Adult Scoliosis



Presentation of scoliosis deformity after skeletal maturity

- must be > 21 years at first presentation

- any of usual causes



- thoracolumbar / lumbar





- most common cause of adult scoliosis

- incidence is  ~ 5% in population

- 5000 adults having IVPs - 4% had lumbar scoliosis >10°




Pain / Progressive deformity




As per scoliosis examination




Standing PA & lateral

- Cobb angle

- balance

- degenerative change




<30° don't progress


Progression seen in

- >60° & thoracic

- lumbar portion of double major curve

- progression is usually 1° per year

- some progress faster especially lumbar with severe degenerative changes


Respiratory compromise seen curve > 60o


Increased mortality when curve >90°


Weinstein & Ponsetti

- Ppogression from 1o per month to 1o per year for curves > 30o

- Average 13o over 40 years 






Analgesics, bracing, physical therapy, injections






1. Progressive deformity

- progressive thoracic curves >60° (young adults)

- thoracic curve >80° with decreased pulmonary function (older patients)

- lumbar curves with rotatory subluxation & pain or stenosis


2. Pain not relieved by non-operative measures

- surgery for relief of pain alone ~ 50% successful




1.  Decompression alone

- stenosis with no major coronal or sagittal deformity & no rotational deformity

- flexion / extension & side bending radiographs show minimal movement

- should not destabilise spine as long as not performed at apex


2.  Decompression & Posterior instrumented fusion


3.  Decompression with Anterior & Posterior Instrumented Fusion

- severe deformities in both coronal & sagittal planes

- curve >80° or kyphosis > 70°

- not correctable on side bending or hyperextension lateral radiographs

- need anterior release / ACDF first

- then posterior decompression and instrumented fusion





Ankylosing Spondylitis



A HLA B27 positive, seronegative spondyloarthropathy with sacroiliac joint & spine involvement

Mainly affects the cartilaginous joints of the axial skeleton


Diagostic Criteria (1966 New York)


1. Positive X-ray Sacroiliitis


Sacroilitis Ankylosing Spondylitis


2. One or more of

- lumbar spine pain 

- lumbar spine stiffness

- chest expansion < 1" at 4th intercostal space




1/1000 Caucasian


FHx in 15 - 20% patients


M:F = 3:1



- less progressive spinal disease

- more peripheral disease


Average onset 25 years






Autosomal Dominant

- 95% of cases


B27 linked to susceptibility factor

- ? Trigger

- ? GIT infection with Klebsiella




Two basic lesions

1. Enthesitis

2. Synovitis of Diarthrodial Synovial Joint




Enthesis is insertion of tendon, ligament or capsular into bone


A.  Discs / Manubriosternal joints / Symphysis pubis

B.  Hip / Shoulder

C.  Spinous processes of vertebrae / Crests / GT

D.  Pelvis Crests / GT /  Ischial tuberosities / Iliac spines / Pubic symphysis

E.  Heels / Achilles / Plantar fascia




Similar changes to RA

- villous proliferation of synovium / pannus destroys cartilage 

- joint ankylosed by fibrous tissue

- converted to bone


TL spine


A. Spondylodiscitis / Anderson lesion 

- erosion of enthesis at anterolateral annulus at endplate


B.  Romano's lesion

- lesions heal by forming new bone / early squaring 


C.  Marginal syndesmophyte

- with repeated episodes forms thin vertical bone due to ossification of annulus fibrosis


Ankylosing Spondylitis Marginal Syndesmophytes


D.  Bamboo spine

- fusion / bony disc casing 


 Ankylosing SpondylitisAnkylosing Spondylitis CT Spine SagittalAnkylosing Spondylitis CT Spine Coronal


