Review of Highest-Yield

Spine Facts
AAOS Board Preparation
and Review Course

A. Jay Khanna, MD, MBA

Professor of Orthopaedic Surgery
and Biomedical Engineering
Vice Chair, Professional Development
Department of Orthopaedic Surgery
Johns Hopkins University
Bethesda, Maryland

Disclosures
Co-Investigator/Grant Support
Siemens Healthcare, Inc.
National Institutes of Health

Teaching/Consultant
OrthoFix Spine
AO Spine North America
American Academy of Orthopaedic Surgeons (AAOS)

Equity
New Era Orthopaedics, LLC
Cortical Concepts, LLC
Boss Medical, LLC

Royalties
Thieme Medical Publishers
Ortho Development
Physical Examination

CTQ

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Nerve Roots
• Above corresponding pedicle in cervical
spine

• Below corresponding pedicle in lumbar

spine
 Netter F.

CTQ

Hoppenfeld S. 1976.
CTQ

Hoppenfeld S. 1976.

CTQ

Hoppenfeld S. 1976.
CTQ

Hoppenfeld S. 1976.

CTQ

Hoppenfeld S. 1976.
CTQ

Hoppenfeld S. 1976.

CTQ

Hoppenfeld S. 1976.
 CTQ

Hoppenfeld S. 1976.

High-Yield Fact CTQ

C4-5
• Herniated C4-C5 disc C5 C4
– C5 nerve
C5

• Herniated L4-L5 disc

– Posterolateral
• L5 nerve root
– Far lateral L4-5
• L4 nerve root
L4
– Foraminal stenosis
• L4 nerve root L5
 YOU MUST KNOW THIS !!
MOTOR SENSORY REFLEX
C5 Deltoid/Biceps Shoulder Biceps

C6 Wrist Ext/Biceps Thumb/Index Brachioradialis

C7 Triceps/ Wrist Long Triceps

Flexors
C8 Intrinsics/grasp Ring/Little Ø

L4 Quad /Hip Add Lat thigh / Medial Tibia Patella Tendon

L5 EHL Anterolateral leg Ø

Gluteus medius Dorsum foot
S1 Gastrocnemius Lat malleolus/ Lat foot Achilles

Neoplastic Disease

Extradural Intradural-Extramedullary Intramedullary

Gonzales R. 2002
Neoplastic Disease
I. Extradural
A. Metastases F. Giant Cell Tumor K. Chordoma
B. Myeloma G. Osteoid Osteoma L. Osteosarcoma
C. Lymphoma H. Osteoblastoma M. Chondrosarcoma
D. Hemangioma I. Eosinophilic Granuloma N. Osteochondrom
E. ABC J. Ewing’s Sarcoma

II. Intradural-Extramedullary
A. Nerve sheath tumors D. Lipoma
(Neurofibroma > Schwannoma) E. Epidermoid
B. Meningiomas F. Dermoid
C. Subarachnoid seeding
(Metastases)

III. Intramedullary
A. Ependymoma
B. Astrocytoma
C. Hemangioblastoma
Walker HS. Radiographics 1987;7(6):1129-1152.

CTQ
 Relational Anatomy: Cervical Spine

Sympathetic chain

Longus colli

vertebral Artery

Cervical nerve root

Lateral mass

Anterior Approach C-Spine

• Recurrent laryngeal nerve
– Left -- Aortic Arch
– Right – Subclavian artery
– Supplies vocal muscles

• Horner’s syndrome
[Inferior Ganglion of Sympathetic Chain]
– Ptosis, CTQ
– Miosis
– Facial Anhidrosis
 Anterior Approach C-Spine
Laryngeal Nerves in ACDF

• Superior laryngeal nerve

– traction in upper cervical surgery
– high note phonation
– no vocal cord paralysis

• Recurrent laryngeal nerve

– vocal cord paralysis on the side of injury
– hoarseness
– aspiration
– can compensate partially for phonation

Oblique Anatomy

–7 cervical vertebra
–8 cervical roots

The lower numbered C5

root exits the numbered
neuroforamen
Therefore, the C5 nerve root
exits the C4-C5 neuroforamen CTQ
Atlantoaxial
Relational Anatomy

• Relationship # 1
– Ring of C1
– Dens
– Transverse
Ligament

Transverse ligament
helps provide C1-C2 stability

CTQ

Applied
Biomechanics
• Lateral C-Spine CTQ
– Normal ADI
• 3.5 mm in Adults
• 4.0 mm in
Children

• Open mouth
– Normal lateral mass
overhang
• 6.9 mm total CTQ
overhang
Clinical Correlate
• Dissection on the ring of C1 should
be < 1.0 cm from the midline

• Atlantoaxial settling in rheumatoid

patients can compress the C2 nerve
causing base of the skull pain

• C2 nerve root is at risk during

placement of the C1-2
transarticular screw
CTQ

Applied Anatomy CTQ

Halo Application Structures at Risk
SAE spine 2003
• A-- insert PIN here

• B-- Supraorbital nerve OTTO

• C-- Supratrochlear nerve

• D– Temporalis

• E– Above the equator

 Thoracotomy: Anatomy

• Dissect along SUPERIOR aspect of rib

– (avoid neurovascular bundle)

• Artery of Adamkiewicz (T9-T11)

CTQ
• Thoracic Duct
– Upper thoracic spine

– Left side of esophagus

– Behind carotid sheath

Miller, MD. Review of Orthopaedics, 5th Edition, 2008.

