing, Osteophyte
- Oblique: Foraminal stenosis

2. Electrophysiological studies
   - NCV, Needle EMG
   - “Extension of physical examination”: useful if equivocal P/E findings (e.g. complex neurologic deficit patterns e.g. mixture of DM neuropathy + cervical radiculopathy)

Treatment:
1. Conservative
- Medication / Injection
- Neck exercise
- Physiotherapy
- Avoidance of poor posture to prevent occurrence

2. Surgery
   - Persistent symptoms despite conservative treatment that are compatible with imaging (i.e. make sure not other causes leading to radiculopathy e.g. DM neuropathy)
   - Motor deficit
   —> Facet joint, Osteophyte: Posterior approach
   —> Disc: Anterior approach

Question 33

4. Cervical myelopathy

Answer 33

• ***Grey matter (cell bodies) more susceptible —> not recover
• Deterioration
  —> 70% do
  —> Stepwise / Slow / Rapid

Causes:
1. ***Spondylotic myelopathy
- Anterior: Disc herniation, OPLL (ossification of posterior longitudinal ligament)
- Posterior: Ligamentum flavum hypertrophy
- Lateral: Facet joints hypertrophy

2. ***Cervical instability (e.g. C1/2 instability)
   - Posterior arch impinge in spinal canal
3. Spinal tumour (SpC Revision)

DDx:
- ***Peripheral neuropathy

Clinical features:
1. Non-specific symptoms
2. Generalised fatigue
3. **Numbness in upper + lower limbs
4. Weakness
5. **Clumsiness of hands (loss of fine motor)
6. **Loss of balance (Wide-based gait)
7. **Gait disturbance (Stiff knee / Spastic gait / Wide-based gait)
8. Bladder and bowel impairment
9. Neck pain (usually **none except in **Cervical spondylotic myelopathy: pain due to degeneration of disc / facet joint)

Investigations:
1. X-ray
- look for risk factors
—> Developmental stenosis: Pavlov ratio (spinal canal diameter: vertebral body ratio —> usually 1:1)
—> Dynamic stenosis (flexion vs extension): distance between Inferior posterior angle of vertebral body to Superior anterior portion of spinous process at ***a level below (>11mm)

2. MRI
   - T2 myelomalacic changes: “Snake eyes” —> cystic necrosis + early proton changes (white signals) in grey matter —> ***cell body undergo degeneration
   - T1 hypointensity (black spots in spinal cord)
   —> poor prognosis for myelopathy recovery

Treatment:
1. Surgery
- Laminoplasty (increase size of space from anterior aspect of spinous process to posterior vertebral body)
- **Anterior spinal decompression + fusion
(2. Prophylactic decompression for stenotic patients?)
(*NO conservative treatment ∵ myelopathy will always deteriorate)

Outcome measures:
1. ***Modified Japanese Orthopaedic Association Score (mJOA)
- Motor dysfunction of UL, LL
- Sensation
- Sphincter problem
- Total of 17

2. JOACMEQ
   - Patient perceived outcomes

Question 34

***Cervical myelopathy signs

Answer 34

1. UMN signs
   - Spasticity
   - Brisk jerks
   - **Inverted supinator reflex (C5/6 lesion)
   - Scapulohumeral reflex (C3 cord compression) (tap on acromion / supraspinatus tendon —> shoulder elevation / upgoing deltoid shrug (abnormal))
   - **Babinski upgoing
   - **Clonus (Ankle / Knee) (abnormal reflex arch)
   - Myelopathic hand signs
2. Balance
   - ***Romberg’s sign
   - Stiff knee / Spastic gait / Wide-based gait

**Myelopathic hand signs
1. Hoffman’s sign
- wrist resting on surface + extended, one hand hold sides of middle finger MCPJ, other hand flick distal phalanx
- involuntary finger flexion (monosynaptic stretch reflex)
- disinhibition of **C8 reflex
- normal people may have

