Spine

Question 1

1. List the features of seen on this plain radiograph of an elderly patient.
2. What is your diagnosis? why?
3. How will you manage this patient who has neck pain following trauma?

Answer 1

Aim: Distinguish DISH and AS.

1. Features
   - loss of cervical lordosis.
   - Non-marginal syndesmophytes noted from C3-C6
   - with preservation of disc space
   - ossification of the PLL
2. Diffuse Idiopathic Skeletal Hyperostosis of the cervical spine
3. Management
   Main aim is to rule out fracture.
   i) Make sure no other areas in the spine is painful.
   ii) Order CT scan for the cervical spine (+ any other spinal segments with pain)
   iii) If no other areas and ONLY CERVICAL SPINE FRACTURE - long spinal fusion.
   iv) if CERVICAL SPINE + OTHER SPINAL FRACTURES - long spinal fusion.
   vi) if NO FRACTURE -non-operative: activity modification, physical therapy, rigid collar, NSAIDS, bisphosphonate therapy.

Question 2

1. Describe abnormalities seen.
2. What further investigations would you order to aid with diagnosis?
3. How will you distinguish from other causes on advanced imaging?
4. How will you confirm your diagnosis?
5. How will you manage this patient?
6. What are your goals of treatment?

Answer 2

Aim: to differentiate between pyogenic vs tuberculous spondylodiscitis

1. Plain radiograph, sagittal plane, thoraco-lumbar spine in view from T12 to L4.
   - Reduced intervertebral disc space, inferior L2 and superior L3 end plates irregularities with sclerosis.
   MRI- End plate erosion, osteomyelitis of L2 and L3, vertebral discitis at IV disc of L2/L3, with some canal compromise.
2. Further investigations
   Blood test- WCC, ESR, CRP
   MRI with gadolinium constrast
   - clinically assess the patient for spinal tenderness and presence of neruological deficit (if this is present, determine the level involved and include this region to be imaged)
3. Differentials on advanced imaging
   a) Pyogenic vertebral osteomyelitis
   - disc and endplate enhancement with gadolinium, hyperintensed with T2-weighted with rim-enhancing lesion seen.
   - paraspinal and epidural inflammation.

b) Degenerative changes
Differentiates from pyogenic spondylodiscitis on T2-weighted MRI looking at the IV disc.
Modic Type 1
- hypointense disc on T2

Pyogenic cause
- hyperintense disc on T2

Will not have erosion of endplates, paravertebral soft tissue mass, abnormal ESR and CRP.

4. Obtain tissue diagnosis
   Least invasive: blood culture - Positive in 33% only.

More invasive:
Tissue biopsy
i) CT-guided biopsy
- if blood cultures are Negative, with help from radiologist.

ii) Open biopsy - transpedicular approach, costotranversectomy, anterior

Samples obtained to be sent for cultures for
- aerobic, anaerobic, fungal, acid-fast cultures.

5. Management
   - Once tissue samples obtained to be sent for culture and sensitivities, can start empirical broad spectrum antibiotics (IF PATIENT IS ILL AND SEPTIC, IF NOT SHOULD WAIT FOR C&S RESULTS)
   eg Vancomycin (for penicillin-resistant, gram+ve bacteria)
   Third generation cephalosporin (for gram -ve bacteria)
   - Once microorganisms identified with antibiotic sensitivities known, treat with IV antibiotics for ~4-6 weeks with monitoring for improvement of symptoms, signs and inflammatory markers.

Conservative:

• If improving, convert to oral antibiotics.
• May prescribe bracing (TLSO) to improve pain and prevent deformity.
• Encourage mobilisation to prevent sequelae from prolonged immobilisation.

Operative:
If neurological deficits are present in the first place.
If refractory to conservative management such as
- abscess formation with neurologic deterioration, extensive bone destruction (multiple levels involved), marked deformity (kyphosis)

Technique:
Anterior debridement, strut grafting, posterior instrumentation

6. Goals of treatment (5)
   i) Identify the microorganism.
   ii) Eradicate the infection.
   iii) Protect neurologic structures and prevent deterioration of deficits or new deficits
   iv) Maintain stability
   v) Optimise nutritional state and host immunity
7. DDX
   Epidural abscess
   TB spine

Question 3

1. List features seen in this plain radiograph.
2. What is your diagnosis?
3. How else may this patient present clinically?
4. If patient complaints of neck pain with no previous history of trauma, how will you manage the patient?

Answer 3

Aim: Distinguish DISH and AS.

1. List features seen in this plain radiograph.

Loss of cervical lordosis

Kyphosis of cervical spine

Marginal syndesmophytes

2. What is your diagnosis?

Ankylosing spondylitis

3. How else may this patient present clinically?

Loss of horizontal gaze

Chin on chest deformity

Associated with increased thoracic and loss of lumbar lordosis

Hip flexion contracture

Complaints - pain and stiffness, gets better with motion

4. If patient complaints of neck pain with no previous history of trauma, how will you manage the patient?

I will need to evaluate for occult fracture, even without history of trauma, by advanced imaging such as CT.

Missing occult fractures will increase risk of neurological compromise

Question 4

1. Describe findings from this plain radiograph.
2. What is your clinical diagnosis?
3. How will you obtain a samples to confirm your diagnosis?

