Special Tests
Tension signs
SLR (N= ~80 deg)
Crossed straight leg raise:
pain reproduced by SLR on uninvolved side = evidence of space ocupying lesion eg disc
Lasegue test-
at pt where pt feels pain in SLR, lower the leg slightly, then DF the foot to stretch nerve
Bowstring-
after Lasegue maneuvre press in popliteal fossa to stretch nerve
Femoral stretch
flex pt knee and lift hip into extension, pain in front of thigh+back
Tests to increase intra thecal pressure
Valsalva
ask pt to bear down - if pain in back or legs produced there is probable pathology either causing intrathecal pressure or involving the theca itself
Milgram Test
pt supine, lift both legs straight 2 above table + hold position for as long as possible- if pt can hold position for 30 sec intrathecal pathology can be ruled out
Tests for SI jt
Pelvic rock test
compress pelvis to midline- +ve if pain in SI jt
Gaenslens sign
supine, pt draws both knees up to chest, then shift pt to side of couch so one buttock extends over edge. Allow unsupported leg to drop over edge while opposite leg remains drawn up to chest- +ve if pain in SI jt
Faber test (Flexion, abduction external rotation)
supine, place foot of involved side on opposite knee ( fig 4 position). To stress SI jt press down on knee with one hand and press down on opposite ASIS with the other hand
Spondylolysis and Spondylolisthesis
Spondylolysis:
presence of a defect in the pars interarticularis
Spondylolisthesis:
Greek - 'spondl' means spine and olisthesis means a downward slipping
Forward shift of one vertebrae on another (usually at L4/5 or L5/S1)
Incidence
Spondylosis +/- spondylolisthesis is ~ 4.4% at 6 yo compared to ~ 6% in adulthood
Male : Female
2:1
Spondylolisthesis does not exist at birth
Aetiology
There is a genetic tendency for stress # of the pars to occur in the first yrs of upright posture
occurs in children after they are able to walk but rarely after they are 5 years old
There is seldom a history of severe injury
Shear stresses are greatest on the pars interarticularis when the spine is extended
incidence in gymnasts - due to repetitive hyperextension
family members of affected individuals
certain Eskimo tribes
sacral spina bifida and sacralisation of the 5th lumbar vertebrae
patients with thoraco-lumbar Scheuermann's disease and thought to be
associated with the compensatory increase in lumbar lordosis
Classification (spondylolysis)
- Congenital (or Dysplastic) (Males less than Females)(20%)
a congenital inadequacy of the facet jts and disc complex resulting
in displacement without a defect or elongation in the pars
rare- problem in high freq of nerve root compression due to intact
lamina being pulled against the dural sac
- Isthmic
may be pars defect (spondylytic)
pars elongation
(effectively a stress fracture) (Males greater than Females)(50%)
- Degenerative (Males less than Females)(25%)
- Traumatic
- Pathologic
due to tumours or other processes causing bone weakness
(5%)
Clinically
Symptoms are relatively uncommon in children and rarely severe enough in adolescents to seek medical attention
Adolescents or adults usually present with back ache or deformity
Look
Increased lumbar lordosis or protruding abdomen
general alignment / posture
position of sacrum- vertical or horizontal
Feel
A step can often be felt in the spinous processes of the lumbar vertebrae
tenderness
muscle spasm
Move
may be normal in the young or reduced in a degenerate spine
80% of symptomatic patients have tight hamstrings
May be an incidental finding on X-Ray done for other reasons
Girls are more prone to severe displacement, an earlier increase in deformity and more clinical symptoms than boys
The actual incidence of spondylolisthesis is lower in girls but a proportionately higher number of girls need surgical stabilisation
Scoliosis is found in 23 - 48% of patients with symptomatic spondylolisthesis but only 13% of those that have spondylolysis and the scoliosis is more often mobile and the spondylolisthesis more often dysplastic
X-Rays
Forward shift of a vertebrae on the one below
Reduced disc height
Oblique films (Scotty dog)
Measure % of slip (gd 1less than 25%, gd 2 less than 50%, gd 3 less than 75%, gd 4 less than 100%)
angle of sagittal rotation of slip angle -line drawn up post surface of sacrum, another line along post body of vertebra slipping forward- angle bw these lines is the slip angle
CT scans should be done with reverse obliquity of the gantry
Bone scan useful to identify if spondylolysis is of recent onset or not and those where there is an established non union from those where an attempt at healing is proceeding
