1. Common spinal disorders
and
General principles
of spinal surgery
For the medical students
Daniel Chan FRCSEd FRCSOrth
Consultant spinal surgeon,
PEOC, RD & E

2. Assessment


History, physical
examination, simple
investigation, special
investigation
Mechanical presentation:
Axial pain



Exclude fractures,
tumours and infection
Red flags
Yellow flags

Neurological presentation







Spinal cord
Cauda euina
Nerve roots
Document the deficit
Duration of the deficit
Rapidity of progression
Deformity :local, regional,
global


Coronal balance
Sagittal balance

3. Non spinal conditions






CVA
Gillain Barre
Transverse myelitis
Amyotrophic neuralgia
MS
Vascular




dissecting aneurysm
Saddle embolism
Peripheral nerve palsies
Herpes zoster

5. Surgical principles

Decompression

Stabilisation






Pathology
Direct
Indirect



In situ
Correction of deformity
Combined
When, how, why





Degenerative
Inflammatory
Neoplastic
Infective
Traumatic
Congenital
developmental

6. Degenerative
L4/5 Disc herniations

7. Indications for Surgery-Absolute


Acute cauda equina syndrome - emergency
Progressive neurological deficit – urgent

8. Acute cauda equina syndrome



LBP
Root Compression
 Motor / sensory
 Uni- / Bilateral
Sphincter Disturbance
Motor
Do a rectal examination and record it
Anal Tone


Urinary Retention
 Residual volume
Sensory
 “Saddle” numbness
 No sensation with bladder
tuck





CESI vs CESC
(Reflexes)
(SLR)

9. Central L4/5 Disc Prolapse
Needs emergency surgery

10. Indications for Surgery-Relative


Natural history favourable: 90% settle over 3 months
Failure of appropriate time and conservative treatment




Unremitting leg pain in appropriate distribution
Nerve tension signs (SLR limited by leg pain)
Imaging confirmation



6-8 weeks
done at time when surgery is contemplated
When patient accepts risk to reward ratio
Recurrent attacks of leg pain

11. Lumbar Microsurgery

12. Degenerative

Spinal stenosis

13. Spinal Stenosis







Elderly patient
Leg pain: radicular or claudicating
Paraesthesia
“Paralysis”: jelly legs
Unusual to have acute deficit…usually additional PID,
synovial cyst or pin hole stenosis
Cervical spondylosis and extension injury = central
cord syndrome
Tandem stenosis

14. Limited segmental decompression

Technique of LSD

15. Degenerative

Degenerative
spondylolisthesis

16. Degenerative spondylolisthesis

17. Degenerative scoliosis

18. Degenerative scoliosis

19. Degenerative scoliosis

20. Degenerative scoliosis

22. Pars interarticularis
Spondylolysis: The Scotty Dog
Spondylolytic spondylolisthesis

23. Spondylolytic spondylolisthesis

27. Cervical Radiculopathy Signs




Shoulder abduction sign
 Rests arm on head – reduces
nerve root tension and empties
epidurals
Holds head tilted to opposite side
 Opens foramen
C7 pain
 Tend to pronate forearm when
describing the pain unlike C6 and
CTS
Extension narrows foramen
 Helps distinguish from muscular
neck pain and shoulder pathology

28. 
C5


C6


Carpal tunnels
syndrome
C7 C8


Turner Parson’s
syndrome (Neuralgic
amyotrophy)
Thoracic outlet
syndrome
C8/T1

Pancoast tumours

29. Cervical Radiculopathy
4.
Acute – Soft Disc
Chronic – Hard Disc
Disc Height ↓ - foraminal compression
Facet - foraminal compression

MRI Gold Standard
1.
2.
3.


CT bony pathology and foramens



Compression in 20% of asymp pts
45 deg to sag plane
Dynamic fluoroscopy for stability
Myelography - rarely

30. Natural History

Favourable








Lees 1963
51pts 2-19yrs FU
45% single episode no recurrence
30% mild Sx
25% persis / worse Sx
No progression to myelopathy
75% recovers
90% recovers over 3 to 6 months
Epidemiology of cervical radiculopathy
A population-based study from Rochester, Minnesota, 1976 through
1990
Kurupath Radhakrishnan1 2 * William J. Litchy1 W. Michael O'Fallon3
,,,
,
and Leonard T. Kurland2

31. Separate the woods from the
trees




Look for signs of myelopathy
Clumpsy arms/hands and legs
Spastic
Upper motor neurone signs!!

