Orthopedic Surgery: Spine: A. Introduction To The Spine

22.
Orthopedic surgery: spine
A. Introduction to the spine

• Anatomy
o Cervical (7) – lordosis
▪ C1 = Atlas
▪ C2 = Axis with dens of axis
o Thoracic (12) – kyphosis
o Lumbar (5) – lordosis
o Sacrum (5, fused)
o Coccyx (5, fuse)
B. Congenital, degenerative, and inflammatory diseases of the spine [8C]

(1) Congenital and developmental abnormalities
• Congenital torticollis
o Twisted neck due to abnormal foetal positioning (breech position, birth trauma, unilateral fibrosis,
contracture of sternocleidomastoid)
o Head tilted to one side and unilateral mass that involves the SCM, facial asymmetry
o Usually resolves after 2-6 months of age
• Hemivertebrae – secondary to structural scoliosis
• Spina bifida
• Craniovertebral junction anomalies
• Idiopathic scoliosis
• Scheuermann juvenile kyphosis
• VACTERL association
• Atlanto-axial instability in Down syndrome
(2) Degenerative disorders

• Degenerative disk disease
• Osteoporosis
• Spinal stenosis
• Osteoarthritis
• Osteoarthrosis
• Spondylarthrosis – broad term to describe degenerative changes of the spine that may result in irritation
and/or damage of the adjacent nerve roots
o Clinic: pain, paraesthesia, weakness
(3) Infectious disorders
• Vertebral osteomyelitis
• Tuberculosis (Pott disease)
(4) Inflammatory conditions

• Rheumatoid arthritis – see 12B
• Ankylosing spondylitis (M. Bechterew)
o HLA-B27
o Arthritis that leads to stiffening of the spine usually starting in the lower back
o Surgery: severe deformity, instability of the spine and neurologic deficits
▪ Osteotomy, joint replacement, spinal fusion
• Reiter’s syndrome – reactive arthritis
o Immune-mediated condition (1-4 weeks after bacterial GIT/GUIT infection)
o Shigella, Yersinia, Salmonella, Campylobacter, Chlamydia
(5) Trauma
• Vertebral fractures
• Spondylolosthesis
(6) Neoplasia
• Bone metastasis
• Primary bone neoplasms
o Osteoblastoma
o Chordoma
• Hematological malignancies
o Multiple myeloma
o Acute leukemia
o Chronic myeloid leukemia
o Chronic lymphocytic leukemia
(7) Neurological disorders

• Radiculopathy
• Spinal cord compression
• Conus medullaris syndrome
• Cauda equina syndrome
(8) Medical procedures

• Spinal anesthesia
• Epidural anesthesia
• Lumbar puncture
21c. Degenerative and inflamatory diseases of the spine
(1) Degenerative disk disease
• Definition: Group of conditions in which disk material is displaced into spinal canal
o Disk protrusion: protrusion of the vertebral disk nucleus pulposus through the annulus fibrosus
o Disk herniation (disk extrusion or disk prolapse): complete extrusion of the nucleus pulposus
through a tear in the annulus fibrosus
o Disk sequestration: extrusion of the nucleus pulposus and separation of a fragment of the disk
o Spondylosis: a broad term used to describe degenerative changes of the spine that may result in
irritation and/or damage of the adjacent nerve roots or spinal cord
* Lumbosacral disk herniation: L5–S1 (most common site), L4–L5 (second most common site)
*Intervertebral disks usually protrude/herniate posterolaterally, as the posterior longitudinal ligament
is thinner than the anterior longitudinal ligament.
• Clinical manifestations:
o Asymptomatic
o Radiculopathy (compression of spinal nerve root):
▪ Acute onset of severe neck or back pain: radicular pain radiates to the legs (sciatic pain) or
arms, pain is either stabbing or resembles an electric shock.
▪ Typically unilateral: paresthesia, motor weakness, loss of deep tendon reflexes in
dermatome and myotome territory of compressed nerve root
o Myelopathy (compression spinal cord):
▪ Typically bilateral or cauda equina syndrome
▪ Medical emergency! Motor weakness, sensory abnorma lities, bowel or bladder
disturbances
• Diagnosis
o Physical exam + MRI
o Other: CT myelogram, X-ray spine
• Treatment:
o Conservative: analgesics (NSAID) and physiotherapy for isolated acute radiculopathy without
severe paresis
o Surgery: Urgent surgical decompression for patients w spinal cord compression, conus medullaris
syndrome or cauda equina syndrome prevent neurological damage
(2) Spinal stenosis
• Definition: Narrowing of the central spinal canal, intervertebral foramen, and lateral recess w cervical spine,
thoracic spine or lumbar spine- resulting progressive nerve root compression.
• Etiology:
o Degenerative joint disease (Spondylolisthesis or disk space narrowing) middle age and elderly
individuals
o Systemic dis: Paget disease, ankylosing spondylitis, tumors
• Clinical manifestations:
o Lumbar spinal stenosis: most common form causes load-dependent lower back pain that radiates
to buttock and legs
o Cervical spine stenosis: neck pain
o Lumbar extension (standing or walking downhill) exacerbates the pain
o Lumbar flexion (sitting or walking uphill) improves symptoms
• Diagnosis
o Clinical features + MRI spine without contrast – compression of spinal cord w nerve impingement
• Treatment:
o Conservative: analgesics (NSAID) and physiotherapy
o Laminectomy: Surgical decompression of spinal cord for patients refractory or severe spinal
stenosis
(3) Osteoporosis
• Veure pregunta 7C
(4) Rhematoid arthtritis
(5) Ankylosing spondylitis
(6) Reactive arthritis
• Veure pregunta 10C

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