Answer 4

Aim: Describe transpedicular biopsy.

ranspedicular biopsy (additional info)

The percutaneous procedure requires a high-resolution image intensifier and a radiolucent operating table.
The image intensifier is oriented until the X-ray beam is colinear with the sagittal pedicle angle determined from the lateral views of the vertebral body.
A ‘bull’s eye’ view of the pedicle must be obtained in an AP view. Repeated AP and Lateral images should be taken.
Local anesthesia is obtained by injecting plain bupivacaine along the proposed needle tract.
A stab incision is made to allow passage of a cannulated serrated sleeve along with the trocar into the vertebral body through the pedicle.
Smooth passage is usually obtained and no undue force is required after initial entry.
If the insertion is forceful or difficult, change either the direction of the cannula or the entry site.
As the cannula and sleeve pass through the pedicle and enter the body (Figures 7 and 9),
the trocar is withdrawn only when it has reached till the affected area of the vertebral body or pedicle (if affected), or after pedicle is penetrated.
If patients complain of radicular pain during the procedure, it suggests irritation of the nerve root and the direction of the biopsy instrument should
be changed.
The cannula tip is sharp and saw toothed, which allows tissue to get inside the cannula.
Retrieval of osteopenic bone and pathologic tissue is enhanced as the tissue gets impacted inside the cannula.
The saw tip of the cannula is made to pass about 80% of the anteroposterior diameter of the vertebral body or through the whole body, if abscess drainage is needed.
The cannula is rotated in a clockwise and anticlockwise motion several times to disengage the tissue from the surrounding tissue.
At this stage, a 10-ml syringe is attached at the backside of the cannula, and the plunger of syringe is pulled out to the maximum to create a suction effect inside
the cannula, while withdrawing the cannula in rotatory motion. T
his will prevent the retrieved soft tissue from pulling out of the cannula during withdrawal.
The integrity of the medial and inferior walls of the pedicle must be preserved to prevent the spread of any infection, tumor or hematoma in the spinal canal.
No drain or any sutures were required.
If adequate sample was not obtained on the first entry, then the cannula was reinserted after threading it over a blunt k-wire, and then under image guidance,
direction of the cannula is altered to be able to obtain another sample.

Question 5

Q1. Describe the plain radiograph.
Q2. What is the mechanism of injury?
Q3. Radiological diagnosis.
Q4. How will you treat this patient?

Answer 5

Q1. Lateral projection of the cervical spine with vertebrae C1 to C6 is well visualized, and there is loss of cervical lordosis and parallelisms of the anterior and posterior vertebrae and spinolaminar lines, and there is a quadrangular fracture pattern seen at the C5, involving the anterior 1/3rd of vertebral body with posterior vertebral subluxation and angular kyphosis is seen.

Q2. Flexion-compression injury at the anterior column, posterior column failed in tension.

Q3. Flexion teardrop fracture of C5.

Q4. Unstable fracture pattern so require anterior and posterior stabilization with internal fixation.

Question 6

Q1. Describe this plain radiograph of the cervical.
Q2. What is your clinical diagnosis?
Q3. What investigations will you order next and why?
Q4. What will be your immediate management of this patient?
Q5. This patient also has neurological deficits. What are your surgical treatment goals?
Q6. How would you perform the closed controlled reduction with traction?

Answer 6

Q1. Describe this plain radiograph of the cervical.
Key points:
True lateral projection
Vertebrae visualized
Cervical lordosis
Parallelism of anterior/posterior vertebral lines and spinolaminar lines
Interspinous distance
Vertebrae height, perching/ jumped facets

Answer:
This is the AP and lateral views of the cervical spinal vertebrae, visualized from C2 to C7, where loss of cervical lordosis and parallelism of the anterior/posterior vertebral lines are seen, with increased interspinous distance is seen at C5/C6 with perching of C5 over C6 vertebra is observed with resulting kyphosis. Otherwise, I cannot appreciate obvious reduction in vertebrae body height or any obvious factures at this point.

Q2. What is your clinical diagnosis?
Bilateral C5-C6 dislocation.

Q3. What investigations will you order next and why?
CT scan- to confirm unilateral or bilateral facet joint dislocation, to rule our fracture, if fracture present for characterization, surgical planning – pedical screw sizes

MRI – to determine if intervertebral disc protrusion- if present soft/hard disc, if fracture fragments got retropulsed into canal (cause of impingement to the spinal cord), presence of posterior ligamentous injury

Q4. What will be your immediate management of this patient?

ATLS protocol- C spine protection +ABCD
Airway patient, need for oxygenation support, circulation adequate KIV fluid resuscitation/ pressors. (PREVENTING IMMEDIATE LIFE THREATENING CONDITIONS)
Neurological deficit – spinal cord. If present- complete vs incomplete. Document this.
GCS of patient – full, intoxicated, brain contusion- for suitability of closed controlled traction for reduction of the cervical spine.

(REDUCTION TO PREVENT SECONDARY SPINAL CORD INJURY)

Non-surgical management - closed controlled traction for reduction of the cervical spine.
Criteria: patient with full GCS (AWAKE), not intoxicated (ALERT), can lie flat (COOPERATIVE), dislocation can be visualized on lateral radiograph for changed during traction.

