|
|
|
Trauma & Orthopaedics Revision
PAEDIATRIC AND ADULT SPINE - Go to Main Contents
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Paediatric spine PROBLEMS:
(1) Pain
(2) Deformity
(3) Neurological abnormalities
Differential diagnosis of back pain
(1) Mechanical
(2) Developmental
(3) Inflammatory
(4) Neoplastic
(5) Conversion reaction
Look for, Scheuermann's disease, Spondylolysis and Infection.
Spondylolysis and Spondylolisthesis are the most common causes of back pain in children.
Treatment of paediatric spinal infection is immobilisation and antibiotics. Occasionally surgical drainage is indicated for spinal infection.
Scoliosis, Kyphosis and Kyphoscoliosis
Two main groups are:
(1) Postural scoliosis and
(2) Structural scoliosis: More than 100 of structural lateral curve is scoliosis.
Anatomical classification:
Apex of the curve is between
(1) T2 to T11 = Thoracic
(2) T12 and L1 = Thoraco lumbar
(3) L2 to L4 = Lumbar curve
Structural scoliosis is classified into:
(1) Idiopathic
(2) Congenital
(3) Neuromuscular
(4) Miscellaneous group
CONGENITAL SCOLIOSIS
Classified by MaCewen into
(1) Failure of formation:
Complete hemi-vertebra: -Fully segmented -Semi segmented or -Non segmented: Incarcerated or Non incarcerated
Incomplete or partial vertebra: -Wedge or -Butterfly vertebra
(2) Failure of segmentation: Unilateral bar or Bilateral bar (block vertebra)
(3) Mixed variety
IDIOPATHIC SCOLIOSIS
(1) Infantile before age of 3
(2) Juvenile between 4 and 9 years
(3) Adolescent idiopathic scoliosis after 10 years of age
NEURO-MUSCULAR SCOLIOSIS
Subclassified into
(a) Neuropathic
-Cerebral palsy
-Spino cerebellar degeneration
-Spinal cord problems like myelomenigocele, syringomyelia
-Spinal cord tumour or trauma
-Lower motor neuron problems poliomyelitis, spinal muscular atrophy
-Traumatic or
-Progressive neurologic disorders.
(b) Myopathic
-Arthrogryposis
-Muscular dystrophy or
-Myotonia
(c) Neurofibromatosis
(d) Mesenchymal
-Marfan
-Ehler-danlos or
-Homocystinuria
MISCELLANEOUS can be post laminectomy or fractures dislocations
IDIOPATHIC SCOLIOSIS
Age at the time of diagnosis is the criteria to diagnose infantile, juvenile or adolescent scoliosis. Most common curve is adolescent idiopathic scoliosis.
Infantile idiopathic scoliosis: Infantile idiopathic scoliosis has higher association with congenital heart diseases, developmental dysplasias of the hip, breach delivery, older mother, inguinal hernia, spinal cord anomalies and neuro muscular disorders. Currently it is believed that significant portion of infantile idiopathic scoliosis will resolve and there is a decline in overall incidence of infantile curves. In contrast to adolescent idiopathic scoliosis, in infantile variety males are more commonly affected and thoracic curve tends to be convex to the left side. Measurements of the curves are done by Rib Vertebral Angle Difference RVAD or Cobb's Angle. All infantile scoliosis will need MRI scan to rule out spinal dysraphism. Serial body casting is still the main stay of treatment in infantile idiopathic scoliosis. Curves more than 400 Cobb's Angle and greater than 200 RVAD are likely to deteriorate without treatment.
Juvenile idiopathic scoliosis:
More common in females. Thoracic curve can be both left and right thoracic curves. Lumbar curves are very rare. About 70% of the juvenile idiopathic curves progress and will need some form of treatment and 50% of them will require surgery. High incidence of intra-spinal pathology is reported in this group. MRI scan is essential. Curves more than 40 to 450 will progress and will need surgical intervention.