Extraskeletal Manifestations


Acute Anterior Uveitis 20-40%

Aortitis + secondary Aortic Regurgitation 90%

Pulmonary fibrosis




Lower back pain

- insidious onset

- usually dull & poorly localised


Back stiffness

- worse in am & after inactivity

- improved by warming up

- improves with exercise


Neck pain & stiffness




1.  Altered posture

- increased thoracic kyphosis

- loss of cervical & lumbar lordosis


2.  Positive "Wall Test"

- cannot put heels / buttocks and Occiput on wall


3.  Reduced ROM

- decreased extension earliest & most severe

- decreased flexion

- Schober's Test < 4cm

- decreased lateral flexion


4.  Pain & tender SIJ

- SIJ Stress Tests / FABER  

- pain on downward pressure on knee in fig 4 


5.  Decreased chest expansion 

- <1" at 4th ICS

- secondary to costovertebral joint ankylosis





- increased in 75% / elevated for life-time



- positive 90%




Sacro-iliac joint

- erosion / sclerosis / finally ankylosis



- marginal erosions / squaring of anterior body concavity

- marginal syndesmophytes

- bamboo spine


Ankylosing Spondylitis AP C SpineAnkylosing Spondylitis Latera C SpineAnkylosing Spondylitis Lateral C spine 2


Hip & Shoulder

- concentric joint space narrowing

- bony ankylosis

- protrusio




Seronegative Seroarthropathies

- Reiters / Psoriasis / Enterocolitis



- °Inflammatory / no SIJ involvement

- non-marginal syndesmophytes



- end plate changes






Simple analgesia



Maintain ROM & posture especially extension


Operative Management




1.  Spinal fracture

2.  Kyphotic deformity

3.  THR


Spinal Fractures


Ankylosing Spondylitis Thoracic Fracture CTAnkylosing Spondylitis Thoracic Fracture CT CoronalAnkylosing Spondylitis Fracture MRI Spine



- fused spine acts as long bone

- fracturs at cervico-thoracic junction / thoraco-lumbar junction


Non operative management

- stable, minimally displaced lesion

- no neurological deficit


Operative Indications

- unstable fractures

- incomplete neurological deficit

- failure of bracing


Ankylosing Spondylitis Thoracic Fracture Stabilisation APAnkylosing Spondylitis Thoracic Fracture Stabilisation Lateral




Indication for corrective osteotomy


A.  Severe cervical kyphotic deformity

- difficulty in looking forward / opening mouth


B.  Respiratory compromise

- chin on chest position



- elderly

- aortic calcification


A.  Cervical


Use brow-chin angle to calculate osteotomy size


Closing wedge extension osteotomy 

- fulcrum must be posterior elements of C7-T1

- avoids vertebral artery at C6

- canal is relatively wide at this level

- C8 nerve root most mobile & expendable

- decompress C8 nerve roots

- short-acting GA when close osteotomy

- wake up test

- HTB post-operatively


Belanger et al JBJS Am 2005

- 26 patients

- average 38o correction

- 1 quadriplegia who died due to subluxation at osteotomy site

- 2 delayed unions

- 5 patients had irritation of C8 nerve root


B.  Thoracolumbar




Smith-Peterson Osteotomy with instrumentation

- osteotomies in SP above & below central vertebra

- centre of correction is disc / must be healthy

- 10o per level / maximum 30o

- major risk is to aorta


Pedicle subtraction osteotomy

- 30 - 40o per level

- centre of correction vertebral body

- more dangerous / increased correction with better union




Good functional outcome

- no increased loosening seen

- must restore centre of rotation


Main complication is HO

- 20% > Brooker III

- indomethacin indicated




Blood Supply Spine

Blood Supply Spine


62 segmental arteries as 31 paired structures branches

- aorta 

- subclavian

- vertebral 

- internal iliac arteries 


Cervical spine 

- vertebral artery  (77%)

- additional supply is from branches of the subclavian artery (thyrocervical and costocervical)


Cervicothoracic spine

- branch from ascending pharyngeal in 60%

- vertebral artery responsible for only 36% of supply


Thoracic and lumbar spine

- aorta gives segmental arteries

- divide into lateral and dorsal branches 


Sacral spine

- internal iliac gives rise to iliolumbar artery (5th lumbar segmental artery) and lateral sacral artery

- additional supply from middle sacral artery


Blood Supply of the Spinal Cord 


General Features

- cord dependant on all three longitudinal vessels

- metabolic demands of grey matter greater than that of white matter

- longitudinal arterial trunks larger in cervical and lumbar regions due to ganglionic enlargements


