- thoracotomy

- thoracoabdominal

- abdominal




Anterior Approaches


C2 - T2

- anterior cervical approach

- may have to split manubrium / sternotomy for lowest levels


T3 - T7

- thoracotomy

- patient on side left side up to avoid veins

- always easier to mobilise aorta

- scapular in the way of the ribs

- release scapula and lift away from ribs

- go through bed of appropriate rib

- usually rib 2 above vertebra

- have to deflate lung with double lumen ETT

- divide segmental artery away from foramen

- identify discs (hills) and vertebral bodies (valleys)


T7 - T12

- thoracotomy

- patient on side

- bed of rib 2 above vertebra

- can usually push lung out of way without deflation


T12 - L1

- thoracoabdominal

- patient on side

- through bed of 10th rib

- diaphragm attaches at T12/L1 and 12th rib

- must take down diaphragm if need to instrument or cross T12/L1


L2 - L5

- anterolateral flank / retroperitoneal approach

- incision below 12th rib

- patient on side



- anterior / transabdominal approach

- pelvis blocks flank approach


Retroperitoneal Approach L2 - L4



- patient left side up 45o

- surgeon stands on right





- in line with 12th rib and towards pubic symphysis



- split musculature / external and internal oblique / transversalis

- identify and preserve peritoneum / stay retroperitoneal

- dissection done with peanuts

- ureter and genitofemoral nerve on psoas / reflect medially

- stay anterior to psoas to preserve nerve roots

- symphathetic chain medial to psoas

- aorta and IVC on vertebral bodies

- tie off segmental arteries

- gently reflect vessels


Transabdominal Approach L4 - S1



- patient supine




Paramedian incision

- stand on right / approach from left

- midway between umbilicus and symphysis

- through skin and subcutaneous fat

- divide anterior rectus sheath (external and internal oblique)

- separate left rectus muscle from posterior rectus sheath

- posterior rectus sheath is deficient by L4/5, ending in semilunar membrane

- divide posterior rectus sheath (transversalis / internal oblique), staying outside peritoneum

- divide peritoneum

- mobilise bowel


Aorta bifurcates at L4/5

- common iliac artery and vein on medial psoas

- identify sacral promontory between

- divide posterior peritoneum in midline distal to bifurcation

- superior hypogastric plexus on common iliac vein / sympathetic

- injury causes retrograde ejaculation



- reflect artery and vein medially

- have to divide and ligate iliolumbar vein




Access between common iliac vessels

- must divide median sacral vein




Crush Fractures



Minimal trauma fracture

- secondary to osteoporosis

- wedge fractures




F > M

More common in elderly patients


Uncommon in men < 75

- look for alternative diagnosis




Renal failure

Malignancy - metastasis





Can present with pain

Can be asymptomatic




1.  Pain


2.  Deformity / kyphosis




Non operative Management




1.  Exclude other diagnosis

- metastasis

- primary malignancy

- infection



2.  Pain relief

- analgesics as required


3.  Manage osteoporosis

- DEXA scan

- bisphosphonates

- vitamin D + calcium


4.  Bracing

- indicated if kyphotic deformity > 20o


5.  Early mobilisation


Operative Management













- non responsive to non operative treatment





- trochar into pedicle under fluoroscopy

- injection PMMA


KyphoplastyKyphoplasty Lateral




Klazen et al Lancet 2010

- RCT of vertebroplasty v non operative treatment

- 431 patients over 50, all T5 or lower

- no complications

- immediate pain relief which was maintained at 1 year follow up





- pain relief

- restoration of deformity




Kyphoplasty InsertionKyphoplasty Insertion LateralKyphoplasty Balloons APKyphoplasty Balloons Lateral