Anterior Lumbar: Anatomy

• L4-5
– Ligation of Iliolumbar Vein often required
CTQ

• Superior Hypogastric Plexus

– Retrograde Ejaculation
CTQ
– Sexual Dysfunction
 Surgical Approach
CTQ
• Genitofemoral n/sympathetic plexus
– Ventral surface of psoas muscle

• Ilioinguinal & iliohypogastric nerves

– Superior br. of lumbar plexus
– Emerge upper lateral border of psoas traveling
toward the quadratus lumborum

• Obturator & femoral nerves

– Deep and lateral to the psoas muscle
– Not visualized during the approach

High-Yield Fact
• Structures at risk during graft harvest?

– Anterior CTQ
• Lateral femoral cutaneous n.
• Anterior thigh numbness

– Posterior CTQ
• Cluneal n.
– 8 cm lateral to PSIS
– Buttock numbness
• Superior gluteal artery
 Spinal Cord

• Dorsal Columns
– Deep Touch
– Proprioception
– Vibratory Sensation

CTQ

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Spinal Cord CTQ

• Lateral
Spinothalamic Tract
– Pain and
Temperature
– Site of Chordotomy
for Intractible Pain

• Lateral Corticospinal
Tract
– Voluntary Muscle
Contraction

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

 Spine
Biomechanics:
A Basic Primer Course
American Academy of Orthopaedic Surgeons
Review Course
Frank H. Shen, M.D.
Professor
Department of Orthopaedic Surgery
University of Virginia

Biomechanical Studies of C1-C2

Posterior Techniques
Flexion Extension Rotation
Modified Good Poor Poor
Gallie
Brooks Good Better Better

Transarticular Best Best Best

Screws

CTQ
Oh, by the way…

2 Random Lumbar Concepts

for the Boards

Anterior: Shear at L5-S1is bad

Posterior: Lumbar distraction is bad

CTQ

Spinal Deformity
L5-S1 Spondylolisthesis
• Q: Choosing between L5-S1 vs. L4-S1
• A: In low grade slips
– Grade I / II (0-50%) slip
– Fairly horizontal L5-S1
– Fuse from L5-S1 only CTQ
• A: In high grade slips
– Grade III/IV (51-100%) slip
– L5-S1 often failry vertical
– Fuse from L4-S1
 Cervical Spine Trauma

AAOS Board Review and Preparation

Course

A. Jay Khanna, MD

The Johns Hopkins Medical Institutions

Department of Orthopaedic Surgery
Baltimore, Maryland

Pseudo-Subluxation
• C2 On C3 CTQ
• Check Spinolaminar Line

• C2 WITHIN 2mm OF
LINE
Atlanto-Occipital Dislocation

CTQ
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

C1 (Atlas) Fracture

• < 6.9 mm
 Halo Vest x 3 Months

• > 6.9 mm
– Treatment Controversial
1. Traction x 6-8 weeks f/b 6
weeks Halo
2. Halo Vest Only

• Flex-Ex after Halo Removed

-Tx C1-C2 Instability
( > 5 mm) with
Fusion
CTQ
Tay, Eismont. OKU: Spine 2, 2002
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.
Odontoid Fracture

Type II (60%)
CTQ
-@ junction of odontoid & C2 body
-nonunion rate is higher-- related to:
-angulation > 10 degrees
-displacement > 5 mm
-age > 60-65 years
(OKU: 40 years)
-smoking

-nonunion rate reported as high as 88%

(average 33%)

-associated w/ C1 Fx in 16%
Tay, Eismont. OKU: Spine 2, 2002
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.
Miller, MD. Review of Orthopaedics, 5th Edition, 2008.
An H. Principles & Techniques of Spine Surgery. 1998.

C2 Isthmus (Hangman’s) Fracture

-Type II
-Tx: Closed extension traction if > 6 mm
translation & halo immobilization x 12
weeks

-Nonunions treated w/ anterior C2-3

fusion or posterior C1-3 fusion

-Acceptable reduction
= < 4 mm translation &
< 10o angulation
CTQ
Miller, MD. Review of Orthopaedics, 5th Edition, 2008.
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.
C2 Isthmus (Hangman’s) Fracture

-Type IIA
-severe angulation with
minimal translation

-Tx: extension and

compression halo
treatment for 6 weeks
and fusion as necessary.

CTQ Miller, MD. Review of Orthopaedics, 5th Edition, 2008.

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

C3-C7 Facet Joint Injuries

CTQ

UFD BFD
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.
 Degenerative Cervical Spine

AAOS Board Review and Preparation

Course

A. Jay Khanna, MD

The Johns Hopkins Medical Institutions

Department of Orthopaedic Surgery
Baltimore, Maryland

Cervical Stenosis
• Congenital
• Acquired
– Traumatic
– Degenerative

• Absolute Stenosis
– Anteroposterior canal diameter (< 10 mm)
CTQ
• Relative Stenosis
• 10-13 mm

Miller, MD. Review of Orthopaedics, 5th Edition, 2008.

 Cervical Spondylosis: Signs and Symptoms
• Degenerative discogenic neck pain
– insidious onset of neck pain w/o neurologic
signs or symptoms
– exacerbated by motion
• Occipital Headache Common
• Findings may overlap d/t intraneural
intersegmental connections of sensory nerve
roots.

