Spine (Complete) Flashcards
What is the ASIA spinal cord injury scale?
Asia A: Complete
- No motor or sensory function preserved in sacral elements
Asia B: Incomplete
- Sensory but not motor function preserved below neurological level
Asia C: Incomplete
- Greater than half the muscles below affected level are < antigravity power (<3/5)
Asia D: Incomplete
- Greater than half the muscles below affected level are > antigravity (>3/5)
Asia E: Normal
How do you determine the ASIA classification in a spinal cord injury?
- Determine if patient is in spinal shock
* Check bulbocavernosus reflex - Determine neurologic level of injury
- Lowest segment with intact sensation and antigravity (3 or more) muscle function strength
- In regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level
- Determine whether the injury is COMPLETE or INCOMPLETE
- COMPLETE defined as: (ASIA A)
- No voluntary anal contraction (sacral sparing) AND
- 0/5 distal motor AND
- 0/2 distal sensory scores (no perianal sensation) AND
- bulbocavernosus reflex present (patient not in spinal shock)
- INCOMPLETE defined as:
- Voluntary anal contraction (sacral sparing) OR
- Sacral sparing critical to determine complete vs. incomplete
- Palpable or visible muscle contraction below injury level OR
- Perianal sensation present
- Voluntary anal contraction (sacral sparing) OR
What cervical spine radiographic parameters should be assessed on plain film xrays?
- Occipitocervical junction
- Harris rule of 12
- Basion-dens interval or basion-posterior axial interval >12 suggests occipitocervical dissociation
- Power’s ratio
- Powers ratio = C-D/A-B
- C-D: distance from basion to posterior arch
- A-B: distance from anterior arch to opisthion
- Ratio ~ 1 is normal
- If > 1.0 concern for anterior dislocation
- Ratio < 1.0 raises concern for:
- Powers ratio = C-D/A-B
- Posterior atlanto-occipital dislocation
- Odontoid fractures
- Ring of atlas fractures
- Atlantoaxial junction
- ADI
- > 3.5mm considered unstable
- > 10mm indicates surgery in RA
- PADI/SAC
- <14mm indicates surgery in RA
- Lateral ADI
- 1-2mm of asymmetry of lateral mass alignment relative to dens may be normal
- Combined lateral mass overhang
- >8.1mm indicates transverse ligament rupture and unstable injury
- Subaxial spine
- >8.1mm indicates transverse ligament rupture and unstable injury
- Anterior vertebral line
- Posterior vertebral line
- Spinolaminar line
- Prevertebral soft tissue shadow
- >6mm at C2, >22mm at C6 = abnormal
- Interspinous distance
- Stacked parallelogram facets
What is the classification of occipital condyle fractures?
Anderson and Montesano Classification
- Type I - comminuted (3%)
- MOI = axial load
- Stable injury
- Type II - basilar skull fracture extending into the occipital condyle (22%)
- MOI = shear injury
- Stable injury
- Type III - transverse avulsion fracture (75%)
- MOI = forced rotation with lateral bending (alar ligament avulsion)
- Potentially unstable (associated with craniocervical dissociation)
What cranial nerve palsies may develop in association of occipital condyle fractures?
CN IX, X, XI
- travel in jugular foramen adjacent to occipital condyle
What is the management of occipital condyle fractures?
- Type I and II = external immobilization (cervical orthosis)
- Type III = depends on if associated with craniocervical dissociation or ligamentous instability
- Stable = external immobilization (cervical orthosis)
- Unstable = occipitocervical fusion
- C0-C2(or C3) instrumentation and fusion
What are the two main presentations of occipitocervical instability?
[Orthobullets]
- Traumatic – often fatal
- Acquired – often associated with Down’s syndrome
What are the radiographic parameters to be assessed on plain film for craniocervical dissociation?
[JAAOS 2014;22:718-729]
- Harris lines (Harris rule of 12s)
- Basion-dens interval
- Normal = <12mm
- Distance from basion to tip of dens
- Basion-axis interval
- Normal = 4-12mm
- Distance between line parallel to posterior cortex of C2 and basion
- Powers ratio [Orthobullets]
- Distance from basion to posterior arch C1/distance from opisthion to anterior arch C1
- Normal = 1
- >1 = anterior dislocation
- <1 = posterior dislocation, dens fracture, ring of atlas fracture
- Wackenheim line
- Line parallel along the posterior portion of the clivus to the upper cervical spine
- Normal = tip of dens is <1-2mm from Wackenheim line
What is the classification system for occiptocervical instability based on direction of displacement?
[Orthobullets]
Traynelis Classification
- Type 1 - Anterior occiput dislocation
- Type 2 - Longitudinal dislocation
- Type 3 - Posterior occiput dislocation
What is the classification system for occipitocervical instability based on degree of instability?