2. **10 Seconds test
   - grip and release test: **>20 within 10 seconds
   - **dyskinesia (cannot open all fingers at the same time)
   - way of open / close hand more important than number of times within 10 seconds
   - **most useful test indicating clumsiness in cervical myelopathy
3. Inverted supinator reflex (***C5/6 lesion)
   - loss of normal supinator reflex + flexion of other fingers
4. Finger escape sign (indicate intrinsic weakness, ***ulnar nerve palsy may mimic but usually unilateral)
   - grade 0-4
   —> grade 0: all finger normal
   —> grade 1: little finger unable to hold adduction
   —> grade 2: little + ring finger unable to assume adduction
   —> grade 3: little + ring finger unable to assume adduction / full extension
   —> grade 4: little + ring + middle finger unable to assume adduction / full extension

Question 35

Ossified Posterior Longitudinal Ligament (OPLL)

Answer 35

• More common in Asians
• Usually in more obese patients

Types:
1. Continuous
2. Segmental
3. Mixed
4. Circumscribed

Treatment:
- ***Posterior surgery preferred due to adhesions (allow spinal cord to float first after posterior decompression to make room for removal of PLL)

Question 36

SpC O/T Seminar: Cervical spine disorders
Basic anatomy of cervical spine

Answer 36

• 7 cervical vertebrae
• 8 cervical nerve roots
  —> C1 root exits above C1
  —> C8 root exits between C7/T1
• Spinal cord ascends during development —> disc lie opposite to cord segment **one lower than root passing them (i.e. L4/5 disc herniation —> compress on L5 nerve root + **L6 cord)

Cervical spine:
1. 5 articulations between each adjacent vertebrae
- 2 facet joints
- ***2 uncovertebral joints (an additional joint that can lead to osteophyte formation —> nerve root + vertebral artery compression)
- IV disc

2. Borders of intervertebral foramina
   - Superior: pedicle of vertebra above
   - Inferior: pedicle of vertebra below
   - Posterolaterally: facet joint
   - Anteromedially: uncovertebral joint, IV disc

Significance:
1. Allow large ROM
- Flexion 80-90o
- Extension 70o
- Lateral flexion 20-45o
- Rotation 90o
—> Prone to injury

2. Atlantoaxial (C1/2) vs Subaxial spine (C3 or below)
   - Different functions
   - Atlantoaxial: more articulation —> motion significantly higher
3. Housing cervical cord
   - Cord injury more devastating than nerve root injury in lumbar spine —> CNS lesion —> poorer prognosis
   - Upper limb + Lower limb + Respiratory function
4. Respiration
   - Intercostal / Abdominal muscles: T1-T12
   - Diaphragm: C3-5
   - Accessory muscles (Trapezius, SCM): Above C3
   - Respiratory centre in brainstem is near to cervical cord (inflammatory lesions may spread upwards)
5. Vertebral artery
   - Passing in Foramen transversarium
   - May be compressed in disc herniation, osteophytes —> Dizziness
   - May be injured during cervical spine surgery —> Stroke

Question 37

Cervical spine deformity

Answer 37

1. Kyphosis
2. C1/2 problem in Ankylosing spondylitis
3. C1/2 rotatory subluxation

Question 38

1. Kyphosis

Answer 38

Kyphosis

Causes:
1. Effect of pain and posture (poor posture to relieve pain)
2. Gravity (∵ muscle weakness)
3. Repeated stress fractures (e.g. osteoporosis)
4. Spondyloarthritis (e.g. Ankylosing spondylitis)
5. Post-laminectomy kyphosis

Problems:
- Vision
- Oral hygiene
- Feeding problem (∵ require some neck movement)
- Hyperextension of C1 (specific to ankylosing spondylitis)

Question 39

Post-laminectomy kyphosis

Answer 39

Laminectomy: Loss of surface for muscle attachment
—> Compromised posterior posterior stabilisers
—> Neck extensor fatigue

• Incidence 20%
• Younger patients: Anterior wedging
• Older patients: less common, Partial fusion

Treatment:
- Preserve facets as much as possible (esp. joints —> damage joint capsule can quicken kyphosis)
- Consider fusion