Insert a balloon first and inflate

- bilaterally into each pedicle

- will restore some anatomy

- then inject PMMA


Kyphoplasty cement APKyphoplasty cement Lateral




Liu et al Osteoporosis Int 2010

- RCT of vertebroplasty v kyphoplasty

- improved vertebral height with increased injected PMMA in kyphoplasty

- no difference in outcome regards to pain relief

- 2/50 adjacent segment fractures in kyphoplasty group

- recommended vertebroplasty




Crush Fracture CompressionCrush Fracture Fusion 2


Degenerative Scoliosis


Lumbar Degenerative Scoliosis


Lateral deviation of the spine that develops after the age of 50

- minimal structural vertebral deformity


Lower lumbar

- convex left





- only very weak links to osteoporosis and degenerative disc disease





- larger curves > 30o

- increased rotation

- lateral lithesis > 6mm

- inter-crest line through or below L4/5 space


Larger curves more likely to have pain






Neurogenic claudication



- nerve roots compressed in concavity




Degenerative Scoliosis APDegenerative Scoliosis Lateral






Decreased height of nerve foramina


Degenerative Scoliosis MRI




Non Operative


Epidural Steroids






Multilevel decompression and posterior instrumented fusion

- laminectomy / foraminotomy

- +/- interbody cages to increase foraminal size


Deformity correction rare


Fusion Degenerative Scoliosis




Lumbar Discectomy Techniques

Disectomy Technique for Posterolateral L4/5 disc 




L4/5 disc at level of facet joints


Interlaminar space is below disc

- have to take inferior aspect of superior lamina


Pedicle and transverse process at same level


Disc usually on one side

- hemilaminotomy

- no need to remove spinous process

- this preserves stability




4 poster support

- abdomen free (decrease venous drainage) / Jackson Table

- knees below hips

- pillows under legs and feet

- pressure care knees

- arms forward on supports

- back level & slightly head down

- protect eyes / CPN at knees / ulna nerve at elbows


Pre-Operative antibiotics


Often dressing + betadine in natal cleft




Careful correlation of clinical and MRI

- level of disc

- side of disc


Iliac Crests L4/5

- mark

- prep with antimicrobial solution

- insert 18G needle into L4/5 interspinous space

- obtain cross table xray to confirm level

- this centres incision




Square drape

LA with adrenalin

Incise skin L4 spinous process to S1 spinous process


Superficial Dissection


Divide thoracolumbar fascia

- in midline down to spinous processes

- subperiosteal dissection down side of spinous process

- with cobb / diathermy

- preserve suprasinous ligament


Subperiosteal dissection to lamina on lesion side

- expose but don't disturb facet joint capsule

- self retractor inserted

- don't go between transverse processes


Lamina spreader between spinous processes

- under supraspinous ligament

- opens up interlaminar space


Recheck level at L4/5 interspinous


Disc Localisation


5 ways to identify L5/S1



- hollow sound 

- non mobile

- midline crest with no ligamentum flavum / interlaminar space

- anterior slope L5 lamina

- large L5 S1 interlaminar space


Lumbosacral Junction


Deep Dissection


Expose Ligament Flavum 

- attaches on top of inferior lamina to superior lamina

- find midline raphae

- incise flavum with scalpel over inferior laminae

- create flap of flavum

- use Watson Cheyne Dissector to gently dissect off dural adhesions

- remove flavum laterally 

- 1, 2 or 3 mm 40° Kerrison Rongeur

- see fat overlying blue dura


Remove inferior aspect of superior lamina

- will take up to L4/5 disc 

- resect medial two thirds of superior facet /  lower one third inferior facet


Lumbar Spine PosteriorLumbar Spine HemilaminotomyLumbar Intervertebral Foramen


Exiting L4 nerve root

- above L5 pedicle


L5 nerve root

- below L5 pedicle

- remove inferior lamina and pars




Retract dura gently

- dural retactor

- remove sequestered disc with pituitary rongeur

- cruciate incision in PLL to remove protruding / extruding disc


L5 nerve root

- exit under pedicle L5 inferiorly

- medial facetectomy

- follow root out laterally around pedicle

- ensure free passage through foramina 

- should be able to pass Watson Cheyne easily


L4 nerve root

- L3/4 interlaminar space

- remove inferior lamina and pars

- will pass under pedicle of L4 inferiorly

- medial facetectomy of L3/4 facet joint

- access L4 pass under pedicle of L4 superiorly


Wiltse Approach to Extra-Foraminal Disc




Paramedian incision

- 2 fingerbreadths / 5cm lateral to midline


Superficial Dissection


Muscles split to intertransverse ligament

- between Longissimus & Multifidus

- always a bleeder on the way down

- clear transverse processes

- preserve posterior ramus by hooking finger around & then follow ramus to nerve


Deep Dissection 


Removed intertransverse ligaments and fascia between TP

- nerve root anterior to fascia and just below TP

- runs at a 45o angle

- follow nerve medially and identify disc

- retract nerve laterally & remove disk

- may have to incise annulus to remove bulge

- if intra-foraminal element, remove lateral facet


Post operatively


Symptoms should be immediately relieved



Watch retention

No anticoagulation

Mobilize ASAP

No heavy lifting 6/52



Lumbar Fusion Techniques

PLIF / Posterior Lumbar Interbody Fusion






1.  Wide laminotomy 

- resection flavum, significant cranial lamina

- preserve if possible the posterior elements

- spinous processes, supra and interspinous ligaments

- these provide tension stability

- resect medial two thirds of superior facet /  lower one third inferior facet


2.  Resect disc

- retract dura and traversing nerve root medially

- distract disc space with lamina spreader

- disc space retractors (insert wedge, then turn on side) 

- remove end plates


3.  Insert interbody device 

- carbon or titanium cages

- wedge shaped

- allows correction of sagittal deformity

- allows restoration of disc height

- immediate stability

- facilitates fusion

- usually contain morcellised allograft / BMP

- check under II that interbody device not too posterior


4.  Stabilise with pedicle screws



- dural tears

- nerve palsy

- hard ware failure

- psedoarthrosis


ALIF / Anterior Lumbar Interbody Fusion


Surgical Technique L2 - L5


Patient supine, stand on right

- find level with II

- make incision through skin and subcutaneous fat

- divide external and intenal obliques and transversus

- mobilise peritoneum around, until see psoas


All dissection with swabs on sticks or peanuts

- ureter lifted up with peritoneum

- diva retractors for bowel, as per general surgery

- self retainers attached to side of bed


Common iliac artery and vein on medial psoas

- mobilise vessels medially, psoas laterally

- will see large sympathetic trunk, mobilise either way (don't damage to avoid retrograde ejaculation)

- may need to divide iliolumbar vein


Identify disc

- check level again with needle


Steinman type pins in vertebral body to keep back bowel


Divide ALL (can keep as layer, especially in Disc replacement)

- remove entire disc

- knife, rongeurs, normal and ring curettes 


Distract disc space

- special lamina spreaders

- disc distractors (wedges inserted then turn on side i.e. 10 - 14 mm)

- pins in bodies above and below and add distracting device as per cervical fusion


Remove end plate to bleeding bone


Interbody cage

- trial for height, depth and angle

- i.e. 6o 10 mm

- check II to make sure not too far back

- insert real prosthesis

- augment with plate


Surgical Technique L5/S1 Fusion


Access between vessels

- much easier than going to the lateral side of one and mobilising it medially

- identify sacral promontory, big angle as sacrum dives away

- use pins and retractors as before


Resect disc and minimal end plate

- just to bleeding bone for fusion

- not too much so bone is soft and cage or disc subsides


Trial for height & angle, II for depth

- insert cage

- these made of plastic with same modulus as bone

- doesn't compress but at same time doesn't subside into bone

- cage is radiolucent except for small opacities to see on x-ray

- cage has cental hole

- fill with synthetic bone graft, mixed with patient's blood and rolled as sushi in BMP membrane

- insert cage, can put more synthetic BG/BMP around it

- check II, ensure not too posterior

- application of anterior plate and screws


Pedicle Screws





- superior to sublaminar wires or hooks

- purchase in all 3 columns

- cross-linkage and converging screws enhances pullout strength



- essential to have fit & fill of pedicle

- bone mineral density of vital importance with pedicle screws

- minor osteoporosis OK

- marked osteoporosis hooks as good as screws

- bicortical fixation improves strength but only safe in S1

- pedicle screws not safe in S2 at all

- if fracture pedicle greatly reduces strength of construct




To place screw through centre of pedicles 

- parallel to upper end plate or slightly angled downward

- screws also converge towards midline

- up to 20% depending on spinal level

- this is to ensure do not penetrate lateral wall of vertebral body



- II facilitates insertion

- can use computer navigation


Entry Points


1.  Thoracic spine

- entry just below rim of upper facet near base of TP

- angle 7-10o towards midline & 10-20o caudally


2.  Lumbar Spine

- entry at junction TP & superior facet

- angle: screws converge 5o at TLJ and increase 10-15o as one progresses from L2-L5


3.  Sacrum

- S1 only safe level

- line tangential to lateral border superior articular facet &

- line along inferior border of superior articular facet

- angle: screws converge towards midline / aim at anterior corner of promontorium




Osteotome away facet joint

- reveal cancellous bone

- entry with curved awl

- ball tip guide, bone on all 4 sides, check II

- pass tap

- insert screw (6.5, 5.5, 4.5, 30 - 40 mm long)

- usually poly-axial heads




Union rate >90%


Screw misplacement 4%


Nerve and spinal injury 1-20%

- most misplaced screws don't cause neural injury

- higher risks with power over hand preparation


Infection 1.1-4.2%

- usually can leave metal in situ with early washout & debridement


Screw breakage 2-60%





Lumbar Herniated Discs



Sciatica > 2/52 1.6%


M:F = 1:1


Most common L4/5 

L5/S1 inherently stable 


Risk factors


Sedentary lifestyle


Frequent driving

Heavy lifting 




Annulus Fibrosis

- circumferential, multilayered rim

- type 1 collagen fibres at 30o to horizontal

- peripheral nerve endings

- high resistance to torsional and axial loads


Nucleus pulposis

- hydrophilic PG + 70% water

- type 2 collagen

- resist axial compression



- nutrients diffuse from the end plate


Wiltse Classification


1.  Bulge 

- annulus diffusely extends beyond the plane of the disc space

- annulus intact / nil focal protrusion


2.  Protrusion

- focal bulging within margin of annulus

- diameter of base is greater than diameter of tissue displaced beyond disc space


Lumbar Disc Protrusion


3.  Extrusion

- under PLL

- mass of discal tissue of greater diameter than the aperature through which it has passed


Lumbar Disc ExtrusionL5 S1 Extruded Disc


4.  Sequestration

- free disc in canal

- fragment with no continuity with tissue in disc of origin


Sequestered Disc MRI 3Sequestered Disc MRI 2Sequestered Disc MRI 4Sequestered Disc MRI 1


