SPINE

RUDI FEBRIANTO, MDOrthopaedic Surgeon

RSUP NTB/FK UNRAM

Curriculum VitaeNama : Rudi FebriantoLahir : Sumbawa, 18 Februari 1975Status : Menikah ( 1 istri, 3 Anak)Pendidikan :

SD 3 MataramSMP 1 MataramSMA 1 MataramPendidikan dokter FK UI 1993 – 1999Pendidikan orthopedi & traumatologi FK UI 2003 – 2008

Ketua SMF Orthopedi & Traumatologi RSUP NTB/FK UNRAM

Spine Anatomy33 vertebra : 7 cervical, 12

thoracal, 5 lumbal, 5 sacrum, 1 coccygeus

Spinal curves: normal curves - Cervical lordosis - Thoracic kyphosis - Lumbar lordosis - Sacral kyphosis

Cervical C1-C2: unique bones allow stabilization of occiput to spine and rotation of head. Motion: rotation and fl exion/extension.

Thoracic Relatively stiff due to costal articulations. Motion: rotation. Minimal flexion/extension.

ThoracolumbarFacet orientation transitions from semicoronal to sagittal. Segments are mobile. Most common site of lower spine injuries.

Lumbar Largest vertebrae. Common site for pain. Houses caudaequina. Motion: fl exion/extension. Minimal rotation.

Sacrum No motion. Is center of pelvis

Radiologic Evaluation

Spinal ProblemStability : stable or unstable?Location : Cervical or Thoracolumbal?Cause : - Infection- Non-infective inflammatory disease - Tumor- Trauma

Management :- early management

- definitve management

StabilityStable fracture is one in which the

vertebra component will not be displaced by movement. - Wedge compression fracture

Unstable fracture is one in which there is a significant risk of displacement and consequent damage to neural tissue- Burst compression fracture, Fracture-

dislocation

Three Column Stabilty Concept

TREATMENT

Objective :

SPINAL DEFORMITIESScoliosis- Postural scoliosis- Structural scoliosis

Kyphosis

SCOLIOSIS• Lateral curvature of the spine• Postural scoliosis

compensatory to some condition outside the spine, as a short leg, pelvic tiltreversible and curvature without rotation

• Structural scoliosisirreversible and curvatrue with rotation in the primary curveetilogy : idiopathic (85%), osteopathic, neuropathic, myopathic

TreatmentAim of treatment are to prevent the

progression, to correct and stabilize a more severe deformity

Non-operative Spinal braces : curve 20° - 40° and with 2 years ageMilwauke brace, Boston brace, TLSO

Operative Idiopathic scoliosis with curve more than 40°and more than 10 years oldCorrection the curvature by combination of spinal instrumentation and spinal fusion.

SPINAL INFECTIONTuberculosis (Spondylitis TB or

Pott’s disease)Spine is the most common site of skeletal tuberculosis and the most dangerous.

The most common site are the lower thoracic and upper lumbar

Granulomatous inflammation, characteristized by slowly progressive done destruction

TreatmentGeneral treatment

- Antituberculosis drugs for 9 month – 1 years- General rest- Nourishing diet

Debridement and stabilisation-spinal fusion after 1 month of drug therapy

Spondylitis TB L2-3 with posterior stabilization

Surgical Indication- Neurologic Defisit – Acute neurologic deterioration, paraparesis and paraplegia- Spinal deformity with instability or pain- Large Paraspinal abscess- No respone to medical therapy, continuing progression of kyphosis or instabilty

ComplicationPott’s Paraplegia - Paraplegia of active disease : develops

realtively early, may result either from extradural pressure or from direct involvement of spinal cord

- Paraplegia of healed disease : develops late, result either from the gradual development of a bony ridge or from progressive fibrosis.

Kyphosis Deformity

Non-infection Inflamatoy DiseaseDegerative Disc DiseaseHerniation of intervertebral discSpinal StenosisSegmental instability

Degenerative Disc Disease• The spinal structures most affected by

degenerative disease are– Intervertebral discs– Articular facet joints

• These conditions are similar to osteoarthritis and degenerative disease of the spine, which is often referred to as “osteoarthritis of the spine,” or spondylosis

• Occurs at all levels of the spine• Asymptomatic degeneration in majority of the

population

SymptomsLow back pain and/or buttocks painIf leg pain also exists, there is likely an additional cause, eg, HNP.