Types of surgery differ depending on the type of the curve. - Posterior fusion - Anterior fusion - Anterior and posterior fusion +/- instrumentation
A crankshaft phenomenon is, continued anterior growth following posterior fusion alone, which is a possible complication in juvenile as well as infantile idiopathic scoliosis
Winter has presented a formula for determining potential loss of axial growth after spinal fusion =
0.07 x number of segments fused x number of years of growth left in centimetres
Adolescent idiopathic scoliosis:
Age at diagnosis after 10, upto 21 years. Right thoracic is the most common - 90%. Next common is double major curve, which is right thoracic and left lumbar; next common is left and right thoraco-lumbar and lumbar; and lastly double thoracic curve. Primary left thoracic curve pattern is known to be associated with fairly high incidence of intra spinal anomaly such as syringomyelia and needs MRI scan.
Risk factors for curve progression are
(1) Younger patient
(2) Pre-menarche female
(3) Lower Risser grade at curve detection
(4) Large curve
(5) Thoracic hypo kyphosis
Boston type of orthosis under arm orthosis is commonly used brace for adolescent thoracic idiopathic scoliosis. There is good evidence in the literature to suggest that braces may not be of much help. Thoracic curves between 50 - 750, progresses 0.75 to 10 per year even after skeletal maturity. Curves over 500 often need surgical correction. MRI scan in adolescent idiopathic scoliosis is some what controversial but atypical curve like left thoracic curve will need MRI assessment.
King's classification of adolescent idiopathic thoracic scoliosis into 5 groups:
King I - Double curve lumbar curve is more structural
King II - Double curve but thoracic curve is more structural
King III - Right thoracic curve
King IV - Long right thoracic curve with lower apex (apex is T8 to T10; L4 is the stable vertebra in type IV)
King V - Double thoracic curve proximal left and main right thoracic
Double major curve has thoracic and lumbar curves of equal structural characteristics.
CONGENITAL SCOLIOSIS
Lateral curvature of the spine secondary to developmental vertebral anomalies producing imbalance of longitudinal growth. Hallmark is vertebral anomaly. Very high incidence of intra spinal anomalies. MRI is essential. Intra spinal lesions can be diastematomyelia, diplomyelia, tethered spinal cord, syringomyelia or low-lying conus. Skin abnormalities like hairy patch or dimple in the midline is often a clue. Neurological assessment is essential. Bracing has a very minor role to play. Surgical treatment is indicated if the conservative measures have failed.
Options available are:
-Posterior in situ fusion or
-Combined posterior hemi arthrodesis and anterior hemi epiphyseodesis to arrest growth on the convex side
NEUROMUSCULAR SCOLIOSIS
Typically has long C type sweeping curves that involve almost entire thoracic and lumbar spine extending from the neck to the pelvis with the sacrum and pelvis being a part of the curve.
Treatment of neuromuscular scoliosis is non-operative, bracing, wheel chair modification or operative with spinal fusion and instrumentation. Operative goal is to have a balanced spine, head centred over a level pelvis with fairly normalised sagittal plane spinal anatomy.
Friedreich's Ataxia is the most common hereditary progressive spino-cerebellar degenerative disease. This has got prevalence of scoliosis very close to 100%.
NEUROFIBROMATOSIS
10 to 40% of neurofibromatosis patients will develop a spinal deformity. Types of scoliosis dystrophic or non-dystrophic. Pseudoarthrosis after spinal fusion is a major problem in neurofibromatosis. Incidence of scoliosis in Marfan's syndrome is between 40 to 75%.
A normal regional alignment of the cervical lordosis is minus 300; thoracic kyphosis is plus 450; lumbar lordosis is minus 600.