Anatomical Classification


1. Central


Lumbar Central Disc Herniation MRICentral Lumbar Disc Herniation


2. Lateral Recess / Posterolateral

- between dura and foramina

- anterior: disc (annulus) and vertebral body

- posterior: facet joint, lamina, ligamentum flava

- lateral: foramen, L5 pedicle


Herniated disc lateral Recess S1 nerve root compressionL45 Posterolateral Disc


3. Foraminal

- anterior: body of L5, L5/S1 disc

- posterior: pars, apex of superior facet of S1


Foraminal Disc MRIForaminal Disc 2 MRI


4. Extra- Foraminal / Far Lateral


Pathophysiology Nerve Root




Poorly resistant to compression

- dural sheath instead of perineurium

- tethered between dura and foramen

- compression impairs blood flow to nerve



- asymptomatic nerve compressions

- studies suggest that normal nerve roots do not generate pain when compressed




Chemical factors

- make nerve root more susceptible to effects of compression





- traversing nerve root is L5

- exiting nerve root is L4


Posterolateral disc

- compresses traversing nerve i.e. L4/5 disc hits L5 nerve root

- this is most common situation


Foraminal disc

- compresses exiting nerve root i.e. L4/5 disc hits L4 nerve root

- require partial medial facetectomy / stand on opposite side of table


Far Lateral / Extra-foraminal disc

- compresses nerve root already exited i.e. L4/5 disk hits L4 nerve root

- Wiltse approach or complete facetectomy / follow nerve out




Typical patient 20-45 year old male



- leg in dermatomal distribution



- numbness / parasthesia / weakness


Cauda Equina Syndrome

- saddle anaesthesia / urinary incontinence / weak EHL




Tension signs


1.  SLR / Straight leg raise / Lasegue's Sign

- elevate leg from hip with knee straight

- reproduce pain below knee

- L5 / S1 nerve roots


Deville et al Spine 2000

- meta-analysis

- SLR very sensitive 90% but lower specificity 26%

- crossed SLR low sensitivity 29% but more specific 88%


2.  Femoral nerve stretch test

- patient prone, knee flexed, extend hip

- reproduces pain

- L4 nerve root



  Pain Sensation Weakness Reflex Test
L2 Lateral thigh Lateral thigh HF    
L3 Medial knee Medial knee Quads    
L4 Anteromedial knee Medial Malleolus T Ant Knee Jerk Femoral Stretch
L5 Dorsum foot First webspace EHL   SLR
S1 Sole / lateral foot Sole / lateral foot FHL Ankle Jerk SLR

DDx L4 nerve root

- CPN / DPN palsy

- test peroneals, tibialis posterior


DDx L5 nerve root

- CPN / DPN / Sciatic palsy

- test peroneals / abductors


DDx S1 nerve root

- tibial nerve

- test tibialis posterior




T2 Sagittal - myelogram


Lumbar MRI T1 Herniated DiscHerniated disc lateral Recess S1 nerve root compressionCauda Equina MRI


T1 Axial - see nerve root against white fat


Lumbar HNP T1 Axial




Infection / Tumour / Fracture




Non-operative Management





- 80% improve after 6/52

- 90% improve after 3/12

- 95% improve after 6/12


Weakness just as likely to resolve as pain


Results Operative v Nonoperative


Peul et al BMJ 2008

- RCT of conservative treatment v microdiscectomy

- symptoms 6 - 12 weeks

- earlier symptomatic relief in surgical group

- no difference at one or two years





- NSAIDs / opiates / steroids / tricyclic antidepressants


Physiotherapy / lumbar stabilisation exercises




Chiropractic manipulation


Epidural steroids


Price Health Technol Assess 2005

- multicentred RCT placebo control

- 220 patients with unilateral sciatica

- minimal and transient value over placebo at 3 weeks

- no difference after 6 weeks

- not cost effective / drain on resources


Arden et al Rheumatology 2005

- WEST study

- exactly the same findings


Transforaminal CS / Nerve Root Injections


Nerve Root Injection


Riew et al JBJS Am 2000

- RCT of patients with unilateral nerve root compression

- all considered suitable for operative intervention

- effectively prevented need for surgery in more than half of the patients

- LA + steroid more effective than LA alone


Operative Management


Absolute Indications


Cauda Equina Syndrome


Relative Indications


Failure of non operative treatment

Severe debilitating anatomical leg pain

Progression neurological deficit


Prediction of good operative outcome


6/6 Nachemson


1. Leg > back pain

2. Symptoms consistent with root irritation

3. Signs consistent with root irritation

4. Tension signs / positive SLR

5. Imaging consistent with Symptoms & Signs

6. Pain > 6 weeks





Standard Discectomy

- open

- microdiscecotmy

Percutaneous / Endoscopic Discectomy





- chymopapain dissolves nucleosus pulposis

- older technique largely out of favour




Muralikuttan et al Spine 1992

- RCT of discectomy v chemonucleolysis

- inferior short term results with chemonucleolysis

- no difference at one year





- suitable for noncontained disc




Dewing et al Spine 2007

- prospective followup of 183 single level lumbar discectomies

- average age 27

- 85% satisfied with surgery

- recurrent disc herniation in 3%

- better outcomes in L4/5 than L5/S1

- better outcomes in sequestered / extruded discs than contained discs

- poorer outcomes in smokers and patients with predominance of back pain


Righesso et al Neurosurgery 2007

- RCT of open v microdiscectomy

- no difference in outcome

- longer scar and inpatient stay in open group

- longer surgical times in microdiscectomy


Percutaneous Discectomy



- contained disc



- image guidance / endoscopic techniques

- interlaminar or transforaminal

- discectomy with cutting / suction probe



- minimal scar

- rapid recovery




Ruetten et al Spine 2008

- RCT of endoscopic interlaminar and transforaminal v microdiscectomy

- 82% relief of leg pain, no difference in each group

- 6% recurrence, no difference in each group

- reduced back pain and complications with improved rehab in endoscopic group


Complications Discectomy


Wrong level surgery


Neural injury

- paraplegia 1: 25 000

- nerve root injury

- cauda equina 0.2%


Dural tears


A.  Intraoperative Management

- head down

- stop ventilating / hand ventilate / anaesthetic valsalva

- ensure free abdomen

- CSF can make nerve root in danger / protect with patty

- attempt primary repair with 6.0 prolene non cutting needle

- supplement with Tisseel glue

- +/- fat graft / thoracolumbar graft

- subfascial drain

- bed rest 2 days


B.  Postoperative CSF leak

- ensure no meningitis symptoms

- glucose / microscopy test to confirm

- adequate fluids / head down / quiet room / bed rest

- antibiotics controversial

- MRI: small leak or large leak


Non operative Management

- insert drain below conus

- decreases CSF pressure

- bed rest / leave drain for 5 - 7 days


Operative Management

- failure nonoperative / large leak

- thoracolumbar fascia / synthetic graft repair


Incomplete decompression / failure to relieve symptoms


Infection 2%


Thromboembolism 1%


Arachnoiditis / Intradural fibrosis


Incidence 5%


MRI changes

1.  Central root clumping

2.  Empty sac appearance

3.  Soft tissue mass in subarachnoid space


HNP recurrence



- life long 6 - 7%

- second time 50%

- third time 90%



- gadolinium MRI

- scar enhances but recurrent HNP does not



- disc resection +/- fusion

Lumbar Spine Degeneration

DefinitionLumbar Disc Degeneration Xray


Lumbar spondylosis

- disc degeneration causing arthritis / lower back pain


Discogenic lower back pain




Annulus fibrosis

- outer aspect of disc

- type I collagen

- fibres continuous with endplate & ALL/PLL

- provides tensile strength to contain NP


Nucleus Pulposus

- water + type II collagen + PG

- semifluid gel

- turns solid as ages and becomes brown

- Keratan : Chondroitin ratio increases as age




100% at autopsy > 90 years

- males > females and earlier




Unknown in 90%



- heavy labour

- obese & tall

- driving / vibration

- smoking

- previous back injury




1.  Dysfunction (15 - 45 years)


Disc degenerates with age / dessication

- concentration of PG declines

- decrease number of chondrocytes

- decrease water content

- collagen fibres thicker in cross section


Lose ability to resist torsional loads

- circumferential & radial tears in disc

- localised synovitis of facets


2.  Instability (35 - 70 years)

- disc herniation

- resorption of disc

- degeneration of facet joint with capsular laxity / subluxation & erosion / osteophytes