• Lower nerve root at a given level is

usually affected (ie. C6 nerve root at CTQ
C5-6)

ACDF: Complications CTQs

• Fact: Recurrent Laryngeal Nerve at Risk
– Lower Levels (C6-7)  Increased Risk
– Uncertainty: Difference Left vs. Right Approach

• Increased Dysphagia Risk at higher levels (C3-4)

• Increased risk of airway obstruction with multiple
levels
• Nonunion Rate: 2-10%
– Increasing Rate with Increased # of Levels

Heller JG. OKU: Spine 2, 2002

 Posterior (“Keyhole”) Foraminotomy

• Preserve > 50% of

Facet Joint CTQ

• Elevate Nerve Root

Superiorly

• Risk: Air Embolism

Cervical Spondylosis: Treatment

• Laminoplasty
• Commonly used for OPLL

• Decreases incidence of
instability associated w/
multilevel laminectomy

• Overall alignment must be

lordotic for this technique to
be successful

• KYPHOTIC Patient
CTQ  Don’t pick Laminoplasty
Heller JG. OKU: Spine 2, 2002
Miller, MD. Review of Orthopaedics, 5th Edition, 2008.
Neurologic Impairment with RA

Classified by Ranawat
CTQ
I Subjective Paresthesias
II Subjective Weakness, UMN Findings
III Objective Weakness, UMN Findings
(A= Ambulatory, B= Nonambulatory)

Pellicci PM, Ranawat CS. JBJS 1981.

Casey AT, et al. J Neurosurgery, 1996.

CTQs

Khanna AJ, ed. MRI for Orthopaedic Surgeons. 2010.

RA: Lower Cervical Spine
• Involvement in 20% of cases
• Joints of Luschka and facet joints affected by RA
– thus, subluxation can occur at multiple levels
• Lower C-Spine involvement more common in:
– males
– steroid use
– seropositive RA
CTQ
– patients with rheumatoid nodules
– patients with severe RA

Miller, MD. Review of Orthopaedics, 5th Edition, 2008.

Ankylosing Spondylitis
• HLA-B27
• Acute Anterior Uveitis
• Renal Amyloidosis CTQs
• Cardiac Conduction Disturbances
• Cardiac Valve Dysfunction

• MRI Examination Critical–

ESPECIALLY IN TRAUMA
PATIENTS

Fischgrund, JS. OKU: Spine 2, 2002.

 Thoracolumbar
Trauma
American Academy of Orthopaedic Surgeons

Frank H. Shen, M.D.

Department of Orthopaedic Surgery
Division of Spine Surgery
University of Virginia School of Medicine

Denis Classification
Three column model
• Anterior
– ALL, anterior ½ annulus / vertebral
body
• Middle
– PLL, posterior ½ annulus / vertebral
body
• Posterior CTQ
– Posterior bony arch
– Posterior ligamentous complex
 Denis Classification
Burst Fractures
• Mechanism:
• Axial compression
• Column involvement
• Anterior column involved
• Middle column involved
• +/- Posterior column
• Look for lamina fractures on
CT scan
• Possible dural tear / nerve
entrapment CTQ

Denis Classification
Burst Fractures
• Surgical Indications
• Neurologic deficit
• Significant Loss of Alignment:
• > 30 degrees jxn kyphosis
• > 50% loss of anterior height
• ???> 50% canal compromise

• Example:
• Burst fracture in patient that is
neurologically intact with
minimal deformity
• Extension bracing !!!! CTQ
 Traumatic Spinal Conditions
“Low” Lumbar Burst Fx (L5)
• Conservative treatment
– Roots at this level
– No conus to worry about, but cauda equina still
possible
• Kyphosis <20 degrees
– Can’t accept as much as at T/L jxn (30 degrees)
– Majority of lumbar lordosis is at L4 to sacrum
• T12-L3: 25% of lumbar lordosis
• L4-sacrum: 75% of lumbar lordosis

Denis Classification
Flexion-Distraction
• No translation
• Associated intra-abdominal
injuries
• Ileus
• Made worse by extension
bracing!!!
• Treatment
• Bony injury-bracing
CTQ
• Ligamentous injury—surgery
• Posterior Tension Band
 Incomplete Spinal Cord Syndromes
• Brown-Sequard
– Stabbing. Penetrating injury CTQ
– Ipsilateral motor. Contralateral pain and temp
• Central cord-common
– Elderly. Hyperextension injury
– Involvement of UE > LE
• Anterior cord
– Vascular injury
– Anterior thoracic surgery. ?Artery Adamkiewicz
– Motor loss. Preserved dorsal column-proprioception
• Posterior cord-rare
– Motor intact. Loss of proprioception

High Yield Facts

• Most common Central Cord
• Least common Posterior Cord CTQ
• Prognosis for ambulation
– Best Brown-Sequard
– Worst Anterior Cord

• Mechanism
– Vascular injury Anterior Cord
– Penetrating injury Brown-Sequard
– Hyperextension in elderly Central cord

• Involvement:
– Upper > Lower Central Cord
– Lower > Upper Anterior Cord
 High Dose Steroids
• Load
– 30 mg/kg iv methylprednisolone bolus for 1 hr
• Infuse
– 5.4 mg/kg iv for 23 hrs if initiated within 3
hours
– 5.4 mg/kg iv for 48 hrs if initiated from 3 to 8
hours

• Aside: Becoming more and more controversial

Neurogenic versus Spinal Shock

• Neurogenic shock
– SCI to lower cervical or upper thoracic CTQ
– Loss of sympathetics
– Hypotensive and bradycardia

• Spinal shock
– Initial period after spinal cord injury
– Metabolic derangement not necessarily
CTQ
structural
– Unable to assess if spinal cord injury is
complete or incomplete.
– Bulbocavernosus signals end of spinal shock
 Thoracic and
Lumbar
Degenerative Disease
American Academy Orthopaedic Surgery

Frank H. Shen, M.D.