[JAAOS 2014;22:718-729]
Harbourview Classification
- Stage I - minimal or nondisplaced (STABLE)
- Often unilateral injury to the craniocervical ligaments
- Treatment:
- External immobilization
- Stage II - minimally displaced (STABLE or UNSTABLE)
- MRI indicates significant soft tissue injury (does not indicate instability)
- Proceed with traction test
- Provocative traction fluoroscopy
- Technique – patient supine with lateral fluoro view centred at C1, Gardner Wells tongs are applied and 5lbs are added (repeat fluoro) then increased to 10lbs (repeat fluoro)
- Positive traction test = Fracture displacement >2mm, atlanto-occipital distraction >2mm, or atlantoaxial distraction >3 mm indicates CCJ instability
- Treatment
- Stable = external immobilization
- Unstable = occipitocervical fusion (C0-C2 or C3)
- MRI indicates significant soft tissue injury (does not indicate instability)
- Stage III – gross craniocervical misalignment
- BAI or BDI >2mm above upper limit of normal
- Usually fatal
- Treatment:
- Occipitocervical fusion (C0-C2 or C3)
What are the radiographic parameters to assess for atlas fractures?
[JAAOS 2014;22:718-729]
- Atlanto-dens interval (ADI)
- Distance between anterior dens and posterior aspect of anterior arch of C1
- Normal = <3mm in adults
- >3mm indicates transverse ligament disruption and C1-C2 instability
- Lateral atlanto-dens interval
- Distance between the lateral surface of the dens and the medial surface of the lateral mass of C1
- Normal = <2mm of asymmetry
- Combined lateral mass overhang
- Combined horizontal distance from lateral border of C1 to lateral border of C2 on open mouth radiographs or coronal CT
- Normal = <7mm
- >7mm indicates transverse ligament rupture and C1-C2 instability
What is the classification system for atlas (C1) fractures?
[Orthobullets]
Landells Classification
- Type I - isolated anterior or posterior arch fracture
- Type II - Jefferson burst fracture (bilateral anterior and posterior arch fractures)
- Type III - unilateral lateral mass fracture
What is the classification system for transverse ligament injuries?
[Orthobullets]
Dickman classification
- Type I - intrasubstance tear
- Type II - bony avulsion from tubercle at lateral mass of C1
What is the treatment of atlas (C1) fractures?
[JAAOS 2014;22:718-729]
Depends on the integrity of transverse ligament injury
- If stable (ligament intact):
- Based on ADI <3, lateral ADI <2mm of asymmetry, combined lateral mass overhang <7mm
- External immobilization (halo or hard cervical orthosis)
- If unstable (ligament disrupted)
- Posterior C1-C2 fusion
- C1 lateral mass screw, C2 pars or pedicle
- Occipitocervical fusion
- If C1 lateral mass purchase inadequate due to comminution
- Posterior C1-C2 fusion
What are the radiographic parameters to assess for atlantoaxial instability?
- Atlanto-dens interval
* Normal <3mm in adults (<5mm in children) - Space available for the cord – SAC (posterior atlantodens interval – PADI)
* Normal >13mm
What is the classification and treatment of atlantoaxial instability?
[JAAOS 2014;22:718-729]
Type A
- Rotationally displaced in the transverse plane (transverse ligament intact)
- Often nontraumatic
- Treatment – reduction and immobilization
Type B
- Translation between C1-C2 (Unstable)
- Transverse ligament disrupted
- Treatment:
- Type I transverse ligament disruption = C1-C2 fusion
- Type II transverse ligament bony avulsion = posterior C1-C2 fusion or halo immobilization following traction
Type C
- Distraction between C1-C2 (vertically unstable)
- Similar to craniocervical dissociation and often associated with it
- Treatment:
- C1-C2 fusion
- C0-C2 fusion if associated with craniocervical dissociation
What is the classification system for Odontoid fractures?
[JAAOS 2010;18:383-394]
- Anderson and D’Alonzo Classification
- Type I - odontoid tip fracture
- Oblique fracture due to bony avulsion of the alar ligament
- Type II - base of the dens fracture
- Does not involve the C2 superior articular facet
- High non-union rate due to watershed area
- Type III – C2 body fracture
- Does involve the C2 superior articular facet
- Grauer modification
- Type IIA - transverse fracture, <1mm displacement
- Type IIB- oblique fracture extending from anterosuperior to posteroinferior
- Type IIC- oblique fracture extending from anteroinferior to posterosuperior
- May be associated with significant anterior comminution
What is the treatment based on odontoid fracture type?