Question 40

2. C1/2 problem in Ankylosing spondylitis

Answer 40

Pathophysiology:
- C1/2 joint: last joint that fuses in AS (∵ from SI joint upwards)
—> Patient will have ***Compensatory hyperextension of C1 on C2 to look forward
—> C1 posterior arch dig into spinal canal / C1 completely dislocated from C2
—> Upper cervical cord compression
—> Cervical myelopathy

Treatment:
1. Posterior C1 arch excision
2. Widening of foramen magnum
3. Correction of overall sagittal alignment

Question 41

3. C1/2 rotatory subluxation

Answer 41

“Cock Robin” deformity (mainly in children)
1. Head tilt to ipsilateral side (∵ C1/2 facet subluxation)
2. Chin rotation to contralateral side (∵ Alar ligament tightening on one side)

Complications:
3. Eye unleveling, plagiocephaly (if chronic subluxation, eyes and face grow at different levels / speed respectively)

Causes:
- Children has lax ligament —> **infection / **inflammation —> further increase ligamentous laxity —> facet dislocation

Alar ligament:
- Attach occipital condyle to odontoid process
- Prevent too much rotation of C1/2

DDx:
- SCM tumour

Investigations:
1. X-ray (***Open mouth view)
- distance between C2 odontoid process and C1 lateral mass medial borders —> should be same on both sides
- C1 lateral mass should not be overhanging above C2 (indicate poor articulation)

2. ***Dynamic CT (Rotation of head to left + right)
   - normally C1 should translate in front of C2 upon head rotation
   - if subluxed —> can only rotate away from side of dislocation (right sided dislocation —> only turn to left side, cannot turn back to right side since joint cannot be reduced)

(Radiological classification of rotatory subluxation:
- Fielding and Hawkins
—> 4 types
—> based on axial CT images)

Treatment:
1. Traction to reduce deformity
- Halter device
2. Surgery
- Fusion of occipital-cervical joint
- Debilitating

Question 42

(Anterior vs Posterior approach: Indications in spine surgery)

Answer 42

Anterior approach:
- Direct decompression of disc herniation
- More powerful deformity correction
- Single / 2 level
- Kyphotic spine
- Requires fusion
- Soft tissue complications
- Pseudoarthrosis / Graft problems
- Adjacent segment degeneration

Complications:
- RLN palsy

Posterior approach:
- Indirect decompression
- Multiple level OPLL
- Can deal with multiple levels at the same time
- More axial neck pain
- Avoid loss of a motion segment
- Lordotic spine
- Developmental stenosis
- Head stabiliser pin

Complications prevention:
- Head and neck control (Mayfield / GW tongs)
- Intraocular pressure (∵ patient’s face downwards)
- Arms by the side
- Pull-shoulder
—> Avoid axilla tape
—> Beware brachial plexus injury
- Pressure padding
- Hinge fracture in laminoplasty —> Spring-back closure

Plates complications:
Screws in lateral mass:
- Too deep: Nerve root injury
- Too caudal: Facet joint penetration

Screws at lamina:
- Too deep: Cord impingement
- Not bicortical: Poor fixation

Question 43

Facet joint dislocation

Answer 43

**Unilateral facet dislocation:
- Cannot see very clearly on lateral C-spine X-ray (only **slight Anterolisthesis)
- **Rotational deformity
- Increased interspinous distance
- CT:
—> Associated fractures of pedicle / lamina / facet
—> **Inverted hamburger on a bun sign

Treatment:
1. Conservative
- Reduction + Traction to restore alignment

2. Surgery indications
   - Posterior ligamentous injury
   - Facet capsule injury
   - Disc disruption / herniation / extrusion
   - Nerve root compression
   —> Prevent future instability + early disc degeneration

**Bilateral facet dislocation:
Mechanism of injury:
- **Hyperflexion +/- Rotation

Clinical features:
- Spinal cord injury (***undoubtedly)

X-ray:
- Obvious translocation of vertebra (***>50% Anterolisthesis)
- Increased interspinous distance

Treatment:
1. ***Surgery to reduce + stabilise spine

Question 44

(Self notes: Causes of C1/2 subluxation)

Answer 44

1. Degenerative
2. Trauma
3. RA, AS
4. C1/2 rotatory subluxation
5. Syndromal (Down’s)