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1

Anatomy of the Spinal Column

 

  • Descending Tracts (motor)
    • lateral corticospinal tract (LCT)
      • UMN are in the lateral portion of the white matter
      • They synapse with anterior horn cells (ventral) in the grey matter, and more central portion of the spinal cord
    • ventral corticospinal tract
      • Rubriospinal
        • smaller, less axons
        • voluntary muscle control
        • primarily flexion (decorticate)
        • extra-pyramidal
  • Ascending tracts (sensory)
    • Synapse with the doral root ganglion and enter via the posterior horn of the grey matter (doral)
    • dorsal columns 
      • deep touch
      • vibration
      • proprioception
    • lateral spinothalamic tract (LST)
      • pain
      • temperature
    • ventral spinothalamic tract (VST)
      • light touch

 

2

ASIA classification of spinal injury

3

Elderly patient with hyperextension injury and UE weakness.  Pathology?  Diagnosis? Treatement?

 

Central Cord syndrome

  • Pathophysiology
    • hands and upper extremities are located "centrally" in corticospinal tract
    • More research suggests that it is the larger neurons that are affected (the LMN are not affected)
    • Wallerian degeneration may occur below the level of the insult
  • Presentation
    • symptoms
      • weakness with hand dexterity most affected
      • Hyperpathia - burning in distal upper extremity
    • physical exam
      • motor deficit worse in UE than LE
      • hands have more pronounced motor deficit than arms
      • sacral sparing
  • late clinical presentation
    • UE have LMN signs (clumsy)
    • LE has UMN signs (spastic)
  • Imaging
    • Radiographs are always the first initial treatment
      • rule out instability
    • CT should be used to discern any fractures that occurred
    • MRI
      • Look for pre-existing causes for stenosis
      • Edema without haemorrhage on T2 and STIR are commonly found
  • Treatment - nonoperative
    • Initially admit to ICU
    • MAP > 85 - consider vasopressors
    • Immobilization in hard collar
    • Early and intensive PT
    • Monitor for progression of neuro symptoms
  • Operative - controversial; may cause worsening of damage to cord
    • Indications
      • Spinal instability
      • Pre-existing severe stenosis
      • Progressive deficient
    • Timing
      • < 24 hrs if acute instability or if progressive deficiet

4

Prognosis of central cord syndrome

  • final outcome 
    • good prognosis although full functional recovery rare
    • usually ambulatory at final follow up
    • usually regain bladder control
    • upper extremity and hand recovery is unpredictable and patients often have permanent clumsy hands
  • recovery occurs in typical pattern
    • lower extremity recovers first
    • bowel and bladder function next
    • proximal upper extremity next
    • hand function last to recover
  • Positive predictors
    • young age
    • preinjury employment
    • level of education
    • absence of spinal cord signal abnormality shown by MRI
    • higher initial ASIA motor score
    • absence of spasticity
    • early motor recovery
    • good hand function
  • Poor predictors
    • spinal column instability
    • degree of canal stenosis
    • persistent spasticity
    • medical co-morbidities 

5

Patient with a flexion/compression injury and motor deficiet LE>UE. Diagnosis?  Treatment?  Outcome?

Anterior Cord Syndrome

  • Pathophysiology
    • anterior spinal artery injury
      • anterior 2/3 spinal cord supplied  by anterior spinal artery
    • direct compression (osseous) of the anterior spinal cord
  • Mechanism
    • usually result of flexion/compression injury
  • Exam
    • LE > UE
      • lateral corticospinal tract
    • dissociated sensory loss
      • lateral spinothalamic (pain, temp)
    • preserved dorsal column
      • DC (proprioception, vibratory sense)
  • Prognosis
    • worst prognosis of incomplete SCI
    • most likely to mimic complete cord syndrome
    • 10-20% chance of motor recovery

6

Patient was minding his own buisness, and was stabbed in the back with a knife!  What spinal cord syndrome would you see?  What are the expected findings and prognosis?