Myelograms or MRI may be indicated if there is a neurological deficit
Pathology
Degenerative spondylolisthesis results from erosion of the superior articular process, the vertebrae slides forward on the one below
foramenal stenosis (usually at L4/5 with L5 root compression)
Spina bifida occulta occurs more frequently in patients with a pars interarticularis defect than in patients without a defect
Treatment
Rest and analgesics for acute episodes of pain
Depends on age of pt, type of defect, level of slip, degree of slip and slip angle
most important- symptoms
Spondylolysis without slip
if asymptomatic- no active treatment- monitor to see whether slip develops
avoid lifting/ strenuous vocation
symptomatic
activity modification, bracing if lesion acutely aquired
if chronic - treat nonsurgically for 6 mths - if still symptomatic then surgical management
surgery- L5-S1- fuse - alar transverse
above L5- S1stabilise with Scott technique- wiring of the TP to the SP bilaterally, pars defect is debrided back to healthy bone and grafted
- Gd 1
- no need for fusion unless chronic pain despite conservative treatment
- Gd 2
- in younger children ( less than 12) likely to progress - fuse even if no symptoms
in adolescents/adults
risk of progression much less
asymptomatic - monitor periodically
symptomatic
fusion L5-S1 for Gd 1+2
- Gd 3+4
- in children and adolescents - poor prognosis
fuse usually L4- S1- posterolat alar- transverse
Severe spondylolisthesis with lumbo-sacral Kyphosis ( ie severe sagittal rotation). These pts have signif deformity- vertical sacrum with absence of buttock contour, shortening of the waistline.
severe lumbar lordosis = compensatory deformity
reduction of these is controversial - risk of neurol damage
technique- combined post decompression and ant reduction
may need vertebrectomy
most pts do well with in- situ fusion
Nerve decompression reserved for those with compression
If the slip is greater than 25% it is said that there is a greater risk of back injury during contact sports etc which therefore should be avoided
Operation if symptoms prevent work etc or there is evidence of progression of the deformity
Prognosis
Development of a pars interarticularis defect with or without spondylolisthesis does not cause pain in most patients
A child with spondylolysis or spondylolisthesis can be permitted to enjoy a normal childhood and adolescence without restriction of activities and without fear of progressive olisthesis or disabling pain
Forceful reduction under anaesthesia has been associated with a 33% neurologic injury rate when done by the world's best spine experts
Unilateral defects are more likely to heal than bilateral ones
Can slip after solid fusion and is related to a high slip angle, a severe degree of displacement or poor quality of the fusion
50 - 100% slips treated operatively: 76% improved post operatively compared to only 30% of the patients who did not have an operation
Disc degeneration and prolapse
The intervertebral disc has blood supply up to the age of 8 years
Nutrition after this time is by imbibition and requires movement of the spinal column
Aetiology
Disc degeneration
Trauma may lead to annular tear and prolapse of nuclear material
Kirkaldy-Willis: all spines degenerate, present treatment for symptomatic relief only and suggests three stages of degeneration
- Dysfunction (15 - 45 years) characterised by circumferential and radial tears in the annulus with localised facet joint synovitis
- Instability (35 - 70 years) characterised by internal disc disruption, disc resorption, degeneration of facet joints with capsular laxity, subluxation and joint erosion
- Stabilisation (greater than 60 years) progressive development of hypertrophic bone about the disc and facet joints leading to segmental stiffening or ankylosis
Disc herniation is a complication of stage 1 & 2
Conditions associated with an increased incidence of back problems are;
Scheuermann's disease
Transitional lumbar / sacral vertebrae
Spondylolisthesis
Incidence
Male : Female
2:1
80% of population affected at some stage in their lives
Back problems account for 2% of GP presentations
70 / 100,000 require surgery
Classification
Contained protrusion
Non-contained herniations
- Sub ligamentous or sub annular extrusion
- Trans ligamentous extrusion
- Sequestered fragment
- Intradural (rare)
Clinically
Criteria for diagnosis of herniated nucleus pulposus
- Leg pain (including buttock pain) greater than back pain
- Dermatomal paraesthesia
- Root tension signs (SLR, bowstring, crossover)
- Root dysfunction (weakness, wasting, sensory or reflex)
- correlative imaging study
