Cervical Degeneration

Cervical Myelopathy

DefinitionCervical Myelopathy MRI


Spinal cord dysfunction
- extrinsic compression of the cord or its vascular supply
- caused by degenerative disease of spine




Most common spinal cord dysfunction in patients > 55 years old

C5/6 commonest level




- congenital / developmental stenosis
- decreased space available for cord
- average mid cervical spine is 17 – 18 mm



1. HNP

2. Osteophytes from facet and uncovertebral joints
3. Ligamentum Flavum

4. Instability

5. Kyphosis
- stretches spinal cord over posterior vertebral bodies and discs
- dictates an anterior approach

6. Ossification of PLL
- more common in certain Asian populations i.e. Japanese



Need to exclude other causes of spinal cord dysfunction


- CVA / AVM / Tumour / Hydrocephalus

- Metabolic or alcoholic encephalopathy


- demyelinating disease / MS / MND
- syringomyelia / Tabes dorsalis

- myopathy / peripheral neuropathy




Neck pain


- global, non dermatomal distribution over upper extremities


Difficulty walking / unsteadiness on feet



- have central cord like presentation
- distal worst than central


- pain , numbness and weakness
- clumsiness of hands common
- difficulty with fine motor function
- may also have radicular symptoms


Bladder dysfunction uncommonly occurs


May present acutely with central cord syndrome




UMN in extremities below lesion

LMN signs at level of lesion




Wide based gait

Unable to heel toe


Poor proprioception

1.  Finger escape sign
- deficient adduction or extension of ulnar digits of affected hand


2.  Romberg Positive




1.  Hoffman Reflex
- flexion of ipsilateral IPJ of index and thumb when long finger DIPJ flexed

- extension of neck increases sensitivity


2.  Inverted Brachioradial Reflex

- spontaneous flexion of digits when BR reflex elicited
- indicates cord compression at C5 and C6 / commonest levels


3.  Babinski Reflex



Narrowed joint space
- C5/6 commonest level followed by C6/7


Osteophytic lipping
- foraminal and uncovertebral osteophytes seen


- lordosis v kyphosis

Cervical Stenosis Kyphotic AlignmentLordotic Cervical SpineCervical Spinal Kyphosis Flexion View


Ossification PLL


Cervical Spine OPLL


Flexion / Extension views show instability
- > 3 o
- > 11 mm


Pavlovs Ratio
- AP diameter of spinal canal divided by the AP diameter of body at same level
- indicator of developmental stenosis
- should be 1.0

- < 0.8 is narrowed and stenotic


AP diameter / SAC
- normal (17mm)
- relative (13mm)
- absolute stenosis (10mm)


NB: X-ray estimates of space available for cord

- do not take into account ST i.e. discs and ligamentum flavum




Helps distinguish disc from osteophytes

- soft v hard disc




OPLL Cervical Spine




Disc herniation

- high incidence of asymptomatic findings
- 19% of asymptomatic patients have abnormality on MRI


Cervical Myelopathy Herniated Discs


Cord changes
- cord oedema with signal change seen


Cervical Myelopathy Cord Changes


AP diameter thecal sac < 10 mm


Compression Ratio
- banana cord
- divide the smallest AP diameter by largest transverse diameter at same level of spinal cord
- ratio of < 0.4 after decompression particularly with myelopathy > 6 months has poor prognosis


Cervical Myelopathy Compression Cord Ratio


Cross sectional area of spinal cord
- < 30 mm2 poor prognosis




Natural history suggests that > 50% of patients become worse if not treated
- some stable
- most slowly progressive
- < 5% acute deterioration




Non operative


Cervical collar
Physiotherapy with isometric strengthening
Ice , heat and massage

Follow up every 6-12 weeks initially followed by yearly if no progression

Traction and manipulation contraindicated

Must counsel them to the risks of trauma




Absolute Indications


1. Progressive neurological deficit
2. Failure of symptoms to improve with 6 months of non operative treatment
- base on severity of clinical neurological fingings


Relative indications


1. Compression ratio < 0.4
2. Transverse spinal cord diameter of < 40 mm2
3. Increased signal intensity of cord on T2 of MRI
4. Acute central cord syndrome
- initially collar and methylprednisolone
- no operation if near full recovery
- decompress if residual neurological deficit




The patient with cervical and lumbar stenosis

- should have the cervical spine decompressed first

- risk of intubation damage to cervical spine
- reduces need for lumbar surgery
- leg symptoms may improve after the cervical decompression




Surgery can be expected to halt progression

- may improve motor, sensory and gait disturbance


The best spinal cord recovery seen in those treated
- decompression within 6 - 12 months
- early, mild myelopathic signs
- transverse area of cord greater than 40 mm2 postoperatively
- age < 60


Preoperative Considerations


NSAIDS ceased 2 weeks prior to surgery


Positioning should avoid hyperextension of the cervical spine

- may need awake fibreoptic intubation




1.  Laminectomy & fusion

2.  Laminoplasty

2.  ACDF

3.  Corpectomy


1. Laminectomy & Fusion


Cervical Myelopathy Posterior Decompression InstrumentedCervical Myelopathy Posterior Decompression Instrumentation




Any posterior decompression procedure is an indirect technique

- requires posterior shifting of the cord in the thecal sac

- to diminish the effect of the anterior compression



Lordotic cervical spine / no kyphotic deformity

Ossification of PLL

- dura may be adhered

- high risk of irreparable dural tears with anterior approach


Indications for fusion





Positioning for the posterior approach
- prone
- Mayfield head tongs in neutral

- protect eyes / elbows (ulna nerve) / knees (CPN)
- pneumatic compression stockings
- infiltration of skin with adrenaline solution



- wide laminectomy +/- foraminotomy


- avoids progressive kyphotic deformity
- lateral mass screws


Cervical Myelopathy Posterior Decompression




Postoperative instability / kyphosis
- > 50% facet resection = instability
- avoid by fusion or laminoplasty


2.  Laminoplasty



- divide lamina unilaterally

- elevate to decompress

- insert device to keep lamina elevated



- maintains stability

- no need to insert pedicle screws



- no kyphotic deformity


3. ACDF / Corpectomy and Arthrodesis





- anterior cord compression

- pathology primarily at disc level

- kyphotic deformity


removes entire disc

- can maintain / restore lordosis

- restores foramina / decompresses nerve root


- difficulty decompressing the nerve roots in foramen from front
- difficult access to the posterior osteophytes




Smith - Robinson approach


- supine with interscapular roll
- head turned slightly to right for left sided approach


Disc removal in full
- MRI reviewed carefully to exclude free disc lying behind the PLL
- resect the disc until the longitudinal fibres of PLL seen

- inspect carefully for defect
- if no defect on MRI findings then should not routinely remove the PLL


Insertion cage 

- contains autograft / allograft / BMP & collagen
- sized first, check on x-ray
- insert cage, ensuring not too posterior
- aiming to decompress foramina


Anterior plate for stability


4.  Corpectomy and strut Graft





- multilevel disease

- soft and hard disc causing compression

- kyphotic deformity




Anterior approach
- decompression of disc above and below

- resection of vertebral body with burr
- leave lateral walls to protect vertebral artery
- typical midline channel is 16 – 18 mm


Bone Grafting Technique
- single level, iliac crest
- multiple level, fibular strut
- autograft superior to allograft


- maintains alignment / improves graft stability

Post op
- usually require HTB




1. Transient sore throat or difficulty swallowing

- most common complication

- superior laryngeal nerve


2. Recurrent Laryngeal Nerve paralysis
- more common in right sided approach
- post operative hoarseness


3. Respiratory compromise
- drains
- strict monitoring

- emergency release of wound stitches if haematoma


4. Neurological injury 1 – 2%


5. Injury vertebral artery


6. Dural tears
- more common if OPLL
- fibrin glue, fascial patch


7. Graft related
- dislodgement
- fracture
- severe settling
- pseudoarthrosis

Cervical Radiculopathy



Clinical diagnosis

- based on a sclerotomal distribution of motor &/or sensory symptoms or signs


Caused by impingement of exiting nerve roots


- zygo-apophyseal / facet joint hypertrophy

- neuro-central joint hypertrophy


May be acute or chronic






Peak age 50-54


C7 > C6


Natural History


Mayo Clinic Natural History Radiculopathy

- 50% of population at some stage

- ~50% recurrent

- 90% asymptomatic at 5 years




Each subaxial C-spine motion segment has 5 articulations


A. Intervertebral disc


B.  2 neurocentral / uncovertebral joints

- along posterolateral vertebral body / Joint of Luschka

- lie between disc & nerve root

- each body has upturned postero-lateral uncinate process

- pedicle is attached below uncinate process


C.  2 facet joints

- angulated 30-50° to transverse plane


Intervertebral foramina boundaries


A. Anterior

- both vertebral bodies, uncinate process & disc


B.  Posterior

- facet joints


C.  Above & below

- pedicles


Foramina are 45° to sagittal plane


Transverse process


3 elements

1. Embryological TP to posterior tubercle

2. Embryological rib to anterior tubercle

3. Tubercles joined by intertubercular lamella


Foramen transversarium in middle with vertebral artery

Dorsal root ganglion and ventral ramus spinal nerve on intertubercular lamella




Posterior tubercle

- Scalenus medius


Anterior tubercle

- Scalenus anterior, longus coli & capitus

- progressively enlarge from C3 down to C6

- C6 Chassaignacs tubercle


Cervical Nerve Roots


Each cervical root exits above the pedicle for which it is named except C8

- C5/6 – C6

- C6/7 – C7

- C7/T1 – C8


Pathophysiology Nerve root compression


1.  HNP

- in contrast to lumbar spine

- both posterolateral and central HNP compress exiting nerve root

- inflammatory and ischaemic components


A. Central - myelopathy

B. Posterolateral - mainly motor weakness

C. Intraforaminal - most common / often dermatomal distribution


Cervical Spine Central Disc HerniationCervical MRI Posterolateral Disc


2.  Spondylosis / Disc degeneration

- loss of height / annular bulging

- foraminal compression


3.  Bony 


A.  Uncovertebral osteophytes / hard discs

- compress nerve root anteriorly


B.  Superior articular facet osteophyte

- extend from ventral surface to compress the neural foramen

- are less common




Pain / parasthesia

- often don’t follow dermatomal distribution



- 60-70% motor deficiency


Spurling maneuver

- hyperextension with tilt toward affected side 

- stimulates radiculopathy symptoms


Nerve root signs (C6 and C7 most common)


C2 Posterior occipital headaches

C3 Occipital headache

C4 Neck and trapezial pain +/- shoulder / scapula pain

C5 Pain lateral upper arm (epaulet) / deltoid weakness / biceps jerk decreased

C6 Radial forearm and hand pain / weak biceps and wrist extension / BR reflex decreased

C7 MF pain / weak triceps / absent triceps jerk

C8 Pain ring and little fingers / weak finger flexors

T1 Ulna forearm pain / weak hand intrinsics


DDx Myopathy


Entrapment syndromes (ulna / median nerves)

Thoracic outlet syndrome

RC disease




Demonstrate loss of disc height and degeneration





- 19% of asymptomatic patients will have evidence of nerve root compression

- difficult to distinguish between hard and soft discs




Adds complementary information to MRI in C spine


Demonstrates the posterolateral impingement is from “hard” disc

- i.e. uncovertebral spur 


Cervical nerve root injections


Confirm diagnosis

- should get some temporary symptomatic relief





- concern re peripheral nerve entrapment



- are usually normal because lesion proximal to DRG



- amplitude decreased proportional to muscle atrophy


Nerve conduction velocity

- not abnormal unless severe demyelination of axons



- best for differentiating peripheral nerve root compression from central

- fibrillations




Non operative





Pharmaceutical / NSAIDS


- hot / cold

- electrical stimulation

- ROM / stretching

- isometric strengthening exercises 

Cervical traction


HCLA / nerve root injections




Lellad et al Ann Phys Rehabil Med 2009

- RCT demonstrating benefit of reducing symptoms with cervical traction


Cervical Traction


Kuijper et al BMJ 2009

- RCT demonstrating benefit of wearing semi-hard collar for 3 weeks 





- severe pain

- severe neurological impairment

- failure non operative treatment





Disc replacement










Anterior Cervical Discectomy and Fusion



- anterior approach

- interbody fusion

- iliac crest bone graft / synthetic bone graft / allograft / cage

- anterior plate / eliminates need for brace



- deal with HNP and uncovertebral osteophytes

- opens up the neuroforamina and decompresses the nerve

- fusion relieves pain of spondylosis

- anterior approach dissects little muscle and has little pain

- scar very cosmetically acceptable




Smith & Robinson / anterior approach

- divide platysma and deep cervical fascia

- SCM laterally

- divide pretracheal fascia / carotid sheath laterally

- divide prevertebral fascia in midline, separate longus colli



- decorticate end plates

- excision of osteophytes controversial

- generally only if causing compression

- otherwise will absorb with stability



- pseudarthrosis

- graft / cage displacement posteriorly

- wrong level

- insufficient decompression

- neurological injury (quadriplegia /  nerve root / RLN / Superior Laryngeal Nerve)