Brown-Segard Syndrome

  • Caused by complete cord hemitransection
    • usually seen with penetrating trauma
  • Exam
    • ipsilateral deficit
      • Lateral corticospinal tract
        • motor function
      • dorsal columns
        • proprioception
        • vibratory sense 
    • contralateral deficit
      • Latearl spinothalamic
        • pain
        • temperature
      • spinothalamic tracts cross at spinal cord level (classically 2-levels below)
  • Prognosis
    • excellent prognosis
    • 99% ambulatory at final follow up

7

What are the ASIA dermatomes and myotomes

Random Myotomes

C2 – Flex/Ext C-spine
C3 – Lateral Flexion C-spine
C4 – Shoulder Elevation (shrug)

Random Dermatomes

C2 – Posterolateral Skull
C3 – Just above SC joint and lateral
C4 – Just below AC joint and medial (coracoid)

8

What is the ASIA classification of spinal injury?

Motor level is the lowest level with > 3 motor

sensory level is the lowest functioning

Can often get some recovery around the zone of injury

9

When do you not need c-spine imaging in trauma?

low energy trauma

no distracting injuries

no midline tenderness

no neuro symptoms

can rotate head in both directions

10

How can you minimize the secondary zone of injury in spinal trauma

aggressive fluid resussitation 

MAP >85 (prevent hypotensin)

pressors

both in ICU and intra-op

11

At what levels do you worry about respiratory and cardiovascular comprimise in SCI?

  • Above C3 can have respiratory arrest
    • C3-5 keeps the diaphragm alive
  • Thoracic levels will loose intercostals and so can have respiratory distress
    • intubate before they go into extremis
  • T1-T4 cardiac accelorator fibers
    • don't function with c-spine injury
  • Injury above T7 - loose your response to stress
    • neurogenic shock; loose the adreniline 
    • vasodilation, bradycardia, hypotension
    • treat with pressors, use a swan-ganz catheter to montior fluids

12

What is your approach to a patient with a c-spine injury in the emerg and in the OR

C-spine precautions

  • c-collar
  • 2 sandbags with head tapped to them
  • off spine board as soon as possible
  • head cut out for kids
  • traction is no longer advocated
  • Intubation/Airway
    • ​to keep precautions
      • ​Manual in line stabilization (MILS)
      • galidoscope
      • blind oral intubation
      • fiberoptic intubation (slow and not recommended for trauma)
      • laryngeal mask airway
      • cricothyrotomy
    • ​above C5 common
    • low threshold
  • ​Circulation
    • ​may have spinal or neurogenic shock (T7)
      • ​fluids, pressors
    • ​hypotension will contribute to secondary injury to spinal cord
      • ​MAP > 85
  • ​Transfers
    • log roll precautions, sliding board
    • turn using spinal positioning table/sandwich
  • Consider neuromonitoring with MEPs
    • very sensitive to inhaled anesthetics

13

Complications associated with SCI post-op

  • Skin problems
    • treatment is prevention
    • start in ER
      • do not leave on back board
      • start log rolling early
    • proper bedding
  • Venous Thromboembolism
    • prevent with immediate DVT prophylaxis
  • Urosepsis
    • common cause of death
    • strict aseptic technique when placing catheter
    • don't let bladder become overly distended
  • Sinus bradycardia
    • most common cardiac arrhythmia in acute stage following SCI
  • Orthostatic hypotension
    • occurs as a result of lack of sympathetic tone
  • Autonomic dysreflexia 
    • potentially fatal
    • presents with headache, agitation, hypertension
    • caused by unchecked visceral stimulation
    • check foley
    • disimpact patient
  • Major depressive disorder
    • ~11% of patients with spinal cord injuries suffer from MDD 
    • MDD in spinal cord injury patients is highly associated with suicidal ideation in both the acute and chronic phase.

14

What are the levels associated patient function?

C1-C3

- Ventilator dependent with limited talking. 