[JAAOS 2010;18:383-394]
- Type I
- Stable fractures (at least one alar ligament and the transverse ligament is intact)
- Cervical collar
- Unstable fractures (associated craniocervical dissociation)
- Posterior C0-C2 fusion
- Type II
- Young patient
- No risk factors for nonunion = halo immobilization
- Risk factors for nonunion = surgery
- Elderly patient
- Surgical candidate = surgical stabilization
- Posterior C1-C2 fusion
- Not surgical candidate = cervical orthosis
- Results in fibrous union in most cases
- Halo vest is associated with high rate of morbidity and mortality in elderly
3. Type III
- Surgical candidate = surgical stabilization
- Cervical orthosis
What are the risk factors for nonunion of odontoid fractures?
[JAAOS 2010;18:383-394]
- Age >40
- Posterior displacement >5mm
- Angulation >11°
- Comminution
- Fracture gap >1mm
- Delay in treatment (4 day delay)
- Concomitant neurological injury
What are the surgical options for odontoid fractures?
[JAAOS 2010;18:383-394]
- Anterior fixation (odontoid screw)
- Anatomic reduction and one or two partially threaded screws under biplanar fluoroscopy
- Indications:
- Grauer type IIb
- Contraindications:
- Osteoporosis, comminution, reverse obliquity (type IIc), short neck, barrel chest, nonunion
- Posterior C1-C2 fusion
- C1 lateral mass, C2 pars or pedicle
- Indications:
- Odontoid screw contraindicated
What is the classification for traumatic spondylolisthesis of the axis (Hangman’s Fracture)?
Levine and Edwards Classification
- Type I
- Minimally displaced pars interarticularis fracture
- Translation <3mm of C2, no angulation
- MOI = axial load and hyperextension
- Type Ia
- Oblique fracture through one pars interarticularis and anterior to the pars within the body of the contralateral side (unstable)
- Type II
- Translation >3mm of C2
- MOI – axial load and hyperextension followed by flexion
- Type IIa
- Angulation (kyphosis) more than translation
- MOI = flexion-distraction
- Type III
- Similar pars fracture as type I plus C2/C3 facet dislocation
- MOI = flexion distraction followed by hyperextension
- ***Note: hyperextension causes the pars fracture and flexion causes PLL and disc rupture
What is the treatment of traumatic spondylolisthesis of the axis (Hangman’s Fracture)?
[JAAOS 2014;22:718-729]
Type I - hard cervical orthosis (12 weeks)
Type Ia - halo immobilization
Type II - halo immobilization (12 weeks)
Type IIa
- C2-C3 ACDF or posterior fixation [JAAOS 2014;22:718-729]
- Reduction with gentle axial load + hyperextension, then compression halo immobilization for 6-12 weeks [Orthobullets]
Type III - posterior reduction and stabilization
- C2-C3 or C1-C3 fusion
What defines the subaxial cervical spine?
C3-C7
What is the classification system for subaxial cervical spine trauma?
- Allen and Ferguson
- 6 classes based on mechanism of injury and static radiographs (used in research)
- Flexion-compression, vertical compression, flexion-distraction, extension-compression, extension-distraction, lateral flexion
- Subaxial Injury Classification System (SLIC)
- Three components
- Morphology
- Integrity of the discoligamentous complex
- Neurological status
- Score dictates treatment
- <4 = conservative treatment
- 4 = treatment at discretion of surgeon
- >4 = surgical treatment
What are the main subaxial cervical spine factures and their management?
[Rockwood and Green 8th ed. 2015]
- Compression fracture
- Characteristics = anterior vertebral height loss, posterior vertebrae not involved
- Nonoperative
- Indicated if stable and PLC intact
- Facet joints are not subluxed or dislocated
- No vertebral translation
- Minimal gapping of interspinous spaces
- Kyphosis <11°
- Rigid cervical collar for 3 months followed by flex-ex views
- Indicated if stable and PLC intact
- Operative
- Indicated if unstable or neurological deficit
- Facet joint subluxation or dislocation
- Vertebral translation
- Gapping of interspinous spaces
- Kyphosis >11°
- MRI findings suggestive of PLC disruption
- Anterior or posterior stabilization
- Burst fracture
- Indicated if unstable or neurological deficit
- Characteristics = comminuted vertebral body fracture involves the posterior vertebral body often with retropulsed fragments
- Nonoperative:
- Indicated if no PLC disruption, no neurological deficit (rare)
- Halo vest or rigid cervicothoracic orthosis
- Operative:
- Indicated if PLC disruption, neurological deficit
- Anterior corpectomy
- Plus posterior instrumentation and fusion if PLC is disrupted
- Flexion teardrop fracture
- Characteristics = oblique fracture line from anterior vertebral body to the inferior endplate (quadrangular fragment)
- May have posterior translation of the posterior vertebral body
- PLC disruption suggested by interspinous and facet gapping
- Nonoperative
- Minimally displaced, little kyphosis, intact PLC
- Rigid cervical collar
- Operative
- Neurological deficit, PLC disruption
- Posterior VB translation, kyphosis >11°
- ACDF
- Extension teardrop fracture
- Neurological deficit, PLC disruption
- Characteristics = small avulsion from anterior vertebral body
- Nonoperative
- Considered a stable injury
- Rigid cervical collar
What is the progression of injury in cervical facet dislocation based on the Allen Ferguson classification of flexion-distraction injuries?