- injury to other structures (carotid artery / oesophagus)

- degeneration at second level


Cervical Disc Degeneration Above Fusion




2. Disc replacement



- as above

- insert disc replacement

- no anterior plate



- maintain some motion

- preserve other disc segments




Murrey et al Spine 2009

- RCT of ACDF v disc replacement

- disc replacement maintained 4o of motion

- significant reduced reoperation rate in disc replacement (1 v 8%)


3. Corpectomy



- multilevel hard and soft compression

- can remove body with disc above and below

- decompress 2 levels


Cervical HNP 2 Levels


Cervical Corpectomy APCervical Corpectomy


4. Laminoforaminotomy



- posterior approach

- deroofing of foramina




Herkowitz et al Spine 1990

- compared ACDF with posterior laminotomy / foraminotomy

- patients with both central and posterolateral discs

- combination of radiculopathy and myelopathy symptoms

- 4 year followup

- 95% vs 75% G/E


Johnson et al Spine 2000

- prospective study of patients with posterolateral disc and radiculopathy

- patients had no neck pain

- removal of HNP + uncovertebral osteophytes

- 91% improved or resolved

- 9% revision (ACDF / repeat posterior foraminotomy)





Cervical Spondylosis



Cervical spondylosis

- chronic disc degeneration & associated facet arthropathy


Cervical myelopathy

- spinal cord dysfunction

- secondary to extrinsic compression of cord or its vascular supply


Cervical radiculopathy

- sclerotomal distribution of motor &/or sensory symptoms or signs

- due to compression of nerve root




Usually begins at age 40-50




Most common at C5/6 > C6/7 > C4/5






Degenerative changes at disc / facet joints / uncovertebral joints


Clinical Features


Neck pain / headaches / local tenderness


Reduced ROM




Typical changes of spondylosis

- disc space narrowing

- osteophyte formation

- degenerative facet & uncovertebral joints


May be present in asymptomatic individuals


Cervical Spine Degeneration


CT scan


Degenerative changes


Cervical Spondylosis CT




Degenerative disc changes

- dessicated (loss of fluid), narrowed, end plate changes


Space available for cord


Neural compression

- intrinsic cord changes

- cord compression / ratio / cross sectional area


Cervical Spine Degeneration MRI






Education & Reassurance

- analgesics

- local modalities

- exercise programme

- traction







- failure non operative treatment

- disease isolated to 1 or 2 levels




Posterior Instrumented Fusion


Cervical Pedicle Screws LateralCervical Pedicle Screws AP







- restores disc height and aligment

- decompresses foramina



- autograft

- allograft

- cage


Jacobs et al Cochrane Database Review 2011

- autograft superior to discectomy alone

- autograft superior to cage in fusion rate but with higher complications


Disc Replacement



- elevate / decompress foramin

- maintain motion / decrease degeneration at subsequent levels


Burkus et al J Neurosurg Spine 2010

- prospective multicentred RCT 541 patients with single level disc degeneration

- disc replacement v ACDF

- improved outcome scores and neurological outcome in disc replacement

- no difference in rates of subsequent level surgery


PLOS One March 2015

- meta-analysis of 19 RCT of ACDF v disc replacement

- disc replacement had better scores, better pt outcome, better ROM, and decreased secondary degeneration



Technique ACDF

Anterior Cervical Discectomy and Fusion






Place the patient in the supine position

- small roll placed under the shoulder blades to drop the shoulders from the field

- exposes the anterior neck

- strap the shoulders at the side with minimal traction 

- allows visualization of the lower cervical spine on lateral radiographs

- apply skull traction with Gardner-Wells tongs

- keep head rotation to a minimum because deep dissection will depend on identifying the vertebrae midline

- prevents inadvertent injury to adjacent structures

- reverse Trendelenburg position facilitates venous drainage and results in less bleeding during surgery




Anatomic landmarks for incision 

- hyoid bone overlying C3

- thyroid cartilage overlying the C4/5 interspace

- cricoid cartilage overlying the C6 level


Use transverse incision for exposure in most cases

- more cosmetic

- from the midline to the anterior border of SCM in Langer's lines

- divide the deep cervical fascia and platysma muscle exposing the middle layer of the cervical fascia

- bluntly dissect the pretracheal fascia and palpate the carotid pulse


When three or more levels are approached, use a longitudinal incision


Dissection through the pretracheal fascia places several structures at risk

- superior and inferior thyroid arteries extend through the pretracheal fascia from the carotid artery to the midline

- travel at the C3/4 and C6/7 levels, respectively

- intervening area provides a relatively avascular plane for dissection


Recurrent laryngeal nerves

- right recurrent laryngeal nerve ascends in the neck after passing around the subclavian vessels

- courses medially and cranially at the C6–C7 level, often along with the inferior thyroid artery

- left recurrent laryngeal nerve ascends after curving around the aortic arch along the tracheoesophageal groove

- more midline and protected position

- left-sided procedure may be safer, especially when lower cervical segments are approached

- the thoracic duct is often visible on the left at the C7–T1 level and must be protected


Retract the sternocleidomastoid muscle and the carotid sheath medially

- contents (common carotid artery, internal jugular vein, and vagus nerve)


Retract the midline structures, including the trachea, esophagus, and thyroid gland medially

- complete blunt dissection through the deeper levels to the prevertebral fascia and vertebral bodies


Once the midline is identified, incise the prevertebral fascia

- elevate the medial edges of the longus colli muscles

- place blunt self-retaining retractors under the leading edges of the muscle

- Tramline retractor is used (Medial Lateral)

- take care to avoid dissecting along the longus colli muscle because of injury to the cervical sympathetic plexus

- screws in vertebral bodies for vertebral distraction





- vertebral bodies by their concave appearance 

- the discs by their more convex contour


Localize the disc space with a radiopaque marker and lateral radiograph


Remove disc

- incise the disc with an annulotomy blade

- cut lateral to medial away from the vertebral artery

- remove the disc contents and endplate cartilage to the PLL

- use thorough evaluative preoperative imaging to determine the presence of a sequestered disc behind the PLL

- palpate the PLL for the presence of a rent that may also indicate a sequestered fragment

- in the event that a rent is noted, or if an expected disc fragment is not identified, remove the PLL with Kerrison rongeurs

- beware of routine removal of the PLL, because reports of postoperative epidural hematoma have been associated with this technique


Removal of endplate and uncovertebral osteophytes is controversial

- disc space distraction reduces ligamentum flavum buckling and increases neuroforaminal area

- it is believed that fusion will arrest spur progression, and stability may allow for resorption over time

- however, this is not a consistent phenomenon

- the location and size of the offending spur must be carefully considered when performing decompression

- exposure of the uncinate processes is critical to safely remove osteophytes

- utilize a high-speed burr to excise the spur from medial to lateral



- judge the adequacy of foraminotomy

- ability to place the tip of a curret anterior to the exiting nerve root without significant resistance




Atlantoaxial Instability



Loss of ligamentous stability between atlas and axis


Spectrum of conditions

1.  Subluxation AP / insufficiency transverse ligament

2.  Rotatory / insufficiency apical ligament




Most common older children and adolescents






Secondary to laxity of transverse ligament


- Larsen's / Marfans




1. Infection

- retropharyngeal abscess / Grisel's syndrome


2. Trauma


3. Hypoplasia

- Down's Syndrome (15%)


- Achondroplasia

- Morquio


4. Inflammatory

- Rheumatoid arthritis


5. Developmental

- Os Odontoideum

- Klippel Feil




Cruciform ligament

A. Transverse ligament

- tubercles medial aspect lateral mass C1

B. Longitudinal bands from transverse ligament

- up to occiput

- down to C2


Alar ligament

- side of the dens up to the lateral margins foramen magnum

- prevent excessive lateral rotation


Apical ligament

- dens to occiput


Tectorial membrane

- extension of PLL

- behind transverse and alar ligaments




Neck pain

Occipital neuralgia

Rarely vertebro-basilar insufficiency




Atlanto-Axial Rotatory Subluxation (AARS)

- Cock Robin Tilt

- Torticollis

- facial asymmetry in children





- fibrosis SCM


Ondontoid fracture


Os ondontoid




Flexion / Extension views


ADI < 3.5 mm in flexion – transverse ligament intact

ADI 3-5 mm – transverse ligament insufficient / type II injury

ADI > 5mm – failure alar ligaments / type III rotatory subluxation


Open mouth xray


Lateral mass C1 rotated & asymmetric

Wink Sign - C1 facet locked over C2


CT Scan


Confirms above diagnosis




Assess transverse ligament


Classification Fielding & Hawkins


Type I



- rotary subluxation with no anterior displacement (ADI < 3mm)

- transverse ligament intact



- often resolves spontaneously

- soft collar and analgesics

- may need correction with halter traction with application HTB


Type II



- rotation about one intact facet with increase ADI 3-5 mm

- transverse ligament insufficient & unilateral capsular tear

- alar ligs intact

- one lateral mass displaced

- other lateral mass acts as pivot



- holter traction till reduced + application HTB


Type III



- bilateral anterior subluxation with ADI > 5mm

- failure of the alar ligament

- Wink sign positive / C1 facet locks over C2



- traction till reduced

- C1/2 fusion


Type IV



- complete posterior displacement of the atlas

- really a posteriorly displaced type II dens fracture

- rare 




Specific Conditions



- often no history of trauma

- reasonable to observe for 1-2/52 as often corrects spontaneously


Down's Syndrome

- may have peg hypoplasia

- increased ADI secondary to transverse ligamentous laxity more common

- ADI > 5mm & asymptomatic = avoid contact sports

- ADI > 5mm & symptomatic = fusion



- transverse ligament incompetent

- often zygapophyseal fusion has occurred

- rarely peg base can be eroded


Operative Management



- neglected fixed deformity

- failure to correct with nonoperative management

- type III & IV

- instability

- neurological problems

- ADI > 10 mm




Posterior C1-C2 arthrodesis

- Gallie / Brooks

- Magerl's screws / transarticular

- Harms



Lower Cervical Spine Fractures


Anatomy Lower Cervical Spine



- 50% of cervical rotation

- 60% of cervical flexion / extension


Uncovertebral joint

- lateral projections of body 

- medial to vertebral artery


Facet joints

- sagittal orientation 30 – 45o


Spinous processes

- bifid C3-5

- prominent C7




Awake, alert, neurologically normal & no neck pain very unlikely to have C-spine injury


Lateral C-Spine C1-T1

- will detect 85% of fractures

- need swimmers view if cannot visualise T1


Swimmers View


AP + Lateral + Peg view

- 92% of fractures


C-spine fracture

- 10% risk another cervical spine fracture

- 30% risk fracture other level in spine (may be masked by neurological injury)




The ability of the spine under physiological loads to maintain the relationship between vertebrae

- without neurological compromise


Instability  / Panjabi & White Spine 1976



- Anterior elements destroyed    2

- Posterior elements destroyed   2

- Sagittal translation >3.5 mm   2

- Sagittal rotation >11°             2

- Positive Stretch Test > 1.7mm 2

- Medullary cord damage           2

- Root damage                          1

- Abnormal disc narrowing         1

- Dangerous loading anticipated  1


Total of 5 or more = Unstable


Stretch Test

- medical supervision / tongs + roll under head

- add 3lb / wait 5 min / add 2lb to max 40lb / xray

- repeat until weight a third body weight / neurological changes / abnormal separation occurs >1.7mm