Classification of Kyphosis:
(1) Postural
(2) Compensatory due to fixed flexion deformity of the hip
(3) Structural kyphosis
a.Degenerative
b.Osteoporosis c.Inflammatory due to Scheuermann's disease, ankylosing spondylitis d.Post traumatic
(4) Congenital, which can be failure of segmentation or Calve's disease. Up to 90% of Thoraco lumbar kyphosis in achondroplastic patient improve without specific treatment. Kyphosis with vertebral body wedging more than 400 in achondroplastic children older than 5 to 6 years do not spontaneously correct
Incidence is 0.5 to 8% in normal population. Males are more commonly affected.
Theories:
(1) Aseptic necrosis of the ring epiphyses
(2) Abnormal endochondral ossification
(3) Mechanical growth deficiency
(4) Genetic transmission
Three forms:
(1) Thoracic type, commonest
(2) Thoraco lumbar type
(3) Lumbar Scheuermann's which is the third type
Radiological criteria for diagnosis
(1) Hyper kyphosis greater than 400
(2) Irregular upper and lower vertebral end plates
(3) Wedging of 50 or more in 3 consecutive vertebrae (Sorenson criteria)
Treatment often conservative. Surgery may be considered if the angle is more than 750
Two most common indications
(1) Pain (2) Cosmetic appearance
POST LAMINECTOMY KYPHOSIS two factors are important
(1) Age. Younger the age more likely to get kyphosis
(2) Anatomical level. Upper thoracic and cervical regions are more likely to produce kyphotic deformities.
Best way to manage post laminectomy spinal deformity is prevention. Facetectomy be avoided.
Is another cause of kyphosis
Wiltse's classification:
Wiltse, Newman, and MacNab have classified spondylolisthesis into 5 types:
(1) Dysplastic due to congenital abnormalities of the upper sacrum
(2) Isthmic due to abnormal pars interarticularis, which is again subclassified as: Lytic Elongated pars and Acute fracture of the pars
(3) Degenerative
(4) Traumatic fractures not involving pars
(5) Pathologic due to underlying diseases
Type (1) and Type (2) are seen in paediatric practice. 80% of isthmic spondylolisthesis occur at L5/S1. L4/5 is the next common level involved.
Meyerding classification is based on the percentage of the slip - grade I to IV, 25, 50, 75 and 100 % and Grade V is spondyloptosis .
Slip angle is the angle of lumbo-sacral sagittal alignment normally L5/S1 disc is 250 to 300 of lordosis. Thus the slip angle is negative in normal persons.
Risk factors for slip progression are young age, female sex, spina bifida, wedging of L5 vertebra, rounding of anterior sacral dome and hyper lordosis.
Surgical treatment is recommended for all slips greater than 50% and 25% symptomatic slips. Standard operative procedure - Bilateral alo-transverse fusion
Controversies:
(1) Reduce the slip or not to reduce the slip
(2) Decompress the nerve root or not to decompress the nerve root. If the nerve root symptoms are present it is logical to decompress the root
(3) One level fusion or multilevel fusion
(4) In-situ fusion or instrumentation after reduction of the slip
FRACTURES / DISLOCATIONS OF THE SPINE
Types of injury:
(1) Blunt trauma
(2) Penetrating trauma (gun shot injuries)
Regional classification:
(1) Upper cervical C0-C2
(2) Subaxial cervical C3-C7
(3) Thoraco lumbar
(4) Sacral injuries
Management:
(1)Initial management (immobilisation and transport)
(2) Medical management (NASCIS) trial of spinal cord injuries, methyl prednisolone administered within 8 hours of the injury
Denis 3 column classification
(1) Compression fractures - fracture of the anterior column