[Neurosurg Clin N Am 28 (2017):125–137][Orthobullets]
- Facet subluxation
- Unilateral facet dislocation (25% displacement on XR)
- Bilateral facet dislocation (50% displacement on XR)
- Complete dislocation (100% displacement on XR)
What is the rate of disc herniation associated with unilateral cervical facet dislocations vs. bilateral cervical facet dislocations?
[Neurosurg Clin N Am 28 (2017):125–137]
Unilateral vs. bilateral = 56% vs. 82.5%
What is the significance of a traumatic disc herniation associated with a cervical facet dislocation?
[Neurosurg Clin N Am 28 (2017):125–137]
- Presence of a disc herniation can lead to neurological injury upon reduction/realignment of the cervical spine
- Herniations with disc material posterior to the displaced vertebral body are most concerning
What is the likelihood of PLC disruption in unilateral vs. bilateral cervical facet dislocations?
[Neurosurg Clin N Am 28 (2017):125–137]
- Bilateral facet dislocations = complete disruption of PLC and facet capsules
- Unilateral facet dislocations = PLC may be intact
What are features of facet dislocation on CT scan?
[Neurosurg Clin N Am 28 (2017):125–137]
- “Reverse Hamburger Bun Sign” (normal = “Hamburger bun sign”)
- “Naked facet sign”
In what situations should an MRI be obtained and not obtained prior to a closed reduction in context of cervical facet dislocation?
[Neurosurg Clin N Am 28 (2017):125–137]
- Obtain MRI
- Neurologically intact patient
- No urgency to perform reduction, if disc is present you can convert a neurologically intact patient to one with deficits if reduction performed
- Obtunded, nonexaminable patient
- If neurologically intact, reduction in presence of disc may lead to neurological deficit
- Planning posterior approach and reduction
- Failed closed reduction or neurological deterioration during closed reduction [Orthobullets]
2. Omit MRI - Awake, alert, cooperative patient with incomplete cord injury or worsening neurological deficit
- Patient would benefit from immediate reduction rather than delaying for MRI
- Complete cord injury
What is the technique for performing a closed reduction for cervical facet dislocation?
[Wiesel 2016]
- Requires an awake, alert and cooperative patient
- Gardner-Wells tongs are applied
- Pins 1cm above the pinna of the ear in line with the external auditory meatus below the equator of the skull
- Placement slightly posterior produces flexion moment (often desirable in cervical facet dislocation)
- Skin is prepped and lidocaine injected subcutaneously and subperiosteally
- Pins are tightened until indicator pin protrudes at least 1mm
3. 10lbs of weight is applied initially then 5-10lbs added incrementally - After each weight – lateral radiograph and neurological examination
- Apply additional weight after 10-15mins
- Once reduction is achieved the weight can be reduced to approximately 10-20lbs to maintain reduction
What are the advantages and disadvantages of an anterior approach for reduction and stabilization following facet dislocation?
[Neurosurg Clin N Am 28 (2017):125–137]
- Advantages
- Removes disc (whether herniated or not) prior to reduction
- Muscle-sparing approach
- May eliminate need for posterior approach and stabilization
- Fuses single motion segment (posterior approach may require more levels)
- Disadvantages
- Reduction more difficult
- Failure to reduce requires a posterior approach (and possible returning to anterior for fixation)
What are reduction techniques for cervical facet dislocation from an anterior approach?
[Rockwood and Green 8th ed. 2015]
- Caspar pins
- Laminar spreader
- Cobb
What are reduction techniques for cervical facet dislocation from a posterior approach?
[Rockwood and Green 8th ed. 2015]
- Towel clip grasping the spinous process
- Penfield 4 elevator over superior articular process of lower vertebra to lever up the inferior articular process of the upper vertebra
- Resect tip of superior articular process of lower vertebra
What are the indications for anterior approach in the management of cervical facet dislocation?
[Rockwood and Green 8th ed. 2015]
- Presence of disc herniation
- Absence of disc herniation (if surgeon prefers over posterior)
What are the indications for posterior approach in the management of cervical facet dislocations?
[Rockwood and Green 8th ed. 2015]
Absence of disc herniation
What are the indications for anterior and posterior approach to cervical facet dislocation?