Professor
Department of Orthopaedic Surgery
University of Virginia School of Medicine

General Comments
Risk Factors LBP
• 30-50 y.o. Males CTQ
• Job occupations
– Heavy lifting, twisting, stressful
– Job Dissatisfaction
• Lower income
• Cigarette smoking
• Prolonged exposure to vibrations 4-5 Hz

• L4-5 and L5-S1 make up 90% of LHD

• L3-4 next most common
 Physical Examination

• Waddell’s signs for nonorganic pathology

– Tenderness to light touch
– Pain in a nonanatomic distribution
– Loss of findings during distraction
– Overreaction
CTQ

Straight Leg Raise (SLR)

• Supine. Many variations exist
• Evaluating L4, L5 and S1 nerve
• Maximal tension at 35 – 70o
Contralateral SLR CTQ
• More specific for HNP, esp for axillary HNP

Femoral Tension Sign

• Prone/lateral position. Hip extension, knee flexion.
• Evaluating L2, L3, and L4 nerve
• Anterior groin, thigh or medial leg pain
Imaging Studies
MRI
• Herniated Disc
– 25-37% abnormal disc in asymptomatic subjects
– MRI with Gadolinium best imaging study for
recurrent HNP
CTQ
• Discogenic Back Pain
– Decreased signal (T2 weighted images)
– High intensity zone (HIZ)
• Increased signal intensity within posterior
annulus on T2

MRI
• Correlating imaging with clinical findings
– False-positive MRI scans are common
• 35% of patients < 40 y.o.
• 93% of patients > 60 y.o.
CTQ

• Objective neurologic 55%

• “+” SLR 66%

• “+” SLR with “+” imaging 86%

• “+” neurologic, SLR, imaging 95%
 Additional Imaging
• CT Myelogram
Spinal
Stenosis
• SPECT CTQ
– Most sensitive method for
detecting isthmic spondylolisthesis
Spondylolysis
• Bone scan
– Infections
– Tumor
– Pars defects

C4-5
High Yield Fact
C4
C5
• Herniated C4-C5 disc
C5
– C5 nerve

• Herniated L4-L5 disc

– Posterolateral
• L5 nerve root L4-5
– Far lateral
• L4 nerve root
L4
– Foraminal stenosis
• L4 nerve root
CTQ L5
Lumbar HNP
Posterolateral
• More common
• Traversing nerve root
affected
CTQ

Far Lateral
• Exiting nerve root affected

High-Yield: Axial Back Pain

Intradiscal Pressure Innervation of Facet Joint:
Highest CTQ
Medial branch of dorsal
Sitting leaning CTQ primary rami and
forward sinuvertebral nerve
Sitting
Standing
Supine
Lowest
 High-Yield Facts
Isthmic Spondylolisthesis
• Pars defect
• “Scotty dog” sign
– See pars defect on OBLIQUE x-ray

• Exiting nerve root affected CTQ

– Fibrocartilaginous reparative process
underneath the pars
– L5-S1 isthmic spondylolisthesis
affects L5 nerve root

High-Yield Facts
Iatrogenic Spondylolisthesis
Causes CTQ
1. Iatragenic removal of the pars

2. Unilateral total facetectomy

(1 x 100%=100%)

3. Bilat >50% partial facetectomy

(2 x 50%=100%)
 Central Stenosis
• Neurogenic claudication: CTQ
– Heaviness/cramping of calves
– Sit/flexion relieves Sx (opens up spinal canal)
– Different from vascular claudications
– Grocery cart sign

Lateral Stenosis
• Radicular symptoms
– Nerve root canal (lateral recess stenosis)
– Intervertebral foramen (neuroforaminal stenosis)

Putting it all together

Spondylolisthesis from Hell

• OITE: 60 y.o. LBP and leg pain.

Degenerative spondy L4-L5. Isthmic
spondy L5-S1. Roots involved?

• L5 !!!!
• Degenerative spondy L4-5
• L4 has exited already
• Lateral recess stenosis (sublux inf articular
facet of L4) L5 nerve root
• Isthmic spondy L5-S1
• Bony/fibrous reparative tissue of pars and
cephalad buldge of L5/S1 disc CTQ
• Foraminal stenosis of L5  L5 nerve root
Lumbar Disc Disease
Cauda Equina Syndrome
Bowel and bladder difficulties
Incontinence or frequency CTQ
Impotence
Perianal/saddle numbness
Diminished rectal tone
Typically motor deficits also present

Lumbar Disc Disease

Cauda Equina Syndrome

Uncommon
Recognition is vital CTQ

Consequences can be disastrous

Spontaneous recovery uncommon
Prompt surgical intervention recommended
 Thoracic Disc Disease
• Imaging
– As with lumbar degenerative disease

• Treatment
– If no myelopathy then nonoperative
– Surgical
• Variety of approaches
• Laminectomy is the wrong answer CTQ
–High rate associated with paralysis
–Poor results

Spinal Cord Injury

AAOS Board Review and Preparation

Course

A. Jay Khanna, MD

The Johns Hopkins Medical Institutions

Department of Orthopaedic Surgery
Baltimore, Maryland
Neurologic Status:
Incomplete or Declining