(2) Burst fracture - anterior and middle columns involved, sometimes middle column protruding into the spinal canal
(3) Flexion distraction injury (seat belt type) distracts middle and posterior columns
(4) Fracture dislocations involves all 3 columns in compression, distraction, rotation and/or shear
Neurological injuries
(1) Upper motor neuron
(2) Conus medullaris
(3) Cauda equina (LMN)
Spinal cord injuries can be:
(1) Complete or
(2) Incomplete
Incomplete spinal cord injuries:
(1) Anterior cord syndrome (motor paralysis with preservation of sensation)
(2) Posterior cord syndrome - very rare
(3) Central cord syndrome (upper limbs more severely affected than lower limbs)
(4) Brown-Sequard syndrome (ipsi-lateral motor paralysis and loss of position sense with contra-lateral loss of pain and temperature sensation)
(5) Conus medullaris - combination of sacral upper motor neuron and sacral or lumbar root injuries usually at the level of L1 or L2
(6) Cauda equina injuries - below L2 vertebral levels most commonly involve bowel and bladder
Frankel (ASIA impairment scale) classification of spinal cord injury:
(A). Complete - no motor, no sensory function
(B). Incomplete - sensory but no motor
(C). Incomplete - motor, but function is not useful below the level
(D). Incomplete - motor function below the level is useful
(E). Normal
'ASIA' Standard Neurological Assessment of spinal cord injury: Motor and Sensory
Motor
C5: Elbow flexion
C6: Wrist extension
C7: Elbow extension
C8: Finger flexion DIP of middle finger
T1: Little finger abduction
L2: Hip flexion
L3: Knee extension
L4: ankle dorsiflexion
L5: long toe extension (EHL)
S1: ankle plantar flexion
Sensory system -
Pinprick & light touch score
Initial management:
(1) Pressure sores
(2) DVT
(3) Cardiac and pulmonary monitoring
(4) Naso gastric tube
(5) Fluid management
(6) Pain killers
(7) Cervical spine
(8) X-ray examination standard AP /lateral, oblique, flexion extension
(9) MRI and CT
(1) Posterior arch
(2) Anterior arch
(3) Jefferson fracture - is burst fracture involving anterior and posterior arches
(4) Transverse process fracture
(5) Lateral mass fracture
Treatment:
Stable fracture orthosis like halo vest. Jefferson fracture may need fixation if lateral mass displacement is more than 6.9mms. C0 to C2 fusion
Neurologic injury is unlikely if there is associated dense fracture. Normal atlanto dense interval - 3mm in adult and 4.5mms in children.
Treatment:
Halo immobilisation. Residual ligamentous instability may need C1/C2 fusion. Gallie posterior fusion
Anderson and D'alonzo classification of odontoid fractures
Type I - Tip of the dense
Type II - base of the odontoid, 20% non-union rate
Type III - fracture into the body of C2
Treatment: All types can be managed in halo immobilisation. Posterior fusion of C1/C2 or anterior trans-oral screw fixation of Type II odontoid fractures may be necessary.
This is traumatic spondylolisthesis with bilateral pars fracture of the axis.
Levine's classification:
Type I - minimally displaced
Type II - displacement greater than 3mm.
Type III - fracture associated with unilateral or bilateral facet dislocation of C2 on C3
Treatment: Halo vest for Type I and II lesions. Open reduction and internal fixation if close reduction fails in Type III. May need internal fixation.
Power's ratio defines the relationship between the occiput and upper cervical spine. Greater than 1 is anterior and lesser than 0.8 is posterior occipital dislocation
Treatment:
Posterior occipito cervical fusion
ATLANTO AXIAL ROTARY SUBLUXATION
Often identified in children who have had minor trauma or upper respiratory tract infection.