Mechanism of Injury / Allen & Ferguson Classification


Determined by

1. Position of the neck at the time of injury - flexion / extension / neutral

2. Direction of the force - compression / distraction / lateral bending


6 Types

- flexion compression / wedge

- vertical compression / burst

- flexion distraction / facet dislocation

- extension compression

- extension distraction 

- lateral flexion


Subaxial Injury Classification Scoring System / SLIC


Dvorak et al Spine vol 32 no 23


1. Injury Morphology / Pattern injury

No abnormality                        0       

Compression                            1 

Burst                                       2          

Distraction / facet perch            3         

Rotation / translation                 4


2. Discoligamentous complex

Intact                                        0                     

Indeterminate (MRI change only) 1   

Disrupted                                   2


3. Neurological status

Intact                                        0                     

Root Injury                                1                                   

Complete cord injury                  2            

Incomplete cord injury               3    

Continuous cord compression    +1


5 or more - surgery                   3 or less - non operative                4 - equivocal



- burst + disrupted ligaments + intact nerves = 4 / equivocal




Burst Fractures




Burst fractures

- injury to anterior and middle columns +/- posterior column




Vertical compression




10% cervical fractures

Most commonly C5/6




Anterior & middle columns fail

- if severe, posterior ligament complex fails


Canal compromise / neurological injury

- retropulsed fragments

- typically one or two main retropulsed fragments




Neck pain


Complete / incomplete cord lesion





- widening between pedicles is hallmark on AP



- > 50% anterior column loss of height very suspicious

- loss of posterior vertebral height




Assess retropulsion / canal compromise




Assess integrity of posterior column


Non operative Management




< 50% height loss

Minimal kyphosis 

Nil neurology

Posterior column intact / nil instability


SLIC score 4+




Collar for 6 weeks


Operative Management









Incomplete cord lesion (urgent / good prognosis)

Complete cord lesion (may gain 1 or 2 levels recovery which is very significant)




Decompression of retropulsed fragments and stabilisation




Tongs + Traction

- incomplete neurology / will decompress canal


Anterior corpectomy / discectomy and fusion

- tricortical graft + anterior plate

- may sometimes need supplemental posterior fixation / cervical lateral mass screws




Complete v Incomplete lesion is best prognostic predictor




Facet Joint Dislocation



Facet joint dislocations secondary flexion distraction injury








1. Unifacet subluxation - interspinous process widening

2. Unifacet dislocation - 25% anterolisthesis

3. Bifacet dislocation - 50% anterolisthesis

4. Complete vertebral translation - 100% anterolisthesis


Unilateral Facet Joint Dislocation




C5/6 or C6/7




Flexion / Distraction / Rotation about contralateral intact facet




Unilateral facet subluxation

- widening of interlaminar or interspinous spaces


Unilateral facet dislocation

- 25% subluxation on lateral X-ray (<50%)


C56 Unilateral Facet Dislocation




Unilateral Facet Joint Dislocation CT


Management Principles


1.  Exclude Herniated Nucleated Pulposis



- large disc could worsen neurology with tong traction

- indication for anterior approach / discetomy / fusion



- disc always looks injured on MRI

- look for herniation


2.  Reduce and fuse


Will improve partial neurology

May gain 1 or 2 levels of recovery in complete

Unreduced unifacet dislocations painful

Facet joint dislocation is a ligamentous injury / poor healing potential


Treatment Algorithm


1.  No neurology

- MRI to exclude HNP

- awake tong traction reduction if conscious and non obtunded


2.  Stable Neurology

- complete or non progressive incomplete neurology

- MRI to exclude HNP

- awake tong traction reduction if conscious and non obtunded

- if successful reduction / collar / fusion when able

- unsuccessful /  reduce in OT and fuse


3. Progressive Neurology

- MRI to exclude HNP

- emergent open reduction and fusion


4.  HNP

- anterior approach / discectomy / fusion





- tong traction


- open reduction


MUA v tong traction


Lee 1994 JBJS

- 210 patients MUA vs traction

- traction more success 88%vs 73%

- traction safer as patient awake & can monitor neurology


Tong traction



- no HNP on MRI

- patient awake and able to communicate if neurology worsening



- obtunded patient



- Gardener Wells tongs 1" above  and behind pinna

- below equator / maximum diameter of skull to prevent slippage

- place towels under head to recreate flexion deformity

- best performed in OT, can use cross table II

- start 10 lb for head, then 5 lb for each cervical level every 10 min

- repeat X-ray after each weight increase

- monitor neurological status

- if neurology worsens, release all traction

- maximum 40% body weight

- once facet unlocked, removed towels to extend head


Successful reduction

- place in HTB

- fusion when able





- experienced surgeon

- failure closed reduction

- intention to proceed to open reduction + fusion if required


Open reduction



- failure closed reduction

- herniated disc

- reduction + fusion



- GA + II + Tongs

- head flexed 45° & rotated 45° away from side of facet dislocation

- traction in above position, then rotate to side of facet dislocation

- should hear click on reduction

- gently extend to stabilize

- similar method if bilateral, but no rotation (flexion / traction / extension)


MRI Post Closed Reduction


MRI Post C5 Unilateral Facet Dislocation






1.  ACDF

- remove herniated disc / anterior plate

ACDF post C56 Unilateral Facet Dislocation


2.  Posterior stabilisation

Unilateral Facet Dislocation Posterior Stabilisation


Bilateral Facet Joint Dislocation




>50% forward subluxation


Cervical Bilateral Facet Joint Dislocation Xray




Evidence of bilateral facet joint dislocation


Cervical Bilateral Facet Dislocation CTCervical Bilateral Facet Dislocation CT 2




Cervical Cord Injury Post Unilateral Facet Dislocation


Cord injury common


HNP 47%


Unstable - posterior & middle ligament failure




As for unilateral facet joint dislocation

- MRI first to exclude HNP

- closed reduction with traction if safe with elective anterior / post fusion

- open reduction if HNP / failure closed reduction


Other fractures

Extension distraction



- 20%

- common with ankylosing spondylitis / DISH




1. Anterior ligament failure

– disc space widening (or transverse fracture of vertebral body)


2. Posterior ligament failure with retrolisthesis of superior vertebral body


Articular process fracture


Superior process fracture


Cervical Spine Facet FractureCervical Superior Articular Facet Fracture0001Cervical Superior Articular Facet Fracture0002


Can allow superior vertebrae to dislocate anteriorly

- incidence of spinal injury



- undisplaced - hard collar

- displaced - anterior fusion


Superior Articular Process Fracture


Inferior process fracture

- don’t allow significant displacement

- Stable ->Orthosis


Clay Shoveller's


Spinous process avulsion C7 secondary to Ligamentum Nuchae

- sudden single overload 

- treat symptomatically

Teardrop Fracture




- diving into swimming pool type injury

- 3 column injury

- high incidence of spinal cord injury


Xray / CT


Large antero-inferior body fragment

- > 20 %

- stays attached to  ALL


Posterior superior fragment retropulsed into canal


Sagittal fracture on CT




Extension tear drop injury

- fragment much smaller

- stable injury




Reduction with tong traction

- improves canal / aids neurology 


Anterior corpectomy + plate

- may need posterior stabilisation as well





Wedge Fracture




Anterior compression / wedge fractures

- injury to anterior column




Flexion compression





Most common at C4/5/6




Usually stable

- rule out burst fracture

- suspicious if > 50% anterior height loss

- CT scan



ORIF Cervical Spine Fractures

C1/2 fusion




1. Sublaminar wiring

- Gallie / Brooks

2.  Transarticular / Magerl screws

3.  Harms technique

- C1 lateral mas screws

- C2 pedicle screws


Gallie Fusion


Gallie Fusion C12



- C1/2 instability

- peg fracture with anterior displacement

- rupture of transverse ligament



- relatively easy technique

- graft firmly fixed between two arches of C1 and C2

- aids in reduction of the anterior subluxation



- sublaminal wiring technique

- can't use with C1 arch fracture

- not suitable for posterior peg displacement




Prone position

- head in line traction with tongs

- midline incision occiput to C4

- soft tissue dissection from midline

- no further than 1.5cm from midline to avoid vertebral artery and venous plexus

- clear soft tissues of posterior arch C1 circumferentially to allow passage of wire

- 1.2mm wire is fashioned as loop with a hook

- loop is passed deep to C1 arch from inferior to superior

- then passed over arch superficially so loop ends up around C2 spinous process

- unless C1 and 2 are reduced significant risk of injury to cord at this point

- decorticate arch of C1 and C2

- corticocancellous rectangular graft 3x4cm removed from post iliac crest

- fashioned into a "H" to fit snugly around SP's

- fashion cancellous surface to fit snugly on post arches

- notch graft laterally to fit wire 

- tie wire over graft to secure in place

- pack with cancellous graft around op site



- HTB for 3/12


Brooks and Jenkins



- C1/2 fusion with sublaminar wiring

- biomechanically superior to Gallie technique

- more rotational control

- able to use with posterior displacement of peg



- clear C1 and C2 post arches circumferentially

- 2 lateral wire loops around each lamina 

- 1.5 x 3.5cm wedged corticocancellous grafts between lamina C1 and C2 both sides


Trans-articular / Magerl Screws



- C1/2 fusion

- acute and chronic atlanto-axial instability

- suitable for posterior arch fracture and posterior dislocation



- technically difficult


Preop CT

- determine sufficient bone for 3.5 mm screw / sagittal reconstructions

- exclude overriding vertebral artery / axial view



- patient prone

- ensure reduction with II

- flex neck

- approach midline occiput to C7

- expose posterior elements C1-C3 as above

- persistent anterior dislocation may be reduced by pushing on C2 SP or pulling on C1

- expose C2 lamina not out to vertebral artery

- under lateral image control pass 2.5mm drill C2 to C1

- entry at lower edge of caudal articular process C2 

- 3mm from inferior surface and 2mm lateral to medial edge

- drill passing through posteromedial surface of lateral mass atlas

– 25o cranially, under II

- drill to anterior cortex and place appropriate 3.5mm cortical screw

- following screw fixation posterior fusion performed



- Collar 6-10 weeks


Harms Technique


Harms Technique C12 fusion





- C1 lateral mass screws

- C2 lateral mass screws




Dens Screw



- maintain motion

- less blood loss



- technically difficult 

- 17% major complication rate 



- obesity

- short fat necks

- irreducible fracture

- reverse obliquity

- comminution

- delayed or nonunion / unable to debride or bone graft





- anterior approach at level C5/6

- this allows correct angle for wire insertion

- split platysma, open deep fascia

- SCM and carotid sheath laterally

- blunt dissect to prevertebral fascia medially

- split prevertebral fascia / between longus colli

- palpate inferior aspect of C2



- anterior displacement easy: extend neck

- posterior displacement more difficult: traction and bring head forward


Cannulated wire insertion

- need good AP and lateral x-rays

- wire inserted at C5/6 disc

- need sufficient anterior bone in C2 to prevent cut out

- 2 wires inserted for rotation control

- 1 single 3.5 mm cortical screw just penetrating tip for extra fixation


Lower C spine


Posterior Wiring C2-T1


Many techniques

- interspinous wiring simplest

- TBW of posterior elements

- Sublaminar wires here have high neurology rate




Midline posterior approach

- essential to identify correct level with II

- hole drilled in each side of spinous process of upper vertebrae of injured segment

- junction upper and middle 1/3's

- connect holes with towel clip

- 1.2mm wire is passed through hole and around inferior spinous process leaving interspinous soft tissue intact

- wires pulled tight then passed around inferior spinous process and tied superiorly

- lamina are decorticated and cancellous graft applied


Triple Spinous process wire



- through spinous process

- about bone graft each side




First wire through transverse hole base SP

- two rectangular graft blocks each side

- second wire through superior SP & each end into superior holes blocks 

- third wire through lower SP & bottom block holes 

- tie ends second and third wires together

- decorticate post laminae


Screw Fixation


Cervical Pedicle Screws


Lateral mass screws

- poly axial heads


Preoperative CT

- location and orientation of foramen and vertebral artery


Entry point

- middle of lateral mass / 1 mm medial to centre

- aim 10 - 15o lateral 

- parallel to superior articular facet




Upper Cervical Spine Fractures

Atlas Fractures

3 types


1. Posterior Arch



- axial compression with hyperextension



- 50% incidence other C1/2 fracture

- i.e. ondontoid fracture



- stable

- soft / philadelphia collar


2. Isolated lateral mass fracture



- asymmetrical axial compression / lateral bend

- fracture runs anterior, posterior or through articular surface


3. Jefferson (3 or 4 part)


Jefferson Fracture 4 Part Axial CT


Jefferson Fracture




Symmetrical axial compression


Management depends on integrity of transverse ligament


Ruptured transverse ligament


1. Peg view


C1 lateral mass displacement

- C1 overlapping on C2 bilaterally

- > 6.9 mm displacement of both lateral masses in total

-  rupture of transverse ligament likely


Jefferson CT Peg View


2. > 5mm ADI on dynamic flexion / extension xray


3. Avulsed fragment on CT




Transverse ligament

- avulsion

- midsubstance tear




1. Undisplaced


Manage with collar


2. Displaced


Reduce with ligamentotaxis / traction tongs



- 8 weeks

- check flexion / extension views


Jefferson HTB XrayJefferson Fracture Flexion Extension Views Stabe0001Jefferson Fracture Flexion Extension Views Stabe0002