3.  Stabilisation (>60 years)

- ankylosis of discs & facets




Lower back pain

- usually worse with activity

- especially bending & lifting


Maybe referred to 

- buttocks / posterior thigh / groin





- loss of lordosis

- decreased ROM, especially flexion




Unexpected finding in 1:2500

- infection, fracture, tumour


Disc degeneration

- disc space narrowing

- vertebral sclerosis

- osteophytes






Spine MRI Normal and Degenerative Discs


Normal disc / bright T2 signal

Degenerative disc / dark T2  


Very sensitive

- 30% of asymptomatic patients < 60 years have abnormality

- 60% > 60 years have abnormality


Modic End Plate Changes


Lumbar Disc Degeneration Modic Changes


Classification of bone marrow changes in bone marrow adjacent to vertebral end plates


Type 1:  High on T2 / Low on T1

Type 2:  High on T2 / High on T1 (lipid changes)

Type 3:  Low on T2 and T1 (sclerotic)





- confirm isolated disc degeneration responsible for pain

- must check disc below and disc above



- inject contrast under pressure / LA and II guidance

- look for dye leak

- look for reproduction of symptoms


Alternative / Discoblock

- inject LA

- positive test if relieves pain




Ohtori et al Spine 2009

- only operative on patients with positive discogram or discoblock

- 15 patients in each group

- treated with anterior discectomy and interbody fusion

- significantly improved results in discoblock group


Natural History


90% lower back pain resolves < 2/12

- 10% chronic

- prognosis poor if pain > 6/12





- crush fracture / isthmic spondylolisthesis



- vertebral osteomyelitis / discitis / epidural abscess



- Benign (Haemangioma / OO / OB / EG / Giant Cell / ABC)

- Malignant (Chordoma / Myeloma / Metastasis)



- AS / Reiter's / Psoriatic arthritis / Enteropathic disease



- primary pathology of nerve roots (Neurilemmoma, neurofibromata, ependymoma)


Viscera / Vascular

- Pelvic viscera / retroperitoneal cancer

- AAA / Superior gluteal artery claudication / Claudication 2° PVD 




Non-operative Management


Acute LBP



- rest 2 days

- local measures - massage / local NSAIDs

- pain relief - acetominophen / NSAIDS


Once pain settles

- exercise

- general fitness important

- core strengthening

- brace no benefit


Chronic LBP


Back School / Structured rehab programme / Lifestyle modification

Relaxation \ Exercise

Avoid narcotics


Epidural Steroids



- lumbar pain without HNP / radiculopathy


Manchikanti et al Pain Physician 2010

- HCLA epidural injections

- 86% significant pain relief at 12 months


Operative Management




Unremitting pain & disability > 1 year

MRI single level disc degeneration


Isolated L5 S1 Disc Degeneration




1.  PLF / Posterolateral Fusion +/- instrumentation


2.  Instrumented PLIF / Posterolateral Interbody Fusion


3.  ALIF / Anterior Lumbar Interbody Fusion


4.  Disc Replacement





- decortication of pedicles / lamina / transverse process

- bone graft applied

- instrumentation added to improve fusion rate



- high fusion rate

- no risk of interbody graft / cage migration

- low risk neural injury




Fritzell et al Spine 2001

- RCT of surgical treatment v non surgical with 2 year follow up

- back pain reduced 33% to 7%

- return to work 36% v 13%


Fritzell et al Spine 2002

- RCT of PLF v instrumented PLF v PLIF

- no significant difference in reduction in pain and disability

- complications 6% v 16% v 30%

- fusion rate 72% v 87% v 91%


Instrumented PLIF


PLIF L5 S1 LateralPLIF L5 S1 AP



- wide post decompression and removal of entire disc

- graft / fusion cage placed between vertebral bodies

- 360o fusion (PLF + interbody)


Advantages over PLF

- excise disc & decompress nerve roots

- disc height restored with graft decompressing foramina vertically

- fusion of anterior column / increased fusion surface / site of arthrodesis compressed



- wide post decompression needed / newer minimally invasive techniques

- risk of canal compromise by graft




Leufven et al Spine

- 29 patients treated with PLIF

- fusion in 27/29

- excellent results in 31% and good in 21%

- fair in 21% and poor in 27%





- anterior approach + complete discectomy and graft




Penta et al Spine

- 108 patients with ALIF at 10 years

- only 34% good or excellent

- not related to fusion rates

- psychological rating intially and at review correlated with outcome


Disc Replacement



- maintain small degree of motion

- prevents adjacent level degeneration




Herkowitz et al JBJS Am 2006

- RCT of disc replacement v ALIF

- 304 patients with single level disease L5S1 or L45

- 2 year follow up

- clinical success 64% in disc replacement v 56% ALIF
- better ROM and restoration disc height in disc replacement


Harrop et al Spine 2008

- systemic review looking at adjacent level degeneration in lumbar fusion v disc

- radiographic degeneration 34% in fusion v 9% in disc replacement

- symptomatic degeneration 14% in fusion v 1% in disc replacement




Mortality 0.2%  

Infection 1.5%

DVT 4%

PE 2%

Neural injury 3%

Instrument failure 7%

Failed back surgery syndrome

Lumbar Stenosis

DefinitionLumbar Stenosis


Reduction of space available for neural elements in spinal canal or intervertebral foramina

- due to degenerative changes, congenital abnormalities or both

- involves compression of the thecal sac or nerve roots




Onset 50 - 60's

- M = F

- associated with onset OA spine


L3/4 & L4/5 most common


Aetiological Classification


1. Congenital



- short thick pedicles and narrowed interpedicular distance




Idiopathic ~ Polynesians

- trefoil-shaped canal


Congenital narrow spinal canal

- most syptomatic patients have canals at lower end of spectrum



- narrow L3




2. Acquired



- most common aetiology

- disc desiccation / loss of height / bulging of annulus

- facet subluxation / capsular hypertrophy / osteophytes

- overall shortening of lumbar spine / decreased volume

- ligamentum flavum hypertrophy







- post-laminectomy

- post-fusion



- Paget's disease

- Fluorosis


- Ankylsing spondylitis

- Tumour

- Infection - TB


Traumatic / Post fracture


Anatomical Classification


1.  Central Canal Stenosis


2.  Lateral Recess Stenosis


3.  Foraminal




1.  Central canal


Posterior wall - ligamentum flavum & laminae

Lateral wall - medial facet joints & intervertebral foramina

Anterior wall - annulus fibrosis & posterior vertebral body


2.  Lateral recess


Extends from where nerve root leaves dural sac to where nerve root enters foramen


Posterior wall - ligamentum flavum & superior part of lamina

Anterior wall - posterior vertebral body & annulus fibrosis

Lateral wall - medial & inferior pedicle


3.  Intervertebral foramen


Extends from inner to outer foramen


Superior wall - inferior part of pedicle above

Inferior wall - superior part of pedicle below

Anterior wall - above is body, below is disc

Posterior wall - pars interarticularis, ligamentum flavum & apex of superior facet of vertebrae below




Stenosis typically at disc level either due to disc or facets


1.  Central Canal

- bulging of annulus posterior

- facet osteophytes posterolateral

- hypertrophied ligamentum flavum posterolateral


Lumbar MRI Stenosis Trefoil Canal


2.  Lateral Recess

- facet subluxation & osteophytes + hypertrophied ligamentum flavum


3.  Intervertebral Foramen

- loss of disc height with approximation of pedicles

- inferior annular bulge

- medial facet hypertrophy





- increased canal narrowing with extension

- also get posterior disc protrusion and redundancy of ligamentum flavum

- root lacks perineurium & hence more susceptible to compression



- interference with metabolic demands of nerve root

- exercise increased nutritional requirements & waste production

- canal constriction limits response = relative ischaemia




Back Pain



- L5 most common, then S1


Neuropathic claudication

- insidious onset

- usually bilateral

- diffuse / no dermatomal pattern

- buttocks / thighs / calves

- heaviness / weakness / burning / cramping / tingling / numbness


Worse with walking, standing & lumbar extension


Relieved by sitting, flexion, walking upstairs, squatting




Often none, but can overlap with HNP




Vascular claudication

- calf pain with exercise

- rapid relief with cessation walking

- no back pain / no numbness

- abnormal pulses


Hip Disease

Diabetic neuropathy

Retroperitoneal pathology




Rule out 

- infection / tumour / fracture


Confirm degenerative changes

- facet hypertrophy / disc narrowing

- decreased AP diameter of canal

- identify associated pathology i.e. spondylolisthesis / scoliosis




T2 Sagittal "MRI Myelogram"