Fielding's classification: I - IV
Type I - Odontoid acting as a pivot, no anterior displacement
Type II - One lateral process acting as a pivot, anterior displacement 3 to 5 mms
Type III - Rotary fixation with anterior displacement > 5mm
Type IV - Rotary fixation with posterior displacement
Treatment: Traction and reduction, immobilisation in halo vest. If unsuccessful open reduction and internal fixation
SUBAXIAL CERVICAL SPINE INJURIES
Ferguson and Allen classification
(1) Compressive flexion
(2) Vertical compression
(3) Distractive flexion
(4) Compressive extension
(5) Distractive extension
(6) Lateral flexion
Five categories need special attention
(1) Isolated posterior element fracture maybe flexion type (Clay shoveler's) or extension type. Initial management halo vest, open reduction and internal fixation may be necessary
(2) Compression fractures - wedge compression, vertebral height less than 30% needs internal fixation
(3) Burst fractures - initial management cervical tong traction, indications for surgical fixation (a)loss of vertebral body height (b)retro-pulsion of the fragment with neurological deficit (c)kyphotic angulation and (d)posterior element injuries
Surgical treatment:
Anterior decompression, corpectomy with strut graft and stabilisation
(4) Teardrop fractures - management depends on severity of subluxation, extent of bony injury, ligamentous injury. Unrecognised posterior ligamentous injury will develop post operative kyphosis
(5) Facet subluxation may be unilateral or bilateral. Bilateral typically has more than 50% anterior olisthesis. Initial management- MRI followed by cervical tong traction to reduce the dislocation. Unilateral facet dislocations are more difficult to reduce and may need 80 to 100 pounds traction. After reduction variety of posterior stabilisation techniques are described.
(1) Compression fractures
(2) Burst fractures
(3) Flexion distraction injuries
(4) Fracture dislocation
(1) Compression fractures: often seen in the elderlies, after minor trauma. Bone scan is essential to rule out metastasis. Management depends on age of the patient, location of the injury, kyphotic deformity and posterior column distraction.
Indications for surgical intervention are: Unstable injury, unacceptable kyphotic deformity or progressive neurological deficit
(2) Burst fractures: Anterior and middle columns are involved with retropulsion of middle column.
Treatment in neurologically intact patient-
Non operative if:
(a) Minimal kyphosis
(b) Bony retropulsion is less than 50% of the spinal canal without progressive neurological deficit
Treatment is controversial in neurologically intact patients with more than 50% of compromised canal. Conservative treatment should be stopped or abandoned if associated cauda equina or progressing neurology.
Operative treatment: Indications -
(a) Three columns with subluxation
(b) Significant kyphosis
(c) Canal compromise more than 60%
(d) Poly trauma
(e) Thoraco lumbar junction or lumbar spine injury (kyphosis poorly tolerated)
(f) Progressive neurology
Treatment in neurologically involved patient is focused around decompression of spinal cord, thecal sac and nerve roots. Almost always accompanied by partial or complete corpectomy with instrumentation. Strut grafting is often used. If burst fracture is highly unstable, anterior and posterior stabilisation is carried out. Stabilisation makes nursing easy.
(3) Flexion distraction Injuries (Chance injuries): Chance fractures are typically 3 column injuries with fracture propagating through the bone.
Treatment:
(a) If fracture is through the bony elements can be successfully managed in hyper extension orthosis
(b) If only osseous injury involves pars interarticularis, it is best managed by open reduction and internal stabilisation
(c) Primary ligamentous or soft tissue damage needs open reduction and internal stabilisation.
(4) Fracture dislocation: Significant energy applied to the spine and forces may include flexion, distraction, extension, rotation, shear and axial loading. Extremely unstable injury. Most commonly associated with neurological damage. Best managed with internal fixation
Caused by high-energy trauma or in elderly due to osteoporosis.
Denis classified into zones.
Zone I fracture lateral to neural foramen
Zone II fracture through the sacral foramen, 28% incidence of neurological deficit
Zone III fractures involve the central canal and 57% will have neurological damage. Zone III often requires operative decompression
Benign or malignant. Most common are metastatic tumours.
Benign:
Most common benign tumours are osteoblastoma and osteoid osteoma involving posterior elements. Other tumours of note are: ABC, Giant cell tumour, haemangiomas, and eosinophilic granuloma.
Common presentation - Pain and Scoliosis
Treatment: Enneking staging is done for all tumours.
Excision of the tumour depends on the location for most of the tumours and internal fixation depends on the stability. Radiation upto 30 to 40Gy are given for ABC and haemangiomas.