Surgical management – surgical reduction and stabilization with instrumentation and fusion

Q5. This patient also has neurological deficits. What are your surgical treatment goals?
Address neurologic deficits by early surgical decompression the spinal cord (<24 hr)- for best chance for neurologic recovery and avoiding complications associated with prolonged immobility.
Anterior cervical discectomy +/- corpectomy for anterior compression.
Posterior laminectomy for posterior compression
Restoring spinal alligment can help through indirect decompression
Restore spinal alignment
Achieve immediate stability and long-term fusion

Q6. How would you perform the closed controlled reduction with traction?
Next slide

Question 7

What is this procedure?
How do you perform this procedure?

Answer 7

Is by using Gardner-Wells tongs traction
Functions to stabilize and indirectly decompress the canal via ligamentotaxis.

Steps:
Identify the location of the proposed insertion points (about 1 finger breath width above the pinna of ear, in line with external auditory meatus, just below the temporal ridge) and shave.
Infiltrate the area on both sides with LA.
Make a small incision about 1 cm in length on each side until down to the bone.
Insert one point holder of the calliper through the temporalis muscle fibres until it is in contact with the skull, keep this point pressed firmly against the skull, adjust the wide of the caliper through the turbbuckle spanner, then guide the second point holder through the skin-temporalis muscle fibres at the other side.
Close the calliper until both point holders have firm contact with the skull. On encountering bone, the stiff spring at point holder yields until the level of the outer end of the spring-loaded point. (Spring is fully compressed and point holder penetrates the outer cortex only)
5. Apply a continuous traction pulley system at the head of the bed with traction correctly applied in the plane of the articulating facets.

6. Ensuring controlled direction of traction can also be through
   - Rotation of the head (with patient supine) may be prevented by placing a sandbag under each projecting knurled end.
   - Alternating pressure pad – eliminate the need for turning (without paralysis/pulmonary problems)
7. Amount of traction
   10 lbs (4.5kg) for the head
   5 lbs (2.3 kg) for each successive interspace above.
   Can tolerate 65 lbs of traction
8. After 24H, the points will have penetrated ~1mm and require retightening of the screw.

Essentials after each successive addition of weight.
Neurological exam performed after each addition, documented, looking for improvement/ worsening neurology.
Lateral cervical radiographs, looking for reduction.

Extra:
Depending on the force you plan to apply to achieve reduction,
e.g. anterior dislocation/displacement will need extension force
posterior dislocation/displacement will need flexion force

Question 8

1. Describe abnormalities seen in this MRI images.
2. What is your diagnosis?
3. What are your differential diagnosis?
4. How will you confirm your diagnosis?
5. How will you manage this patient if she/he has postural lumbar pain and weakness of the lower limbs?
6. What is the regimen for anti-TB to ensure patient is compliant?

Answer 8

1. Describe abnormalities.
   A) T1 weighted sagittal image demonstrates hypointense signal in T12–L2 vertebral bodies with epidural mass and subligamentous spread from T12 to L2.
   B) T2 weighted sagittal image shows heterogeneously hyperintense signal.
   C) Contrast enhanced T1 sagittal weighted image shows heterogenous enhancement of T12–L2 vertebral bodies.
   D) Axial contrast enhanced T1 weighted image shows paraspinal abnormal enhancement and paraspinal abscess-like lesion with peripheral well-enhanced thick wall (well defined paravertebral).
2. TB spondylodiscitis
3. Pyogenic spondylodiscitis with epidural abscess
4. CT-guided tissue biopsy for acid fast bacili, TB PCR, culture and sensitivity.
5. Surgically because
   - neurological deficit
   - spinal instability

through anterior decompression, corpectomy, strut grafting with posterior instrumented stabilisation

Medically- involving ID team to start anti-TB treatment.

6. Chemotherapy regimen
   In 2 phases
   a) Intensive phase: 2 months with 4 types
   HRZE- Isoniazid (H), Rifampin (R ), Pyrazinamide (Z), Ethambutol (E)
   b) Continuation phase: 6/9/12 months with 2 types + Ethambuthol

Question 9

1. Name this implant and its indication.
2. What are some differences noted in these implants?
3. How to increase pullout strenght when using this implants in osteoporotic patients?
4. What are some precautions to take note during insertion of pedical screw in spinal vertebrae?

Answer 9

3. i) Increasing the outer diameter of pedicle screw.
   ii) Increasing pedical screw lenght to increase the depth achieved within the vertebral body.
   iii) Conical core and cylindrical thread screw > cylindrical core and thread screw > conical core and thread screw.
   iv) Titanium screws have superior mechanical and biological properties over stainless steel;
   - with a lower modulus of elasticity, it is more flexible than stainless steel, which would allow for a reduction in stress shielding.
   - bioactive which will thus promote osteointegration between the bone and screw.
   v) Cement augmented screw
   vi) Increasing the insertion angle
   vii) Bicortical fixation

Increasing pullout strenght:
https://www.hindawi.com/journals/bmri/2014/748393/

4. Breach of the medial wall of pedicle, thus injuring neural elements.
   Tip of pedicle screw penetrating the anterior cortex, injuring aorta

Question 10

Difference between cauda equina syndrome and conus medularis syndrome.

Answer 10

1. Trauma to vertebral level Th12–L2 will likely cause a CMS, whereas damage to vertebral level L3 and below will cause a CES.

A CMS may result from a trauma to vertebra T12–L2 in combination with neurological impairment in dermatomyotomes Th12–S5. The most cranial ISNCSCI level for CMS is Th11.