- Electric wheelchair with head or chin control

C3-C4

- Initially ventilator dependent, but can become independent

Electric wheelchair with head or chin control

C5

- Ventilator independent

- Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to feed oneself

- Independent ADL’s; electric wheelchair with hand control, minimal manual wheelchair function 

 

C6

- C6 has much better function than C5 due to ability to bring hand to mouth and feed oneself (wrist extension and supination intact)

- Independent livingmanual wheelchair with sliding board transfers, can drive a car with manual controls

C7

- Improved triceps strength

- Daily use of a manual wheelchair with independant transfers

C8-T1

- Improved hand and finger strength and dexterity

- Fully independent transfers

T2-T6

- Normal UE function

- Improved trunk control

- Wheelchair-dependent

T7-T12

- Increased abdominal muscle control

- Able to perform unsupported seated activities; with extensive bracing walking may be possible

L1-L5

- Variable LE and B/B function

- Assit devices and bracing may be needed

S1-S5

- Various return of B/B and sexual function

- Walking with minimal or no assistance

15

What are surgical indications for stabilization in SCI

  • most incomplete SCI (except GSW)
    • decompress when patient hits neurologic plateau or if worsening neurologically
    • decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)
  • most complete SCI (except GSW)
    • stabilize spine to facilitate rehab and minimize need for halo or orthosis
    • decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)
  • consider for tendon transfers
    • e.g. Deltoid to triceps transfer for C5 or C6 SCI 
  • metastatic CA patients with > 6 mos life expectancy
  • GSW with
    • progressive neurological deterioration with retained bullet within the spinal canal
    • cauda equina syndrome (considered a peripheral nerve)
    • retained bullet fragment within the thecal sac
    • CSF leads to the breakdown of lead products that may lead to lead poisoning

16

Diagnosis?  Epidemiology? Orthopedic and Non-orthopedic manifestations?

Ankylosing Spondylitis

  • An systemic chronic autoimmune spondyloarthropathy characterized by 
    • HLA-B27 (90%)
      • carries have a 20-50% risk of having disease
    • RH negative (seronegative)
    • primarily affect axial spine
  • Pathoanatomy - unknown
    • HLA-B27 aggregates with peptides in the joint and leads to a degenerative cascade
      • cytotoxic T-cell autoimmune reaction against HLA-B27
    • enthesitis
      • entheses inflammation leads to bony erosion, surrounding soft-tissue ossification, and eventually joint ankylosis
      • preferentially targets sacroiliac joints, spinal apophyseal joints, symphysis pubis
      • this differentiates from RA, which is a synovial process
    • disc space involvement
      • inflammation of the annulus lead to bridging osteophyte formation (syndesmophytes)
  • Genetics
    • there is a genetic predisposition, but mode of inheritance is unknown
    • HLA-B27 is located on sixth chromosome, B locus
  • Epidemiology
    • 4:1 male:female
    • affects ~0.2% of Caucasian population
    • usually presents in 3rd decade of life
    •  juvenile form <16-years-old includes enthesitis 
    • fewer than 10% of HLA-B27 positive patients have symptoms of AS
  • Diagnostic criteria 
    • bilateral sacroiliitis
    • +/- uveitis
    • HLA-B27 positive 
  • Systemic manifestations
    • acute anterior uveitis & iritis
    • heart disease (cardiac conduction abnormalities)
    • pulmonary fibrosis
    • renal amyloidosis
    • ascending aortic conditions (aortitis, stenosis, regurgitation)
    • Klebsilella pneumoniae synovitis
      • HLA-B27 individuals are more susceptible to Klebsilella pneumoniae synovitis
  • Orthopaedic manifestations
    • bilateral sacroiliitis
    • progressive spinal kyphotic deformity
    • cervical spine fractures
      • large-joint arthritis (hip and shoulder)
    • Note: the atlanto-occipital joint is the last to fuse which can lead to atlantoaxial instability

17

What are the orthopedic and systemic manifestions of ankylosing spondylitis

Systemic manifestations

acute anterior uveitis & iritis
heart disease (cardiac conduction abnormalities)
pulmonary fibrosis
renal amyloidosis
ascending aortic conditions (aortitis, stenosis, regurgitation)
Klebsilella pneumoniae synovitis

Orthopaedic manifestations

bilateral sacroiliitis
progressive spinal kyphotic deformity
cervical spine fractures

large-joint arthritis (hip and shoulder)

Note: the atlanto-occipital joint is the last to fuse which can lead to atlantoaxial instability

18

What does this patient have?  What does your work-up include?