Lumbar MRI Stenosis Sagittal T2Lumbar Stenosis MRI SagittalLumbar Stenosis MRI


Stenotic Measurement


A.  Volume

- more accurate

- critical area is 100 mm2


B.  AP diameter less accurate

- normal if > 12mm

- absolute stenosis if < 10mm


Intervertebral foramina

- no fat about nerve root

- reduced height


Lumbar Foraminal Stenosis L45 MRILumbar MRI Tight Intervertebral Foramina L3


B.  Axial slices



- no fat about dura

- trefoil shape canal

- lateral recess or foramina compression

- nerve root compression


Lumbar MRI Stenosis Trefoil CanalLumbar stenosis axial MRILumbar MRI Axial Stenosis




Not clear not all patients progress


Johnsson 1993 Clin Orthop

- 32 patients followed 4 years

- 70% unchanged

- remainder: half worse, half better




Non-Operative Management




Rest / Avoid aggravating activities



- simple analgesia

- short course NSAIDS


Back support

- prevent extension



- back strength in flexion

- stabilise abdominal muscles

- aerobic fitness on exercise bike 


Epidural steroids


Koc et al Spine 2009

- RCT of exercise v epidural steroids v control in spinal stenosis

- exercise and epidural steroids both efficious up to 6 months




Podichetty et al Spine 2004

- RCT of calcitonin v placebo

- no difference in two treatment groups


Operative Management






Cauda equina syndrome




Failure to respond to non operative treatment

Disabling neurogenic claudication

Progressive neurological deficit


Back pain is not an indication




Decompression +/- fusion


Interspinous devices

- limit extension


Indications for fusion


1.  Degenerative Spondylolisthesis


2.  Radiological instability

- > 3mm or > 11o


3.  Intra-operative destabilisation

- removal of > 1 facet joint or pars

- i.e. radical decompression required laterally


4.  Degenerative scoliosis


5.  Significant low back pain / disc degeneration




Define site of compression

- central / lateral recess / foramina


Define levels

- single / multilevel



- must be prepared to fuse if cause instability

- consent




Operative v Non Operative


Weinstein et al Spine 2010

- SPORT trial

- RCT of operative v non operative treatment lumbar stenosis

- 289 patients with 4 year follow up

- substantially improved pain and function in operative group


Interspinous Devices


Hsu et al J Neurosurg Spine 2006

- RCT of non operative v X Stop interspinous device

- significant improvement in QOL, with results similar to surgical decompression


Decompression v Fusion


Niggemeyer et al Eur Spine J 1997

- meta-analysis

- if symptoms < 8 years, decompression without fusion yields best results

- if symptoms 15 years or more, decompression with instrumented fusion best results

- decompression and fusion without instrumentation had worst results




Epidural haematoma



Nerve root injury

Dural Tears


Technique L4/5 Decompression



- abdomen free to limit venous pressure and bleeding

- 4 poster / knee below hips / arms on bolster

- feet / knees / elbows / face / eyes cushioned


- betadine packs in buttocks

- +/- Jackson table (enables more lordotic position if instrumentation planned)


Landmarks / Check level

- iliac crest L4/5 interspinous space

- prep area aseptically, spinal needle

- check with lateral x-ray

- square drape



- inject LA with A

- midline

- meticulous haemostasis

- divide thoracolumbar fascia


Superficial Dissection

- subperiosteal elevate of supraspinous muscles (Cobb's and diathermy)

- sequentially pack with rolled swabs / sausages to control bleeding

- out to lateral extent of pars

- expose facet joints, but preserve capsule if not fusing

- beware parafacetal arteries

- don't extend between transverse processes as nerve root at risk


Deep dissection (L4/5)


L4 5 DecompressionL4 5 Decompression Laminectomy


Recheck level

- L4/5 interspinous gap


Resect L4 spinous process

- remove ligamentum flavum above and below

- Kerrison Rongeur / knife

- remove all of L4 lamina

- expose L4/5 disc space

- L5 nerve root exits inferior

- L5 nerve root will pass below L5 pedicle


Remove L4/5 disc fragments if needed

- nerve root retractor

- gently retract dura to each side

- take out with pituitary rongeur


L4/5 medial facetectomy

- above L5 pedicle

- L5 nerve root exits inferior to it

- decompress, pass Watson Chaney


Preserve pars & half of facet

- may have to remove entire facet joint & pars

- preserve one facet joint at each level

- can be 1/2 on each side




Spondylolisthesis Degenerative


Spondylolithesis L4/5

Spondylolithesis caused by

- facet joint degeneration

- no pars or dysplastic pathology

- disc space usually preserved


Most common at L4/5 level




More common in elderly females

- F: M = 5:1






1.  Facet degeneration

- body weight displaces lumbar vertebrae ventrally 

- resisted by facet joints


2.  Sagittal orientation of facet joints obviates restraining effect 


Boden JBJS 1996

- facet joint angle L4 or L5 >45° to coronal plane

- 25x more likely to have degenerate spondylolisthesis


3.  Segmental Instability




Slip usually mild / rarely past Meyerding Grade II

- average 15% 

- maximum 30% 

- facet involvement may be asymmetrical & this causes rotatory component 




1.  Low Back Pain 80%


2.  Radiculopathy

- sciatica 50% 

- usually L5 in lateral recess

- can be L4 via narrowing foramen


3.  Neurogenic Claudication 50% 

- worse with standing, relieved by flexion

- claudication distance is variable

- sensory changes

- normal pulses


4.  Cauda Equina 5%





- normal lumbar forward flexion

- pain on extension


Minimal tenderness & spasm 


Neurological deficit 50%

- sensory alteration 30%

- weakness 20%





- facet hypertrophy / osteophyte formation 



- mild forward slip 


Dynamic Views

- >10° or 4mm = objective instability




Degeneration of facet 


Degenerative Spondylolithesis CT 2Degenerative Spondylolithesis CT 1




Demonstrate stenosis with spondylolithesis


L45 Spondylolithesis MRI




Don't tend to progress past Grade II


Do well if have no neurological symptoms


Often need surgery for neurological claudication / stenosis








Mild symptoms / short duration / unfit for surgery




Activity modification / analgesics / physio




Weinstein et al N Eng J Med 2007

- RCT of operative v non operative, multicentred

- operative group had substantial improvement in pain and function at 2 years


Pearson et al Spine 2009


- RCT of operative v non operative

- operative group had significantly better outcomes

- grade 1 better outcome than grade 2 with surgery

- dynamic instability better outcome than static





- failure of non operative treatment 

- radiculopathy / neurogenic claudication

- progressive neurological defect

- bladder or bowel symptoms


Principles / Issues


1.  Decompress + fusion

- demonstrated superior results in degenerative spondylolithesis


Herkowitz et al Spine 1991

- fusion & decompression alone had better results at 3 years than decompression alone 

- slip increased 95% vs 30%


2.  Instrumentation

- instrumentation increases fusion rate

- ? solid fusion improves outcome


Fischgrund et al 1997

- RCT of PLF with and without instrumentation

- increased fusion rates with pedicle screws (82% v 45%)