Anterior Spinal Artery / ASA

- formed by union of anterior spinal branches of vertebral arteries at foramen magnum

- runs in anterior median fissure from medulla oblongata to conus medullaris

- narrows and may become absent in thoracic cord

- variable segmental supply

- probably supplies entire cord except posterior columns


Posterior Spinal Artery / PSA

- smaller than anterior spinal artery

- bilateral

- aries from posterior inferior cerebellar arteries or vertebral arteries at foramen magnum

- usually double running in between and behind posterior rootlets of spinal nerve

- anastomoses with anterior spinal artery particularly at conus

- may be noncontiguous areas

- variable segmental supply but more numerous and smaller than ASA


Segmental Supply

- average of 8 ASA radicular arteries (range 2-17)

- average 12 paired PSA radicular arteries (range 6-25)

- T4-T8 is narrowest portion of longitudinal supply and usually is fed by a single radicular artery

- thoracolumbar cord supplied by one or more prominent arteries


Artery of Adamkiewicz  

- originates on left from T9-T11 in 80% of cases (range T7-L4)


Cord Distribution

- ASA and PSAs give off central end arteries and peripheral branches

- central branches penetrate the cord via sulci

- peripheral branches anastomose with small pial branches of segmental vessels

- supply the periphery of the cord and are responsible for sacral sparing in ASA lesions


Venous Drainage


External venous plexus

- anterior to vertebral bodies


Internal venous plexus

- in epidural space

- anterior median spinal veins drains anterior cord


Posterior spinal veins are double and receive small radial veins from the posterior columns

- subsequent drainage into anterior and posterior medullary veins

- unite to form a segmental vein which anastomoses with the external plexus

- ultimate drainage into vertebral, azygous and lumbar veins and IVC


Surgical Considerations


T4-T9 is the critical vascular zone in which interference with the circulation is most likely to result in paraplegia


Principles of anterior spinal surgery

- ligate segmental spinal arteries only as necessary to obtain exposure

- ligate segmental spinal arteries at aorta rather than cord

- ligate segmental arteries on one side only

- limit dissection in vertebral foramina to a single level to preserve  anastomoses