Usually aged 20 - 40 years
First severe attack may be precipitated by a minor episode of backache (the annular tear)
Develops severe back pain while lifting or stooping (the prolapse) which results in pain in the back, buttock and the lower limb
Backache and sciatica are exaggerated by coughing or straining
Cauda equina compression may rarely occur
Symptoms usually subside in a few days or weeks and while present there is usually a list or scoliosis which may be towards the side of the lesion (if the prolapse is in the axilla of the root) or away from it (if it is lateral to the root)
There is usually loss of the lumbar lordosis and para-vertebral muscle spasm
SLR or femoral stretch will be restricted and other nerve root tension signs may be evident such as a positive bow-string sign or a crossed SLR sign
Patient may display neurological abnormality (sensory, motor or reflex)
Root irritation is characterised by myotomal pain and muscle tenderness
Root compression: characterised by dysfunction of the nerve with weakness +/- sensory changes
Cervical myelopathy due to degeneration or disc pathology may cause a myelopathic state with lower leg signs and symptoms (urgency of micturition is a classical feature of cord pathology)
Non organic physical signs: (Waddell : Spine 1980)
- Superficial and non anatomic tenderness
- Simulated test pain eg during slight axial loading or rotation
- Alteration in severity or presence of pain if distracted (SLR particularly)
- Regional disturbances that do not follow anatomical distributions either of a sensory or motor type
- Over-reaction is the most important non organic physical sign but also the one most influenced by the subjective impressions of the observer
The presence of non organic signs even in the presence of definite pathology may identify those patients requiring formal psychosocial assessment before surgery
Imaging
X-Rays
List or scoliosis may be evident
Exclude bony pathology
(Macnab) Traction spur 2 - 3mm from the distal border of the anterior and lateral surfaces of the vertebral bodies at the point of attachment of the outermost anular fibres denotes segmental instability.
Knuttson's sign of gas in the disc (disc vacuum sign)
Myelography (preoperative investigation)
confirm level of pathology usually with CT scan
accuracy in diagnosis of lumbar disc herniation ~ 60 %
not the imaging of choice alone
Water soluble non ionic contrast medium used (eg metrizamide or iopamidol)
CT advantages over myelography
better visualisation of lateral lesions
lower radiation dose
no adverse reactions
differentiate bw bony and soft tissue compression
disadvantages
cuts only at lower 3 levels- may miss pathology at higher level
ref: Jackson etal Spine 14: 1356- 1367, 1989
for lumbar disc herniations
CT discography: 87% accuracy
contrast CT sensitivity 78%, specificity 76%, acccuracy 77%
plain CT: sensitivity 71%, specificity 76%, accuracy 74%
myelography: accuracy 58%
Suspect sequestered fragment if defect is seen cephalad or caudad to the disc space and extends over more than three CT cuts
MRI accuracy as good or better than CT myelography ie ~ 77% or better
is the imaging of choice for HNP
Advantages
good definition of normal and abnormal structures
no radiation
images in any plane
shows disc degeneration (increased signal intensity on T2 image)
Gadolinium-DTPA (diethylenetriamine pentaacetic acid)
useful in evaluation of the postoperative spine
has a 96% agreement with surgery in distinguishing epidural fibrosis from recurrent disc herniation- epidural scar has a blood supply and enhances after injection of Gd-DTPA, where disk herniation does not enhance
Discography
described by Lindblom , 1948
determines
1. morphology of the disc
2. pt response to injection
normal MRI does not rule out disc degeneration ( Kornberg, Spine 14: 1368, 1989 )
Colhoun etal JBJS 70B: 267-271, 1988
89% of pts in whom discography had demonstrated disc disease and provoked symptoms had significant and sustained benefit from operation
Walsh etal JBJS 72A: 1081-1088, 1990
in 10 asymptomatic volunteers with discography at 3 lumbar levels there were no cases of provocation of pain - ie specificity 100%
Discography useful to identify painful levels when contemplating spinal fusion
Other investigations
Differential Epidural
pt grades pain 1-10 during procedure using varying concentrations of LA- those not helped by a full spinal are unlikely to be helped by surgery
Nerve root block
Facet jt injection
no benefit in treatment of chronic LBP
Psychological Testing
MMPI:
those with scores greater than 75 for hysteria and hypochondriasis have poor prognosis
Pain diagrams