• Steroids best if within 3 hours

• Next best within 8 hours

CTQ
• Emergent intervention

Spinal Shock
• Occurs immediately after spinal cord injury

• Spinal cord nervous tissue dysfunction due to

physiologic reasons rather than structural
damage

• Results in: flaccid paralysis, hypotonia,

areflexia
• Bulbocavernosus reflex (BCR) absent during
spinal shock CTQ
• When BCR returns--> spasticity,
hyperreflexia, clonus
Neurogenic Shock
• Results from loss of autonomic reflexes
-hypotension
-bradycardia

• Attributed to sympathetic outflow disruption (T1 - L2) and

unopposed vagal tone

• Treatment
-invasive monitoring, fluids, vasopressors CTQ
• May coexist w/ hypovolemia

Tay, Eismont. OKU: Spine 2, 2002

Miller, MD. Review of Orthopaedics, 5th Edition, 2008.

Spinal Cord Injury: Autonomic Dysreflexia

• Sudden Hypertension, Pounding Headache,

Flushing, Profuse Sweating, Blurred Vision, Nasal
Congestion

• Potentially catastrophic hypertensive event

• Can occur w/ injuries above T5

• Usually caused by obstructed urinary catheter or

fecal impaction CTQ
Freedman MK, Fried GW. P&P of Spine Surgery, 2003.
Miller, MD. Review of Orthopaedics, 5th Edition, 2008.
 Spinal Cord Injury
Functional Level Determined By:

1. Most Distal Intact Functional

Dermatome (Sensory Level)

2. Most Distal Intact Motor Level

> Grade 3-4/5 provided that
next rostral level is 5/5

CTQ Apple DF. OKU: Spine 2, 2002.

Miller, MD. Review of Orthopaedics, 5th Edition, 2008.

Central Cord Syndrome

• Most common

• Usually secondary to C-Spine

extension in elderly w/ pre-
existing stenosis

• Upper extremities more

affected than lower

• Motor and sensory loss

CTQ
• Perianal sensation preserved

Tay, Eismont. OKU: Spine 2, 2002

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.
Anterior Cord Syndrome

• Less common
• Usually flexion-
compression mechanism
• Lower extremities more
affected than upper
• Posterior column sensory
pathways preserved CTQ
• Worst prognosis Tay, Eismont. OKU: Spine 2, 2002
(16% have neuro improvement) Miller, MD. Review of Orthopaedics, 5th Edition, 2008.
Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Brown-Sequard Syndrome
• Penetrating injury
• Ipsilateral motor loss
• Contralateral pain and
temperature loss
• Ipsilateral joint position,
vibration and tacticle
discrimination loss.
• Best prognosis for
segmental recovery
(90% of Patients)

CTQ Tay, Eismont. OKU: Spine 2, 2002

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.
Posterior Cord Syndrome

• Rare

• Preservation of motor
function

• Loss of sensory function

-joint position
-vibration
-deep pressure

• Ambulation possible only

with visual feedback

CTQ Tay, Eismont. OKU: Spine 2, 2002

Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998.

Cauda Equina Syndrome

• Severe low back pain

• Unilateral or bilateral sciatica
• Saddle Anesthesia
• Motor Weakness
• Loss or reduction in LE reflexes
• Varying degrees of bladder or rectal
dysfunction

• Relatively rare
• Often missed

Lemma et al. P&P of Spine Surgery, 2003.

Cauda Equina Syndrome

• Immediate MRI or CT myelography for evaluation

• May consider urodynamic studies

• Emergent/urgent surgery for decompression

– No minimally invasive procedures
– Standard mid-line incision and wide decompression

• Outcomes better with surgery <48 hours than >48

hours

Lemma et al. P&P of Spine Surgery, 2003.

Ahn UM et al. Spine, 2000.
Kostuik JP, et al. JBJS, 1986.

GSW to Spinal Cord/Spine

• Nonoperative treatment unless direct passage

through esophagus or colon CTQ
• Or progressive neurologic deterioration w/
proven neurologic compression w/ bullet, bony
fragments or hematoma

Tay, Eismont. OKU: Spine 2, 2002

Miller, MD. Review of Orthopaedics, 5th Edition, 2008.
 Infections
of the
Spine
American Academy of Orthopaedic Surgeons

Frank H. Shen, M.D.

Professor
Department of Orthopaedic Surgery
University of Virginia School of Medicine

Presentation: Osteodiscitis
Symptoms
• Based on acuity (acute, subacute, or chronic)
• Pain most common
• Only ~ 50% had fever
CTQ
• Clinically significant abscess is uncommon
– C-spine: retropharyngeal  mediastinum
– T-spine: paraspinous/retromediastinal
– L-spine: psoas abscess
• Abscess from spine can drain almost anywhere
 Presentation
Laboratory Studies
• ESR/CRP
– Elevated > 90%
• WBC
– Elevated in only 42% of cases
– Typically normal in chronic cases CTQ
• Blood cultures
– Positive in 24% of patients with pyogenic infections

Empirical Treatment
• Parenteral Abx
– Four to six weeks
– High failure rates with treatment < 4 weeks
• Oral Abx
– ESR/CRP- reasonable indicators of response CTQ
– Consider repeat biopsy if ESR/CRP does not decrease
• Consider orthosis for immobilization
– Pain control
• Address co-morbidities CTQ
– Nutrition, hypoxia, metabolic deficit, diabetes
– Treat any underlying infections
 Pyogenic infections
Prognosis
• Recurrent infection
– Up to 25% of cases
– Lower if treated >28 d with appropriate antibiotics
• Neurologic deficits (overall <15%)
– Worse prognosis:
• Patients with increased age CTQ
• More cephalad lesion
• Diabetes, RA, immune deficiency disorders
– Root lesions do better (even if treated nonoperatively)

