Disorders of the adult spineFunction of the spine:Stability BalanceMovements (cervical and lumbar spine)

Maintain posture

Function of the spine: Stability: if two adjacent segments of the spine can not be displaced from their junction

Disorders of spine:Mechanical: instabilityBiological:

Intervertebral disc diseases Tumors Inflammatory diseases (eg. rheumatoid arthritis, ankylosing spondylitis) Infections (tbc – destructive process – substance of vertebral bodies is destroyed –

compression, „Pott’s gibbus”)

INSTABILITY OF SPINEAbnormal movements between adjacent spinal segments, that can be proven by imaging technique- serious condition with potential neurological damage, requiring immediate operation

Examination in disorders of the spineAnamnaesis: time of onset of pain, character of pain (consistent with movement, radiating into periphery)Look: posture (antalgic), deformityFeel: muscle nodules (myogelosis) - lasting spasmMove: cervical - lumbar spine (pain on certain movements!)Neurological examination: sensation, movements - power of muscles, reflexes (patella, Achilles jerk)

Examination in disorders of the spine - imaging techniquesX-ray: Skeletal maturity, deformities of individual vertebrae, deformitiy of spinal segment(s), intervertebral space (narrowing, osteophytes)CT: narrowing/compression of spinal canalMRI:condition of spinal cordContrast injection: myelography (show stop - compression of spinal canal), discography

Contrast myelography: combined with CTRight L 5 nerve root is „cut off” – sign of nerve root compression by disc prolapse

Lumbar 4 nerve root symptoms:Motor disorder:_ m. tibialis anteriorReflex disorder: patella areflexia or hyporeflexiaSensory disorder: lack of sensation at inner edge of foot

Instability of spine:SPONDYLOLYSIS – SPONDYLOLISTHESIS (Potential instability – may lead to „true” instability with severe neurological damage) Localisation: lumbar spine (L IV-V, L V – S I) Morphological disorder: vertebral arch is broken (without displacement – spondylolysis with displacement - spondylolisthesis)Causes :

congenital (dysplastic) , traumatic, degenerative, pathological (tumor)

Spondylolysis:Vertebral arch is broken at pars interarticularis

Most frequent types:1. Dysplastic2. Degenerativ3. Traumatic

Classicalappearance on X-ray:„Scottie dog”

a. Spondylolysisb. Spondylolisthesis: + displacement

Most severe form of spondylolisthesis: „spondyloptosis”5th lumbar vertebra slipped forward – fully displaced

„Sacralisation” of 5th lumbar vertebra: transverese process of 5th lumbar vertebra nearly fused with sacrum

„segmental” disorders of the spine: disorder, pathology is localised in to one (or more) segments• Disc herniation• Intervertebral arthritis• Intervertebral arthrosis (degenerative process)• B: osteophyte, compressing on nerve root• intervertebral disc still intact

Various forms of intervertebral disc disorderVarious forms of disc disease (discopathy):

a. Sprain with edema around discb. B. disc protrusionc. C disc ruptured. All 3 can cause nerve root irritation and/or compression

„Antalgic” posture-Typical clinical sign in disc disease, or sciatica (sciatic nerve is affected)A: disc protrusion under the nerve root – leaning towards this side releaves the painB: disc protrusion is above nerve root – leaning towards the opposite side releaves the pain

Antalgic posture – leanes away from the side of pain: „sign of Pisa”

Intervertebral disc – types according to localisation: • a- central (may compress the spinal cord), • b- mediolateral

Compression of S 1 nerve root:Motor signs – weak flexorsReflex sign: Achilles areflexiaSensory signs: outer edge of foot hyposensibility

Laségue – sign, or straight leg raising: if nerve roots of sciatic nerve are affected, extreme pain can be provoked (typical sign in sciatica)

Spinal canal – A: normal widthb.: spinal stenosis – narrowing of spinal canal, may cause spinal cord compression(can be caused by disc prolapse, fracture of vertebral body, tumour)

Operation: discectomy (can be done percutaneously, with endoscope too)

Transpedicular fixation – introduction of screws through pedicles into vertebral body, screws connected on each side with metal barUsed for treatment of spinal instability

-Transpedicular fixation of lumbar 4-5 segment („posterior stability”) + TITANIUM CYLINDER in the intervertebral space (to provide „anterior” stability)

Disc prosthesis in cervical spine: future trend?

Tuberculosis of spineInfection spreads to vertebral body by bloodLocalisation of infection: on both sides of intervertebral disc (above and belowConsequence: collapse of vertebral body above and below the affected disc spave – leading to sharp angulation (KYPHOS)

TBC of spine: Pott’s gibbus, Pott’s paraplegia (if spinal cord is compressed)

Tb of spine: Destruction of 7.-8.-9- thoracic vertebral bodies, with wide paravertebral soft tissue shadow- „cold” abscess (it will sink eventually downwards and cause fistulation around the inguinal region)[Fistula=abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect]

Tubecrulous sinus filled up with contrast (sinogram) – cold abscess seen on buttock

Compression of cervical spinal cord: due to destruction of C 5 vertebral body – TB)

Tuberculosis of spineTreatment:Combines antituberculous chemotherapy (streptomycin, INH etc – at least three drugs at the same time,at least for 6 months)Surgery: evacuation of abscess, decompression of spinal cord

Low back pain:It is so frequent, that it became a disease in itself3 forms:

1. Transient backache- simple back strain - , rest, antiinflammatory drugs are sufficient2. Sudden acute pain with sciatica:pain radiating along The sciatic nerve - disc prolapse is likely -

operate if severe disc prolapse is detected3. Chronic low back pain- arthritis oir arthrosis of intervertebral joints (may mimic disc prolapse,

MR or CT are helpful diagnostic tools) – spinal instability may be the underlying cause too BEWARE: TUMOR INSIDE The PELVIS OR METASTATIC BONE TUMORS MAY BE ThE UNDELYING CAUSE AS WELL!! (ALWAYS NEEDS CHECKUP – THOROUGH EXAMINATION TO EXCLUDE MORE SEVERE DISEASES)

Causes of low back pain from the spine, from organs inside the pelvis, metastatic disease

Osteoporosis treatment(?)KYPHOPLASTICA TECHNIQUEBallon pressure 3,4-20,4 atmTh5-10 lateral-extrapedicular INSERTION OF CANULATh10-L5 transpedicular insertion of canula, through which bone cement is injected into balloon in collapsed vertebral body