B.  Fuse if midsubstance tear transverse ligament

- unlikely to heal

- as opposed to avulsion


3. Peg + Jefferson


Unstable & requires fusion


NB Elderly > 70

- increased mortality with HTB 20 – 36%

- often don’t tolerate hard collar

- soft collar / trial of life




Bony Occiput / Atlas / Axis




Occiput / atlas joint

- occipital condyles - lateral masses

- synovial joint

- often flatter in children which explains increased incidence of injury in children


Atlas / axis

- 3 synovial joints

- posterior atlas and dens

- lateral facet joints




1.  Extrinsic

- anterior tubercle attaches ALL and longus colli

- posterior tubercle attaches ligamentum nuchae


2.  Intrinsic (dorsal to ventral)


A. Tectorial Membrane

- continuation of PLL 

- posterior body of axis to anterior foramen magnum


B. Cruciate ligaments

- anterior to tectorial membrane / behind odontoid

- transverse ligament (posterior odontoid to anterior arch of atlas)

- vertical bands (from axis to foragmen magnum)


C. Odontoid ligaments

- from tip of odontoid

- paired alar ligs to occipital condyles (strong)

- small apical ligament to foramen magnum



- Tectorial

- Alar



- 40 – 45o flexion / extension (equal between C0/1 and C1/2)

- 40 – 45o rotation (mainly C1/2)





- 3 parts 

- 2 neural arches and one body



- 4 parts

- dens + 2 neural arches and one body


Goals of treatment


Protect the neural structures

Reduce and stabilise injured segment

Provide long term stability




Neck pain

Paraesthesia / Paralysis

Head / scalp lacerations

Palpate spine / Step-off Tenderness




3 trauma series


Anterior Soft Tissue

- "6 at 2 and 2 at 6"

- 6 mm at C2 normal

- 2 cm at C6 normal

- not applicable in children


SAC / Space available for Cord


- 1/3 Peg 1/3 Cord 1/3 Space

- if < 10mm cord compression



- children < 5mm

- Adults < 3mm


Stress Xray


High suspicion posterior ligamentous injury

- stretch test

- > 1.7mm increased disc space

- > 11° angle


Low suspicion ligamentous injury

- supervised flexion / extension view

- contra-indicated in decreased consciousness


CT Scan


To define bony fractures

- more sensitive upper cervical spine




To detect HNP prior to attempted reduction with incomplete lesion

Demonstrate oedema i.e. suspicious of C0-1 dislocation



Dens Fracture

Classification Anderson & D'alonzo


Type 1


Tip avulsion

- alar ligament avulsion

- fracture off one side of tip of dens



- associated with atlantoaxial instability

- manage in collar


Type 2


Fracture of base of dens


Dens Fracture Type 2 Undisplaced0001Dens Fracture Type 2 Undisplaced0002


Type 3


Fracture through body of axis

- union rates 95%


Type 3 Dens Fracture Coronal CTType 3 Dens Fracture CT Coronal



- elderly / Philidelphia collar

- young / HTB


Type 2 Dens Fracture




Undisplaced v displaced

- risk of nonunion 30% higher with displacement




Risk factors

- > 65 years

- > 5 mm displaced

- >10° angulation

- posterior displacement

- comminution

- delay in treatment

- smoker


Type 2 Dens Fracture Displaced


Management Acute Fracture


1. Undisplaced 


HTB 3/12


Platzer et al Neurosurgery 2007

- 90 patients average age 69 years treated in HTB

- union in 84%

- non union associated with elderly / displacement / delay in treatment


2. Displaced


A.  Traction

- reduces dens


B.  Ondontoid screw


C.  C1/2 Fusion


Gallie / Brooks fusion


Magerl fusion

- trans-articular screws


Harms fusion

- poly axial screw and rod fixation

- C1 lateral mass screws

- C2 pedicle screws


Dens Nonunion C12 fusion


3.  Elderly



- high risk of failure of fixation due to poor bone

- risk of HTB

- risk of non union


Koech et al Spine 2008

- 42 patients > 70 treated in HTB or collar

- 50% osseous fusion and 90% fracture stability in collar

- 37% osseous fusion and 100% fracture stability in HTB


Ondontoid Screw Fixation



- preserves motion compared to C1/2 fusion

- 50% rotation from C1/2



- irreducible fracture

- comminution

- osteopenia

- ondontoid + transverse ligament injury / will remain unstable

- oblique fracture configuration / need to place screw perpendicular to fracture




Platzer et al Spine 2007

- ondontoid screw fixation in 102 patients

- nonunion rate 4% in patients < 65

- nonunion rate 10% in patients > 65


Management Nonunion



- pain

- instability / myelopathy / risk sudden death


Type 2 Dens NonunionType 2 Dens Nonunion Coronal CT


1.  Patients < 65 years


C1/2 fusion


Dens Nonunion Instability0001Dens Nonunion Instability0002Dens Nonunion C12 fusion


2.  Elderly


Most patiens have a fibrous nonunion

- stable on flexion / extension views


Hart et al Spine 2000

- series of elderly patients with unstable nonunions

- treated non operatively

- no development of myelopathy or sudden death







Bilateral Pars Fracture C2

- traumatic axis spondylolisthesis




Neurological injury uncommon

- fragments separate and decompress


Different to judicial hanging where spinal cord is severed




Hangmans Fracture XrayHangmans Xray


Levine & Irving Classification


Type I


Vertical pars fracture with no displacement / <3mm


Hangmans CT Undisplaced0001Hangmans CT Undisplaced0002Hangmans CT Undisplaced0003


Type II


Vertical pars fracture translated anteriorly > 3mm

- hyperextension injury / windshield


Hangmans Fracture Type 2Hangman's Fracture Type 2 Axial


Type IIA


Oblique fracture pars with angulation and displacement

- flexion & distraction injury

- entire C2/3 Disc avulsed & fails in flexion

- only ALL left intact


Type III


Bilateral facet dislocation C2/3 and pars fracture






Type I

- manage in semi-rigid collar 8/52

- flexion / extension views to ensure stability


Type II

- traction + extension

- application HTB 8/52

- flexion / extension views


Type IIA

- traction contra-indicated

- extension and HTB

- some centres advocated fusion if high level angulation



- reduction / HTB or fusion




Vaccaro et al Spine 2002

- HTB treatment of 27 type II and 4 type IIA

- all type IIA went on union

- 21 type II went on to union

- high initial degree angulation associated with failure treatment


Operative Management




C2/3 instrumented fusion

C2 transpedicle stabilisation

Anterior cage and plate construct




Ma et al Spine 2011

- C2/3 pedicle screw fusion for unstable hangman's fracture

- 35 patients, solid and stable union achieved in all patients


Hangmans Fracture Non Union Posterior Fusion




Occipital Condyle Fractures




- unilateral

- bilateral





Lateral Compression





Skull base pain

Cock Robin

Cranial nerve injury


Classification Anderson & Montesano


Type I


Impaction of a condyle 



- Stable / Brace 8/52


Type II


Condyle fracture associated with basilar / skull fracture



- Stable / Brace 8/52

- Displaced / HTB 8/52


Type III


Condyle avulsions fracture secondary to rotation

- rupture strong alar ligaments



- unstable 

- HTB / fusion (C0 - C2)




Maserati et al J Neurosurg Spine 2009

- follow up of 104 occipital condyle fractures

- occipital-cervical fusion in 2 who had evidence of craniocervical malalignment

- remainder all treated with collar

- no late instability / malalignment / nerve compression



Occipito Atlantal Dislocation



Deadly & rare

- usually post mortem


More common in children due to

- immature joints 

- larger head to body ratio

- relative ligamentous laxity




High velocity trauma




- hyperextension, distraction & rotation




Pure ligament injury usually



- anterior occipital displacement (most common / head anterior)

- vertical

- posterior (rare)




Basion anterior to tip ondontoid

- most common is anterior occipital displacement

- should be located at tip of ondontoid


Basion-Dens Interval / BDI

- most sensitive

- from basion to dens

- assesses vertical displacement

- should be less than 12 mm


Basion-Axial Interval / BAI

- distance to posterior axial line / line posterior border ondontoid

- increased > 12 mm with anterior displacement


Power's Ratio BC/AO > 1 

- head goes anterior

- basion to posterior arch / opisthion to anterior arch




Reduction / HTB


Reduce in OT

- II

- putting sandbags under thorax

- allows head to reduce posteriorly

- assess with II

- apply HTB

- add compression


HTB 3 months

- assess stabilty with flexion / extension views




Is a ligamentous injury and inherently unstable

- may require atlanto-occipital fusion



Pseudo subluxation



Subluxation in children up to 8

- C 2/3 in 40% children

- C 3/4 14%

- up to 4 mm




Horizontal facet joints

- flat orientation of paediatric facets and laxity of ligaments


Become more vertical with age




1. Swischuk's Line

- drawn along spinolaminar line C1 & C3

- C2 should be within 1.5 - 2mm of this line


2. Pseudosubluxation will reduce with extension


Rheumatoid Neck



Neck involved in 86%

- second most common site after hands and feet

- closely associated with MCPJ subluxation




Males / Steroid use / Seropositivity Nodules / Severe long standing disease




Atlanto-axial subluxation

Subaxial subluxation

Superior migration ondontoid


1.  Atlanto - Axial subluxation (AAI / AAS)




A. Attrition of transverse ligament

B. Erosion of peg




Most common of RA cervical deformities

- occurs in up to 50% of patients


May cause myelopathy




1.  Lateral view AADI

- anterior atlantodental interval

- AADI > 3 mm


Cervical Flexion Instability Increased AADI


2.  AADI


A.  Instability : > 3 mm difference in flexion / extension views


RA neck Flexion View AADA /> 3 mmRA Neck Extension View AADI 1 mm


B.  Severe instability: > 7 mm difference


AADI greater than 5 mm


3.  PADI

- posterior atlantodental interval / SAC (space available for cord)

- > 14 mm 94% predictive no neural deficit

- < 14 mm 97% predictive neural compression


2.  Superior Migration of Odontoid / Pseudobasilar Invagination / Atlantoaxial vertical subluxation


Superior Migration Ondontoid CT CoronalSuperior Migration Ondontoid CT Sagittal



- vertical translocation of Dens into foramen magnum

- compresses medulla



- due to erosion of lateral masses of atlas and occipital condyles

- can lead to compression of brain stem

- risk of myelopathy / sudden death



- seen in 40% of RA patients



- C1/C2 compression gives occipitocervical pain

- ventral pressure can compress respiratory centre and cause sudden death




Superior Migration Ondontoid Lateral XraySuperior Migration Ondontoid Lateral Xray Close Up


Ranawat measurement < 13 mm

- line between anterior and posterior arch atlas

- centre of pedicle of C2


SMO Ranawat Measurement



- line of foramen magnum

- tip of dens should not protrude above this line


SMO McCrae LineSMO McCrae Line CT


McGregor line > 4.5 mm

- line hard palate to posterior occiput

- if tip of dens > 4.5 mm above this line = vertical settling

- severe > 8 men or > 10 women


SMO McGregor Line


Redlund-Johnell measurement

- assesses entire occiput to C2 complex

- base of dens to McGregor line

- men <34mm & women <29mm = abnormal

- if abnormal -> highly correlated with severe disease & neurology


SMO Redlund-Johnell


3.  Subaxial Subluxation (SAS)



- anterior subluxation of one vertebral body on another


Rheumatoid Arthritis Subaxial InstabilityRheumatoid Arthritis Subaxial Instability Extension View