Zung depression scale combined with Modified Somatic Perception Questionairre best discriminator in a comparison of 8 psychometric tests ( Greenough and Fraser)
Pathology
Disc degeneration associated with individuals who lift heavy objects, smoke cigarettes and drive (18% greater mean disc degeneration scores in the lumbar spines of smokers compared to non smokers in discordant twin study)
Earliest changes are biochemical and trauma may be superimposed
The first morphological change probably is damage to the cartilage end plate
Circumferential tears develop in the annulus which lead to development of radial tears and may result in prolapse of nuclear material (95% of disc ruptures occur at the L4/5 and L5/S1 levels)
Lumbar entrapment syndromes:
Sub articular entrapment
Foraminal encroachment
Pedicular kinking
Extra-foraminal entrapment
Spinal stenosis
Disc ruptures
Adhesive radiculitis
Treatment
Treatment options (following a period of conservative treatment):
- Reduce disc volume (chemonucleolysis)
- Relocate disc material
- Remove disc material (discectomy)
Always think root, not disc
- Nonoperative
- Rest and analgesia (unload the spine and commence NSAIDs) 70 - 90% recover
No real place for the use of muscle relaxants, oral corticosteroids or antidepressants in the management of acute back pain
Physiotherapy good for pain relief but no proven benefit, traction reults in decreased intra discal pressure but often have recurrent pain on removal of traction
Exercise to strengthen abdominal and extensor muscles of benefit once over acute attack and back education shown to be of benefit (back education reults in 70% subjective improvement in symptoms)
Epidural injection of local anaesthetic and steroid (Celestone chronodose after informed consent), may also use foraminal steroids, results in 60 - 85% success in short term and 30 - 40% in the long term (6 months)
greater than 90% of pts conservatively treated will do well
- Chymopapain:
- Proteolytic enzyme from papaya latex
Does not affect annular collagen but disrupts proteoglycan structure (hydrolysis of cementing protein of the high molecular weight glycosaminoglycans) decreasing the water binding capacity with a reduced disc pressure and volume
- Indications
- Should have adequate trial of conservative treatment first and need to fulfil selection criteria (ie: leg pain greater than back pain, +ve tension signs, correlative imaging)
- Contraindications to the use of Chymopapain;
- Absolute:
- Sensitivity: of pts in 1.5% and anaphylaxis reported in 0.5% of cases
Rapidly progressive neurological deficit
Possibility of spinal cord tumour
Not if bulge seen on greater than 3 CT cuts or fragment occupies greater than 50% canal diameter (suggests sequested fragment)
- Relative:Severe spinal stenosis
- Pregnancy
Previous treatment with Chymopapain (? sensitivity)
Severe arachnoiditis
- Technique
Test dose of 0.3ml and if no reaction after 10 mins give the remaining 1.2ml of the therapeutic dose which gives a total of 3,000 units of the enzyme (should be administered with antibiotics)
- Results of Chymopapain
- Gogan and Fraser Chymopapain - a 10 yr double blind study
80% of chymopapain pts regarded injection as successful vs 34% of saline pts
20% of chymo pts required surgery vs 47% of saline pts
- Complications
- May get increased back pain after injection
Anti-inflammatory medication, walking and swimming are the best modalities used during convalescence
- Surgery
- Radicular pain
- Indications for surgery
- Cauda equina compression (bladder or bowel involvement)
- Failure of conservative treatment (generally at least 6/52)
and at least 3 of the criteria for diagnosis of disc herniation, with correlative imaging
- Increasing neurological defects
Results:90-95% success in relief of leg pain
~ 80% success relief of back pain
results same for conventional discectomy as for microdiscectomy
Long term results after discectomy not significantly different than those after no surgical treatment
- Chronic LBP ( for symptomatic disc degeneration)
- rationale- that immobilisation of the offending motion segment will alleviate the pain
indications
chronic and disabling LBP +/- leg pain severe enough to prevent work or other physical activities
failure of conservative treatment (incl exercise program)
pain present min 6/12
pathology well localised on investigation (MRI, discography)
realistic pt expectations
contraindications
no definite pathology to explain symptoms, multiple level degeneration where symptoms cannot be localised, major psychological stress
results - overall ~ 66% pts have satisfactory outcome from fusion