Ankylosing Spondylitis

  • History
    • Full and AMPLE history of pain and function
    • lumbosacral pain and stiffness
      • present in most patients
      • worse in morning
      • insidious onset in 3rd decade of life
    • neck and upper thoracic pain 
      • occurs later in life
      • acute neck pain should raise suspicion for fracture
      • Pain will improve as the spine fuses
    • sciatic
      • likely originates from sciatic nerve involvement in the pelvic (piriformis spasm)
    • loss of horizontal gaze
    • Other associated issues including eye irritaiton, chest pain, bowel issues, rashes
      • shortness of breath
    • Neurological symptoms, bowel/bladder
    • PMHx, family medical history, treatment to date
  • Physical exam 
    • limitation of chest wall expansion
      • < 2cm of expansion is more specific than HLA-B27 for making diagnosis
    • Schober test 
      • used to evaluate lumbar stiffness
    • kyphotic spine deformity
    • chin-on-chest (flexion) deformity of the spine
    • chin-brow-to-vertical angle (CBVA) 
      • measured from standing exam of standing lateral radiograph
      • useful for preoperative planning
      • correction of this angle correlates with improved surgical outcomes
    • hip flexion contracture 
      • examining patient in supine and sitting position helps differentiate sagittal plane imbalance due to hip flexion contractures or kyphotic spinal deformity
    • sacroiliac provocative tests 
      • Faber test
  • Differential (can have similar imaging findings to AS)
    • psoriatic arthritis
    • reactive arthritis
    • arthritis associated with inflammatory bowel disease
    • undifferentiated spondyloarthropathy
  • Radiographs 
    • spine  - standing full-length AP and lateral of axial spine
      • negative in 50% of cases with spine fractures
      • squaring of vertebrae with vertical or marginal syndesmophytes 
      • "shining corners" = sclerosis at the disovertebral junction
        • Romanus lesions
      • Zygoapophyseal joints = fusion of posteiror elements
      • late vertebral scalloping (bamboo spine)
      • measurements
        • chin-brow to vertical angle
          • used to measure chin-on-chest deformity
    • pelvis & lower extremity 
      • Ferguson pelvic tilt view 
        • allows for improved visualization of anterior SI joint
        • xray beam directed 10 to 15 degrees cephalad
        • findings
          • bilateral symmetric sacroiliac erosion 
          • earliest radiographic sign is erosion of iliac side of sacroiliac joint
          • joint space narrowing
          • ankylosis
    • ​​If possible to flex-ex views to assess for AAI pre-op to make for safer intubation
    • CT 
      • will show bony changes but not active inflammation
      • CT is most sensitive test to diagnose cervical fractures in patients with AS
    • MRI
      • will detect inflammation, making it the best modality for early detection of AS in young patients
      • obtain with cervical fractures to look for epidural hemorrhage
    • Bone scan
      • will show inflammation in the sacroiliac joints, but lacks specificity
  • Labs 
    • little diagnostic value
    • often see nonspecific elevations in ESR and CRP
    • RF negative, HLA-B27 positive
  • Diagnostic Injections 
    • SI joint injection
      • local anesthetic injected into SI joint under fluoroscopic guidance
      • often most sensitive diagnostic test

 

19

What are the pertient physical exam findings in ank spond

  • limitation of chest wall expansion
    • < 2cm of expansion is more specific than HLA-B27 for making diagnosis
  • Schober test 
    • used to evaluate lumbar stiffness
  • kyphotic spine deformity
  • chin-on-chest (flexion) deformity of the spine
  • chin-brow-to-vertical angle (CBVA) 
    • measured from standing exam of standing lateral radiograph
    • useful for preoperative planning
    • correction of this angle correlates with improved surgical outcomes
  • hip flexion contracture 
    • examining patient in supine and sitting position helps differentiate sagittal plane imbalance due to hip flexion contractures or kyphotic spinal deformity
  • Faber test