Complications:
(a) Scoliosis
(b) Recurrence
(c) Malignant change
Malignant:
80 to 85% involve anterior column, 50 to 75% in the thoracic spine, 5 to 20% will develop neurologic deficit, breast, lung and prostate account for majority. Biopsy is usually to confirm the diagnosis.
CT guided percutaneous needle biopsy can be done.
Treatment: Goals of treatment - Pain management Structural compromise and Neurological deficit and Improve quality of life
Modalities: Radiation Chemotherapy Hormonal manipulation and surgery
Beware of excessive bleeding in thyroid and renal cell malignancies and consider pre-operative angiography and embolisation. Often combined anterior and posterior reconstruction will be necessary after excision of the tumour. Expected life expectancy is an important factor to consider while deciding on the type of internal fixation after excision of the tumour. Result of stabilisation is quite good in terms of pain relief and neurological recovery.
DEGENERATIVE DISORDERS OF THE LUMBAR AND THORACIC SPINE
Pathoanatomic consideration:
(1) Discogenic pain may be due to (a) Free nerve endings in the outer layers of the annulus fibrosus and within the longitudinal ligaments (b) Changing composition of the disc leads to fragmentation and fissuring of the annulus (c) Asymmetrical radial tears of the annulus are more likely to be painful
(2) Facet joint pain: Each facet joint receives innervation from two spinal levels. Pain difficult to localise, often increases on extension
(3) Nerve root pain: May be due to hypertrophied posterior element, herniated disc, spondylolysis and spondylolisthesis leading to (a) Alteration in intraneural blood flow (b) Problems with exoplasmic transport and (c) Inflammation
(4) Muscle induced pain
(5) Referred pain
(6) Dorsal root ganglion pain
(7) Sacro iliac joint pain: Stress test for SI joint are (a)Patrick's test known as FABER (Flexion, abduction and external rotation) test (b) Gaenslen's test is extension of the hip on one side while the other hip is flexed (c) Pelvic compression
(8) Piriformis syndrome
(9) Other sources of back pain
Investigations:
(1) Plain radiography
(2) Blood investigations for inflammatory arthropathy
(3) CT scan for spondylolysis
(4) Myelography if necessary
(5) MRI
(6) Nuclear imaging
(7) Discography
(8) Injection studies
(9) Electro diagnostics
(10) Psychosocial testing
Treatment: Conservative measures - McKenzie system of exercises are directed toward maintaining a position of comfort in the spine, extension exercises, heat treatments, ultrasound, chiropractic manipulations, traction, lumbo-sacral braces, NSAID and back schools.
Surgical treatment:
(1) Discectomy- thoracic discectomy should always be an anterior discectomy
(2) iscectomy with fusion
(3) Discectomy, fusion and instrumentation. Vast majority of the lumbar degenerate disk with acute back pain and/or sciatica improve with time without surgery. Lumbar disc herniation with progressive neurologic deficit particularly cauda equina need urgent disc decompression.
Lumbar discectomies can be
(1) Open
(2) Percutaneous discectomy
(3) Laser discectomy and
(4) Endoscopic removal of herniated disc fragments.
Complications: Wrong level surgery, dural tear, nerve root injuries
Classification of spinal canal stenosis by Arnoldi
(1) Congenital or developmental as in achondroplasia
(2) Degenerative can be central or lateral foraminal stenosis
(3) Post spondylolisthetic stenosis can be degenerative or isthmic
(4) Miscellaneous like Paget's disease or spinal tumours
Degenerative spondylolisthesis most commonly occur at L4/L5.
Clinical presentation - typically have pain relief on flexion. Differential diagnosis must include neurogenic claudication and vascular claudication. CT scan to measure the spinal diameter and MR scan to look for the highest level of spinal cord compression.
Treatment: Non operative treatment is not always successful.
