Daniel Chan FRCSEd FRCSOrthDaniel Chan FRCSEd FRCSOrthConsultant spinal surgeon, Consultant spinal surgeon,

PEOC, RD & EPEOC, RD & E

Common spinal Common spinal disorders anddisorders and

General principlesGeneral principles

of spinal surgeryof spinal surgery

For the medical For the medical studentsstudents

AssessmentAssessment

History, physical History, physical examination, simple examination, simple investigation, special investigation, special investigationinvestigation

Mechanical Mechanical presentation: Axial presentation: Axial painpain Exclude fractures, Exclude fractures,

tumours and infectiontumours and infection Red flags Red flags Yellow flagsYellow flags

Neurological Neurological presentationpresentation Spinal cordSpinal cord Cauda euinaCauda euina Nerve rootsNerve roots Document the deficitDocument the deficit Duration of the deficitDuration of the deficit Rapidity of progressionRapidity of progression

Deformity :local, Deformity :local, regional, globalregional, global Coronal balanceCoronal balance Sagittal balanceSagittal balance

Non spinal conditionsNon spinal conditions CVACVA Gillain BarreGillain Barre Transverse myelitisTransverse myelitis Amyotrophic neuralgiaAmyotrophic neuralgia MSMS VascularVascular

dissecting aneurysmdissecting aneurysm Saddle embolismSaddle embolism

Peripheral nerve palsiesPeripheral nerve palsies Herpes zosterHerpes zoster

Surgical principlesSurgical principles

DecompressionDecompression Direct Direct IndirectIndirect

StabilisationStabilisation In situIn situ Correction of Correction of

deformitydeformity CombinedCombined

When, how, whyWhen, how, why

PathologyPathology DegenerativeDegenerative InflammatoryInflammatory NeoplasticNeoplastic InfectiveInfective TraumaticTraumatic CongenitalCongenital developmentaldevelopmental

DegenerativeDegenerativeL4/5 Disc herniations

IndicationsIndications for Surgery- for Surgery-AbsoluteAbsolute

Acute cauda equina syndrome - Acute cauda equina syndrome - emergencyemergency

Progressive neurological deficit – urgentProgressive neurological deficit – urgent

Acute cauda equina Acute cauda equina syndromesyndrome LBPLBP Root CompressionRoot Compression

Motor / sensoryMotor / sensory Uni- / BilateralUni- / Bilateral

Sphincter DisturbanceSphincter Disturbance MotorMotor

Anal ToneAnal Tone Urinary RetentionUrinary Retention Residual volumeResidual volume

SensorySensory ““SaddleSaddle”” numbness numbness No sensation with No sensation with

bladder tuckbladder tuck CESI vs CESCCESI vs CESC (Reflexes)(Reflexes) (SLR)(SLR)

Do a rectal examination and record it

Central L4/5 Disc Central L4/5 Disc ProlapseProlapse

Needs emergency surgery

Indications for Surgery-Indications for Surgery-RelativeRelative

Natural history favourable: 90% settle over 3 Natural history favourable: 90% settle over 3 monthsmonths

Failure of appropriate time and conservative Failure of appropriate time and conservative treatment treatment 6-8 weeks 6-8 weeks

Unremitting leg pain in appropriate distributionUnremitting leg pain in appropriate distribution Nerve tension signs (SLR limited by leg pain)Nerve tension signs (SLR limited by leg pain) Imaging confirmation Imaging confirmation

done at time when surgery is contemplateddone at time when surgery is contemplated When patient accepts risk to reward ratioWhen patient accepts risk to reward ratio Recurrent attacks of leg painRecurrent attacks of leg pain

Lumbar MicrosurgeryLumbar Microsurgery

DegenerativeDegenerative Spinal stenosisSpinal stenosis

Spinal StenosisSpinal Stenosis

Elderly patientElderly patient Leg pain: radicular or claudicatingLeg pain: radicular or claudicating ParaesthesiaParaesthesia ““Paralysis”: jelly legsParalysis”: jelly legs Unusual to have acute deficit…usually Unusual to have acute deficit…usually

additional PID, synovial cyst or pin hole additional PID, synovial cyst or pin hole stenosisstenosis