A.  Instability on Flexion / Extension views

- > 3mm

- > 11o


B.  Space available for cord / SAC

- subaxial canal diameter on lateral

- < 13 mm high incidence neurology


RA Subaxial Subluxaton SAC



- facet erosions / ligament incompetence



- 10-20% of RA patients



- may see at multiple levels with stepladder type deformity & kyphosis

- occurs beneath previous cervical fusions

- anterior subluxation / destructive changes of facet joints / destruction of disc

- can result in 2° canal stenosis


Cervical Spine MRI Subaxial Subluxation


Neurological Classification Ranawat


I        No neurological deficit

II      Subjectively weak / hyperreflexia & dysesthesia

IIIA   Objectively weak / ambulatory

IIIB   Objectively weak / non ambulatory


Clinical Features



- neck radiating to shoulders / occipital headaches

- occipital neuralgia / greater occipital nerve compression

- ear pain / greater auricular nerve compression

- facial pain / trigeminal





- most common & earliest symptom 

- pain & temp / spinothalamic tract compression




Frequency or retention / constipation




Incidence of cervical involvement increases with duration of disease

- after 10 years 60% will have AAS


Postmortem study of 104 patients with RA

- 10% died 2° medullary compression

- impossible to predict which patients will progress




Supplanted CT

- site of compression

- accurate SAC / account for soft tissue



1.  Foramen magnum SAC < 14 mm = neurological compression

2.  C1-2 SAC < 13mm

3.  Subaxial spine SAC < 12mm


Rheumatoid Arthritis Limited Space Available for Cord


Cervicomedullary angle (MRI)

- long axis brainstem to long axis cord

- normal angle is 135-175°

- <135° = vertical settling & is correlated with myelopathy




Goals of Treatment


1. Prevent development of neurologic deficit

2. Prevent sudden death due unrecognised neurological compromise
- 10% of deaths in RA occur suddenly due neurological complications




Cervical spine flexion / extension xray

- mandatory in all patients pre-operatively




2 Groups 

1.  Intractable pain or neurologic compromise -> fuse

2.  No pain & no neurology – controversial





1. PADI >14mm -> observe

2. PADI < 14mm MRI

3. Cervicomedullary angle <135° / SAC < 13 - fusion




1.  C1/2 fusion

- if instability reducible / no decompression needed


2.  Occipito-cervical fusion

- instability irreducible

- must decompress / remove lamina C1


C1/2 fusion

- fusion in situ if reducible and no neurology

- laminectomy C1 + fusion if fixed deformity with neurology


A. Gallie / Brooks fusion

- contra-indicated if any displacement or neurology

- unable to perform decompression / laminectomy


C1 C2 Posterior Spinous Process WiringC1 C2 Posterior Spinous Process Wiring


B.  Transarticular / Mageryl screws

- 95% fusion rates

- +/- laminectomy of C1 if displaced or with neurology

- pannus resorbed in 19 of 22 patients with fusion


Occipitocervical fusion


C0 C3 fusion AAI Rheumatoid




90% of pts improve 1 Ranawat grade if have neurology pre-op

- PADI < 10mm predicts patinet unlikely to improve



- due to bone erosion may be insuffiency bone quality for C1/2 fusion

- may need C0 - C3




More serious & should be treated more aggressively

- xray screening

- MRI in flexion to evaluate cord compression



1. No symptoms & no cord compression on MRI

-  observe

2. Cord compression

- occipitocervical fusion

- +/- C1 laminectomy +/- anterior dens excision if fixed deformity & neurology



- 75% improve


Occipital Cervical Fusion LateralOccipito Cervical Fusion AP





- SAS >14mm & no symptoms -> observe

- SAS < 14, MRI for true SAC

- SAC < 13 or instability - surgery



1.  Anterior decompression and fusion


Subaxial Stabilisation


2.  Posterior laminectomy and fusion

- may need long fusion to prevent SAS above and below


Cervical Spine Posterior Fusion for SASCervical Spine Posterior Fusion for SAS



Smith Robinson Approach

Via the carotid triangle


SCM / posterior belly digastric / superior belly omohyoid




Exposes inferior body C2 - T1




1.  Supine in tongs

2.  Sit on head board with head taped and slightly extended


Table 30° up

Turn head away from side of incision


Which Side


Most surgeons approach from the left

- the course of the Recurrent Laryngeal Nerve / RLN is more predictable on left


Right sided approach

- used sometimes for C7/T1 to avoid thoracic duct


Recurrent Laryngeal Nerve


Right side

- given off the vagus at the level of the subclavian artery

- slopes from lateral to medial across lower part of wound to reach the oesophagus / trachea interval

- crosses the surgical approach in 50% of cases

- usually at C6/7

- may be at C5/6


Left side

- arises at the level of the aortic arch

- doesn't slope across the wound


3 Fascial layers


1.  Deep Cervical Fascia

- under the subcutaneous fat

- invests neck like collar

- clavicle / sternum / spine scapula - mandible / base of skull

- invests SCM & trapezius

- Have to incise so can retract SCM


2.  Pretracheal

- covers trachea

- deep to the strap muscles

- extends from hyoid into chest

- splits to enclose thyroid

- fuses laterally with carotid sheath

- have to divide to retract carotid sheath laterally


3.  Prevertebral

- base of skull to T3

- invests longus colli and sympathetics

- divide to separate longus colli muscles to approach verebrae




Medial border SCM

Carotid Artery lateral to SCM



- Hyoid = C3

- Thyroid Cartilage = C4/5

- Cricoid = C6

- Carotid Tubercle = C6




Inject LA with adrenaline

Transverse incision at level required from midline to posterior border SCM


Superficial Dissection


Divide Platysma vertically at anterior border SCM


Superficial plane

- through investing layer of deep cervical fascia

- between strap muscles (Sternohyoid & Sternothyroid) & anterior border SCM


Deep Dissection


Palpate the Carotid Artery 

- divide the pretracheal fascia medial to the Carotid Sheath

- open plane between carotid sheath & medial structures

- medially oesphagus, trachea & thyroid

- note that anterior carotid sheath fuses to pretracheal fascia

- retract the carotid sheath & SCM laterally





- superior thyroid artery / superior laryngeal nerve behind

- common venous trunk of superior thyroid / lingual / facial vein



- ligate middle thyroid vein

- inferior thyroid artery


Blunt dissection medially

- behind the oesophagus

- expose the vertebrae covered by Longus Colli, prevertebral fascia & ALL

- sympathetic chain lies on the Longus Colli, just lateral to the vertebrae

- incise the Longus Colli in the midline

- subperiosteally expose the Vertebrae

- place retractors under Longus Colli


Check level with II




1. Recurrent Laryngeal Nerve

- lies between trachea & oesphagus

- on right crosses field from subclavian artery at C6/7 with inferior thryoid artery


2. Superior Thyroid Artery/ Superior Laryngeal Nerve

- C3/4

- superior thyroid artery pass from the Carotid Sheath medially to the midline structures

- superior laryngeal nerve runs with artery

- can divide artery but must preserve nerve

- otherwise get dysphagia


3.  Inferior Thyroid Artery

- lower approach may pass from lateral to medial


4. Sympathetic Chain on transverse processes

5. Vertebral Artery

6. Carotid Sheath with Vagus inside

7. Oesophagus

8. Trachea

9. Thoracic duct on left at C7 / T1 level




Cord Injury

Cauda Equina



Compression of some or all of the nerve roots in the cauda equina

- bladder dysfunction

- bowel dysfunction

- saddle anaesthesia

- variable motor and sensory loss





- most common


Epidural haematoma

- post surgical

- spinals and anticoagulation


Epidural abscess



- metastatic prostate / lung / breats




Chronic stenosis / spondylithesis


Post surgical

- seen post stenosis decompression

- cause unknown




Spinal cord ends at L1 / conus medullaris

- L3 in children

- spinal cord appears to migrate proximally with growth

- relative greater growth of the spinal column


Conus medullaris

- attached to coccyx

- filum terminale


Dural sac containing L2 - S5




Lower motor neurone symptoms in leg

- weakness

- sensory loss

- decreased / absent reflexes


Bladder dysfunction


S2-4 disruption

- parasympathetic nerves

- promote bladder emptying

- contract detrusor & relax internal sphincter


Unable to feel bladder filling


Unable to void

- retention

- eventual overflow




Nerve roots

- very susceptible to compression

- don't have 3 layers like peripheral nerve roots

- endoneurium only

- then CSF and dura


May develop ischaemia

- radicular arteries

- form of compartment syndrome




Injury to the sacral nerve roots can be permanent

- need early decompression < 24 hours

- otherwise permanent bladder and bowel dysfunction




Two groups

- acute presentation - severe pain

- insidious presentation - stenosis / spondylolithesis


Bladder dysfunction

- difficulty initiating / stopping stream

- progresses to retention

- progresses to overflow incontinence



- unable to feel or control / incontinence


Other symptoms

- severe back pain

- severe sciatica

- lower leg weakness and parasthesia 

- saddle anaesthesia / can't feel toilet paper




Perianal sensation

- may have preserved light touch

- may need pin prick

- S 3,4,5


Rectal tone

- decreased



- full

- increased volume on bladder scan

- cannot feel tug on catheter




Usually a disc will take up > 1/3 of canal diameter




Urgent Decompression



- evidence of improved outcomes for decompression within 48 hours versus > 48 hours

- no evidence for < 24 hours

- reasonable to do so as soon as able




Buchner and Schiltenwolf Orthopedics 2002

- 17 / 22 regained full urinary function


Outcome likely related to

- duration of symptoms / timing of decompression

- severity of initial symptoms / signs / bladder dysfunction




Central Cord Syndrome



Most common pattern cord injury


Hyper-extension injury in middle aged man with osteoarthritic spine


Usually C3/4 and C4/5




Most common type / in older patient with pre-existing spondylosis / OPLL

- hyperextension injury

- compression of the cord

- anteriorly by osteophytes

- posteriorly by infolded ligamentum flavum




Injury of central gray matter

- weaker in arms than legs

- LMN in arms 

- UMN in legs

- sacral sparing common




Flaccid paralysis in upper limbs


Spastic paralysis in lower limbs

- more likely to be preserved




Typically normal / no fractures




Demonstrates stenosis



- high signal intensity on T2

- localise level of injury






Usually regain walking and bladder function

Hands have the worst prognosis




Aarabi et al J Neurosurg Spine 2011

- 42 patients, 82% men, average age 58

- admission ASIA scores and midsagittal diameter of cord most related to prognosis




Decompression v non operative management


Surgical Timing


Chen et al J Neurosurg Spine 2009

- review of surgical decompression in 49 patients

- no difference between decompression < 4 days or > 4 days

- younger patients did significantly better

- 1/3 patients dissatisfied with outcome




Observe initially

- maximise medical treatment / HTN / oxygenation


If improving

- non operative


No improvement

- operative management




Spinal Cord Injury



Complete Lesion 

- bulbocavernosus reflex present 

- no cord function below lesion

- very poor prognosis for recovery


Incomplete Lesion

- bulbocavernosus reflex present

- some cord function below lesion

- good prognosis for recovery




Vertebral Canal narrowest at T8/9

- Also area of vascular watershed


Dorsal Columns 

- light touch, vibration & proprioception

- CTLS (cervical fibres central, sacral fibres lateral)

- decussate in medulla

- Cuneate Nucleus = Cervical & Thoracic

- Gracile Nucleus = Sacral & Lumbar


Lateral Corticospinal Tract

- motor tract

- CTLS (cervical central, sacral fibres peripheral)

- decussate in medulla


Anterolateral Spinothalamic Tract

- pain & temperature

- decussate immediately after cord entry


Incomplete Patterns


1.  Central Cord Syndrome

- most common

- hyperextension injury

- UL > LL due to arrangement of fibres in dorsal column and anterior corticospinal


- distal > proximal

- sacral sparing


2.  Anterior Cord Syndrome

- complete paralysis with dorsal column sparing

- anterior spinothalamic & lateral corticospinal tracts lost

- secondary to ischaemic event

- maintain BP and oxygenate patient

- very poor prognosis


3.  Brown Sequard

- cord hemisection

- usually secondary to laceration

- ipsilateral dorsal columns & motor

- contralateral loss pain & temperature


4.  Posterior Cord Syndrome

- rare

- dorsal column loss only

- due to tumour / iatrogenic (sublaminar wires etc)