A trauma to vertebra L3–L5 with neurological impairment of the nerve roots is always a CES in patients without pre-existing spinal deformities. The most cranial ISNCSCI level for CES is L2.

2. Patients with CMS tend to have symmetric sensory–motor deficits, whereas patients with CES tend to have more asymmetric sensory–motor deficits.
3. Prognosis of the CES might be superior compared to CMS.
4. CSM has presence of UMN signs, CES only LMN signs.
5. In CES, urinary retention occurs later.
6. In CES, distal myotomes weakness are worse.

Ref:

https://www.ncbi.nlm.nih.gov/books/NBK537200/

https://www.nature.com/articles/sc201754

https://www.lipkinapter.com/injury-advice/differences-between-conus-medullaris-syndrome-and-cauda-equina-syndrome

Question 11

1. What is a spinal brace?
2. When is it indicated?

Answer 11

1. Spinal brace

is an external device made out of rigid or non-rigid material, applied onto a torso of a patient extending from underneath the armpits to the hips,

Rigid braces use the 3-point pressure treatment principle to limit or stop the progression of the scoliosis. Deformity held in corrected position by passive correction.

Dynamic braces do not use the 3-point pressure treatment principle but use dynamic forces (muscle contraction) to stabilise a curve. Deformity held in corrected position by active correction.

2. Indication to start bracing.
   i) First time Cobb angle ≥ 30 deg.
   ii) Cobb angle 20-30 degrees with progression of curve (> 5 deg in 2 consecutive Xrays).

Question 12

What is spinal shock?

What are the priorities in management of a patient in spinal shock?

Question 13

What is spinal cord injury?

What are the important aspects in evaluation of SCI?

Question 14

Fracture: Thoracolumbar

1. Describe this radiograph.
2. What is your diagnosis?
3. How will you classify this injury?

Answer 14

2.

3. Using Thoracolumbar Injury Severity Score (TLISS)
   * based on 3 separate injury axes
   a) Injury mechanism
   b) Intergrity of PLC
   c) Neurological status

Score

3 and below = non-operative

4 = operative or non-operative

5 and above = operative

Question 15

Fracture: Thoracolumbar

1. Define the common injuries type in thoracolumbar lumbar fracture.
   a) Burst #
   b) Bony Chance #
   c) Soft Tissue Chance #

Answer 15

a) Burst #

Fracture involving anterior & middle column (Denis column

b) Bony chance #

Failure of posterior tension band , with fracture extending through pedicles & into vertebral body

(AO classification type B2)

c) Soft tissue chance #

Failure of posterior tension band, a.k.a. posterior ligamentous complex, comprising interspinous ligament, facet joint capsule, and ligamentum flavum posteriorly, and posterior longitudinal ligament & intervertebral disc anteriorly, ie. all structures anterior to ALL

Question 16

Fracture: Thoracolumbar

What is the management principles for thoracolumbar fracture?

Answer 16

Based on TLICS

• based on 3 separate injury axes
  a) Injury mechanism
  b) Intergrity of PLC
  c) Neurological status
  1. Non-operative:

Indication

• neurologically intact
• no instability pattern

a) PLC preserved
b) no focal kyphosis in flexion and extension radiographs
c) kyphosis < 30 deg
d) vertebral body loss only < 50% of vertebral height
* TLICS < 4

Method

• Activity as tolerated
• TLSO (hyperextension orthoses)- if no concomitant chest or abdominal injuries, purpose for symptomatic relief.

Outcomes

• resorption of retropulsed fragment with time, unlikely to cause neurological deterioration.
• better outcome that patients who had prolonged bedrest as the latter will decondition and have other complications from immobility.

2. Operative
   a) Posterior instrumented stabilisation with fusion (No decompression as neurologically intact)

Indication:

i) Unstable fracture patterns

• injury to PLC
• progressive kyphosis
• lamina fracture

ii) Polytrauma
* to aid with recovery and rehab

Method

• MIST-Minimally invasive spine stabilization
• 3 levels above & 2 levels below
• Modern construct allows 1 level above & 1 level below - however short segment not suitable for thoracolumbar junction, can lead to loss of sagittal plane correction.
• Can fuse short segment but long instrument construct.
• Overdistaction of anterior column can lead to pseudoarthrosis, chronic pain, recurrent deformity.

b) Posterior instrumented stabilisation with fusion + decompression (neurological deficit)

Indication:

• Neurological deficit- complete and incomplete
• Radiological evidence of cord/thecal sac compression
• TLICS > 4

Method: anterior vs posterior

• Dependant on direction of compression
• Other considerations

i) Posterior approach

Favoured when

• below conus so possible to medialize thecal sac to perform decompression of canal / posterior corpectomy and expandable cage
• injury to PLC so posterior tension-band stabilization required
• fracture dislocations

ii) Anterior approach - limited by diaphragm

• Neurologic deficits caused by anterior compression (bony retropulsion) , especially above the conus medullaris (above L2)
• Allow for thorough decompression of the thecal sac
• Substantial vertebral body comminution, so approach anteriorly in order to reconstitute the anterior column
• Kyphotic deformity >30°
• Chronic injuries
  greater than 4-5 days from the injury

Question 17

Fracture: Thoracolumbar

1. How to manage retropulsed fragment?
2. What are the techniques to achieve neural decompression in thoracolumbar fractures?