Complicationsof surgery:
- Neurological damage
- Wound infections
- Discitis
- CSF fistula
- Haematoma
- Great vessel injury
- Pulmonary embolus
- Late stenosis, instability or secondary scaring or arachnoiditis
The results of all forms of treatment needs to be compared with the natural history of the disease and the most important criterion for success remains the proper selection of patients
Prognosis
Weber, Spine 1983
controlled trial: showed statistically significant better results in the surgically treated group at one year follow up compared to the conservative group
After four years the operated patients still showed better results but the difference was no longer statistically significant and only minor changes were evident after that time up to 10 years
After 1st episode 90% improve and do not relapse
2nd episode 90% improve and 50% relapse
3rd episode 90% improve and 100% relapse
50 - 60% of back pains recover in one week and 90% in 3 months, the 10% who recover slowest account for 80% of the costs to the community
within 1 wk:
nearly 60% will return to work
2 wks:
70% return to work- of the remainder 25% will be off work at 6 mths
6 wks:
80% return to work- of the remainder 45% will be off work at 6 mths
6 mths:
92% return to work- of the remaining 8%- only 35% will return to work in next 6 mths
Spinal Stenosis
Narrowing of the spinal canal, nerve root canal or intervertebral foramen
Classification
- Congenital:
- Associated with achondroplasia and hypochondroplasia or idiopathic
Developmental or congenital stenosis by itself is rare as usually there are symptoms in combination with degeneration or other pathology
- Aquired:
- Degenerative:Often superimposed on a congenitally narrow spinal canal and may be central or peripheral (lateral recess and nerve root canals)
- Spondylolisthetc:
- Due to guillotine effect of one vertebrae moving forward on another
- Miscellaneous:
- Pagets disease, spina tumours, infection or TB
Aetiology
Pain likely to be a vascular phenomenon due to claudicant nature of symptoms
Possibly a vascular steal or due to venous congestion and stasis
Clinically
Most commonly affects the third, fourth and fifth motion segments of the lumbar spine and symptoms usually do not develop until the seventh decade (Mgreater thanF)
Aching, heaviness, numbness, burning, and paraesthesia in the thighs and legs on standing or after walking for 5 - 10 minutes
Back pain often aggravated by standing or walking and leg pain of variable distribution which may be unilateral or bilateral and usually not present at rest
Relieved by sitting, squatting or flexing the spine but symptoms change with changes in position and pain increases with extension of the lumbar spine
Restless legs: uncontrolled leg movements experienced especially at night in bed
Symptoms are often unilateral and a neurological deficit may develop with activity and a lack of clinical signs is not uncommon
Root tension signs are usually negative
Disturbance of bladder function, frequency, nocturia or incontinence after walking
Differentiation of vascular claudication:
- Pain is maximal in thighs more than the calves
- Associated with paraesthesia and weakness after walking
- Stopping and keeping the back extended will not relieve the pain
- Walking with back flexed increases the walking distance(eg pushing shopping trolley)
Investigations:
Bloods eg Elecs, CBP & ESR to exclude other pathology and may include serum electrophoresis and acid phosphatase or PSA
Plain X-Rays: short pedicles, narrow inter-pedicular distance, degenerative changes, spondylolisthesis, end plate sclerosis etc
Myelography:
Use a water soluble non ionic contrast medium and done as a day case in private institutions (cost ~ $280 - $300)
Metrizamide only one approved for use but a number are being used (often Iopamidol)
Complications;Headaches 20 - 30% and a few are severe and require blood patch (10ml autologous blood injected in the extradural space)
30% have nausea and seizures may occur if contrast gets around the base of skull or brain
Anaphylaxis is a rare complication and are associated with allergies when contrasts used IV (less so in CSF)
Myelography in the presence of a complete block may precipitate local oedema and inflammation with neurological deterioration (be ready to operate)
MRI may be indicated, good definition of soft tissue elements of the spine and a myelogram like picture of the CSF column. Root canals can also be visualised
CT / Myelography is still probably the gold standard
Pathology
Minimal cross sectional area is normally at the level of the facet joints and is least at the level of L3/4