5.  Cauda Equina Syndrome

- injury below L1

- only nerve roots at this level

- LMN injury to lumbar and sacral nerve roots

- large L5/S1 disc commonest cause in narrow canal < 100 mm2

- faecal incontinence + urinary incontinence

- nil anal tone or sensation


6.  Conus medullaris injury

- cord ends at L1

- injury at this level results in LMN LL weakness and UMN sacral lesions

- may have a spastic bladder which enables urination without catheterisation

- T12 / L1 burst fracture most common cause


Sacral Sparing


Triad of

- anal voluntary contraction

- perianal sensation

- FHL function



- incomplete injury

- potential for recovery

- due to pial arteries on cord surface supplying small amount of tissue 


Blood Supply


Anterior Spinal Artery

- arises from vertebral arteries at foramen magnum

- supplies entire cord except for dorsal columns

- narrows and may become absent in thoracic region


Posterior Spinal Arteries

- paired

- smaller


Segmental Arteries

- average of 8 paired arteries

- may be single segmental supply between T4 and T8

- Artery of Adamkiewicz from left between T9-11 in 80% cases


Micturition control


Stretch receptors in bladder wall


As distension occurs

- afferent signal travels up pelvic splanchnic nerves (S2/3/4)

- sacral cell bodies send signal back via efferent in same nerves

- produce contraction of detrusor


Parasympathetic control

- this is a lower motor neuron reflex arc

- override by higher cortical centres with development


Cauda Equina

- LMN to S2-4

- flaccid bladder / overflow incontinence


Conus medullaris injury

- results in UNM changes at that level

- detrusor mm spastically contracts

- higher cortical control disrupted

- result is spastic bladder - incontinence


Surgical division sacral nerve roots 

- produces LMN effect

- if leave at least 1 S3 - 100% continent

- if leave at least 1 S2 - 50% continent

- if above S2 incontinent because pelvic splanchnics removed




Spinal shock


Refers to flaccid paralysis due to physiologic disruption of all spinal cord function

- all motor, sensory and reflexes absent below level of injury


An accurate assessment can only be made when spinal shock has resolved

- 48 hrs in 99%


Absence of SS confirmed by the return of cord mediated reflexes below the anatomic level of the injury

- bulbocavernosus reflex is the lowest and thus the first to return


Frankel Grading


A Complete

- no motor or sensory function in the sacral region


B Incomplete

- sensory intact

- no motor function below the neurological level and includes sacral segments S4-S5


C Incomplete

- motor function is preserved below the neurological level 

- at least half the muscles have power < grade 3


D Incomplete

- motor function is preserved below the neurological level 

- at least half the muscles have power > grade 3


E Normal motor and sensory function


MRC Power Grading (Medical Research Council)


0 - no visible movement

1 - palpable or visible contraction

2 - active movement with gravity eliminated

3 - active movement against gravity

4 - active movement against some resistance

5 - active movement against full resistance


ASIA Dermatomes (American Spinal Injury Association)


C5 Elbow Flexor / Lateral Arm Sensation

C6 Wrist Extension / Dorsal thumb

C7 Elbow Extension / Dorsum MF

C8 Finger Flexion (MF DP) / Dorsum LF

T1 Interossei / Medial Arm sensation

T2 Armpit sensation


L1 Inguinal ligament sensation

L2 Hip Flexors / Middle Medial Thigh

L3 Knee extension / Knee sensation

L4 Ankle DF / Medial malleolus

L5 Long toe extension / First web space

S1 Ankle PF / Heel 

S2 Back of knee sensation


Each muscle rated 0 - 5 for power

- score out of 50 for R and L

- total score out of 100


Sensory Levels


T4 - nipple

T7 - xiphisternum

T10 - umbilicus

T12 - groin




Cremasteric Reflex T12-L1

- stroke thigh & scrotal contraction


Anal Wink S2-4

- stroke cleft for anal contract



- upgoing = UMN



- stroke tibial crest & toes go up


Bulbocavernosus Reflex



- squeeze glans / clitoris or pull on catheter

- anal contracture


If present with complete cord lesion

- indicates S2-S4 region firing

- spinal shock resolved

- can prognosticate about level of neurological injury



- returns in 99% in 24 hours

- indicates end of spinal shock


TL fracture may permanently damage BCR


Medical Treatment




Bracken N Engl J Med 1990

- randomised multi-centre trial

- methylprednisone v naloxone or placebo

- suggested benefits of corticosteroids within 8/24 but not after

- based on oedema reduction

- GIT haemorrhage may result or be exacerbated


Bracken Cochrance Database Syst Review 2012

- review of 8 randomised control trials

- shown that methylprednisolone, if given within 8 hours, improves motor recovery


Canadian Spine Society

- some of the efficacy seen in trials is only in post-hoc analysis

- evidence is actually very weak, level II and III

- side effects include sepsis, pneumonia and GI complications

- is not standard of care, but only a treatment option





- 30 mg/kg bolus

- 5.4 mg/kg/hr for 23/24



- > 8 hours after presentation

- penetrating spinal injury

- infection

- diabetes

- < 13 years old

- pregnancy


Surgical Decompression




Progressive neurology 

- urgent decompression


Non Progressive Neurology

- decompress as soon as stable

- timing uncertain


Results from decompression



- improvement in both incomplete & complete cord injury

- 1 or 2 extra levels in cervical spine improves function significantly



- improvement in incomplete cord injury

- no improvement with complete cord injury

- extra level in thoracic spine doesn't improve fuxnion

- prevents late degeneration / deformity / pain





Spinal Cord Injury Management



RTA 50%

Falls 20%

Sport 20%


Unconscious after MVA or fall

- 10% chance cervical spine injury

- Cervical > Thoracic > Lumbar

- cervical spine is mobile & not protected

- quadriplegia more common than paraplegics

- assume cervical spine injury till cleared 


Permanent paralysis 10%

- incomplete > complete deficit


Natural History


Death in first year secondary to CRF and Infection

- 20% of Quadriplegics

- 10% of Paraplegics


Useful recovery

- complete lesions < 10% chance

- incomplete ~ 75% chance



- inpatient stay ~ 9/12

- OT doesn't decrease this

- life expectancy decreased by 10 years



- inpatient stay ~ 4/12

- OT does decrease this 

- life expectancy normal


Mechanism of injury


Primary response / Mechanical

- Contusion (No.1) / Compression / Stretch / Laceration


Secondary response

- Ischaemia / Vascular Injury / Vasoactive Substance / Inflammation




Neurological level

- lowest level at which motor and sensory function is normal


Complete lesion / no sacral sparing

- absence of sensory and motor function in the lowest sacral segment

- no sacral sparing


Incomplete lesion / sacral sparing

- presence of sacral and motor function in the lowest sacral segment

- indicates preserved function below the defined neurological level


Complete Cord lesion




90% recovery of one & 20% recovery two root levels

- if motor grade at level is 2/5 at one week, will gain functional recovery

- if pinprick spared in dermatome, will likely recovery functional > 3/5 strength

- this may be significant i.e. diaphragm, elbow extension C7

- may be increased with surgical decompression

- majority recovery in first 6 - 9 months





- portable ventilation



- need CPAP at night

- mouth controlled wheelchairs



- active elbow flexion

- dependant for transfer and bed position



- shoulder stability (RC)

- wrist extension

- can give them tenodesis grip



- triceps

- can roll over and transfer

- eat independently



- independent



- > grade 3 hip flexion on one side

- > grade 3 knee extension on other side


Neurogenic Shock




2° unopposed parasympathetic vagal tone

- sympathetic tone lost

- loss of vasomotor tone with marked vasodilatation

- result is hypotension + bradycardia



- hypotensive + bradycardia + warm periphery 




Response to fluids moderate (CVP)

- trendelenburg position

- Atropine (0.6 mg push)

- may require inotropic support / Dopamine


Pharyngeal suction & intubation stimulate vagus

- may produce bradycardia & cardiac arrest




Midcervical lesion

- C3/4/5

- phrenic nerve defunctioned

- paralysis of diaphragm


Low cervical / high thoracic lesion

- paralysis of intercostal muscles


Accessory muscles & abdominal respiration used in both circumstances


At The Scene


Unconscious  Patient


Assume spinal fracture secondary to force that caused unconsciousness

- place neck in neutral

- stabilise with gentle longitudinal traction

- hard collar + sandbags


Conscious Patient


Spinal injury assumed if

- complaining of sensory abnormality / weakness / paralysis

- back or neck pain



- as above




Spinal care / log roll

- monitor airway & O2 saturations

- beware overhydration

- keep patient warm


Initial Hospital Management



- Mechanism of injury

- any neurological deterioration / improvement since injury



- paraesthesia masks abdominal & leg injuries


Vertebral assessment

- log-roll to allow visualisation

- palpate for tenderness / step

- perform PR (saddle anaesthesia / anal tone)


Features cord injury

- flaccid areflexia

- lax anal tone

- diaphragmatic breathing

- pain > clavicle only

- hypotensive & bradycardic

- priapism


Neurological Assessment / SMART



- spinothalamic tracts (Pin prick)

- posterior column (Fine touch, Proprioception)