- no evidence of superior outcome


Martin et al Spine 2007

- systematic review

- fusion leads to better outcome than decompression alone

- evidence that instrumentation increases fusion rate

- no evidence that instrumentation improves outcome


3.  Interbody cages

- increase foraminal height / important if radiculopathy

- improve fusion rates




Decompression + PLF without instrumentation

Decompression + instrumented PLF

Decompression + PLF + interbody cage / PLIF / 360o fusion




Abdu et al Spine 2009


- 360 patients comparing PLF / instrumented PLF / PLIF (360o fusion)

- no difference at 4 years in outcome


Decompression + Instrumented Posterolateral Fusion 


Degenerative Spondylolithesis PLF




Midline incision

- elevate para-spinal muscles

- expose L4/5 facets and TP's

- laminectomy +/- foraminotomy

- pedicle screws + rods

- decorticate lamina, transverse processes, facet joints

- posterolateral fusion with BMP collagen and synthetic BG sushi rolls




Decompression and PLIF / 360o fusion


Adult Spondylithesis PLIF

Spondylolisthesis Dyplastic Isthmic



Forward slip of one vertebra relative to inferior one




Wiltse  "DID TIP"










1. Dysplastic 20 %


Congenital Dysplasia of Upper Sacrum 

- occurs at L5-S1

- hypoplasia of superior facets of S1

- dysplastic L5/S1 facet joints


Usually around 6 years old


Spina bifida ccculta common

- more unstable


Prone to more severe slips


Most high grade slips are dysplastic


2. Isthmic 50 %


Pars Discontinuity / Defect

- L5 /S1 80%

- unilateral or bilateral

- can have a pars defect at L4/5

- typically adolescent

- due to repetitive stress with fracture

- increased in competitive sports eg gymnastics, football

- is a genetic predisposition due to increased pelvic incidence

- tend to be mild and non progressive


Tend to present in 2 groups

- some present in young patient

- some present in adulthood when the disc degenerates and foramina compressed


Isthmic SponydlolithesisL4 Pars Defect


3 types


A Stress fracture


B Elongated type


Spondylithesis Elongated


C Acute fracture


3. Degenerative


2° to Facet OA

- L4/L5

- > 40 years old

- associated with DM

- F>M

- compared with lytic the disc tends to be preserved


Degenerative Spondylolithesis L45


4. Traumatic


Bilateral acute fracture through neural arch outside pars

- i.e. hangman's fracture


5. Iatrogenic


Post surgical


6. Pathological


Pathological weakening of neural arch or pedicle 

- OI / Larsen / Marfan's / tumour




Occurs after walking

- never present at birth 


Spondylolysis seen in 5% causcasion population

- 15% develop spondylolithesis



- more common in boys 

- girls more severe slips


NHx Lytic


Early NHx

- by early adulthood L5-S1 disc narrowed

- anterior sacrum develops sclerotic lip

- further slip unlikely in adulthood

- will only progress whilst skeletally immature


Late NHx

- increased incidence of L5-S1 disc degeneration

- significant increase in LBP > 50% slip

- may develop nerve root pain when foramina compressed due to disc degeneration


Aetiology Isthmic


Fracture of pars  


Lumbar extension concentrates shear stresses on thin pars 

- inferior articular process of cranial vertebrae continuously impacts on pars

- nutcracker mechanism


Most common

- soldiers /weight lifters / footballer's

- female gymnasts 10%



- positive FHx in 15%


Pelvic Incidence


Isthmic associated with increased pelvic incidence > 50o

- patients have increase lumbar lordosis with increased shear stress

- predisposed to pars fracture if engage in certain sports with hyperextension



- line superior border sacrum / sacral slope

- drop perpendicular line from centre of sacral slope line

- line to centre femoral head

- pelvic incidence is line between the two


Pelvic IncidencePelvic Incidence > 50 degrees


Aetiology Dysplastic 


Secondary to posterior element abnormality

- increased incidence of sacral spina bifida



- positive FHx in 33%




1.  Isthmic


Usually lower grades

- posterior elements left behind

- canal diameter increased


L5 nerve root compression

- fibrocartilage mass at pars defect 

- stretched over posterior sacrum


2.  Dysplastic


Higher grades

- severe lumbosacral kyphosis

- canal diameter decreased


L5 nerve root + cauda equina pressure

- intact neural arch of L5 pulled forward




Usually asymptomatic in children

- only 10% are painful

- pain usually in growth spurt adolescents 


Back pain

- low back / buttocks & thighs 

- initiated by strenuous activity 

- repetitive flexion extension

- relieved by rest


Can often recall a specific inciting event



- radicular pain 

- exiting nerve root / usually L5 in both dysplastic and isthmic




Lumbar hyperlordosis


Lumbosacral step off with severe slips


Numbness in L5 area



- increased incidence in symptomatic slip 

- 25-50% 

- more common with dysplastic



- acute presentation with severe back pain

- hands on knees, hips and knees flexed

- bladder and bowel dysfunction


Standing AP and Lateral X-ray




May miss subtle listhesis on supine XR

- spondylosis

- Meyerding classification

- slip angle

- sacral inclination




Pars Defect Lateral Xray



- radiolucent defect of pars 



- acute - narrow gap & irregular edges 

- pars elongated & thinned

- chronic - wide gap with smooth sclerotic edges


Scotty Dog / Oblique Xray

- Ear (superior articular facet) / Nose (TP) / Eye (pedicle)

- Front leg (inferior articular facet) /  Body (lamina and body with superimposed SP)

- Tail (superior articular facet of other side) /  Back leg (inferior articular facet of other side)

- Neck (Pars and if Collar then has defect)


Scotty dog NormalPars Defect Oblique Xray


Meyerding Classification


Degree of slip compared with width of S1

- Grade I 0-25%

- Grade II  25-50%

- Grade III  50-75%

- Grade IV 75-100%

- Grade V  > 100% / Spondyloptosis



- stable / slip < 50%

- unstable / slip > 50%


Spondylolithesis Meyerding Classification


Slip Angle / kyphotic angle



- line along inferior border L5

- line along superior border S1


Normally L5/S1 disc is in 20-30° lordosis 

- angle is negative


As L5 slips forward it slips into kyphosis

- angle becomes positive

- sacrum becomes more vertical with high grade slips 

- this worsens the kyphosis further



- typically > 10° with dysplastic

-  > 30° high risk progression progression


Sacral inclination


Angle between posterior border of sacrum and vertical

- > 60o associated with progression


Chronic Changes


Seen in older presentation

- anterior sacral erosion

- domed sacrum

- L5 Trapezoidal 

- L5/S1 disc degeneration


Bone Scan


1.  Diagnosis




2.  Prognosis


Hot lesion

- will heal


Cold lesion

- not healing


CT scan



- reverse gantry



- perform instead of obliques

- oblique x-rays have high radiation dose with little extra information compared with CT 


Spondylithesis L5 S1 with disc degenerationPars Defect Bilateral CT





- neurological signs

- rule out other diagnosis




Infection - vertebral OM / discitis 

Tumour - osteoid osteoma / cord tumour

Herniated disc 

Inflammatory - Scheuermann's / Ankylosing Spondylitis




High Risks Progression


1. Clinical

- skeletally immature

- female 


2.  X-ray

- dysplastic slip 

- grade III or IV (> 50%)

- slip angle  / kyphosis > 30° (normal is -20° i.e. lordosis)


Non Operative




Minimal symptoms

Low risk progression

- isthmic

- mild slip (Meyerding I / II, slip angle < 30o)