Answer 17

1)No surgical intervention if No neurological deficit and stable fracture pattern.

• Retropulsed fragments resorb over time and usually do not cause progressive neurologic deterioration;
• Tissue recoiling post-injury or post-surgery can minimise the extent of displacement.

2) Surgical management
1. Direct decompression

• a) Posterior decompression*
• Retropulsed bone can be removed via transpedicular approach
• Usually done below the level of the conus medullaris (L2)
• Significant dural retraction required, which may iatrogenically damage the cord
• Avoid laminectomy if possible as it will further destabilize the spine by compromising the posterior supporting structures.
• b) Anterior decompression*
• Corpectomy performed with direct removal of canal-occupying fragments
• Ipsilateral pedicle and transverse process are removed
• corpectomy performed until the medial wall of the contralateral pedicle is visualized
• Preferrable for fractures at or above the level of the conus medullaris (L1-2)

2. Indirect decompression

• via distraction and lordosing rod construct leads to ligamentotaxis of the retropulsed fragments
• attachements of the annulus fibrosis and posterior longitudinal ligament to the fragments facilitates reduction
• less effective if performed 4-5 days after the injury
• restored height and sagittal alignment with posterior instrumentation
• monoaxial screws provided greater distractive forces for deformity correction

Question 18

Fracture: Thoracolumbar

What are the common complications during neural decompression via

a) anterior approach?
b) posterior approach?

Answer 18

a) anterior approach

• ileus
• pleural effusion

b) posterior approach

• dural tear
• iatrogenic cord injury - from excessive thecal cord retraction above conus medullaris
• iatrogenic instability - if perform laminectomy in an already disrupted PLC

Question 19

Fracture: Thoracolumbar

What are common complications from operative treatment for thoracolumbar fractures?

Answer 19

Common complications

• Dural tear- posterior approach
• Chronic pain -overdistraction with instrumentation
• Progressive kyphosis - unrecognised injury to PLC, loss of anterior column support, laminectomy without instrumented fusion.
• Flat back
• SSI-10%, trauma predisposes to infection (catabolic state, soft tissue damage, inflammatory response)
• Pseudoarthrosis - overdistraction
• Iatrogenic neurologic injury-1%, overmedialised pedicle screw, manipulation of spinal cord.

Question 20

Burst fracture

1. Definition.
2. Management of Burst fracture?
3. What are the components of LSC?

Answer 20

1. Definition

• fracture involving anterior & middle column (Denis column)
• fracture involving posterior vertebral wall + single end plate (incomplete burst) or both end plates (complete burst), with an intact posterior tension band (AO classification type A)

2. How to approach thoracolumbar burst fracture?
   1) Acute management
   2) Classify according to TLICS, operate if 4 or more

3) If for Operation, decide on anterior or posterior approach, long or short segment (SRU protocol)

anterior vs posterior?

• Local soft tissue condition -> ligamentous facet injury -> posterior
• Neurological deficit -> posterior
• Load-sharing classification 7 or more -> anterior

How to decide between short vs. long segment posterior stabilisation?
Score <6 short segment posterior stabilisation
Score 7 or more long segment posterior stabilisation

3. Component of LSC

1) Comminution
2) Apposition of fragments
3) Reducibility of sagittal deformation

Question 21

What are the different classifications of stability of thoracolumbar fractures?

Answer 21

1) Denis 3-column theory
2) McAfee
3) White & Panjabi
4) McCormack: LSC
5) Magerl
6) TLICS
7) AO

Question 22

What is an unstable thoracolumbar spine burst fracture as defined by McAfee?

Answer 22

1) >50% loss vertebral body height
2) Kyphosis >20 degrees
3) Progressive neurological deficit
4) Retropulsed fragments in canal
5) Posterior ligamentous complex disruption

Question 23

Brace - Scoliosis

1. What is a brace?
2. Name 2 types of brace used in case of scoliosis.
3. When to start brace?
4. How will brace help with scoliosis.
5. When is bracing not effective?
6. When is bracing contraindicated?

Answer 23

1. 2Brace is an external device used to maintain the position of pre-existing spinal deformity, stop and slow progression of curve, in skeletally immature patients but it does not reverse the curve.
2. Types of brace
   a) Boston underarm thoracolumbosacral orthosis (TLSO)
   * curve with apex below T7
   b) Milwaukee cervicothoracolumbosacral orthoses (CTLSO)
   * curve with apex above T7
3. Starting brace

• first time at diagnosis > 30 degrees
• progression of curve noted in patients who have Cobb angle between 20-30 degrees.** progression is defined as > 5 degrees in 2 consecutive X-rays

4. How does brace work?

Deformity is held in the corrected position by

a) Passive correction - using 3 point fixation
b) Active correction- muscle contraction pulling body away from the pads
5. Not effective

• not compliant patients who wear < 12 hours/day. effectiveness of brace is dose dependant.
• boys
• overweight patients

6. Contraindication
   - Thoracic lordosis/hypokyphosis

Question 24

Brace - Scoliosis

1. Which types of patients are suitable to prescribe brace for?
2. What are the common complication of brace?
3. How will you counsel a parent and child to wear brace?
4. When to wean off brace?
5. How to wean?