The narrowest A-P diameter is usually from the posterior vertebral wall to the upper border of the spinous process. Verbiest defined less than 10mm as absolute stenosis and less than 12mm as relative stenosis
In the cervical spine less than 13mm AP diameter or less than 0.8 times the AP diameter of the adjacent vertebral body is defined a spinal stenosis
Canal area of 180 m3 +/- 50 m3 is normal in the lumbar spine, less than 100 m3 is spinal canal stenosis and 100 - 130 m3 is early or relative canal stenosis
The interpedicular distance should be 16 mm and the lateral canal usually measures 5 mm diameter and less than 2 mm indicates stenosis
Developmental stenosis or degenerative disease in association with vascular problems (venous hypertension or ischaemia), inflammation of neural elements and irritation of cauda equina, nerve roots, sinu-vertebral nerve and posterior primary rami
Central canal stenosis may be exaggerated by hypertrophy (realy just bunching up) of ligamentum flavum, hypertrophy and osteophyte formation of the facet joints, annular bulging of the disc and thickening of the lamina
Lateral recess stenosis can result from loss of disc height and over-riding facets, osteophyte formation of the facet joints, hypertrophy of ligamentum flavum / capsule of the joint (probably not true hypertrophy but bunching up) and posterior annular bulge
Impingement may also be caused by extradural arachnoid cysts or perineural cysts
Treatment
Posturing
Analgesics and anti-inflammatories
Steroid epidural may give improvement but usually not long lasting
Quality of life remains the key determinant in deciding when to proceed with additional assessment that is aimed at the consideration of surgical intervention
Decompression good for relieving leg pain but may not improve the back pain and in fact may increase instability problems with the occasional need for associated spinal fusion (particularly if major component of symptoms is back pain or if degen spondylolisthesis with stenosis - best results if fuse as well as decompress
Use prophylactic antibiotics
Prognosis
Central canal stenosis decompression: 65 - 85% good outcome
Nerve root decompression: 62% complete success and 24% partial success (Crock S1 decompression)
Degenerative spondylolisthesis pre-operatively have 40 - 65% risk of further slipping and 65% good result post operation (further slipping not associated with poor prognosis
Neoplastic disease
Compartments:
- Extradural
- mets greater than primary
intradural/ extramedullary
primary greater than mets
intradural/ intramedullary
primary greater thangreater than mets
Extradural Tumours
- Primary:
far less common than metastatic tumours and account for less than 10% of all primary bone tumours
benign
- nonaggressive
haemangioma (A)
osteochondroma
monostotic fibrous dysplasia
EG
- locally aggressive
- ABC (P)
osteoid osteoma (P)
osteoblastoma (P)
GCT (A)
- possible premalignant lesions ie can undergo sarcomatous change
- neurofibromatosis (~ 10%)
Pagets (1%/ yr)
diaphyseal aclasia
enchondroma
- Malignant
- solitary plasmacytoma
chordoma
lymphoma
Ewings
osteosarcoma
chondrosarcoma
haemangiosarcoma
- Secondary
- spine is the most common site for skeletal mets
vertebral body 4-7 x greater than pedicle - but greater vol of bone must be destroyed before XR changes visible
primary sites
thyroid, lung, breast, kidney, prostate, lymphoma, myeloma
Between 30 and 50% of the vertebral body must be destroyed before any changes can be recognised on X-Ray
More than 70% of patients who die from malignant disease have evidence of spinal mets and post elements are involved only 1/6 as often as the vertebral body
Intradural Tumours
v rare
Intradural Extramedullary
Neurofibroma/ Schwannoma
Meningioma
- Others
- AVM
lipoma
epidermoid/ dermoid/ teratoma
haemangioblastoma
mets
eg lymphoma
Intradural Intramedullary
ependymoma
astrocytoma
- others
- AVM
syrinx
schwannoma
Clinically
Symptoms:
pain at rest and at night, local or radicular, painful scoliosis in young, may be from pathol #
sphincteric disturbance - late
cauda equina syndrome, myelopathy
Signs:
sensory
extramedullary Brown- Sequard
intramedullary
suspended dissociated
sacral sparing suggests intramedullary lesion
motor
UMN below level of lesion, LMN at level of lesion
Investigations:
search for primary
blood screens
serum immunoelectrophoresis
CXR
urinalysis
plain XR
CT
bone scan
MRI
Staging
prior to biopsy
biopsy FNAB
trans pedicular core bx
open - rare
Treatment
Extradural benign primary tumours
symptomatic surgical resection
intralesional curettage- high rate of recurrence ~20%