Burners & Stingers



Neurological pain in arm after injury in sport

- usually due to brachial plexus injury




Contact sports

- ice hockey

- rugby

- american football

- basketball




Brachial plexus injury

Cervical nerve root injury




Traction injury

- hit onto shoulder

- head pushed in opposite direction to arm




Pain / Parasthesia / Burning down arm

Temporary weakness


May last minutes to weeks




A stinger is a diagosis of exclusion


Cervical spine fracture

Herniated disc

Brachial plexus injury


Xray / MRI


Important to exclude fracture / HNP





Soft Collar




Self limiting condition

- return to sport when asymptomatic


Recurrence prevention

- sports collars

- change tackling techniques








Pain in region of coccyx





- often obese

- mean age 40 years






Difficult vaginal delivery


Subluxation / hypermobile coccyx




3 or 4 fused coccygeal vertebrae


Triangular structure


Usually a joint with sacrum

- can be fused




Symptomatic patients

- no evidence increased number of segments

- often more angular

- increased rate of sacral - coccygeal fusion




Pain in coccyx

Difficulty sitting




Painful to touch




Coccyx Xray


Dynamic radiographs

- standing and sitting radiographs

- looking for hypermobility

- > 25o


Note: Not all coccygodynia is from hypermobile coccyx


Spicule on coccyx

- may be seen in immobile coccygodynia


Bone scan / MRI


Show inflammation




Non Operative










1.  HCLA


Mitra Pain Physician 2007

- injection HCLA under II in 14 patients

- patients with acute pain / < 6 months fared much better


2.  Manipulation


Maigne et al Spine 2006

- randomised trial of intra-rectal manipulation (x3) v physiotherapy

- mild improvements in group with manipulation

- best results in patients with acute, traumatic coccydynia




Excision of Coccyx




Bowel prep


Oral metronidazole

- 24 hour treatment

- day before surgery


Pre-op and post operative antibiotics

- Penicillin / Gentamicin / Metronidazole



- patient prone on 4 poster

- want to flex hips as much as possible

- vertical incision away from perianal skin

- through fascia

- G max reflected

- subperiosteally dissect coccyx

- ensure don't leave tip




Trollegard et al JBJS Br 2010

- 41 patients with coccygectomy

- post trauma / childbirth / idiopathic onset

- 33/41 good or excellent results

- 5 superfical infections





Diffuse Idiopathic Skeletal Hyperostosis

- non-inflammatory disease

- ossifying enthesopathy / bone forming diasthesis

- most commonly involves spine / anterior longitudinal ligament


AKA  Forestier's disease




Ankylosing Spondylosis



- non inflammatory

- no facet or SIJ involvement

- no squaring of anterior vertebral body

- non marginal syndesmophytes


Diagnostic Criteria for DISH


1.  Flowing ossification along the anterolateral aspect of at least 4 contiguous vertebrae

2.  Preservation of disc height / relative absence of significant degenerative changes

3.  Absence of facet joint ankylosis or sacroiliac erosion


DISH Thoracic VertebraeDISH Thoracic Vertebra LateralLumbar DISH Lateral





- 1/3 over age 65


Middle-aged or elderly 









Normal incidence of HLA B27


Clinical Presentation


Principal symptom is LBP


Occasional dysphagia

- anterior osteophytes in cervical spine impinging on oesophagus


Occasional spinal stenosis 

- due to ossification of PLL


Achilles tendonitis




Thoracic vertebra


DISH Right sided


Most common right sided and unilateral

- anterior & lateral spine


Non marginal syndesmophytes 

- flowing / candle wax  

- marginal osteophytes of ankylosing spondylitis very vertical


Integrity of disc spaces & facet joints maintained 

- not an arthritis


Cervical spine

- less frequent


Cervical DISHDISH Cervical Spine Lateral


Lumbar spine

- least common


DISH LumbarDISH Lumbar VertebraLumbar DISH





- osseous whiskering at sites of ligament attachment

- iliac crests / ischial tuberosity / trochanters


DISH Pelvis Osseous Whiskering


Pelvic Whispering DISH



- calcaneal spurs / achilles tendonitis



- periarticular bone formation with intact joint space

- increased risk of HO in THR



- hyperostosis deltoid insertion, LT, GT



- olecranon spurs








Physiotherapy to maintain motion




Surgery rarely required to remove osteophytes

- sometimes in cervical spine to relieve symptoms



- high risk of fracture

- need to be carefully assessed

- high risk of neurology and instability

Inflammatory Arthopathies



No pathognomonic signs for gout

- identification of negative birefringent crystals under polarising light 

- trial of indomethacin if suspected


Inflammatory Bowel Disease / Enteropathic


Crohn's & Ulcerative Colitis

- spinal manifestation similar to Ankylosing Spondylitis

- 15-60% of IBD


Two different forms

- mild & asymptomatic

- HLA B27 positive with progressive & aggressive disease


Colectomy does not improve spondylosis




20% develop spondylitis


Reiter's Spondylitis


Men more common

- 3rd decade

- post infectious reactive arthritis


Back pain &/or Sacroiliitis

- 20-30%