Tuberculosis Spondylitis
Differences from Pyogenic Infections

1. Pathologic changes usually take longer to develop

2. Discs relatively resistant and may be preserved

despite extensive bone loss

3. Large Paraspinal Abscesses more common

4. Frequently associated with greater deformity

CTQ
 Epidural Abscess
• Incidence increasing
– 7% spine infxns have epidural abscess
• Hematogenous
• Contiguous spread
– Discitis
– Vertebral osteomyelitis
• Direct inoculation
– Intraoperative
– ESI CTQ
– Lumbar puncture
• Patients are more systemically ill than
vertebral osteomyelitis patients

Epidural Abscess
Medical Management

• Antibiotic therapy alone for epidural abscess

– Rarely indicated CTQ
• Poor surgical candidate
• ? No significant neurologic deficit
• ? Significant multiregional spinal canal involvement
• ? Complete neurologic deficit for > 3 days
Summary
• Establish the diagnosis!
– MRI with gadolinium
– Percutaneous biopsy (off antibiotics)

• Identify medical vs surgical management

– Discitis / Osteomyelitis
• Typically MEDICAL
– Not septicemic
– No abscess
– No deformity
– Epidural abscess
• Typically SURGICAL CTQ

Thank You
 Spine Hi Yield Review

AAOS Board Review Course

Frank Shen, M.D.

Warren G. Stamp Professor of Orthopaedic Surgery
Division Head, Division of Spine Surgery
Co-Director, Spine Center
University of Virginia

Anatomy
 High Yield Facts

• Structures at risk during graft harvest?

• Anterior
• Lateral femoral cutaneous n.
• Anterior thigh numbness

• Posterior
• Superior cluneal nerve.
• 8 cm lateral to PSIS
• Buttock numbness
• Superior gluteal artery

Pure Anatomy
• Artery of Adamkiewicz
• Left side
• Posterior intercostal artery
• T8-T12 (T9-11)
• Its relevance to iatrogenic spinal cord problems is still
uncertain.

• Thoracic duct
• Left side
• Posterior to structures of carotid sheath

• Carotid tubercle
• C6
High-Yield Facts

• Horner’s
• Preganglionic C8-T1
• Ptosis (drooping eyelid)
• Miosis (constricted pupil)
• Anhidrosis (absence of sweat)

• Anterior cervical plate

• Lies posterior to the trachea and
esophagus

High-Yield Vertebral Artery

• Relational Anatomy
• Posterior to longus colli
• Anterior to lateral mass

• Trauma: Bilateral C5/6 facet dislocations

• Vertebral artery injury
• Diplopia, vertigo, tinnitus

• C1-C2 anatomy
• 1.5 cm lateral from posterior midline dissection
• 1.0 cm lateral for superior midline dissection
 Relational Anatomy: Cervical Spine

Sympathetic chain

Longus colli

vertebral Artery

Cervical nerve root

Lateral mass

Greater Occipital Nerve

• Anatomy
• C2 nerve root
• Exits between C1 and C2

• Rheumatoid arthritis
• Compression can cause base of the skull pain

• Trauma
• At risk during C1-C2 transarticular screws placement
 Retroperitoneal Lumbar Approach

• Structures at risk
• Ureter lies in peritoneal cavity
• Genitofemoral nerve and Sympathetic chain at
risk
• Superior Hypogastric plexus

Retroperitoneal Lumbar Approach

• Vascular anatomy of the anterior lumbar spine

• IVC to the right of descending Aorta in lumbar
spine
• Bifurcation of Great Vessels are at L4/5 disc
space
• Iliolumbar vein at level of L5
• Segmental vessels at level of mid body
Sexual Dysfunction after Anterior Lumbar Surgery

• Erectile dysfunction
• Usually nonorganic.
• Parasympathetics deep in the pelvis at S2-3 and
S3-4
• Erectile function not affected by sympathetic injury

• Retrograde ejaculation
• Superior hypogastric sympathetic plexus injury
• Anterior surface crossing at L4-5 and L5-S1 level

“Point and Shoot”

Degenerative Spine
 Herniated Disc

• Management HNP
• Conservative measures initially
• Pain without significant motor deficit.
• Painless Great Toe weakness
• Surgery
• Failed conservative > 3 mos
• Progressive neurologic deficit

• Herniated C4-C5 disc

• C5 nerve
• Herniated L4-L5 disc
• Posterolateral L5 nerve root
• Far lateral L4 nerve root
• Foraminal stenosis L4 nerve root

Spinal Stenosis

• Neurogenic claudication without spondylolisthesis

• Decompressive laminectomy

• Neurogenic claudication with degenerative slip

• Laminectomy with posterolateral fusion +/-
instrumentation

• Iatrogenic instability
1. Iatragenic removal of the pars
2. Unilateral total facetectomy (1 x 100%=100%)
3. Bilateral partial facetectomy >50% (2 x 50%=100%)
 Word Association
Cauda Equina

• Abdominal bloating
• Urinary retention
• Saddle anesthesia
• Bladder function = S2, S3, and S4 nerve roots.
• Decreased rectal tone and urinary retention
• Urgent surgical decompression