Answer 24

1. Which types of patients are suitable to prescribe brace for?

Risser 1,2,3 with Cobb angle 20-45 degs

Risser 1 with Cobb angle > 45 deg

Risser 2 with Cobb angle > 45 deg with open triradiate cartilage

2. What are the common complication of brace?

• skin - hyperpigmented, congested, pressure ulcers
• wrong pressure points, resulting in worsening of the curve
• discomfort due to warm and humid environment
• stiffness of spine

3. How will you counsel a parent and child to wear brace?

• explain indication
• explain definition of brace
• draw diagram how wearing brace reduces curve progression.
• mention that effectiveness of bracing with idiopathic scoliosis is dose dependant, ideally worn 20-23 hours/day
• Common complication of bracing
• Follow up schedule

1. Brace fitting with orthotist
2. Follow up at clinic after 2 weeks to check for proper fit by doctor. If not suitable, step 1 again.
3. If good fitting, follow up 4-6 monthly with repeated Xrays with and without brace wearing.
4. If no curve progression, can continue. If there’s curve progression, may need surgery. So compliant is important.
5. When to wean off brace?

Meets 2 out of 3 criteria

i) No growth for 6 months
ii) Risser IV or IV- skeletally mature
iii) Hand film demonstrates closed epiphyses everywhere except distal radius and ulna
5. Weaning off brace should be done over 6 months
a) First 2 months - off brace for 8 hours, can go to school without brace, otherwise wear brace at other times. Total duration = 16 hours.
b) Second 2 months - wear brace during sleeping hours only. Total duration = 8 hours.
c) Last 2 months - may be entirely out of brace

Repeat xrays, no progression noted.

Then review in 1 year, then 2 yearly

Question 25

Surgery for scoliosis

1. What are reasons for spinal fusion in scoliosis?
2. What are the types of spinal fusion in scoliosis and indications?
3. What are common complications of spinal fusion in scoliosis?

Answer 25

1. Reasons for surgery

• to prevent worsening of curve
• to improve magnitude of curve in coronal, axial and sagittal planes
• to prevent further deterioration of lung function
• to create more abdominal space
• for better cosmesis - taller, balanced shoulder, trunk and neck, less prominent thoracic or lumbar hump.

2. Types of spinal fusion in scoliosis.
   i) Posterior instrumentation and fusion
   * Cobb angle > 45, all types of idiopathic scoliosis, gold standard for thoracic and double major curves.
   ii) Anterior instrumentation and fusion

• uncommon to be used alone.
• Used in

a) single thoracic fusion: if hypokyphosis
b) single thoracolumbar/lumbar fusion

with normal sagittal profile

iii) Combination of anterior and posterior

• larges curves (> 75°) or stiff curves
• Young age (Risser grade 0, open triradiate, girls <10 yrs, boys < 13 yrs)

3. Common complications of spinal fusion.

General surgical complications

• Infection = 1.2-1.3%, acute vs delayed

Spinal fusion related

• Pseudoarthrosis =1-3%
• Neurological deficit =0.5-0.7%
• Crankshaft pnenomenon
• Flat back syndrome
• SMA syndrome

Question 26

Scoliosis

1. What is Crankshaft Phenomenon?
2. What are the risk factors for this problem?
3. How to overcome this problem?

Answer 26

1. What is Crankshaft Phenomenon?

Increased rotational deformity of the spine (with Cobb angle or RVAD progression of > 10 degree) as a result of continued anterior spinal linear growth after PSF in a skeletally immature patient.

2. What are the risk factors for this problem?

• Open triradiate cartilages
• Girls < 11 years, boys < 13 years
• PSF performed before or during peak height velocity (during Risser 1)

3. How to overcome this problem?
   * perform anterior discectomy and fusion + PSF (need combine anterior and posterior fusion)

Question 27

Scoliosis

1. What is Adding-on Phenomena?
2. What are the risk factors for this problem?
3. How to overcome this problem?

Answer 27

1. What is Adding-on Phenomena?

• Is worsening of the instrumented primary of atleast 5 degrees and distalization of the end vertebra.
• and a change in disc angulation of 5 degrees or greater, below the lower-instrumented vertebra from the first erect to the 2 year follow up radiographs.

1. What are the risk factors for this problem?

• Kings IV
• Lenke 1A-R curve
• Neutral vertebra not included in fusion block
• Skeletally immature patient

Question 28

Scoliosis - Approach

How to approach scoliosis?

Answer 28

A) Diagnosis scoliosis
B) Structural not structural
C) Idiopathic not idiopathic
D) Complications

1) How to diagnose scoliosis? Angle >10’
2) How to differentiate structural or postural?