ABC- embolisation with polyvinyl alcohol foam
GCT- attempt en bloc excision as more aggressive
Malignant primary tumours
prognosis dependent on tumour type
The single most important ffactor in determining the prognosis is the ability to obtain a complete excision at the initial surgery
may have to sacrifice function to achieve this goal esp in sacral lesion
chemo and radio therapy as for extremity tumours
Metastatic Tumours
Commencement of high dose dexamethasone immediately after verification of the diagnosis of spinal cord compression is widely accepted
Radiotherapy for radio-sensitive tumours in clinically stable patients but improvement may take 5 - 6 days and may therefore require surgery early if deteriorate despite radiotherapy
Surgery reserved for cases where the diagnosis is in doubt
previous radiation exposure
radio-resistant tumours
neurologic deterioration during or despite radiation
the presence of spinal instability
bone compression of neural structures
85% of the tumours are anterior, therefore, the majority of decompression procedures should also be anterior as there is a positive correlation between the location of the extradural metastatic deposit and the response to surgical treatment
Anterior approach yielded favourable results and 70 - 80% of patients regained or maintained ambulation
The success rate for ventrally located tumours decompressed by the anterior approach was 80% cf only 39% with laminectomy
Can use PMMA if life expectancy less than 1 year
The source of the primary tumour cannot be identified in 9% of cases of spinal metastases
Harrington Classification
- No neurological loss or bone involvement
- Bone involvement without collapse or neurology
- Neurological loss without significant bone involvement
- Vertebral collapse with mechanical back pain but no significant neurological loss
- Collapse and neurological loss
I & II: Chemotherapy +/- radiotherapy
III: Radiation therapy and steroids
IV & V: Surgery
Tuberculous Spondylitis
Incidence
still a problem in 3rd World
until recent AIDS epidemic a rare disease in the first world
M greater than F
most common level L1
Aetiology
Mycobacterium tuberculosis
Pathology/ Pathophysiology
usually a secondary infection - primary lesion in lung, GIT or GUT
rarely spine involved in direct spread from other structures
The infection begins in the paradiscal vertebra. Infection tends to spread across the periphery of the disc to involve the metaphyses of the vertebrae above and below. It is typical to see more than one vertebra involved ( av ~ 3)
The ant and post longitudinal ligs and periosteum are stripped up, arteries thrombose and bone dies as well being directly destroyed by the granulomatous process
The disc, being relatively avascular is relatively spared and destroyed late in the disease
- Thus progression:
- granuloma formation
pus production +/- abscess formation
bone loss, death +/- collapse
neurological involvement may be seen in active disease or healed disease
Active disease:pressure from pus, granuloma, bony sequestra, disc material, bony collapse
Can get TB meningitis or meningomyelitis
Healed disease: due to internal bony bridge or fibrous tissue constriction
Clinically
depends on stage of disease
General:
fever, malaise, wght loss
evidence of TB elsewhere
Local:
pain
rest pain, worse with motion
muscle spasm
deformity
sinus
Neurological
- Investigation
- Bloods:
WCC, ESR, CRP
Mantoux:
Radiology:
CXR
plain films
CT
MRI
Biopsy:
Z-N staining of material
high yield in active disease, poorer in healed disease
- Diagnosis
- combination of the above
DDx other infection, neoplasia
Healed TB can resemble congenital fusions
Treatment
triple therapy:
Streptomycin: initial 2-3 mths
Isoniazid: 9 mths
Rifampicin: 9 mths
commence antibiotics ~ 1 wk prior to surgery
indications for nonsurgical treatment aloneare pts with early disease with minimal bone involvement and medical contraindications to operation
Surgery is indicated in all others - esp in the paraplegia of active disease
Surgery - recommended is the Hong-Kong operation- consists of excision of the disease focus and strut grafting
- advantages
- adequate material for analysis
prevention of progression of abscess
relieve pressure on neural tissue
graft under compression - fusion almost sure- thus late kyphosis prevented
Prognosis
good prognosis for recovery in neurological compromise of active disease
poor prognosis in paraplegia of healed disease probably due to causes - ie fibrosis constricting cord, or impingement of cord on hard bony bridge arising from multilevel disease
Severe kyphotic deformity may result if a larger no of levels are involved