Observation until mature

- review annually to ensure no progression of slip


Consists of

- activity modification 

- cease aggravating symptoms


- hamstring stretches

- brace





- spondylosis / grade 1 spondylolithesis

- acute / hot on bone scan



- attempt to heal pars fracture

- healing is not required for symptoms to settle



- anti-lordotic

- 3/12 full time, no sport

- 3/12 full time with sport




Debnath et al Spine 2007

- 42 patients with unilateral spondylysis hot on SPECT

- 6/12 non operative treatment including bracing

- 81% avoided surgery / complete resolution of symptoms

- remainder had CT confirmed non union and underwent unilateral pars fixation


Operative Management




1.  High risk slip

- slip degree > 50%

- slip angle > 30o

- dysplastic

- skeletally immature


2.  Progression of slip


3.  Neurological symptoms

- L5 Radiculopathy / Stenotic symptoms / cauda equina


4.  Debilitating pain

- spondylysis

- spondylolithesis




1.  Pars fusion

- painful spondylysis

- minimal spondylolithesis


2.  Fusion


A.  In situ v reduction

- not required for grade 1 - 2

- consider if sagittal malalignment

- associated with risk neurology especially L5

- controversial if should be performed in high grade slips


B.  Instrumented / non instrumented


C.  Levels

- L5/S1 if grade I or II / 50% or less

- L4/S1 if 50% for more


D.  Interbody cages

- useful in long standing spondylolithesis presenting in adulthood

- degenerative disc disease

- nerve root pain from interforaminal compression

- improves nerve root space

- improves healing rate


E.  Posterior v circumferential

- circumferential approaches may improve fusion rates and outcome in high grade slips


Fusion of Pars



- normal discs and facets

- pain relieved by pars injection

- failure brace / non operative treatment

- minimal slip


Pars Defect LA Injection



- lesion identified / debrided / iliac crest bone graft


Options ORIF


1.  Screw across lytic defect

- unilateral defect


Lytic Pars Grade 1 SpondylolithesisLytic Spondylithesis CT Unilateral Pars Defect


Lytic Pars Defect Unilateral Pars Screw0001Lytic Pars Defect Unilateral Pars Screw0002Pars Defect Screw CT


2.  Pedicle screw + laminar hook

- bilateral defect


Pars Defect Bilateral CTPars Defect Hook and Screw L50001Pars Defect Hook and Screw Lateral


Bilateral Pars Defect Union


3.  TBW spinous process and transverse process




Kakluchi et al JBJS Am 1997

- 16 patients with failure non operative treatment bilateral pars defect

- pain relieved by pars injection with LA

- pedicle screw + lamina hook

- nerve root decompression where required

- union in all 16

- 3 patients only had occasional back pain


Fusion in Situ


A.  Wiltse Lateral Mass Fusion in situ



- in situ fusion via a paraspinal muscle splitting approach

- no reduction or instrumentation



- for L5/S1 with minor slip in young patient

- rarely done these days

- most surgeons perform instrumented fusion



- midline incision

- two paramedian incisions in lumbodorsal fascia 4.5cm lateral to midline

- paraspinous muscle splitting approach 2 fingerbreadths lateral to midline

- split sacrospinalis using finger to dissect through muscle

- don't go anterior to TP or risk damage to nerve root

- decorticate TP / Sacral ala / facet / famina and add crest graft / allograft / BMP



- spica 3/12 with 1 leg incorporated   

- activity modification for 6/12


Instrumented fusion in situ without reduction



- slip grade 1 or II

- grade III or IV with no sagittal malalignment


Levels instrumentation

- L5 / S1 grade I or II

- L4 / S1 grade III or IV



1.  Pedicle screw instrumentation


Spondylolithesis PLF


2.  PLIF / interbody cage


Isthmic Spondylolithesis PLIFSpondylolithesis PLIF


3.  Bohlman procedure

- interbody fusion with fibula strut

- augmented with decompression and PLF


Dysplastic Spondylolithesis Bohlman Procedure


4.  Transfixing L5 / sacral screw


Spondylolithesis Transfixing Screw LateralSpondylolithesis Transfixing Screw Lateral


Reduction + Instrumented fusion



- sagittal malignment



- risk of neurology (L5)

- up to 25%, usually transient



- cosmesis

- less pain from correction of alignment

- more likely fusion, less pseuodoarthrosis

- improved neurological decompression




A.  Posterior approach

- wide foraminatomy bilateral to protect L5 nerve root

- disc removed

- screws used to correct angulation +/- some translation

- interbody fusion device to restore height


B.  Anterior approach






A.  L5 vertebrectomy / Gaines procedure


B.  Reduction and fusion as above

Thoracic Disc Disease



0.05% incidence

- rare due to stabilising effect of rib cage

- even more rare to have symptoms



1.  Discs are narrower

2.  Foramina larger

3.  Thoracic spine

- facet joints orientated for rotation

- lumbar spine for flexion extension

- flexion is typically the motion which ruptures annulus




Increase in size from T1 to T12

- small pedicles

- long spinous processes

- relatively large intervertebral foramina

- facets nearly vertical

- TP come off the pedicle

- costal articulation TP and vertebral body


Thoracic Vertebrae




Present with intercostal radiculopathy or myelopathy




Disc space narrowing / degenerative changes


> 50% thoracic discs associated with calcified disc material in canal

- probably indicates chronicity


Thoracic Disc Calcified CT 1Thoracic Disc Calcified CT 2




Very sensitive 

- 40% incidence asymptomatic thoracic disc protrusion


Thoracic Herniate Disc SagittalThoracic Herniate Disc Axial


Thoracic Disc MRIThoracic Disc MRI Axial




Non Operative



- single level disease

- no myelopathy

- operation rarely indicated

- usually settles with physiotherapy / analgesia





- myelopathy 

- unrelieved radiculopathy




Posterior approach / discectomy via laminectomy

- contraindicated

- spinal cord does not tolerate retraction 


Anterior Approach

- costotransversectomy

- corpectomy (2 level disc)


A.  Thoracotomy and Costotransversectomy



- resection of rib + transverse process



- single level disc resection

- unilateral disc



- posterior approach

- remove of rib and transverse process

- ipsilateral pedicle removal

- removal disc protrusion


B.  Thoracotomy and Corpectomy



- 2 level disc protrusion


Thoracic disc 2 Level Precorpectomy




Thoractomy Approach

- loin incision

- removal of rib 2 levels above

- through bed of rib

- extrapleural approach

- from left to avoid IVC


Tie off segmental artery on one side

- disc convex, body concave

- allows access to disc protrusion

- discectomy + / - corpectomy as required for exposure / 2 level disc

- anterior +/- posterior stabilisation if corpectomy

- if simply remove disc may not need stabilisation especially in elderly

- will autofuse


Thoracic Corpectomy HNP




Cord injury


Cord infarct 

- ligation segmental artery

- exceedingly rare with unilateral approach

- much higher risk with bilateral approaches

- CTA to look for artery adamkiewicz


Intercostal neuritis 

- not uncommon

- treat with repeated intercostal nerve blocks



- usually from segmental artery

- patient presents difficulty breathing / hemothorax

- may have high output from drain

- > 200mls / hour clamp drain and urgent return to OT with vascular surgeon




Thoraco Lumbar Fracture

Xray Assessment


A:  Alignment

B:  Bony

C:  Canal

D:  Disc

S:  Soft tissues


Goals of surgery


1.  Correct deformity

2.  Restore stability

3.  Decompress neural elements if required





- defines level of conus

- may need anterior rather than posterior surgery if lesion above conus


Denis's 3 column Classification 1982


> 3 columns injured with translation

- unstable


Posterior column 

- supraspinous / infraspinous ligament / ligamentum flavum

- neural arch (lamina / pedicle / facet joints / spinous process)


Middle column 

- PLL, posterior disc & annulus

- posterior half vertebral body

- most important


Anterior column 

- ALL, anterior disc & annulus

- anterior half vertebral body


Denis Classification


1.  Compression fracture

- anterior column only


L1 anterior compression fracture MRI


2.  Burst fracture

- anterior and middle column disrupted

- widening of pedicles on AP

- decreased posterior body height compared to anterior

- may have retropulsed fragment

- this occurs at top of vertebral body between pedicles

- obscured by pedicles on lateral xray


Burst Fracture CT


3.  Flexion-distraction

- distraction of posterior structures

- disruption of middle column

- splaying of spinous processes on AP and lateral

- bony or ligamentous

- chance injury (pure bony)