[Rockwood and Green 8th ed. 2015]
- Highly unstable bilateral facet dislocations
- Presence of facet gap or kyphosis following anterior surgery
- Delayed presentation with fixed deformity
Describe the Denis three-column model of spinal stability
[Rockwood and Green 8th ed. 2015]
- Anterior column = anterior half/part of vertebral body/disc and ALL
- Middle column = posterior half/part of vertebral body/disc and PLL
- Posterior column = posterior elements including pedicles, facets, lamina, spinous process and ligaments
***NOTE – based on this system fractures extending into the middle column are largely considered unstable
What defines the posterior ligamentous complex (PLC)?
[Orthobullets]
- Supraspinous lig
- Interspinous lig
- Ligamentum flavum
- Facet joint capsules
What are the radiographic features of an injury to the middle column?
[Orthobullets]
- AP view = widened interpedicular distance
- Lateral view = loss of height of posterior cortex
What is the classification system for thoracolumbar spine injuries?
[JAAOS 2010;18:63-71]
- Thoracolumbar Injury Classification and Severity Score (TLICS)
- 3 injury characteristics
- Injury morphology
- Neurological status
- Integrity of PLC
- Score dictates treatment
- <4 = nonsurgical
- 4 = nonsurgical or surgical
- >4 = surgical
- AO Thoracolumbar Classification (Morphology)
- TYPE A = Compression Injuries
- A0 = Minor, nonstructural fractures
- Fractures which do not compromise the structural integrity of the spinal column (eg. transverse process and spinous processes)
- A1 = Wedge-compression
- Fracture of a single endplate without involvement of the posterior wall of the vertebral body
- A2 = Split
- Fracture of both endplates without involvement of the posterior wall of the vertebral body
- A3 = Incomplete burst
- Fracture with any involvement of the posterior wall; only a single endplate fractured
- Vertical fracture of the lamina is usually present and does not constitute a tension band failure
- A4 = Complete burst
- Fracture with any involvement of the posterior wall and both endplates
- Vertical fracture of the lamina is usually present and does not constitute a tension band failure
- A0 = Minor, nonstructural fractures
- TYPE B = Distraction Injuries
- B1 = Transosseous tension band disruption (Chance fracture)
- Monosegmental pure osseous failure of the posterior tension band
- B2 = Posterior tension band disruption
- Bony and/or ligamentary failure of the posterior tension band together with a Type A fracture
- Type A fracture should be classified separately
- B3 = Hyperextension
- Injury through the disc or vertebral body leading to hyperextended position of the spinal column
- Commonly seen in ankylotic disorders
- Anterior structures, especially ALL are ruptured but there is a posterior hinge preventing further displacement
- B1 = Transosseous tension band disruption (Chance fracture)
- TYPE C = Translation Injuries
- C = Displacement/dislocation
- There are no subtypes because various configurations are possible due to dissociation/dislocation
- Can be combined with subtypes of A or B
- C = Displacement/dislocation
What patients are the best candidates for nonoperative management of thoracolumbar fractures?
[AAOS comprehensive review 2, 2014]
- Neurologically intact
- <25° kyphosis
- <50% vertebral height loss
- <50% canal compromise
- Intact PLC
What is the nonoperative treatment of choice for thoracolumbar fractures?
[AAOS comprehensive review 2, 2014]
Hyperextension thoracolumbar orthosis (eg. Jewett) or casting for 3 months
What is the operative construct for a thoracolumbar burst fracture?
[Drew]
- Posterior instrumentation and fusion
- 2 levels above and 2 levels below affected level
- Don’t end at junction
- Decompression if neurological compromise
What is the operative construct for a flexion distraction injury?
[Drew]
Short segment posterior instrumentation and fusion if anterior column intact
What are the techniques for decompression from a posterior approach in thoracolumbar fractures?
[AOfoundation]
- Indirect decompression through ligamentotaxis
- Direct decompression
- Laminectomy, retraction of thecal sac and direct decompression of bone fragments (tamps to push fragments back into vertebral body)
- Only below level of conus
- Transpedicular decompression
- Can be performed at T1-L5 without risk from retraction to thecal sac
- Superior and inferior laminotomy followed by burring and thinning of the medial pedicle to allow access to tamp fragments back into vertebral body
- Can be performed at T1-L5 without risk from retraction to thecal sac
What are the causes of cervical radiculopathy?
[JAAOS 2007;15:486-494]
- “Soft Disc” herniations
* Nuclear material from acute disc - “Hard Disc” herniations
* Secondary to degenerative disc disease with annular bulging without frank herniation or uncovertebral osteophytes - Disc height loss leading to foraminal height loss
- Facet joint hypertrophy
- Inflammatory cytokines from disc herniation
What nerve root is affected in a cervical disc herniation?
[JAAOS 2007;15:486-494]
- Cervical nerve roots exit above their numbered pedicles
* Except C8 which exits above T1 - Exiting nerve roots affected
* Eg. C5-C6 disc herniation affects the C6 nerve root
What is the most common levels of nerve root involvement for cervical radiculopathies?
[JAAOS 2007;15:486-494]
C6 and C7
What are the presenting symptoms of a cervical radiculopathy?