20

What are the radiographic findings you are looking for in ank spond

  • spine  - standing full-length AP and lateral of axial spine
    • negative in 50% of cases with spine fractures
    • squaring of vertebrae with vertical or marginal syndesmophytes 
    • "shining corners" = sclerosis at the disovertebral junction
      • Romanus lesions
    • Zygoapophyseal joints = fusion of posteiror elements
    • late vertebral scalloping (bamboo spine)
  • measurements
    • chin-brow to vertical angle
      • used to measure chin-on-chest deformity
  • pelvis & lower extremity 
    • Ferguson pelvic tilt view 
      • allows for improved visualization of anterior SI joint
      • xray beam directed 10 to 15 degrees cephalad
      • findings
        • bilateral symmetric sacroiliac erosion 
        • earliest radiographic sign is erosion of iliac side of sacroiliac joint
        • joint space narrowing
        • ankylosis
  • ​​If possible to flex-ex views to assess for AAI pre-op to make for safer intubation
  • CT 
    • will show bony changes but not active inflammation
    • CT is most sensitive test to diagnose cervical fractures in patients with AS
  • MRI
    • will detect inflammation, making it the best modality for early detection of AS in young patients
    • obtain with cervical fractures to look for epidural hemorrhage
  • Bone scan
    • will show inflammation in the sacroiliac joints, but lacks specificity

21

What is more specific than HLA-B27 for making diagnosis of ank spond

limitation of chest wall expansion

< 2cm of expansion is more specific than HLA-B27 for making diagnosis

22

What is the number one procedure performed on patients with ank spond

THA

  • Most will recommend do this prior to spinal correction
    • ​if very bad can do osteotomy first to prevent malaligment of the acetabulum
  • Indications
    • ​Unilateral - arthritis
      • ​more verticle, anteverted acetbulum
    • Bilateral - flexion contracture
      • at risk for dislocation
  • Considerations
    • some consider at risk for HO, but no study to say you should put them on prophylaxis
    • uncemented is ok

23

What is the earliest sign of sacroilitis in ank spond

Ferguson pelvic tilt view 

allows for improved visualization of anterior SI joint
xray beam directed 10 to 15 degrees cephalad
findings

bilateral symmetric sacroiliac erosion 
earliest radiographic sign is erosion of iliac side of sacroiliac joint

24

Diagnosis?  Treatment?

Kyphotic Deformity from ank spond

  • Rule out hip flexion contracture first
  • Get flex-ex views
    • ​Be aware of potential for atlano-axial instability as atanto-occipital joint is the last to fuse
  • Lumbar osteotomy 
    • indications
      • thoracolumbar kyphotic deformity
  • Perioperative preparation
    • Fiberoptic intubation
    • Appropriate positioning to account for kyphosis
    • Neuromonitoring
    • Some advocate for wake up test which is more sensitive than neuromonitoring
  • closing wedge (pedicle subtracting) osteotomy  - lowest rates of complications
    • transpedicular decancelization procedure with removal of posterior elements
    • location of osteotomy determined by type of spine flexion deformity
    • hinge located on anterior vertebral body
    • considered procedure of choice due to
      • greater deformity correction (30 t0 40 degrees per level)
      • better fusion and stability due to direct bony apposition
      • fewer complications
  • vertebral body resection 
    • entire vertebral body is removed and replaced with a cage 
  • single-level opening wedge osteotomy
    • hinges on posterior edge of vertebral body
    • requires rupture of ALL
  • multi-segment opening osteotomy
    • advantage of less bone loss and preservation of ALL by distributing correction over multiple levels
  • outcomes & complications 
    • lumbar approach avoids complications of thoracic cage, spinal cord injury, and has potential for greater correction due to long lever arm
    • Dural tears (secondary to dural ectasia)
    • Transient nerve root compression
    • Loss of correction
    • Implant failure
    • Postoperative instability
    • Aortic injury

25

Complications associated with ank spond osteotomy

Dural tears (secondary to dural ectasia)
Transient nerve root compression
Loss of correction
Implant failure
Postoperative instability
Aortic injury

Note - can get 30-40 deg correction with PSO

26

Diagnosis?  Treatment?