- usually unilateral compared with Ankylosing Spondylitis



- see juxta-articular osteoporosis

- joint space narrowing & erosive changes


Behcet's Syndrome


Rare seronegative disease involving many systems

- oral & genital ulcers

- uveitis

- CNS involvement

- + arthritis, thrombophlebitis & skin lesions



- ? viral ? immunolgical

- endemic in parts east Europe and Asian



- asymmetric appendicular arthritis especially knee

- sacroiliitis & spondylitis may occur


Alkaptonuria & Ochronosis


Inborn error of metabolism in which homogentisic acid can not be oxidised


A form of HA 

- black deposit in tissues 

- deposited in connective tissue containing hyaline & fibrocartilage


Most common spinal problem is spondylosis

- deposits in disc with ossification & marginal syndesmophytes

- SIJ usually unaffected


Neuropathic Spondyloarthropathy



- tabes dorsalis

- syrinx in cervical spine



- deformity, instability, crepitation & hyper-mobility








Abnormal posteriorly directed sagittal plane curve of spine


Scoliosis Research Society 




Normal range thoracic kyphosis is 20-40° 

- measured over T1 to T12 by Cobb method

- upper limit of normal thoracic kyphosis < 45°


Cervical & Lumbar

- lordosis is normal

- any kyphosis (>5°) considered abnormal


Classification Scoliosis Research Society




Scheuermann's Disease


Inflammatory / Ankylosing Spondylitis



- failure of segmentation / formation / mixed



- post laminectomy / tumour excision in child / radiotherapy



- acute fracture / anterior wedging

- chonic - osteoporosis, OI



- TB



- Osteoporosis

- OI

- Mucopolysaccharidoses



- Polio

- Spinal muscular atrophy

- UMN Syrinx

- SB



- Achondroplasia


- morquio's 


Postural Kyphosis


Often confused with Scheuermann's




Gradual, no angular curve


Patient can voluntary correct roundness on stance


Prone hyperextension test

- reversal of thoracic spine hyperkyphosis




No structural vertebral changes


Corrects on supine xray on bolster




No treatment necessary


Post - Laminectomy Kyphosis




Occur because posterior supporting structures removed

- normally resist gravity producing kyphosis




Following radical laminectomy

- facet joints removed bilaterally


Infection post surgery


Kyphotic deformity Post Fusion


Growing child


Usually after excision spinal cord tumour

- radical laminectomy removing facet joints bilaterally





- prevention is key

- must preserve at least 1/2 of each facet joint or one whole facet / level

- if not possible, fusion indicated



- must recognise potential for deformity & closely observe child

- orthoses don't often work

- if deformity develops & progresses, fusion usually indicated


Post-Traumatic Kyphosis


Risk Factors


Wedge fracture with initial kyphosis of > 30o


Focal kyphosis may develop if there is damage to the anterior column

- worse if posterior column fracture as well

- Most common TL junction


Indication for surgical intervention


Neurological deficit due to kyphosis

Refractory pain

Progress of deformity

Poor cosmesis 




If curve < 60°  

- posterior instrumentation & fusion 


If curve > 60° 

- anterior approach usually necessary to obtain releases


Lumbar Scheuermann



Different entity to thoracic Scheuermann's

- end plate abnormal but no kyphosis or wedging


Natural History


Self - limiting condition




Young athlete / labourer




Adolescent who presents with low grade levels of low back pain

- more pain than thoracic




Rigid marked flattening of the lumbar lordosis 

- hypolordotic


Flattening not reversible by hyperextension

- hamstring spasm common

- no lumbar wedging


Limbus Vertebrae 

- anterosuperior pseudofractures of the body




Diagnostic Criteria


1. Irregular endplates

2. Schmorl nodes - diagnostic

3. Disc narrowing

4. No wedging or kyphosis


Large defects of the lower thoracic & lumbar vertebral bodies at their anterosuperior borders 

- focal enlargement of vertebral bodies is noted occasionally

- defects anterosuperior bodies resolve, but some kyphos remains




Respond to TLSO with moulded lumbar lordosis for 12/12 & activity modification


No long term sequelae




Scheuermann's kyphosis



Structural kyphosis of thoracic or thoracolumbar spine

- characterised by vertebral wedging & subsequent growth disturbance of vertebral end plate


X-ray Diagnostic Criteria Sorensen 1964


1.  Kyphosis > 45°


2. > 5° wedging 3 or more adjacent apical vertebrae


Other features

- Schmorl nodes

- irregularity & flattening of vertebral end-plates

- narrow disc spaces

- increased AP diameter of apical vertebrae

- spondylosis in adults




Prevalence 0.5 to 8%


M:F 2:1 


High familial predilection

- AD with high penetrance and variable expression




Many theories proposed / true cause unclear


1.  AVN of ring apophysis

- but Ring Apophysis doesn't contribute to vertebral growth


2.  Schmorl Nodes

- protrusions of cartilage of disc through endplate into body

- ? nodes decrease enchondral ossification with growth arrest of anterior body

- but nodes present in normal patients (40-75% autopsies)