[JAAOS 2007;15:486-494]
- Unilateral neck pain
- Upper trapezial and interscapular pain
- Radiculopathy patterns/Symptoms
- C2
- Posterior occipital headaches, temporal pain
- C3
- Occipital headache, retro-orbital or retroauricular pain
- C4
- Base of neck, trapezial pain
- C5
- Lateral arm pain
- Motor loss - Deltoid
- Reflex - Biceps
- C6
- Radial forearm pain, pain in the thumb and index fingers
- Motor loss - Biceps, wrist extension
- Reflex - Brachioradialis
- C7
- Middle finger pain
- Motor loss - Triceps, wrist flexion
- Reflex - Triceps
- C8
- Pain in the ring and little fingers
- Motor loss - Finger flexors
- T1
- Ulnar forearm pain
- Motor loss - Hand intrinsics
What special tests can be performed for cervical radiculopathy?
[JAAOS 2007;15:486-494]
- Spurling’s test
- Shoulder abduction test (Bakody’s test)
- For C4-6 impingement
- Patient puts hand on hand, relief of symptoms is positive test
What is the management of cervical radiculopathy?
[JAAOS 2007;15:486-494]
- Nonoperative – First Line
- 75% of patients improve without surgery
- Nonoperative modalities may not alter natural history
- Options include brief immobilization, home traction, medications, PT, manipulations, steroid injections
- Operative
- Indications:
- Severe or progressive neurological deficit
- Significant pain that fails to respond to nonoperative treatment
What are the advantages and disadvantages of ACDF and posterior decompression?
[JAAOS 2007;15:486-494]
- Anterior cervical discectomy and fusion*
- Advantages
- Direct removal of anterior pathology without neural retraction
- Anterior bone graft restores height and provides indirect decompression of neural foramens
- Fusion may improve associated neck pain
- Fusion prevents recurrent neural compression
- Low rates of infection and wound complications
- Muscle-sparing approach
- Disadvantages
- Pseudoarthrosis
- Plate complications
- Adjacent joint disease
- Speech and swallowing difficulties
- Autograft harvest morbidity if used
- Posterior laminoforaminotomy
- Advantages
- Avoids fusion and related complications
- Can be done with minimally invasive techniques
- Minimal morbidity
- Disadvantages
- Possible incomplete decompression
- Inability to restore disc and foramen height
- Progressive degeneration in absence of fusion (recurrence of symptoms)
- Removal of anterior pathology would require neural retraction
What is the usual clinical course of cervical spondylotic myelopathy (CSM)?
[JAAOS 2015;23:648-660]
Often stepwise deterioration with periods of stability, can be progressive neurological decline
What are risk factors for developing CSM?
[JAAOS 2015;23:648-660]
- Inherited predisposition
- Congenital stenosis
What structures/pathology is responsible for narrowing of the spinal canal in CSM?
[JAAOS 2015;23:648-660]
- Degenerative disc (anterior)
- Uncovertebral joint osteophyte (anterior)
- Hypertrophied/infolded ligamentum flavum (posterior)
- Facet joint degeneration (posterior)
What are clinical features of CSM?
[JAAOS 2015;23:648-660]
- Axial neck pain and decreased ROM
- Gait instability/balance impairment
* Diminished proprioception due to dysfunction of posterior column - Diminished hand dexterity/difficulty with fine motor tasks
- Bowel/bladder dysfunction (advanced CSM)
- Inability to ambulate (advanced CSM)
What clinical tests are relevant for CSM?
[JAAOS 2015;23:648-660]
- Gait
- Heel-toe walking
- Romberg test
- Finger escape sign
* Ulnar two digits drift into abduction with fingers in extension for >1 minute - Grip-and-release test
* Normal = 25-30 in 15 sec - Long tract signs
- Babinski
- Hoffmann
- Inverted radial reflex
- BR reflex elicits flexion of the long finger flexors
- Hyperreflexia
- Sustained clonus >3 beats
- Lower motor neuron signs
* Hyporeflexia - Sensory deficits may be present in UE and LE
What are the imaging findings to assess for in CSM?
[JAAOS 2015;23:648-660]
- Radiographs
- Torg-Pavlov ratio = AP width of spinal canal/AP width of vertebral body
- Stenosis = <0.80
- Categorize the alignment
- Lordotic, neutral, kyphotic, sigmoid
- MRI
- Myelography effect
- T2 images should demonstrate fluid both anterior and posterior to the cord
- Effacement of CSF
- Cross sectional cord deformation
- Oval or kidney bean in severe stenosis
- Signal change within the cord
- Poor prognosis = high signal on T2 (myelomalacia) and low signal on T1
- Compression ratio [Orthobullets]
- Smallest AP diameter of cord/largest diameter of cord (at a single level)
- Poor prognosis = <0.4
- Modified K-line
- Line connecting the midpoints of the spinal cord between C2 and C7
- Helps predict if adequate posterior drift back will be achieved from anterior sites of compression
- Measure the minimum interval distance between the line and anterior compressive factors.