32. Acute cord compression
cervical disc herniation
Needs emergency / urgent surgery

34. Myelopathic Symptoms









Subtle / varied presentation
Pins & needles / numbness in hands
Stiff hands and reduced dexterity
Balance problems / recurrent falls
Stiff legs that tire easily
Shooting sensations through body
Spontaneous twitching / jerking limbs
Bowel or bladder disturbance
(uncommon)
Pain is not a common symptom

35. Upper motor neurone signs
Lower limbs
Upper limbs








Unsteady wide
based gait
Romberg / Walking
Romberg
Unable heel toe
gait
Triangle step test
L’Hermittes sign
Hyperreflexia
 Knee / Ankle
Clonus
Extensor Plantar
Response
(Babinski)


Hoffman’s sign
Ono 1987
 Grip release test
 Finger escape
sign
Hyperreflexia
 Inverted Radial
Reflex
 Scapulohumeral
reflex

37. Natural History - Poor

Clarke 1956




120 pts
75% episodic ↓
20% slow ↓
5% rapid ↓

Nurick 1972



Phillips 1973


Symon 1967


67% steady ↓

30% ↑ non surg
50-73% ↑ surg
37% ↑ non surg
57-73% ↑ surg
Sampath 2000



Surgery better
↓ neuro Sx and pain
↑ functional status

40. Spinal infection

43. Infection

48. Infection


Pyogenic or TB
At risk:
i.v drug users
 elderly
 Immuno compromised
 Diabetics
 Renal failure
 Urological manipulation
 Cardiac: SBE

Epidural abscess
MRI + Gad
 Neurology in cord
area needs
emergency
decompression



Spondylodiscitis

instability and
acute deformity

49. Spinal infection: important lesson






Late diagnosis frequent
High index of suspicion
Risk factors!
Early diagnosis antibiotics alone suffice
Late diagnosis with bone destruction leads to
spinal deformity and further neurological
compromise
Difficult surgery then needed

50. MSCC






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
Any neurological deficit requires urgent/ emergency
MRI
Staging for prognosis
What is the primary
Is it metastatic
Is it operable
Is it treatable with radio/chemotherapy alone
Surgery is palliative
Will the patient benefit from surgery

51. Tumour
59/F
Backpain + (L) leg
weakness
L3 mets with neural
compression

52. Pre op

53. Pre op
Pre embolisation
Post embolisation

54. Intra op

55. Post op
Lateral view
AP view

56. Mechanical low back pain







i.e…..Not infective, metabolic, traumatic, metastatic
?diagnosis
Speculative
Degenerative discopathy?
Facet pain?
Segmental pain
Specific mechanical pathology:


spondylolytic spondylolisthesis
Post surgical destabilisation

57. Clinical Standards Advisory Group 1994
Red flags








Thoracic pain
Fever and unexplained weight loss
Bladder or bowel dysfunction
History of carcinoma
Ill health or presence of other
medical illness
Progressive neurological deficit
Disturbed gait, saddle anaesthesia
Age of onset <20 years or >55
years
Yellow flags





A negative attitude that back pain
is harmful or potentially severely
disabling
Fear avoidance behaviour and
reduced activity levels
An expectation that passive, rather
than active, treatment will be
beneficial
A tendency to depression, low
morale, and social withdrawal
Social or financial problems

58. Inflammatory - RA

60. RA

61. Inflammatory - AS

62. AS





Prone to fractures
Often unstable, fractures like chalk stick
Neurological deficit frequent
If originally kyphotic, strapping spine board may
be dangerous
Bamboo spine with fixed kyphosis

63. Cervical osteotomy - AS

64. Inflammatory - AS

65. Trauma
Aims of fracture treatment
 anatomical reduction
alignment
 maintain alignment
 rehabilitation

Preserve neurological
function
Tissue healing
 bone heals with bone
 bone healing may malunite
 soft tissue heals with
fibrous tissue
 fibrous healing remains
unstable

66. Scoliosis
Isola instrumentation

67. Double rod systems : Kaneda

68. Growing rod




Paediatric down sized implants
Instrumentation without fusion
Periodic lengthening of rod
Allows continuing growth

69. Growing rod

70. Summary




Keep it simple
Axial pain and stability
problem
Neurological problem
Apply the 2 principles of
decompression of neural
structures and
stabilisation of bony
ligamentous structures

72. Summary





Presents with brachiagia with or without
sensory and or motor symtoms
Dermatomal distribution identifies level
Consider important differentials
Favourable natural history favours
conservative treatment
Response to surgery generally good

73. My experience




Retrospective
47 patients
72% satisfactory
(good/excellent)
clinical outcome
97% fusion rate

74. Investigations

MRI

Other

Bloods


Remember Coag
CT myelogram

75. Radicular Pain

Mechanical

Biological / Chemical


Inflammation



IL-1, IL-6, Sub P, TNF-α
blood vessel permeability
Oedema of root / DRG
Metabolic disorders with neuropathy e.g. diabetes

Increased susceptibility to radiculopathy