3.  Mechanical Factors

- likely that kyphosis occurs first

- increases pressure on vertebral end-plates anteriorly and causes secondary body wedging 


4.  Osteochondritis or Epiphysitis

- but no inflammatory features or necrotic bone


5.  Abnormality of Cartilage endplate identified 

- Abnormal matrix


6.  Tight ALL




Onset prior to puberty ~ 10 years old



- mechanical and usually in area of deformity

- ceases with maturity




Kyphotic Deformity

- fixed / remains with hyperextension

- worsen's on Adam's forward bending



- compensatory lumbar hyperlordosis 

- increased cervical kyphosis 

- associated mild - moderate scoliosis common


Lateral standing X-ray


Cobb angle

- line along superior & inferior end-plates of each body 

- measure angle of intersection

- often difficult to see T1 - T5


Individual vertebral wedging

- > 5o

- > 3 adjacent vertebrae


Schmorl nodes


Irregularity & flattening of vertebral end-plates


Hyperextension Lateral X-ray


Over bolster

- structural degree of deformity

- degree of correction




1.  Postural kyphosis 

- more flexible,  disappears prone, normal x-ray, disappears with hyperextension lateral


2.  Osteoporosis / crush fracture


3.  Congenital kyphosis / anterior bar


4.  Infection, tumour


5.  Ankylosing spondylitis


6.  Post laminectomy


7.  Congenital / Developmental

- OI / SED / Achondroplasia / Morquio's


Natural History


Weinstein 1993 Iowa

- 67 patients average kyphosis 71°

- follow up 32 years vs age match controls



1.  More intense back pain but no increased analgesia use

2.  No difficulty with ADL's

3.  Normal recreational activities

4.  No increased numbness

5.  More sedentary jobs 

6.  ROM

- decreased extension

- weaker extension

7.  Normal self esteem


Curve <100° 

- normal pulmonary function


Curve >100° 

- restrictive lung disease




Non Operative Management





No progression on serial Xray

No / mild pain




No long-term correction

- useful to maintain flexibility / correct lumbar lordosis

- strengthen extensors of spine i.e. swimming, pilates





- skeletally immature

- curve < 75°



- Milwaukee Brace / thoracic kyphosis

- TLSO / TL kyphosis




Brace full-time for 18/12

- then part-time until skeletal maturity



- trying to get a 15 year old boy to wear a CTLSO for 3 years


Operative Management





- pain +++ uncontrolled by brace 

- kyphosis > 75° & progressing

- most surgeons won't operate until 90°



- pain +++ despite non-operative treatment




1. Correction of kyphosis

2. Arthrodesis of spine






Posterior Approach

- failure rate high with loss of correction & pseudarthrosis if curve large

- fusion on tension side of spine


Correction films

- crucial

- posterior instrumentation will only give you 10o correction

- if corrects only to > 50o , need to release ALL


One Stage


Curve < 75° & corrects to < 50°

- one stage posterior instrumented fusion


Two Stage


Curve > 75° & corrects to > 50°

- two stage procedure

- anterior thoracotomy / release of ALL

- discectomy & interbody fusion of 5 or 6 apical levels with ribs

- posterior instrumented fusion 2/ 52 later


Last Instrumented Vertebra LIV


Sagittal line from the posterior edge of the sacrum should intersect the LIV

- supine & standing hyperextension Xrays

- should be distal to first lordotic disc

- usually L1 if apex T6; L2 if apex T8; L3 if apex T10




Coe et al Spine 2010

- retrospective review of 683 cases

- 50% posterior fusion, 40% anterior and posterior, 10% anterior only

- mean patient age 21

- 4% infection rate

- 2% acute neurological injury

- 4 spinal cord injuries (0.6%)

- 4 deaths (0.6%)