- >4mm of space related with an optimal neurological recovery in non-lordotic patients after laminoplasty
3. CT
- >4mm of space related with an optimal neurological recovery in non-lordotic patients after laminoplasty
- Assess for spondylotic bars, OPLL, disc osteophyte complex
4. CT myeolography - Blockage of flow of contrast indicates regions of compression
What is the natural history of CSM?
[JAAOS 2015;23:648-660]
20-60% of patients with mild CSM progress over time in absence of surgery
What is the goal of surgery in CSM?
[JAAOS 2015;23:648-660]
Prevent progression of neurological dysfunction
What is the management of an intraoperative alert while using intraoperative neuromonitoring?
[JAAOS 2015;23:648-660]
- Intraoperative pause
- Communicate with anaesthesiologist, surgeon, neuromonitoring team
- Check equipment
- Ensure blood pressure is adequate (MAP >80mmHg recommended)
- Ensure oxygen saturation is adequate
- XR to check hardware placement
- Reverse surgical interventions until baseline achieved
- If alert persists perform wake-up test
What approaches can be used in surgical management of CSM?
[JAAOS 2015;23:648-660]
- Anterior
- Traditionally, preferred for 1 or 2 segment pathology
- Regional kyphosis >13° is an indication for anterior
- Anterior procedures include:
- ACDF
- Anterior subtotal vertebrectomy
- Anterior cervical corpectomy
- Posterior
- Traditionally, preferred for >2 segment pathology
- Posterior procedures include:
- Laminectomy alone
- Laminectomy and fusion*
- Laminoplasty (open door or French door)
- Combined
What is a simplified treatment algorithm for the management of cervical spondylotic myelopathy?
[Orthobullets]
- >10° rigid kyphosis
- 1 or 2 levels of compression = anterior approach
- ACDF/Corpectomy
- 3+ levels of compression = combined anterior and posterior
- Anterior corrects kyphosis and decompresses
- Posterior decompresses
- <10° rigid kyphosis
- 1 or 2 levels of compression = anterior approach
- ACDF/Corpectomy
- 3+ levels of compression = posterior approach
- Laminectomy + fusion OR laminoplasty
What is the most common nerve root palsy following surgery for CSM?
C5 palsy (4.6% of patients)
- Thought to be due to posterior migration of the spinal cord with tethering of the nerve root
What is Ossification of the Posterior Longitudinal Ligament (OPLL) by definition?
[JAAOS 2014;22:420-429]
Replacement of the PLL with lamellar bone
What are risk factors for the development of OPLL?
[JAAOS 2014;22:420-429]
- East Asians
- Male
- DISH
- Hyperparathyroidism
- Hypophosphatemic rickets
- Hyperinsulinemia
- Obesity
What is the presentation of OPLL?
[JAAOS 2014;22:420-429]
Cervical myelopathy
What are the risk factors for the development of myelopathy in OPLL?
[JAAOS 2014;22:420-429]
- >60% spinal canal stenosis (occupancy ratio)
- ≤6mm SAC
- Increased cervical ROM
- OPLL that is laterally deviated in the spinal canal
What imaging should be ordered in the work up of OPLL?
[JAAOS 2014;22:420-429]
- Radiographs
- CT
- MRI
What are the 4 types of OPLL based on lateral radiographs?
[JAAOS 2014;22:420-429]
- Solitary – one vertebral level or space
- Segmental – multiple separate lesions
- Continuous – single lesion involving multiple interspaces
- Mixed – combines features of the other 3
What is the kyphosis line (K-line) on a lateral radiograph and what is its significance in OPLL?
[JAAOS 2014;22:420-429]
- Line from center of the spinal canal at C2 to center of canal at C7
- Assesses the affect of the size of OPLL and the cervical lordosis
- Negative K-line = OPLL protrudes posterior to the K-line
- Positive K-line = OPLL protrudes anterior to the K-line
- Significance = negative K-line is a negative predictor of outcome for posterior surgery alone
What is the importance of the CT scan in assessing OPLL?
[JAAOS 2014;22:420-429]
- Better detects OPLL
- Allows assessment of the occupancy ratio and location of the OPLL (central vs. lateral)
- Detects dural ossification
- Appears as “double layer sign”
- If present >50% dural tear rates with anterior decompression
What is the importance of the MRI in OPLL?
[JAAOS 2014;22:420-429]
Assesses the cord compression and condition of the cord
***Note – OPLL appears as hypointense on T1 and T2
What are the indications for nonoperative management of OPLL?
[JAAOS 2014;22:420-429]
No symptoms of myelopathy
What are the indications for surgery in OPLL?