Cervical spondylosis and extension injury = Cervical spondylosis and extension injury = central cord syndromecentral cord syndrome

Tandem stenosisTandem stenosis

Limited segmental Limited segmental decompressiondecompression

Technique of LSDTechnique of LSD

DegenerativeDegenerative

Degenerative Degenerative spondylolisthesisspondylolisthesis

Degenerative Degenerative spondylolisthesisspondylolisthesis

Degenerative scoliosisDegenerative scoliosis

Degenerative scoliosisDegenerative scoliosis

Degenerative scoliosisDegenerative scoliosis

Degenerative scoliosisDegenerative scoliosis

Pars interarticularisPars interarticularisSpondylolysis: The Scotty Dog Spondylolysis: The Scotty Dog Spondylolytic spondylolisthesisSpondylolytic spondylolisthesis

Spondylolytic Spondylolytic spondylolisthesisspondylolisthesis

Cervical Radiculopathy SignsCervical Radiculopathy Signs

Shoulder abduction signShoulder abduction sign Rests arm on head – reduces Rests arm on head – reduces

nerve root tension and empties nerve root tension and empties epiduralsepidurals

Holds head tilted to opposite sideHolds head tilted to opposite side Opens foramenOpens foramen

C7 painC7 pain Tend to pronate forearm when Tend to pronate forearm when

describing the pain unlike C6 and describing the pain unlike C6 and CTSCTS

Extension narrows foramenExtension narrows foramen Helps distinguish from muscular Helps distinguish from muscular

neck pain and shoulder pathologyneck pain and shoulder pathology

C5C5 Turner Parson’s Turner Parson’s

syndrome (Neuralgic syndrome (Neuralgic amyotrophy)amyotrophy)

C6C6 Carpal tunnels Carpal tunnels

syndromesyndrome C7 C8C7 C8

Thoracic outlet Thoracic outlet syndromesyndrome

C8/T1C8/T1 Pancoast tumoursPancoast tumours

Cervical RadiculopathyCervical Radiculopathy1.1. Acute – Soft DiscAcute – Soft Disc

2.2. Chronic – Hard DiscChronic – Hard Disc

3.3. Disc Height Disc Height ↓ - foraminal compression↓ - foraminal compression

4.4. Facet - foraminal compressionFacet - foraminal compression

MRI Gold StandardMRI Gold Standard Compression in 20% of asymp ptsCompression in 20% of asymp pts

CT bony pathology and foramensCT bony pathology and foramens 45 deg to sag plane45 deg to sag plane

Dynamic fluoroscopy for stabilityDynamic fluoroscopy for stability Myelography - rarelyMyelography - rarely

Natural HistoryNatural History FavourableFavourable

Lees 1963Lees 1963 51pts 2-19yrs FU51pts 2-19yrs FU 45% single episode no recurrence45% single episode no recurrence 30% mild Sx30% mild Sx 25% persis / worse Sx25% persis / worse Sx No progression to myelopathyNo progression to myelopathy 75% recovers75% recovers

90% recovers over 3 to 6 months90% recovers over 3 to 6 monthsEpidemiology of cervical radiculopathyA population-based study from Rochester, Minnesota, 1976 through 1990Kurupath Radhakrishnan1,2,*, William J. Litchy1, W. Michael O'Fallon3 and Leonard T. Kurland2

Separate the woods from the Separate the woods from the treestrees

Look for signs of myelopathyLook for signs of myelopathy Clumpsy arms/hands and legsClumpsy arms/hands and legs SpasticSpastic Upper motor neurone signs!!Upper motor neurone signs!!