- anterior column intact / no translation


4.  Fracture-dislocation

- all three columns disrupted

- characterised by translation


Surgical Indications


1.  Neurology 

- decompress 

- complete v incomplete


2.  Deformity

- correct deformity


Gertzbein SRS 1992

- 1109 patients

- kyphosis >30° associated with increased back pain


3.  Stability

- prevent neurology

- prevent deformity / late pain


4.  Multi-trauma patient


TLISS (Thoracolumbar Injury Severity Score)


Spine Trauma Study Group 

- 3 issues

- calculate a score

- gives an indication if patient needs surgery


1.  Injury Mechanism


Compression 1

Burst 2

Rotation 3

Distraction 4


2.  Posterior Ligament Complex


Intact 0

Suspected 2

Definite 3


3.  Neurology


Nil 0

Nerve root 1

Complete cord 2

Incomplete cord 3

Cauda equina 3


10 is maximum score

- < 4 no treatment

- 5 or more - surgery

- 4 - either way


Burst fracture

- 2 points for burst

- 2 for indeterminate posterior injury

- usually no neurology

- 4 in total




Incomplete neurology

- emergency

- especially if neurology worsening

- have more time if neurology stable

- i.e. time to get MRI


Complete neurology

- not an emergency

- surgery still indicated

- gain 1 or 2 neurological levels (crucial in C spine)

- prevent syrinx

- prevent development of neuropathic pain

- aid nursing / rehabilitation


Bohlman 1985 JBJS


184 thoracic spine fractures with complete cord injury

- no recovery with or without OT

- posterior fusion only to speed recovery


17 incomplete cord injuries treated with laminectomy

- 7 became worse

- hence contra-indicated


8 incomplete cord injuries treated with anterior decompress+ fusion

- all improved  

- decreased rehabilication time by 50% in operative group







- flexion distraction

- fracture dislocation

- compression fractures

- +/- burst


Requires integrity of posterior column

- Gaines score



- disruption of posterior column

- higher risk of dural tears





- decompression required

- i.e. burst with retropulsed fragment

- perform corpectomy via anterior approach


Anterior & Posterior


Gaines / Load sharing Classification


Enables decision be made

- short segment posterior stabilisation v

- anterior decompression and stabilisation


Gaines Class >/=7 = failure with pedicle screw construct alone


A. Comminution vertebral body on lateral X-ray

1. <30%

2. 30-60%

3. >60%


B. Apposition of Fragments

1. Minimal displacement

2. 2mm or <50% of body

3. > 2mm or >50% body


C. Deformity Correction

1. Kyphosis 3o or less

2. 4-9o

3. >10o needed


Score of 3-9


1.  Compression Fractures



- burst

- pathological


CT scan

- xray only 25% accurate distinguishing compression from burst

- indicated if anterior body height < half posterior body height

- i.e. > 50% anterior wedging

- assess integrity of middle column / look for retropulsed fragments


Operative Indications

- kyphosis > 30o


Non Operative Management

- elderly - mobilise

- young - extension orthosis / TLSO

- check standing X-ray 2/52

- ensure kyphosis < 20 - 30o



- posterior approach

- instrumentation


2.  Burst Fracture



- axial load

- most common thoracolumbar junction

- retropulsed fragment here causes conus



- anterior & middle column disrupted

- posterior column injured but no displacement / translation



- pedicle widening on AP

- posterior body height decreased on lateral < 50%


Thoracic Burst Xrays LateralThoracic Burst Xrays AP Widened Pedicles




Look for canal compromise

- cord signal change

- kyphotic deformity


Burst Fracture CT No Canal CompromiseBurst Fracture Coronal


Retropulsed fragments

- always between pedicles

- typically one or two main fragments (saloon door)

- assess canal compromise


Thoracic Burst CT Canal Fragment SagittalThoracic Burst CT Canal Fragment Axial


Burst Fracture Axial CT




- cord signal change

- assess posterior ligament integrity

- assess level of conus medullaris


Thoracic Burst MRI Sagittal Kyphosis and Cord SignalThoracic Burst MRI Canal Compromise




1.  High association abdominal trauma

- duodenum, aorta, spleen


2.  Neurology

- complete v incomplete

- from retropulsed fragments


Non-Operative management



- no neurology 

- no deformity / < 30o kyphosis

- stable




Surgical Indications



- usually means neurology


Kyphotic deformity


Failure non operative


Anterior corpectomy and strut graft



- decompression of retropulsed fragments in patient with neurology


Lumbar Burst Fracture0001Lumbar Burst Fracture0002Lumbar Burst Fracture0003Lumbar Burst Fracture0004



- approach as per level

- thoracoabdominal for T11 - L1

- thoracotomy for T2 - T10

- remove disc above and below and remove vertebral body

- remove fragments / need to know if 1 or 2

- screws in vertebral body above and below

- 2 screws in a lateral plane

- insert fibular strut allograft / titanium cage

- augment with cage


Posterior instrumentation 



- < 7 gaines criteria

- no neurology



- ligamentotaxis clears canal / PLL acts as bowstring

- pedicle screws lumbar, avoided in thoracic

- use transverse process and pedicle hooks in thoracic

- bone graft inserted via pedicles

- need to do before 5 days post injury


Burst Fracture Posterior stabilisation 3Burst Fracture Posterior stabilisation


Thoracic Burst Posterior Stabilisation APThoracic Burst Posterior Stabilisation Lateral


3.  Flexion Distraction




Seat belt injuries

- injury all 3 columns

- posterior fails in tension

- anterior and middle in distraction

- anterior undisplaced with no translation


Associated injuries


1.  Hollow viscus


Anderson et al J Orthop Trauma 1991

- 2/3 have injury to hollow viscus

- duodenum very common as second part fixed

- 1/4 have hemoperitoneum from mesenteric laceration


2.  Ileus

- very common

- manage NBM / NGT




1.  Pure bony

- through vertebral body

- Chance fracture


2.  Ligamentous

- through disc space and facet joints


Thoracolumbar Chance Fracture CT CoronalThoracolumbar Chance Fracture CT Sagittal


3.  Combined

- rare injury




Bony chance

- can heal in hyperextension orthosis

- assess reduction in brace / < 15o kyphosis

- otherwise can fix with pedicle screws and TP hooks of same vertebrae



- treat surgically as unstable and ligament heals poorly

- respond well to short segment posterior instrumentation

- above and below disc space injured

- i.e. T12 and L1 instrumented


TL Chance Fracture Stabilisation LateralChance Fracture Stabilisation APTL Chance Fracture


Neurology / deformity

- reduction and posterior stabilisation

- add decompression if required


4.  Translational - Fracture / Dislocation


T12 L1 Soft Tissue Chance CT 2T12 L1 Soft Tissue Chance CTT12 L1 Soft Tissue Chance MRI




3 Column injury

- high energy

- unstable by definition

- required operative stabilisation

- profound neurological deficit common



1.  Shear

2.  Flexion-distraction with translation

3.  Flexion-rotation

- unilateral facet dislocation

- < 25% translated




Incomplete or no neurology

- rare

- great care must be taken to not worsen patient

- MRI to exclude disc / determine level of conus



- posterior approach / decompression / reduction / stabilisation

- consider anterior approach if HNP / above level conus



- 1 up and 1 down sufficient unless

- osteoporosis

- thoracolumbar junction


T12 L1 Soft Tissue Chance OTT12 L1 Soft Tissue Chance Posterior StabilisationT12 L1 Soft Tissue Chance Posterior Decompression