[JAAOS 2014;22:420-429]
Myelopathy
What are the advantages and disadvantages of anterior or posterior surgery for OPLL?
[JAAOS 2014;22:420-429]
- Anterior decompression and fusion
- Advantages
- Direct decompression, most effective for severe disease (>60% canal occupancy)
- Disadvantages
- Technically demanding
- Higher complication rate
- Cannot decompress above C2
- Laminectomy and fusion
- Advantages
- Allows decompression of entire cervical spine
- Low complication rate
- Low risk of kyphotic progression
- Disadvantages
- Indirect decompression
- Risk of OPLL progression
- Poor results for severe compression
- Risk of C5 palsy higher than anterior approach
- Laminoplasty
- Advantages
- Allows decompression of entire cervical spine
- Lowest immediate complication rate
- Motion preserving
- Disadvantages
- Similar to laminectomy and fusion but with higher rates of disease progression
- Contraindicated with loss of lordosis
When is anterior surgery preferred over posterior for OPLL?
[JAAOS 2014;22:420-429]
- OPLL occupies >60% of the canal
- Loss of cervical lordosis
What is the most common diagnosis prompting spinal surgery in patients >65?
[JAAOS 2016;24:843-852]
Lumbar spinal stenosis
What level is most commonly involved in lumbar spinal stenosis?
[JAAOS 2016;24:843-852]
L4/5
What is the etiology of lumbar spinal stenosis?
[JAAOS 2016;24:843-852]
- Acquired
- Secondary to degeneration (spondylosis) – most common
- Degenerative disc disease
- Loss of disc height
- Bulging of the anulus fibrosis
- Facet arthropathy
- Loss of disc height transfers load posteriorly resulting in facet joint hypertrophy, osteophyte formation
- Ligamentum flavum hypertrophy and buckling
- Degenerative disc disease
- Others:
- Post surgery
- Trauma
- Inflammatory
- Neoplastic
- Congenital
What inherited condition is associated with lumbar spinal stenosis?
[JAAOS 2016;24:843-852]
Achondroplasia
- Congenitally short pedicles
- Thick lamina
- Interpedicular distance that decreases caudally
What are the locations of lumbar spinal stenosis?
[JAAOS 2016;24:843-852]
- Central
* Disc-osteophyte complex and ligamentum flavum hypetrophy - Lateral recess
* Facet hypertrophy and osteophytes - Foraminal
- Loss of disc height
- Foraminal disc protrusion
- Osteophyte
- Scoliosis
- Extraforaminal
* Far lateral disc herniation
What MRI slice is best for visualizing foraminal stenosis?
[JAAOS 2016;24:843-852]
Sagittal T1
- Often defined as foraminal diameter <3mm or foraminal height <15mm
What are the clinical features of lumbar spinal stenosis?
[JAAOS 2016;24:843-852]
- Central stenosis
- Neurogenic claudication
- Pain in low back, buttocks and/or posterior thighs
- Worse with standing and better with sitting or leaning forward
- Worse with walking, not relieved when standing still
- Better with activities in flexed position (bicycling, pushing shopping cart)
- Lateral stenosis
* Radicular symptoms
What are the physical examination findings of lumbar spinal stenosis?
[AAOS comprehensive review 2, 2014]
Usually normal
What is the management of lumbar spinal stenosis?
[Orthobullets]
- Nonsurgical – first line
* Tylenol, NSAIDs, PT, steroid injections - Surgical – failure of nonoperative
- Pedicle to pedicle decompression
- Pedicle to pedicle decompression and instrumented fusion
- Indicated in presence of instability
- Spondylolisthesis
- Scoliosis
- Iatrogenic
- Created by complete laminectomy and/or removal of > 50% of facets
- Indicated in presence of instability
What is the most common level of lumbar disc herniations?
[JAAOS 2017;25:489-498]
Up to 95% at L4-L5 and L5-S1
What are the locations of lumbar disc herniations?
[Orthobullets]
- Central
- Causes back pain
- Can cause cauda equina
- Paracentral (posterolateral)
* Affects the descending nerve root (L4/5 affects L5) - Foraminal (far lateral)
* Affects the exiting nerve root (L4/5 affects L4)
What are the 3 lumbar disc herniation morphologies?
[AAOS comprehensive review 2, 2014]
- Protrusion
* Eccentric bulging through an intact anulus fibrosus - Extrusion
* Disc material crosses the disrupted anulus fibrosus but is continuous with the disc space - Sequestered
- Free fragment
- Disc material is not continuous with the disc space
What are the symptoms associated with lumbar disc herniation?
- Sclerotomal pain (mesodermal)
* Low back, buttock, posterior thigh pain - Radicular pain
- Leg pain in dermatomal distribution
- Worse with Valsalva
- Cauda equina