Adam forward or sit patient

• Curve doesnt disappear - structural

3) If confirmed structural -> is it idiopathic or non-idiopathic?
- chief complaint:

• spine deformity - what kind of spine deformity? eg. was it shoulder imbalance? curvature at the back? waist crease asymmetry? trunk imbalance?
• noted by whom?
• birth history: premature, consanginuity, NICU
• past medical history: lung, kidney, heart, gut; past surgical, allergy to metal/earrings/necklace
• family history of scoliosis

Examination from front:
Syndromic facies

Abnormal posture/movements (Cerebral palsy)
Height, arm span (Marfan)
Shoulder balance - on standing
(do not mention neck tilt)
Pelvic obliquity
Cafe au lait (Neurofibromatosis)

Examination from back:
Tuft of hair, loss of dimple (Spina bifida)
Curvature: main thoracic or main lumbar, right or left
Asymmetrical lumbar crease
Plumb line
(Adam) Bend forward: Hump does not improve - structural or postural scoliosis
-> if structural, *scoliometer straightaway

Neurology:

Tone (UMN, LMN)

Limb reflexes (UMN, LMN)
Abdominal reflexes

4) If AIS, is it infantile, juvenile or adolescent based on age of ONSET

5) Determine curve: main thoracic/main lumbar
- skeletal maturity: clinical (change of voice, pubic hair; menarche, breast, pubic hair) or radiological (Risser, Sanders)
- any curve progression: skeletal maturity, peak height velocity (any growth 6cm or more?)

6) Any complications from scoliosis?
- neurology: must check abdominal reflexes for asymmetry (absence of abdominal reflexes is not a positive sign; make sure patient not guarding*)
*Jendrassik manouvre - reinforcement
- School activities, breathing difficulties, effort tolerance, early satiety

Question 29

Cervical Radiculopathy

1. Definition
2. Which nerve root more commonly affected

Answer 29

1. A clinical presentation characterized by radiating pain to the upper extremity following a specific dermatome caused by nerve root compression in the cervical spine.
2. C7 → C6

Question 30

Degenerative Spondylolisthesis

1. Definition
2. Imagings & purpose
3. Common site
4. Clinical presentation if neurological involvement
5. Other complaints
6. Single test to perform to differentiate neurogenic vs vascular cause?

Answer 30

1. Definition:

• subluxation of one vertebral body anterior to adjacent inferior vertebral body
• with intact pars interartciularis

2. Imagings

Diagnosis - Lateral lumbosacral xray in erect

Presence of instability- Lateral lumbosacral xray, erect, in flexion and extension. Instability = 4 mm translation, 10 degrees angulation compared to adjacent segment.

MRI - to identify central or foraminal stenosis, degree of impingement, to confirm clinical findings. (site and severity)

3. Common site: L4-L5
4. Presentations of neurological involvement

if central & lateral recess stenosis → L5 traversing nerve root

if foraminal stenosis -→ L4 exiting nerve root

5. Other complaints:

Mechanical back pain - most common.

Neurogenic claudication (buttock & leg pain)

• relieved only when sitting and leaning forward
• standing doesn’t relieve
• exacerbated by lying down

6. Provocative walking test

Get patient to walk across the room

• ask onset of symptoms- reproduction of pain at buttocks and legs
• standing still doesnt relieve
• ask patient to sit down and lean forward - relieve

Question 31

Degenerative spondylolisthesis

1. Management
2. Complications

Answer 31

1. Management
   i) Non-operative

1st line:

NSAIDs

Neuropathic drug

Physical therapy

Activity modification

2nd line:

Epidural injection OR

Transforaminal selective nerve root injection

• observation 6 weeks
• if improve, can continue for 6 more weeks

ii) Operative

Indication

• failed non-operative
• progressive neurological deficit
• cauda equina
• persistent and disabling pain affecting ADL

Options:

a) posterior lumbar decompression

either through posterior midline approach OR MIO

decompression via laminectomy

+ instrumentation (pedicle screws)

+ fusion (PLIF/TLIF)

2. Complications

• Pseudoarthrosis
• Adjacent segment disease
• Surgical site infection
• Dural tear
• Positioning neuropathy eg LFCN, brachial plexopathy, ulnar nerve

Question 32

Adult Isthmic Spondylolisthesis

1. Definition
2. Common site
3. Common types
4. Management

Answer 32

1. Definition

• subluxation of one vertebral body anterior to adjacent inferior vertebral body
• with DEFECT in intact pars interarticularis

2. L5-S1, affecting exiting nerve root
3. According to Wilste-Newman, Type 2 has 3 types

A- pars fatigue fracture

B- pars elongation due to multiple healed fracture

C- pars acute fracture

4. Management
   a) Non-operative

Similar like degen spondy

b) Operative

Indication

• for patients who failed non-operative management after 6 months
• slip proggression
• worsening neurological deficit

Options:

i) L5-S1 decompression, instrumented fusion +/- reduction
* low grade spondylolisthesis
ii) L4-S1 decompression, instrumented fusion +/- reduction
* high grade spondylolisthesis

Reduction- indicated when

• neural compression
• sagittal imbalance

Question 33

The three possible locations for spinal metastases
are

Answer 33

intradural intramedullary, commonly shortened
to intramedullary, intradural extramedullary and
extradural

Question 34

How to perform Transpedicular Vertebral Kyphoplasty?

Answer 34

Additional points for Percutaneous Transpedicular Kyphoplasty

Position- same

Anesthesia- GA, as extra procedures required so longer surgery.

Steps
- All individual surgical steps are performed bilaterally.
- The skin is opened by means of a small, transverse, stab incision craniolateral to the pedicle entry site.
- A bone needle is placed at the junction between the transverse process and cranial articular process (at 3 and 9 oclock, directly lateral to pedicle)
- Bone needle is driven into the pedicle with light mallet blows, and the passage though the pedicle is monitored fluoroscopically in both planes.
- Spinal canal violation is avoided by strictly ensuring that the medial pedicle cortex (in the anteroposterior projection) is not crossed before the
posterior vertebral wall has been reached (in the lateral projection).