Motor - Corticospinal Tracts

Autonomic ~ Priapism

Reflexes - DTR / Abdominal / Anal / BCR





Lateral film  

- must see C7/T1

- swimmer's view may be necessary

- pick up 85-90%


Cervical trauma series

- AP + Peg / Ondontoid View + Lateral

- up to 95%




Early Management


1.  Stabilise Spine



- unstable - Gardner Wells Tongs 4 kg initially

- stable - bed rest, hard collar



- patient lies supine

- no flexion


2.  Respiratory


Worse if chest trauma 

- monitor ABG's

- physiotherapy

- incentive spirometry / triflow

- if respiratory function deteriorates may require intubation


3.  CVS


Avoid hypotension

- maintain SBP > 90 mmHg

- CVP monitor

- IDC monitor urine output


4.  Urinary


Bladder usually acontractile

- initial retention

- stretching of Detrusor muscle may delay return of function

- initial IDC followed by intermittent catheterisation

- high incidence UTI & calculi 


5. GIT


Paralytic Ileus 


Usually occurs

- NBM 48/24

- NGT 


Abdominal distension splints diaphragm

- vomit & aspiration may occur

- monitor electrolytes & supplement K+



- problem after a few days

- microlax & laxatives


Gastric ulceration

- can be masked

- ranitidine


6.  Skin & Position


Turn every 2 hours & inspect skin

- 4 Person lifts

- Edgerton Tilt bed

- Stryker frame


7.  Joints & Limbs


Daily Passive ROM

- foot drop splints

- hand splints 



- Baclofen, Dantrolene


HO common

- especially with head injury

- presents as hot red swelling


8.  Medication



- high risk of DVT & PE 

- anticoagulation indicated if no contra-indications i.e. surgical stabilisation

- subcutaneous Heparin & TEDS



- controversial

- main reason why spinal injuries progress is lipid peroxidation

- bolus dose of Methylprednisolone could inhibit peroxidation



- prophylaxis not indicated

- treat infection only


9.  Autonomic Dysreflexia


Occurs > T5

- usually with cervical spine injuries

- splanchnic nerves / sympathetic exit at T8 and are interrupted


Distended viscus / bladder or bowel

- efferent sympathetic outflow from cord

- vasoconstriction causes HTN

- HTN stimulates carotid body

- centrally mediated vagal response

- bradycardia & vasodilation



- 80% within the first year



- severe HTN / systolic BP > 200

- headache / facial flushing / bradycardia


May result in

- cerebral hemorrhage

- seizures

- pulmonary oedema



- decompress organ - IDC / fecal disimpaction

- sublingual nifedipine

- IV Hydralazine



Tendon Transfer



Nearly 2/3 cervical level injury survivors have C6 root level function

- biceps and wrist extension function




1. Transfer / Triceps


2. Object manipulation

- grip 

- key grip / self catheterisation 




Consider > 18/12



- serial evaluation

- psychological adjustment


Delayed if evidence of neurological recovery




1. Start on side with most function / or dominant limb


2. If 2 point discrimination > 10mm

- operate on only one limb, as patient uses visual cues


3. Keep treatment simple


4. Restore elbow extension first if C6

- Moberg Deltoid - Triceps

- aids transfer


5. Perform only one operation at time


6. Don't transfer spastic muscles

-  ? dynamic EMG


7. Remember principles of tendon transfer




Neurologic level 

- lowest level with normal motor & sensory function bilaterally

- level of bony fracture doesn't exactly correspond with level of cord injury


Frankel Grade


A Complete neurological deficit

B Sensory only below injury level

C Motor < 3 below level

D Motor < 5 below level

E Normal


Transfer summary



- Moberg deltoid to triceps transfer



- Moberg deltoid to triceps transfer

- FPL tenodesis



- BR to EDC / EPL for finger extension

- ECRL to FDP for finger flexion



- Zancolli FDS tendodesis to prevent intrinsic plus


C5 Quadriplegia



- deltoid / supraspinatus / biceps



- elbow extension / Moberg deltoid to triceps

- forearm pronation / Zancolli Biceps tendon re-routing


A.  Deltoid to Triceps transfer  - Moberg



- Triceps < Grade 3



- helps stabilisation in wheelchair

- helps transfers

- improves control of self-help devices



- posterior 1/3 of deltoid isolated

- dissect up till see AXN entering posterior deltoid & stop

- preserve as much of its tendinous insertion

- tendon grafts obtained / EDL or T anterior

- tendon grafts interlaced between distal deltoid belly & triceps aponeurosis


Post op

- elbow immobilised in extension for 6/52 with GHJ adducted

- then slowly flex 10° per week

- avoid transfer for 3/12 


B.  Zancolli Biceps Tendon Rerouting 


C5 level patients lack ability to place hand in working position




1.  Obtain passive pronation first

- removal of interosseous membrane + DRUJ


2. Biceps tendon exposed

- Z Plasty

- distal 1/2 rerouted around neck of radius

- sutured to at tension to obtain full pronation & yet allow extension


C6 Quadriplegia



- wrist extension - BR, ECRL, ECRB 

- pronation



- elbow extension / Moberg biceps to triceps transfer

- stronger wrist extension / BR to ECRB

- Key pinch / BR to FPL / Moberg FPL tenodesis 


A.  Moberg FPL Tenodesis



- strong wrist extensors with no finger flexors i.e. C6 lesion

- creates key pinch



- tenodesis of FPL to provide flexion with wrist extension




Release of A1 pulley of thumb

- permits bowstringing

- increases mechanical advantage


FPL tenodesis to volar radius

- exposed in forearm

- divided 6 cm proximal to wrist

- tenodesed to volar radius by passing through hole in radius & sutured to itself 


Dorsal tenodesis of extensor hood of thumb MCPJ 

- stops MCPJ hyperflexion

- hood sutured to dorsum of MC through drillholes


Fusion of IPJ of Thumb

- at zero degrees

- via longitundinal K wire


Post op

- thumb spica for 4/52


B.  BR to FPL 



- strong ECRL or ECRB


C.  BR to ECRB



- strong BR with weak ECRB/ ERCL



- allows wrist extension for tenodesis effect of finger flexors

- gives grasp


C7 Quadriplegia



- triceps




- finger & thumb flexion




Many SCI patients can be helped with hand surgery - 75%


Suitable criteria

- 2 point discrimination < 10mm

- plateau of neurology 12-18/12

- grade 4 MRC power of transfer (lose minimum 1 grade)

- no uncontrolled spasticity

- no excessive pain in hand

- psychologically stable


Zancolli 2 Stage procedure


Stage I / Finger & thumb extensors

- BR to EPL / EDC

- use CMCJ thumb 

- thumb MCPJ volar plate capsuloplasty / suture plate to MC neck / stop hyperextension

- transfer BR to EPL & ED via long radial incision

- immobilize for 4/42


Stage II / Grasp

- 6/12 later



Options to power FPL

1. TT to ECR Tertius if present

2. Side to side suture to ECRB

3. Passive tenodesis (Moberg)


C8 Quadriplegia






- prevent MCPJ hyperextension


Zancolli FDS Lasso tenodesis



- divide FDS slips at A2 level

- pass proximal slips under A1 

- suture slips to FDS above A1 

- effectively suture FDS to A1





Epidural Abscess



Pus collection in the epidural space




Usually haemotogenous seeding


Very rare

- 37 / 1 000 000 patients with LBP

- 1 /10 000 admissions

- most common in old men


Average age 68 years


3/4 males


Rare in paediatrics


Mortality > 12%


Risk Factors


IV drug abuse

Remote infection / UTI


Invasive spinal procedures / Epidurals

Spinal instrumentation


- DM / RA / CRF / Transplant / CA /HIV

Blunt trauma / vertebral fracture


Relhsaus et al Neurosurg Rev 2000

- meta-analysis of 900 cases epidural abscess

- most common risk factors DM / trauma / IVDU / alcoholism

- 5% had had an epidural

- skin infection / abscess most common cause





- thoracic spine

- cervical & lumbar spine less common

- spans average of 4 vertebrae


May be anterior or posterior to thecal sac

- dorsal thoracolumbar spine 

- ventral 2° vertebral OM / more common in cervical spine



- S aureus 60%

- Streptococcus 10%

- E coli 20% (IVDU, UTI)

- TB

- often unknown


Bacterial Route


1.  1/2 Haematogenous 

- remote infection

- UTI / Drug abuse 


2.  1/4 Direct Spread

- vertebral osteomyelitis

- abscess usually anterior


3.  Following Spinal instrumentation / Surgery/ Epidural injection


4.  Adjacent foci



- psoas / pelvic / retropharyngeal / perinephric


1/4 Unknown


Spinal Cord Injury


1. Direct Compression

- mass effect of pus

- ? causes early symptoms

- pus usually tracks freely in epidural space


2. Vascular Occlusion

- decreased arterial flow or epidural vein thrombosis

- responsible for clinical features later in course

- probably more important 




1.  Back pain and fever

2.  Radicular irritation

3.  Weakness / sensory deficit / sphincter incontinence

4.  Paralysis


Clinical Features


Classical triad of

1. Back pain & tenderness

2. Fever

3. Elevated ESR




Back pain is hallmark

- 95% / usually very severe / may have nerve root pain

- develops over 72-96 hours


Cord compression < 50%

- weak / numb / urinary Retention





- present in 2/3

- may be absent with chronic abscess or antipyretics


Local Signs

- tenderness

- pain on movement


Neurological deficit

- weakness / sensory loss / urinary retention

- may be ambulatory weak / non ambulatory paralysed

- meningitis





- almost always elevated

- usually~ 100



- usually elevated 


Blood Culture

- often identifies organism




Investigation of choice

- T1:  Low signal intensity mass 

- T2:  High signal intensity mass

- 85% sensitivity


Cervical Epidural Abscess T2 MRICervical Epidural Abscess T1 MRI


Gadolinium enhancement T1

- peripherally or homogenous / typical of all abscess on MRI

- increases sensitivity to 95%


Assess levels

- multi level epidural pus 

- need multilevel laminectomy and passage of catheter to aid washout


Also assess

- vertebral body osteomyelitis

- cord pathology

- other DDx (HNP, tumour, cord infarct) 


Bone Scan


For non specific symptoms

- fever / malaise

- pyrexia of unknown origin (PUO)

- guides further investigation




Initial diagnosis incorrect in 80% patients

- delayed diagnosis typically


Mechanical LBP

Vertebral OM


Vertebral metastasis


Transverse Myelitis






Mainstain of treatment is diagnosis and treatment before neurology develops

- this gives patient best prognosis


Delayed diagnosis most common problem

- 70% patients present with fever and back pain


Poor Prognosis


Delay in diagnosis


Cervical / high thoracic




Non Operative Management




Poor surgical candidates

Complete paralysis > 3/7

No neurology




CT guided biopsy

- obtain cultures / guide antibiotic

- aspiration and drainage of collection




Treat broad spectrum initially (flucloxacillin + gentamicin)

- 60% S aureus

- 30% Gram negative

- duration of therapy 4 - 8 weeks


Operative Management



- decompress cord

- debridement / drainage 

- MCS of organism

- stabilise spine if needed




1.  Posterior laminectomy

- posterior abscess with no anterior body OM

- washout +++

- leave drain in


2.  Anterior vertebrectomy and stabilisation

- severe vertebral OM




No significant improvement despite medical advances


Karikari et al Neurosurgery 2009

- 104 patients treated over 10 years

- mortality 17% in non operative / 23% in operative

- 30% with dorsal abscess were quadriplegic / paraplegic

- 7% in the ventral abscess group

- 11% improvement in non operative group

- 25% improvement in operative group



Postoperative Infection



Decreasing incidence in recent decades most likely attributable to preoperative antibiotics




Conventional discectomy </= 1%

Fusion 2%

Fusion & instrumentation 5-6%


Instrumentation doubles infection rate in lumbar fusion


Risk factors 



Poor nutritional status

Rheumatoid arthritis

Steroid use 

History of previous infection

Previous wound irradiation




Cervical Post op Abscess




Aggressive wound debridement of devitalised tissue with adequate drainage mandatory

- may leave open & packed

- antibiotic loaded beads 

- removal of hardware may leave spine unstable


Postoperative discitis

SymptomsT45 discitis


Period of pain relief after disc surgery

- followed by increasing back pain & occasional leg pain


Pain may be disproportionate to physical findings


Low grade fever common


SLR & femoral stretch tests elicit pain in some cases 




Normal WCC common 

ESR & CRP elevated 


Xray / MRI


Discitis XrayDiscitis MRI


MRI with Gadolinium


Investigation of choice

- well vascularized inflammatory tissue enhances on T1


MRI Gadolinium Post Operative Discitis T1MRI Gadolinium Post Operative Discitis T2


Osteomyelitis changes include

- confluent hypointensity of involved bodies on T1

- hyperintensity of involved bone and disc on T2

- loss of distinction of involved bone & disc

- abnormal disc appearance




Medical management


CT guided aspirate if culture required

- appropriate antibiotics

- brace


Surgical Indications


Failure non operative management

Epidural abscess



Post Op Discitis with Deformity




1.  Percutaneous Discectomy and Drainage


Li et al Arch Orthop Trauma Surg 2011

- 31 patients with post-operative discitis

- half had positive cultures, other half sterile


2.  Laminectomy and Drainage

Spinal Tuberculosis



Most common site for skeletal TB

- usually haematogenous spread

- can be direct from lung


3 patterns


1.  Peridiscal (50%) - originating in metaphyseal region

2.  Central - high incidence of vertebral collapse

3.  Anterior - instability less common with less bony destruction




Affects multiple contiguous vertebrae

- starts anterior 1/3 vert body

- doesn't stay within body

- spreads along fascial planes

- spreads under ALL


More likely to produce kyphosis


Disc sequestered rather than destroyed


Posterior elements frequently involved unlike pyogenic




Short kyphotic deformity

- known as Gibbus Deformity




May be mistaken for neoplasia


Similar Xray appearance 

- brucellosis, hydatid disease

- fungus (aspergillosis / Cryptococcus / candidiasis)




Age influences risk of paralysis


Cervical in patient younger than 10 years

- 17% risk of cord injury


Cervical in patient older than 10 years 

- up to 81% risk of paralysis




Non operative


British Medical Research Council

- 77% settled with drug treatment alone

- no patients with neurology / paralysis

- drug treatment for 12/12

- spontaneous fusion can be expected




Indications for Surgery


1.  Deformity

- kyphosis

- >50% verterbral body destruction


2.  Neurology


3.  Biopsy


4.  Failure nonoperative treatment




Hong Kong Procedure

- debridement of infected bone

- decompression of spinal canal

- correction of kyphotic deformity using structure grafting

- instrumentation


Vertebral Osteomyelitis



M:F =2:1


30-40 years


20% diabetic


50-80% identifiable source




Lumbar (50%) > Thoracic > Cervical (<10%)




1.  Haematogenous

- arterial rather than venous


Risk factors

- UTI (40% of all cases)