Surgical options:
(1) Decompression laminectomy, preserving most of the facet joint
(2) Laminectomy with lateral recess decompression, which may need facetectomy in which case instrumentation will be necessary
DEGENERATIVE SPONDYLOLISTHESIS
Most common level is L4/L5 and nerve root is often compromised.
Surgical Treatment:
(1) Decompression alone
(2) Decompression with in-situ fusion
(3) Fusion with instrumentation
(4) Decompression, posterior instrumentation and fusion along with anterior surgery to help restore sagittal alignment
DEGENERATIVE DISEASES AND DISC DISORDERS OF CERVICAL SPINE
CERVICAL SPONDYLOSIS
Pavlov's ratio has become a standard parameter to diagnose clinically significant cervical canal compromise. This ratio is calculated by the size of the canal divided by AP diameter of the vertebral body. Greater than 1 is normal, between 1 to 0.8 indicates relative stenosis and less than 0.8 denotes absolute stenosis.
Differential Diagnosis includes
(1) Intra and extra spinal tumours
(2) Entrapment syndromes of median, ulna and radial nerves
(3) Thoracic outlet syndrome
(4) Brachial plexus and shoulder disorders
Diagnosis: Plain x-ray studies, CT scan, MRI scan and discography.
Treatment: Pain without radicular symptoms will need a trial of conservative therapy:
(1) Isometric neck strengthening exercises, emotional and physiotherapeutic support
(2) Trigger point injections
(3) NSAID
Surgical management:
Factors to consider -
(1) Disc herniation
(2) Cervical alignment
(3) Significant arm pain not responding
(4) Neurologic deficit with radicular pain
(5) Proper corresponding imaging studies
Approaches and techniques are:
(1) Anterior surgical approach (Smith Robinson Technique, Cloward Technique)
(2) Anterior cervical disc excision without fusion
(3) Posterior surgical approaches
(4) Key hole foraminotomy
(5) Hemi laminectomy
General agreement is that 13mm or less sagittal diameter of the spinal canal from C3 to C7 is abnormal. Pavlov's index or spondylosis index can be measured. Most of the literature on the natural course of the cervical spondylotic myelopathy suggests that more than 50% will progress and deteriorate.
Surgical Treatment:
(a) Laminectomy at one or more levels (b) Expansive open door laminoplasty (c) Anterior cervical discectomy and fusion for multi level pathology
First change is seen in the sacro iliac joints. Next skeletal changes appear at thoraco-lumbar, lumbosacral and mid-lumbar areas. Bamboo spine is pathognomonic.
Common pathologies in the cervical spine:
(1) Atlanto axial subluxation
(2) Subaxial fracture deformity with instability
(3) Occipitoatlantal destruction
(4) Fixed kyphotic deformity
Operative stabilisation is required
RHEUMATOID SPONDYLOSIS OF THE CERVICAL SPINE
Pathologies are
(1) Atlantoaxial subluxation
(2) Occipitoatlantal and atlantoaxial joint destruction with cranial settling
(3) Subaxial subluxation
Ranawat classification of rheumatoid neurologic deficit:
Class I - pain, no neuro deficit
Class II - subjective weakness
Class III - objective weakness, long tract signs further subclassified as (A) ambulatory and (B) non-ambulatory
Frankel grading scale is also be used.
Radiological assessment:
(a) Atlantoaxial subluxation, ADI more than 3.5 to 4 mm.
(b) Cranial settling ( basilar invagination ) McGregor's line - is the line drawn from the hard pallet to the caudal surface of the occiput, invagination is considered present in men when the tip of the odontoid is 8 mm above the line and in women when it is 9.7 mm above. Ranawat's index minimum distance between the line from the center of the anterior arch to that of the posterior arch of the atlas and the center of the pedicles, normal value 15 mm females and 17 mm for males Posterior atlanto dental interval less than 14mm. is abnormal
(c) Subaxial subluxation: canal size less than 14mms is abnormal and less than 13mms needs surgical arthrodesis.