AP trajectory: From 3 o’clock, advance to opposite side
- If on AP view, the trocar is at the medial border of the pedicle, on lateral view, the trocar should be just past the posterior border of the vertebra
- if on lateral view the trocar still has not reached vertebral body, means the trocar is in the spinal canal

-The initial trajectory of the bone needle must be based on fracture type (i.e., whether it is osteoporotic or traumatic).
- The final needle position for osteoporotic fractures is in the middle of the VB’s cancellous bone.
- The target for traumatic fractures is the fracture zone because, unlike osteoporotic bone, healthy cancellous bone will not yield to the pressure of balloon inflation.
- The next step involves feeding a Kirschner wire through the bone needle to serve as a guide for the working cannula, which is driven into the VB over the wire.
- Once the Kirschner wire and the trocar of the cannula have been removed, the working cannula remains in the posterior third of the VB.
- All subsequent steps in the VB must carefully avoid perforating the cortex, which would provide points of minimal resistance through which cement could leak during injection.
-If required, a biopsy specimen of the VB can be taken at this point.
- Channels, made on each side with a hand drill, are convergent toward the midline.
- Deflated KP balloons are placed into each channel.
- The size of the balloon is chosen relative to the size of the VB (15 mm long with a filling volume of 4mL or 20mm long with a filling volume of 6 mL).
- Each end of the balloon is fitted with radio-opaque markers, thus allowing the final position of the balloons to be verified in both planes fluoroscopically.
- With a manual pressure injection system, pressures of up to 28 bars (~400 psi) can be generated in the balloons. However, a pressure of approximately 7 bars (~100 psi)
usually is sufficient if the balloon’s position is correct.
- The gradual, pressure-controlled inflation of the balloons displaces the damaged cancellous bone and, ideally, lifts the adjacent endplate.
- Once the fracture has been reduced or a sufficiently large cavity has been created, the balloons are deflated and removed.
- The cavity (defect zone) that remains in the VB is filled with augmentation material (usually polymethylmethacrylate) through the cannulae.
- To prevent epidural or paravertebral leaks, the augmentation material should be highly viscous and introduced gradually with low pressure.
- The cavity-filling volume, known from the volume reached by the KP balloons, is slightly exceeded to achieve interdigitation with the cancellous bone.

Question 35

How to perform Transpedicular biopsy?

Answer 35

transpedicular biopsy (additional info)

The percutaneous procedure requires a high-resolution image intensifier and a radiolucent operating table.
The image intensifier is oriented until the X-ray beam is colinear with the sagittal pedicle angle determined from the lateral views of the vertebral body.
A ‘bull’s eye’ view of the pedicle must be obtained in an AP view. Repeated AP and Lateral images should be taken.
Local anesthesia is obtained by injecting plain bupivacaine along the proposed needle tract.
A stab incision is made to allow passage of a cannulated serrated sleeve along with the trocar into the vertebral body through the pedicle.
Smooth passage is usually obtained and no undue force is required after initial entry.
If the insertion is forceful or difficult, change either the direction of the cannula or the entry site.
As the cannula and sleeve pass through the pedicle and enter the body (Figures 7 and 9),
the trocar is withdrawn only when it has reached till the affected area of the vertebral body or pedicle (if affected), or after pedicle is penetrated.
If patients complain of radicular pain during the procedure, it suggests irritation of the nerve root and the direction of the biopsy instrument should
be changed.
The cannula tip is sharp and saw toothed, which allows tissue to get inside the cannula.
Retrieval of osteopenic bone and pathologic tissue is enhanced as the tissue gets impacted inside the cannula.
The saw tip of the cannula is made to pass about 80% of the anteroposterior diameter of the vertebral body or through the whole body, if abscess drainage is needed.
The cannula is rotated in a clockwise and anticlockwise motion several times to disengage the tissue from the surrounding tissue.
At this stage, a 10-ml syringe is attached at the backside of the cannula, and the plunger of syringe is pulled out to the maximum to create a suction effect inside
the cannula, while withdrawing the cannula in rotatory motion. T
his will prevent the retrieved soft tissue from pulling out of the cannula during withdrawal.
The integrity of the medial and inferior walls of the pedicle must be preserved to prevent the spread of any infection, tumor or hematoma in the spinal canal.
No drain or any sutures were required.
If adequate sample was not obtained on the first entry, then the cannula was reinserted after threading it over a blunt k-wire, and then under image guidance,
direction of the cannula is altered to be able to obtain another sample.

Question 36

Implant used in Spine surgery

Pedicle screw

Answer 36

1) Types of screws used.
Mono vs polyaxial pedicle screw
Mono
1. Monoaxial screws with incorporated screw and shaft result in a stiffer construct and reduced von Mises stress on the screw
2. Monoaxial pedicle screws inserted in the fractured vertebra show higher stability in flexion and extension of the spine.
3. Monoaxial pedicle screws with greater lever effect on restoring height of fractured vertebra body.
4. Monoaxial screws show improved uplift and restoration of the collapsed upper endplate, thereby allowing for superior repair of the injured intervertebral disc.

Poly
1. polyaxial screw head is vulnerable to fatigue failure especially at the junction between the screw head and the shaft.

Source: doi: 10.21037/atm-21-881