Sacral Root Anatomy

Posterior

S4

S2-3

S1

Anterior
 High Yield Facts
Conus Medullaris vs. Cauda Equina Syndrome

• Conus medullaris syndrome

• Conus ends at level of L1 typically
• Typically injury at T12-L1 or T11-T12
• Isolated loss of bowel and bladder function

• Cauda equina syndrome

• Injury at the lumbar levels
• Large HNP, tumor, severe stenosis
• Some degree of lower extremity motor loss

Degenerative Spinal Conditions

Mechanical axial LBP
• Make sure there are no red flag questions
• Conservative measures if <4 wks
• Imaging not indicated if <4 weeks of Sx
• Imaging -- start with plain films
• Think rheumatologic stuff
• esp if they give you ESR, titers, etc
• Discogram
• Concordant pain at one level best
indicator for success with surgical fusion
 Dural Tears

• Management of intraoperative tear.

• Primary repair whenever possible.
• Water tight closure.
• Bed rest 48 hours
• No drain necessary

• Management of post-operative tear.

• Subarachnoid drain, Abx, bed rest
• If persists greater than 3-4 days then surgical re-
exploration

• Post-op nausea on PCA after Lumbar disc surgery

• Don’t forget about dural tear as a possibility

Spinal Deformity
Harrington Instrumentation

• Flatback
• Lumbar distractive instrumentation
• Sagittal malalignment
• Loss of lumbar lordosis
• Positive sagittal balance
Classic Images: Spondylolisthesis and Spondylolysis

Isthmic Spondylolisthesis

• Pars (interarticularis) defect

• Scotty dog
• 5% of the general population
• Progression uncommon
• Familial predisposition
• SPECT- Most sensitive test for isthmic spondy
• Repetitive Hyperextension
• Football player with low back pain
• Gymnast with low back pain
• Swimmer with low back pain
• L5-S1 isthmic spondylolisthesis– L5 nerve root
• TLSO with thigh extension
 Basic Science

High Yield Facts

• Spinal fusions
• NSAIDs decrease fusion rate
• Ketoralac
• Ibuprofen
• Nicotine
• Decreases
• Smoking
• Stop preoperatively and 6 months postoperatively
• When compared with cobalt-chromium and
stainless steel implants, a titanium implant
has what biomechanical properties?

1- Lower modulus of elasticity

2- Improved notch sensitivity
3- Increased hardness
4- Increased risk of corrosion
5- Decreased biocompatibility

Preferred response: 1

High-Yield: Axial Back Pain

Intradiscal Pressure

Highest

Sitting leaning forward

Sitting
Standing Test
Supine

Lowest
 High-Yield Facts

• Characteristics during disc degeneration?

• Begins gradually during third decade of life

• Glycosaminoglycan (GAG) levels in nucleus decline.
• Water content decreases in the sixth decade and beyond.
• Corresponding increase in noncollagen glycoprotein.

GAG & H2O

Noncollagen glycoprotein

Traumatic Spine
 Traumatic Spinal Conditions
Spinal Cord Neuromonitoring

• Stagnara wake-up
• Gold standard
• Especially for motor fxn
• MEP
• Motor evoke potentials
• Anterior column
• SSEP
• Sensory=dorsal column=may miss anterior/motor
fxn

Traumatic Spinal Conditions

Nerve Root Neuromonitoring
• Stagnara Wake-up
• Gold standard
• Good for both spinal cord and nerve root
• EMG
• Identifies nerve root irritation
• Dermatomal
• Nerve root
• Pudendal nerve root monitoring
• Monitors S2-S4 nerve roots
• Sacral tumors
• ? Maybe high grade spondy
 Important Facts

• Trauma
• Radiographs must include C7/T1
junction
• Adhere to ABCs and primary survey
• Spine precautions
• If there are associated facial fractures
• Consider cricothyroidotomy for airway

High-Yield Facts

• Dens fracture Type II

• Risk of Nonunion
• 50 y.o.
• 5 mm posterior displacemnt
• 10 degrees angulation
• Frontal oblique
• Treatment chronic nonunion
• Defined as 3 months or greater
• PSF C1-C2
• Dens fracture Type III
• Halo
 High-Yield Facts
• Neurogenic shock
• Lower cervical upper thoracic spine injury
• Usually does not occur in SCI below T6
• Loss of sympathetics
• Bradycardic with hypotension
• Peripheral vascular dilatation, hypothermia

• Spinal shock
• Complete loss of all neurologic function below
the injury level
• Including reflexes and rectal tone

Traumatic Spine

• Spinal cord injury

• Spinal shock
• Unable to determine if complete or incomplete
spinal cord injury
• Complete
• Return of bulbocavernosus
• Lowest spinal reflex arch
• Incomplete
• Sacral sparing
 Traumatic Spinal Conditions
Word Association

• Mechanism Jumped facet

• Distractive flexion

• Mechanism Chance
• Flexion distraction

• Mechanism Burst
• Axial compression

Traumatic Spinal Conditions

Fall from height

• Thoracolumbar burst fracture

• Mechanism: axial load

• Surgical indications:
• Neurologic deficit
• Kyphosis > 30 degrees
• Anterior loss of height > 50%
• Retropulsion > 50%

• Most burst fractures can be treated

nonoperatively
 Traumatic Spinal Conditions
Fall from height

• Surgical Decision Making

• Anterior decompression, fusion, and instrumentation
• Neurologic deficit with retropulsion
• Late treatment for deformity / post-traumatic kyphosis
• Posterior procedure
• LAMINA fracture  possible trapped nerve roots
• Early treatment: 24-48 hours
• Reduction through ligomento/annulotaxis with
instrumented PSF
• Laminectomy alone is not the answer!