Acute cord compression Acute cord compression cervical disc herniationcervical disc herniation

Needs emergency / urgent surgery

Myelopathic SymptomsMyelopathic Symptoms Subtle / varied presentationSubtle / varied presentation Pins & needles / numbness in Pins & needles / numbness in

handshands Stiff hands and reduced dexterityStiff hands and reduced dexterity Balance problems / recurrent fallsBalance problems / recurrent falls Stiff legs that tire easilyStiff legs that tire easily

Shooting sensations through bodyShooting sensations through body Spontaneous twitching / jerking Spontaneous twitching / jerking

limbslimbs Bowel or bladder disturbance Bowel or bladder disturbance

(uncommon)(uncommon) Pain is not a common symptomPain is not a common symptom

Upper motor neurone signsUpper motor neurone signsLower limbsLower limbs

Unsteady wide Unsteady wide based gaitbased gait

Romberg / Romberg / Walking RombergWalking Romberg

Unable heel toe Unable heel toe gaitgait

Triangle step testTriangle step test LL ’’Hermittes signHermittes sign HyperreflexiaHyperreflexia

Knee / Ankle Knee / Ankle Clonus Clonus

Extensor Plantar Extensor Plantar Response Response (Babinski) (Babinski)

Upper limbsUpper limbs HoffmanHoffman’’s signs sign Ono 1987Ono 1987

Grip release testGrip release test Finger escape Finger escape

signsign HyperreflexiaHyperreflexia

Inverted Radial Inverted Radial ReflexReflex

Scapulohumeral Scapulohumeral reflexreflex

Natural History - PoorNatural History - Poor

Clarke 1956Clarke 1956 120 pts120 pts 75% episodic 75% episodic ↓↓ 20% slow ↓20% slow ↓ 5% rapid ↓5% rapid ↓

Symon 1967Symon 1967 67% steady ↓67% steady ↓

Nurick 1972Nurick 1972 30% 30% ↑ non surg↑ non surg 50-73% ↑ surg50-73% ↑ surg

Phillips 1973Phillips 1973 37% ↑ non surg37% ↑ non surg 57-73% ↑ surg57-73% ↑ surg

Sampath 2000Sampath 2000 Surgery betterSurgery better ↓ ↓ neuro Sx and painneuro Sx and pain ↑ ↑ functional statusfunctional status

Spinal infectionSpinal infection

InfectionInfection

InfectionInfection

Pyogenic or TBPyogenic or TB At risk:At risk:

i.v drug usersi.v drug users elderlyelderly Immuno compromisedImmuno compromised DiabeticsDiabetics Renal failureRenal failure Urological manipulationUrological manipulation Cardiac: SBECardiac: SBE

Epidural Epidural abscessabscess MRI + GadMRI + Gad Neurology in Neurology in

cord area needs cord area needs emergency emergency decompressiondecompression

Spondylodiscitis Spondylodiscitis instability and instability and

acute deformity acute deformity

Spinal infection: Spinal infection: important lessonimportant lesson

Late diagnosis frequentLate diagnosis frequent High index of suspicionHigh index of suspicion Risk factors!Risk factors! Early diagnosis antibiotics alone sufficeEarly diagnosis antibiotics alone suffice Late diagnosis with bone destruction Late diagnosis with bone destruction

leads to spinal deformity and further leads to spinal deformity and further neurological compromiseneurological compromise

Difficult surgery then needed Difficult surgery then needed

MSCCMSCC Any neurological deficit requires urgent/ Any neurological deficit requires urgent/

emergency MRIemergency MRI Staging for prognosisStaging for prognosis What is the primaryWhat is the primary Is it metastaticIs it metastatic Is it operableIs it operable Is it treatable with radio/chemotherapy Is it treatable with radio/chemotherapy

alonealone Surgery is palliativeSurgery is palliative Will the patient benefit from surgeryWill the patient benefit from surgery

TumourTumour

59/F59/F

Backpain + (L) leg Backpain + (L) leg weaknessweakness

L3 mets with neural L3 mets with neural compressioncompression

Pre opPre op

Pre opPre op

Post embolisationPost embolisation Pre embolisationPre embolisation

Intra opIntra op

Post opPost op

AP viewAP view Lateral viewLateral view

Mechanical low back painMechanical low back pain

i.e…..Not infective, metabolic, traumatic, i.e…..Not infective, metabolic, traumatic, metastaticmetastatic

?diagnosis?diagnosis SpeculativeSpeculative Degenerative discopathy?Degenerative discopathy? Facet pain?Facet pain? Segmental painSegmental pain

Specific mechanical pathology:Specific mechanical pathology: spondylolytic spondylolisthesisspondylolytic spondylolisthesis Post surgical destabilisationPost surgical destabilisation