Red Flags

Red Flags in Back Pain


For Cancer

- > 50 years

- history of cancer

- smoker

- pain worse at rest

- night pain

- unexplained weight loss

- anorexia


For Infection

- prolonged use of steroids 

- immunosuppression 

- history of IV drug use

- UTI or other infection

- DM

- alcoholic


For Fracture

- history of significant trauma

- prolonged use of steroids

- > 70 years



Sacral Fractures



High energy usually


Occasionally osteoporotic fracture in elderly



- radiotherapy

- fatigue fracture in children


Don't present as isolated injury

- associated with pelvic fracture


Denis Classification


Zone 1

- lateral to foramina

- neurologic injury from proximal migration & compression of L5 nerve root


Zone 2

- through foramina

- 28% incidence neurology

- usually S1 compression


Zone 3 

- medial to foramina / central canal

- 57% incidence neurology

- loss sphincter tone & cauda eqina




Zone 1



- symptomatic treatment only


Zone 2 & 3


Non weight bearing 8 weeks



Spinal Braces



1.  Motion Control


2.  Spinal Realignment


3.  Trunk Support


4. Weight Transfer


Soft Collar


Cheap & Comfortable

- ineffective

- allows 70% Flexion Extension / 80% Rotation / 90% Lateral bend


Philadelphia Collar


Better than soft collar but less comfortable

- allows 35% Flexion Extension / 40% Rotation / 60% Lateral bend

- excellent immobility in acute situation when combined with sandbags & forehead tape


SOMI Brace


Sterno-Occipital Mandibular Immobilizer

- effective control C1/2 & C2/3

- allows 30% Flexion Extension / 30% Rotation / 60% Lateral bend


Yale Brace


Cervico-Thoracic Brace

- Philadelphia Collar but with chest extension & strap 

- best of conventional braces

- allows 10% Flexion Extension / 50% Rotation / 25% Lateral bend


HTB / Halo-Thoracic Brace


Best overall but highest complications

- 4 % Flexion Extension

- 1 % Rotation

- 1 % Lateral bend


HTB Xray



- roll patient on side in controlled manner

- fit posterior chest brace

- roll back, apply anterior chest brace, tighten

- size halo

- should have 1 - 2 cm gap from skull

- sits 1 cm above pinna and eyebrows

- 4 pins

- 2 above pinna, 2 above upper and outer eyebrow

- must miss supra-orbital nerve

- can shine torch through holes to mark sites of pins

- LA to sites

- must close eyes before supraorbital pins to avoid problems closing eyes

- tighten to 8 pounds / SI

- often come with snap lock pins



- use oral antibiotics

- may need to remove pins


Gardner Wells Tongs


Used to obtain and maintain reduction


Graphite / MRI compatible available


Insertion sites as per HTB


Thoraco - Lumbar Orthosis / TLSO


Types of TL Orthosis


2. Three point brace

3. Moulded Body Jacket


CTLSO / Milwaukee


TLSO with neck brace


For lesion with apex above T8


Spinal Cord Concussion



Transient disturbance of spinal cord function

- +/- vertebral column injury

- no pathological changes in spinal cord




Rapid change in velocity following trauma

- football / ice hockey




Congenitally narrow spinal cord





Athlete describes numbness / paralysis in arms and legs

- temporary

- passes after short time




Most resolve completely

Can have some sequelae




High risk with return to sport




AP canal < 10 mm

- high risk


Reinjury can mean quadriplegia


Waddell's Signs

Waddell Spine 1980


Non-organic illness behaviour

- operative intervention more likely in their absence

- 3 or more significant




1. Distraction 

- perform SLR when not looking, or seated


2. Regional 

- non-anatomically numbness or weakness


3. Tenderness 

- superficial "Pinch Test" gives pain


4. Over-Reaction

- Collapse / Verbalisation / Sweating


5. Simulation

- axial loading by head compress causes pain

- passive pelvic rotation





Isolated posterior ligament injuries

- PLL / Posterior interspinous ligament / Paraspinal muscles


Excludes fracture / dislocation / HNP






Hyperflexion injuries




Large spectrum clinical presentation

- neck ache 

- nausea & vomiting 

- headache 

- visual symptoms




Dufton et al Spine 2006

- study of 2000 patients looking at poor prognostic factors

- older age > female > higher pain intensity > legal action


Other studies

- radiculopathy symptoms




42% Symptoms > 1 years

36% Symptoms > 2 years


Chronic pain


Likely related to facet joints




Physiotherapy / Collar / Reassurance