- elderly

- respiratory infection

- immunocompromised

- DM


2.  Direct spread

- pelvis or psoas

- percutaneous or open spinal procedures




Staph aureus 60%




Gm negative

- Ecoli, Proteus

- UTI / GUT procedures


Salmonella in sickle cell


Pseudomonas in IVDU


TB / Fungus

- in immunocompromised

- may require life long therapy







- steroids

- transplant

- DM, RA




Initial focus at end plates

- septic emboli to end arterial circulation

- series of inter-metaphyseal artery allows infection of contiguous vertebrae

- spreads by direct extension to adjacent vertebrae unlike TB


Disc destruction

- disc is avascular 

- allows infection to spread here as well

- forms collection / abscess



- due to body and disc destruction

- kyphotic



- compression from epidural abscess

- infarction of regional supply to cord

- pathological fracture fragments

- kyphosis


Clinical Presentation


Back pain / tenderness + fever + elevated ESR


Diagnosis often delayed 4-6/12 due to vague symptoms


90% back pain

- insidious, non-mechanical, night pain

- localised tenderness


50% fever


< 10% neurological deficit




ESR elevated > 90%

- most sensitive test


WCC elevated 35%


Blood culture's

- often negative

- especially if low virulence


Urine culture



- albumin / lymphocyte count




Changes 4-6/52



- loss of disc height

- end plate irregularities/erosions

- vertebral destruction

- contiguous vertebrae

- collapse usually without severe kyphosis of TB




Soft tissue involvement

Good for TB 


Cervical Osteomyelitis CT


Bone Scan


Localise area of problem if diagnostic dilemma




Vertebral Osteomyelitis MRICervical osteomyelitis


Investigation of choice

- 95% accurate

- diagnose vertebral osteomyelitis

- look for epidural abscess



- T1 loss of distinction between disc and end plate

- T2 loss of normal disc intranuclear cleft

- specific for infection


Gadolinium T1

- ring enhancement





- preservation of disc



- no increased T2 in disc


CT guided biopsy 



- If organism unknown



- aspiration if abscess

- bone biopsy otherwise



- culture 75% of microbes prior to antibiotics

- only 25% after antibiotics given


Open biopsy



- if no CT available / unsuccessful



- posterior approach

- specimen obtained through pedicles 

- T-spine through costotransversectomy



- culture aerobic / anaerobic / AFB / fungus

- diagnostic in > 80% cases


TB VS Pyogenic


Pyogenic                         TB

Single focus                      Multisegments involved

Symmetric collapse           Kyphosis

Spread bone                     Fascial planes

Disc destroyed                  Disc sequestered

Anterior column                All 3 columns (posterior inv)

Epidural abscess               Paravertebral abscess

More acute                       Insidious








1.  Important to delay antibiotics until cultures taken

- BC's

- urine M/C/S

- CT biopsy


2.  After biopsy

- most settle with antibiotics

- 6-8 weeks IV treatment (until ESR norm)

- continue orals 3-6/12


3.  Immobilisation important

- Bed rest



4.  Adequate nutrition important

- serum albumin


- transferrin


5.  Spontaneous fusion occurs in 60%


Operative Management




1.  Biopsy for diagnosis and M/C/S


2.  Failure medical management

- systemically unwell


3.  Neurological deficit


4.  Deformity / instability


Anterior approach & corpectomy


1.  Adequate debridement crucial


2.  Autograft preferred

- iliac crest, fibula, rib

- can use allograft 


3.  Instrumentation

- anterior +/- supplemental posterior




Lu et al Neurosurgery 2009

- review of 36 patients treated with corpectomy + titanium cage

- nearly all patients required anterior + posterior instrumentation

- 2 infection recurrences, 1 each with autograft and allograft

- all had neurological improvement

- 81% pain free


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








- 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





Primary malignancy arising from remnants of the notochord




Rare malignant tumour


Middle-aged adults (50-70)






In midline in axial skeleton


Base of skull 35%


Vertebrae 15%

- especially cervical


Sacrum 50%




Sacral Tumour


Usually presents late (long History LBP)

- slow-growing

- large potential space to expand into

- often very large on presentation


Perineal pain

Bladder & bowel dysfunction

Mass effect

Neurological compression


Usually can feel rectal mass ~ 50%




Bony destruction is hallmark + soft tissue mass

- 50% Calcification within mass



- irregular areas of bone destruction

- sacral expansion

- soft tissue mass


CT Scan / MRI 


Useful to delineate tumour


Sacral Chordoma MRI0001Sacral Chordoma MRI0002





- lobulated bluish / gray

- extensive gelatinous translucent areas which are focally cystic & haemorrhagic



- lobular framework of Physaliphorous cells

- cells have bubbly pink cytoplasm & Bulls-Eye nucleus

- vascular fibrous septa

- mucinous matrix

- 1/3 significant Chondroid production (can be mistaken for chondrosarcoma)





Chondrosarcoma / OS / Ewing's / Myeloma







Most important predictor of survival is clear surgical margin

- usually difficult due to location


Sacral Surgery

- leave at least 1 S3 - 100% continent

- leave at least 1 S2 - 50% continent

- above S2 incontinent because pelvic splanchnics removed





- resection not possible

- positive margins


Rarely effective




Metastasis 30-50%

- pulmonary mets may occur (late)


Death usually 2° local infiltration



Primary Spinal Tumours








Osteoid Osteoma





Giant Cell tumour










Multiple myeloma





Prostate / Breast / Lung / Thyroid / Kidney


DDx by Site


Posterior elements


- chordoma / osteosarcoma


Vertebral body

- giant cell

- hemangioma



- chordoma

- Ewing's


Benign Spinal Tumours




Patient in teens or twenties

Night pain

Posterior elements





Surgical resection

- complete to prevent recurrence


Giant cell tumour


30 - 40 years

In sacrum

Present with pain

May have bladder and bowel dysfunction




Wide excision

- may get incontinence

Adjunctive radiotherapy

Now using serial embolisation




Hemangioma Spine


Very common

- usually asymptomatic and incidental finding

- vertebral body or posterior element

- thoracic spine



- striations



- High signal on T2




Indicated for collapse or neurology

Surgical excision




Osteoid Osteoma


Male between 20 - 40


Posterior elements lumbar spine

- < 2 cm


Can cause scoliosis

- in apex of convexity




Surgical Removal / High frequency radioablation

Often scoliosis will then resolve if not too long standing




Osteoblastoma Spine0001Osteoblastoma Spine0002Osteoblastoma Spine0003


Similar histology to OO

- > 2 cm


Much more aggressive / less common


Found in the posterior elements

- male teens, twenties




Osteoblastoma Exision and Fusion0001Osteoblastoma Exision and Fusion0002


Wide excision +/- posterior fusion


Can recur

- life long follow up


Eosinophilic Granuloma


Vertebroplanar in young child < 10




Self limiting

- will reconstitute up to 50% vertebral height


Primary Malignant Tumours




Rare slow growing malignant tumours

- arise from primitive nervous system

- slow to metastasise


50% sacrococcygea


Elderly patients




Surgical Resection

- very difficult


Adjunctive Radiotherapy


Life expectancy 10 - 15 years after diagnosis





Vertebral body




Radical excision

Adjunctive radiotherapy and chemotherapy




Middle age or older


Patient with Maffucci / Ollier's



Wide surgical resection

Overall prognosis is poor as this is difficult




Can be solitary lesion

Anterior element




Radiotherapy and Chemotherapy

Surgery if unstable / deformity




50% in sacrum

Young male in teens




Surgical resection

Radiotherapy and chemotherapy

20% 5 year survival


Multiple Myeloma / Plasmocytoma


50 - 80 years




Radiotherapy and chemotherapy

Surgery for instability


Spinal Cord Tumours


DDx by Location



- neuroblastoma

- ganglioneuroma

- Ewings sarcoma

- leukaemia

- lymphoma

- synovial cysts


Spine Synovial Cysts MRI


Extramedullary Intradural

- dermoid

- epidermoid

- meningioma

- neurofibroma



- astrocytoma

- ependymoma

- lipoma




Slow Growing

F:M 9:1

Intra-dural / extramedullary



- intradural resection

- RTX for residual tumour which is growing


Thoracic Meningioma




Primary glial tumour of spinal cord

- intramedullary

- tend to be benign in spinal cord (c.f. intracranial


Ependymoma Conus MRI SagittalEpendymoma Conus Axial MRI



- debulking

- radiotherapy

Spinal Metastasis

EpidemiologyThoracic Metastasis


80% cancer patients have spinal metastasis at autopsy 


Spine is number one site for bony metastasis (50%)




Hexagon: PBBLTK


                 Prostate    Breast


Bronchus      MM     Lymphoma        Bowel


                 Renal        Thyroid




20% of develop cord compression

30% survive >12/12





- thoracic spine  - 70%

- lumbosacral > cervical spine


Usually multilevel 


Vertebral body 

- 85%

- usually posterior body near pedicles

- posterior elements uncommon



- neural compression - demyelination / ischaemia

- pathological fracture

- spinal instability


Method of Spread


1.  Arterial metastasis

- haematogenous via nutrient arteries

- lung / breast


2.  Direct invasion

- through intervertebral foramen 

- lymphoma


3. Venous 

- via Batson's Plexus

- valveless veins from the pelvis to the internal venous plexus of the spine / prostate

- GIT tumours commonly spread to liver first via the portal system 

- then later to bone


4.  Lymphatic





- 95% neoplastic pain (night and rest pain)



- 75% at diagnosis

- bilateral & symmetrical


Sensory loss

- 50% at diagnosis

- ssually affects the feet first 


Loss of sphincter control

- 50% at diagnosis




75% have abnormality


Winking Owl Sign

- pedicle loss on AP


Lytic / Sclerotic lesion

- need 30% bone loss to see lytic area


Vertebral body collapse 


Lumbar Metastasis XrayCervical Metastasis MRI


Bone Scan


Very sensitive 

- detect metastasis > 2mm

- screening tool


False positive

- crush fracture


False negative

- myeloma



- symmetric increased uptake

- metastatic disease

- renal or endocrine abnormality


CT Scan 



- bony abnormality

- deformity

- potential instability


Cervical Lesions


Cervical Spine Metastasis CTDens Metastasis




Lumbar Metastasis CTLumbar Spinal Met CT





- soft tissue masses 

- nerve and cord impingement


Lumbar Metastasis MRI


Metastatic Tumour L1 MRI T1Metastatic Tumour L1 MRI Axial


Cervical Metastasis MRI


Classification Harrington


Class I

- Minimal bone involvement


Class II

- Bone destruction < 1/2 body / no instability / no cord compression 


Class III

- Spinal canal compromise due to epidural disease / no significant bone involvement


Class IV

- Pathological fracture ± deformity / no significant neurological compromise


Class V

- pathological fracture with collapse / instability & neurological compromise






Outcome after treatment = Neurological impairment before treatment

- most ambulatory patients remain ambulatory after treatment

- few paraplegic patients are able to walk after treatment


Radiotherapy v Surgery


Patchell et al Lancet et al

- randomised multicentred trial

- patients with spinal cord compression from metastasis

- trial had to be stopped

- superior results for surgery c.f. radiotherapy and steroids

- improved patient walking ability / retained walking ability

- better maintenance of continence and Frankel grades




1. Preserve neurological function

- ambulation

- bladder and bowel 


2. Pain relief


3. Spinal stability


Decision making


Team approach

- oncologists

- radiation oncologists

- palliative medicine



- life expectancy

- fitness for surgery

- tumour type

- spinal stability


Harrington Classification


Group 1 & 2 +/- 3

- radiotherapy +/- chemotherapy


Group 4 & 5

- collapse / instability / impending deformity / deformity / neurology

- surgery






Very - myeloma, lymphoma

Moderate - breast, lung, bowel, prostate

Resistant - thyroid, kidney, melanoma



- Harrington 1 & 2 +/- 3 radiosensitive

- no neurology

- neurology with poor prognosis or unfit for surgery


Operative Management



- neurology / cord compression

- failure of radiotherapy

- deformity

- instability

- > 3/12 to live

- fit for surgery



- > 50% height loss

- anterior and posterior columns at same level

- bone loss > 2 vertebrae




1.  Decompressive laminectomy

- historical operative associated with poor outcomes


2.  Percutaneous PMMA / Vertebroplasty



- stable lesion


Spinal Met Percutaneous PMMA


3.  Posterior stabilisation


A.  Long segment stabilisation


Thoracic Spine Pathological Fracture StabilisationCervical Tumour Posterior Stabilisation


B.  Short segment stabilisation + PMMA


Lumbar Metastasis Posterior Stabilisation with PMMAVertebral Met Posterior Stabilisation + PMMA


3.  Corpectomy / PMMA / Anterior stabilisation



- remove body and disc to dura

- PMMA sufficient if LE < 6 months

- titanium cage and BG / structural graft if LE > 6/12

- stabilised with anterior plates


Cervical Spine Metastasis Anterior StabilisationCervical Spine Anterior Stabilisation 2


Post op Radiotherapy


Week 2 if no bone graft

Week 6 if bone graft used