Chin on Chest deformity - Ank Spond

  • Pre-op considerations as previous
  • C7-T1 cervicalthoracic osteotomy 
    • Contra-indicated in patients who previously did not have pain, and now have pain as this may indicate a fractre
  • indications 
    • cervicothoracic kyphotic (chin-on-chest) deformity
    • goals 
      • slight under-correction with final brow-to-chin angle of 10 degrees
  • advantage of  C7-T1 osteotomy include 
    • vertebral artery is external to transverse foremen
    • larger canal diameter
    • mobile neural elements
      • requires wide decompression with removal of C7 lateral mass and portions of C7-T1 pedicles to prevent iatrogenic SCI
  • instrumentation 
    • usually a combination of lateral mass screws, pedicle screws, and sublaminar hooks
  • postoperative 
    • postoperative halo immobilization often required in patients with poor bone quality
  • outcomes & complications 
    • increased risk of venous air embolus (VAE) in the sitting operative position
    • C8 palsy
    • Quadrepelegia
    • subluxation

 

27

Diagnosis?  Treatment?

Fracture Associated with Ank Spond

  • Introduction 
    • C7-T1 common becasue of folcrum of head
    • often extension-type fracture that involved all three columns
    • may be occult so if suspicious consider CT scan (best modality to make diagnosis)
    • high mortality rate secondary to epidural hemorrhage
    • 75% neurologic involvement
      • neurologic symptoms often present late
  • traction, orthotic or halo immobilization
    • indications 
      • stable spine fractures with no neurologic deficits
    • technique 
      • low-weight traction may facilitate reduction
  • spinal decompression with instrumented fusion 
    • indications 
      • progressive neurologic deficit
      •  epidural hematoma with neurologic compromise
      • unstable fracture patterns
    • Positioning
      • Fiberoptic intubation
      • Appropriate positioning to account for kyphosis
      • Neuromonitoring
      • Some advocate for wake up test which is more sensitive than neuromonitoring
    • decompression 
      • decision to go anterior or posterior depends on fracture level, presence and location of hematoma, and osteoporosis
    • instrumentation 
      • need to obtain long fusion construct
      • multiple points of fixation
        • fosteoporosis
        • long lever arms of the ankylosed spine
    • do not make an effort to correct deformity
  • outcomes & complications
    • progressive deformity
    • nonunion
    • hardware failure
    • infection

28

Diagnosis?

DISH (Diffuse Skeletal Idiopathic Hyperostosis)

  • Common disorder of unknown etiology characterized by back pain and stiffness
  • Non-marginal syndesmophytes at three successive levels
    • Everywhere in the spine, usually on the right
    • Forestier disease
    • Different from AS
      • No involvement of SI, usually older patients
  • 6-12%
    • More common in older patients with gout and diabetes
  • Sequelae
    • Lumbar stenosis
    • Dysphagia
    • Cervical melopthy
    • Spinal cord injury resulting form even minor trauma
    • Increase risk of heterotopic ossication after THA
  • Presentation
    • Chronic back pain, stiffness
    • Often incidental
  • Imaging
    • Non-marginal syndesmophytes at three successive levels
    • Lateral radiographs can be helpful to differentiae from AS
      • DISH -anterior bone formation, preserved disc space
      • AS - interbody fusion
  • Treatment
    • Usually non-op
    • Surgical treatment may be indicated for certain sequelae

29

What does it mean to have a positive provocative discography

  • criteria for a positive test 
    • concordant pain response
    • abnormal disc morphology on fluoroscopy and postdiskography CT
    • negative control levels in lumbar spine
  • outcomes - studies show provocative discography is associated with the following
    • increased incidence of lumbar disc herniations
    • loss of disk height
    • endplate changes

30

Indications for total disc replacement

outcomes at least equal to fusion

single level disease

no associated facet OA