CClinical linical SStandards tandards AAdvisory dvisory GGroup 1994roup 1994

Red flagsRed flags Thoracic painThoracic pain Fever and unexplained weight Fever and unexplained weight

lossloss Bladder or bowel dysfunctionBladder or bowel dysfunction History of carcinomaHistory of carcinoma Ill health or presence of other Ill health or presence of other

medical illnessmedical illness Progressive neurological Progressive neurological

deficitdeficit Disturbed gait, saddle Disturbed gait, saddle

anaesthesiaanaesthesia Age of onset <20 years or Age of onset <20 years or

>55 years>55 years

Yellow flagsYellow flags

A negative attitude that A negative attitude that back pain is harmful or back pain is harmful or potentially severely potentially severely disablingdisabling

Fear avoidance behaviour Fear avoidance behaviour and reduced activity levelsand reduced activity levels

An expectation that passive, An expectation that passive, rather than active, rather than active, treatment will be beneficialtreatment will be beneficial

A tendency to depression, A tendency to depression, low morale, and social low morale, and social withdrawalwithdrawal

Social or financial problemsSocial or financial problems

Inflammatory - RAInflammatory - RA

RARA

Inflammatory - ASInflammatory - AS

ASAS

Prone to fracturesProne to fractures Often unstable, fractures like chalk Often unstable, fractures like chalk

stickstick Neurological deficit frequentNeurological deficit frequent If originally kyphotic, strapping If originally kyphotic, strapping

spine board may be dangerousspine board may be dangerous

Bamboo spine with fixed kyphosisBamboo spine with fixed kyphosis

Cervical osteotomy - ASCervical osteotomy - AS

Inflammatory - ASInflammatory - AS

TraumaTrauma

Aims of fracture treatmentAims of fracture treatment

anatomical reduction anatomical reduction alignmentalignment

maintain alignmentmaintain alignment rehabilitationrehabilitation

Preserve neurological Preserve neurological functionfunction

Tissue healingTissue healing bone heals with bonebone heals with bone bone healing may malunitebone healing may malunite soft tissue heals with soft tissue heals with

fibrous tissue fibrous tissue fibrous healing remains fibrous healing remains

unstableunstable

Scoliosis Scoliosis Isola instrumentationIsola instrumentation

Double rod systems : Double rod systems : KanedaKaneda

Growing rodGrowing rod Paediatric down sized implantsPaediatric down sized implants Instrumentation without fusionInstrumentation without fusion Periodic lengthening of rodPeriodic lengthening of rod Allows continuing growthAllows continuing growth

Growing rodGrowing rod

SummarySummary Keep it simpleKeep it simple Axial pain and Axial pain and

stability problemstability problem Neurological problemNeurological problem Apply the 2 principles Apply the 2 principles

of decompression of of decompression of neural structures and neural structures and stabilisation of bony stabilisation of bony ligamentous ligamentous structuresstructures

SummarySummary

Presents with brachiagia with or without Presents with brachiagia with or without sensory and or motor symtomssensory and or motor symtoms

Dermatomal distribution identifies levelDermatomal distribution identifies level Consider important differentialsConsider important differentials Favourable natural history favours Favourable natural history favours

conservative treatmentconservative treatment Response to surgery generally goodResponse to surgery generally good

My experienceMy experience

RetrospectiveRetrospective 47 patients47 patients 72% 72%

satisfactory satisfactory (good/excellent(good/excellent) clinical ) clinical outcomeoutcome

97% fusion 97% fusion raterate

InvestigationsInvestigations

MRIMRI

OtherOther BloodsBloods

Remember CoagRemember Coag CT myelogramCT myelogram

Radicular PainRadicular Pain MechanicalMechanical

Biological / ChemicalBiological / Chemical IL-1, IL-6, Sub P, TNF-IL-1, IL-6, Sub P, TNF-αα

InflammationInflammation blood vessel permeabilityblood vessel permeability Oedema of root / DRGOedema of root / DRG

Metabolic disorders with neuropathy e.g. diabetesMetabolic disorders with neuropathy e.g. diabetes Increased susceptibility to radiculopathyIncreased susceptibility to radiculopathy