Traumatic Spinal Conditions

“Low” Lumbar Burst Fx (~L4, L5)

• Conservative treatment in most cases

• Roots at this level
• No conus to worry about
• Surgical indications are similar except for:
• Kyphosis >20 degrees
• Can’t accept as much as at T/L jxn (30
degrees)
• Majority of lumbar lordosis is at L4 to sacrum
 Traumatic Spinal Conditions
MVA and lap belt

• Flexion distraction injury.

• Usual at thoracolumbar junction
• Don’t miss associated visceral injuries!!!
• Ileus. Perforation of duodenum or cecum.
• Positive DPL.
• Neurologic intact
• Hyperextension bracing
• Look for evidence of posterior element injury
• MRI ligaments disrupted
• Anterior loss of height > 50%
• Splaying of posterior elements

Generalization about SCI

• Psychogenic erection not possible

• Normal ejaculation is not possible

• Reflex erections are possible with external

stimulation

• Ejaculation possible with electo or vibratory

ejaculation

• Sterility is a concern secondary to loss of thermal

regulation of testes
 Traumatic Spinal Conditions
Word Association

• HA, diaphoresis in SCI patient

• Autonomic dysreflexia

• What is autonomic dysreflexia?

• Sympathetic overdrive

• What should you look for in patients

with autonomic dysreflexia?
• Orthopaedic issues, GU, GI

Factosarcomas

Anteriorly placed SI screws

place L5 nerve root at risk
Infections and Tumor

Pathologic/Infectious Spinal Disorders

Spinal Infections
• Osteomyelitis/Discitis
• Biopsy for tissue diagnosis
• Typically medical treatment
• Epidural abscess
• Typically surgical treatment
• Granulomatous infection
• Typically medical treatment
• But look for late deformity
 Factosarcomas
Tumor locations
• Posterior elements
• Osteoid osteoma
• Osteoblastoma
• Aneurysmal bone cyst

• Anterior body
• Metastases
• Giant cell tumor
• Hemangiomas
• Eosinophilic granuloma
• Chondrosacroma
• Osteosarcoma

Chordoma

• Midline
• Primitive notocord-midline
structure
• Sacral-coccygeal 50% (sacral mass)
• Occipitocervical 30%
• Remaining spine 20%

• Surgical
• Not sensitive to chemoTx or XRT
• Cure: en bloc resection
• Histology: Physaliphorous cell
 Classic CT: Osteoid osteoma
• Osteoblastic lesion
– Osteoid osteoma < 2cm
Osteoblastoma > 2 cm

• 2nd and 3rd decade of life

• Pain
– Unrelated to activity
– Persistent
– Noted mostly at night

• Response to aspirin is not

universal

Classic X-ray: Winking Owl Sign

Think:
• Spine Tumor

• Pedicle missing
• Require 50% bony
destruction to see lytic lesion
on spine radiographic
• Obtain MRI with Gadolinium
 Case Example:
Isolated Spinal Metastases
• Young female. Breast carcinoma. Isolated spinal metastases
to vertebral body. Pain with neurologic deficits. Mgt?

• Considerations:
• Young person
• > 3-months life expectancy
• Pain with neurologic compromise
• Answer: Surgery
• Anterior
• Corpectomy / Reconstruction
• Instrumented fusion
• PSF only as a supplement to anterior procedure

High-Yield Fact

• Best predictors of postoperative neurologic

prognosis:
• Pretreatment neurologic status.
• 60 - 90% who are ambulatory at the time of
diagnosis will retain this ability after treatment
• Location
• Less space is available for the cord in the
thoracic spine.
• Lesions located in vascular watershed regions
may disrupt the vascular supply of the cord.
 Compression Fracture Risk

• 2 or more previous osteoporotic compression fractures

• Future risk is increased by 12 fold
• A decrease of two standard deviations in BMD
• Future risk is increased 4-6 fold
• Positive family history
• Future risk increased by 2.7 fold
• Premature menopause
• Future risk increased by 1.6 fold
• Smoking
• Future risk increased by 1.2 fold.

Inflammatory Arthriditis
Classic Imaging: Ankylosing Spondylitis

High-Yield Facts
Ankylosing Spondylitis
• Features
• Limitation of chest expansion to 1 inch or less
• Bamboo spine

• Neck pain
• Assume fracture
• Spine precautions
• Admit
• CT scan with recon
• Halo immobilization (+/- Surgery)
 Rheumatoid Neck

• Once neurologic symptoms  surgical intervention

recommended
• AAS - atlantoaxial subluxation
• Most common deformity
• PADI more important
• 10 mm and 14 mm
• Fuse C1-C2
• AAI - atlantoaxial invagination
• 4.5 mm above McGregor’s line
• Cervicomedullary angle (CMA) <135 degrees
• Surgical intervention: Fuse to occiput
• SAS - subaxial subluxation
• Fuse to the lowest level of sublux

28 y.o. LBP. Urethral discharge

• THINK: Reiters Syndrome

• LBP
• Small joint polyarthalgia
• Nongonocalccal urthritis
• Urethral discharge!
• HLA-B27 in 88% cases
• Elevated ESR 72%
GOOD
LUCK !

Thank
You !