DiagnosisPatient examinationCT/MRI

Nonoperative careRest for acute, low back painNSAID medicationPhysical therapy

Exercise/walkingLow-impact aerobicsTrunk strengthening

• Surgical care Failure of nonoperative treatment

Minimum of 6 weeksFusion

Removal of disc and replacement with bone graft, or a cage-filled bone graft, or a bone graft substitute

ArthroplastyArticulating disc replacement

Segmental Instability

• Spondylolisthesisforward shift of the spine in relations to the vertebra segment immediately below

• Spondylolysisdefect in one or both side of the neural arc of lumbar vertebra

• Spondyloloptosiscompletely dislocation

SpondylolisthesisUsually occur in lumbar spine,

paricularly in L5-S1Type :

- Spondylosis spondylolisthesis- degenerative spondylolisthesis- Traumatic spondylolisthesis- Congenital spondylolisthesis

• Gradation of spondylolisthesis– Meyerding’s Scale

• Grade 1 = up to 25%• Grade 2 = up to 50%• Grade 3 = up to 75%• Grade 4 = up to 100%• Grade 5 >100%

(complete dislocation, spondyloloptosis)

SymptomsGradual onset of low back pain that aggravated by standing, walking, running and relieved by lying down Nerve root irritation that cause sciatica

Nonoperative CareRestNSAID medicationPhysical therapySteroid injections

Surgical care Failure of nonoperative

treatmentDecompression and fusion

InstrumentedPosterior approachWith interbody fusion

Spinal StenosisA bony narrowing of the spinal canalBony narrowing may be congenital or may

be acquired

–Central stenosis• Narrowing of the

central part of the spinal canal

–Foraminal stenosis• Narrowing of the

foramen, resulting in pressure on the exiting nerve root

–Far lateral recess stenosis• Narrowing of the

lateral part of the spinal canal

Nonoperative careRestNSAID medicationPhysical therapy

Exercise/walkingSteroid injections

Surgical care Failure of nonoperative

treatmentMinimum of 3-6 months’ duration

DecompressionBone removal to widen area

Laminectomy Foraminotomy

High success rateMay require adjunct fusion

to address instability

Herniation of intervertebral discThe progressive degeneration of a disc,

or traumatic event, can lead to a failure of the annulus to adequately contain the nucleus pulposus

Herniation of intervertebral disc is not synonimus degeneration disc disease, but may be complication of degerative disc disease

Most common sites is L4-5, L5-S1, and L3-4

• Varying degrees• Disc bulge

– Mild symptoms• Usually go away with

nonoperative treatment

– Rarely an indication for surgery

• Extrusion (herniation)– Moderate/severe

symptoms• Nonoperative treatment

Posterolateral herniation: nerve root compression cause sciatica

Medline herniation : cauda equina compression cause cauda equina syndrome

Cauda Equina Syndrome symptoms :Bilateral leg painLoss of perianal sensationParalysis of the bladderWeakness of the anal sphincter

Surgical intervention in these cases is urgent

Nonoperative CareInitial bed restNonsteroidal anti-inflammatory (NSAID) medicationPhysical therapy

Exercise/walkingSteroid injections

Surgical care Failure of nonoperative treatment

Minimum of 6 weeks in duration Can be months

DiscectomyRemoval of the herniated portion of the discUsually through a small incision

Spinal TumorMost spinal tumor are metastase

and malignancie20 – 40% primary spinal tumors

are benignTypically, benign lesion are in

posterior elements, and most anteriorly located lesions are malignant

Posterior Element TumorOsteoid TumorOsteoblastomaOsteochondromaAneurysma bone cyst

Vertebral Body TumorsHemangiomaEosinofilic GranulomaGiant cell tumorPrimary Malignat tumor

- Osteosarcoma- Ewing Sarcoma- Multiple myeloma

Metastatic tumor- Breast, lung, prostat, kidney, GIT, and thyroid cancer

TreatmentIrradiation

indication : pain, slowly progressive neurological symptoms in the presence of a radiosensitive tumor, spinal canal compromise Instability is a relative contraindication, because of the potential collapse and progression of deformity that could occur with tissue necrosis

OperativeIndication : decompression and stabilization, radioresistan tumor

Spinal TraumaCervical injury

- Jefferson’s fracture- Odontoid fracture- Hangman’s fracture- Subaxial cervical fracture

Thoracolumbal injury- Compression fracture

wedge and burst fracture- Fracture – dislocation

Cervical InjuriesCervical spine

injuries must be suspected in patient with :unconsciousmaxilofacial traumaneck pain

CevicalC1 Fracture

(Jefferson’s Fracture)

Sudeen load on the top of headUsually no neurologis damage

C2 fracture (odontoid fracture)

UncommonFlexion injury after high-velocity or severe fallNeurological symptoms occur in about 20% cases

Fracture of pedicle C2 (Hangman’s Fracture)

Associated with C2/3 facet dislocation, need open reduction and stabilization.

Lower Cervical Injury (Fracture from C3 – C7)Wedge fracturePosterior ligament injuryBurst fractureHiperextension injuryFracture-dislocation Tear drop injurySubaxial cervical fracture

Tear drop fracture C7

Fracture Dislocation C7 – T1

Thoracic & Lumbar injuryRelatively common, particularly in

thoracolumbar regionMost common fracture are

compression fracture, wedge and burst.

Less common but more serious are fracture-dislocation.

Wedge Compression FractureVertebral body

crushed anteriorly, posterior ligament remain intact.

Stable injuriesClinically symptoms

relative mild, but may be there is local tenderness

Burst Compression FractureFailure of both anterior

and middle column Posteior column and

intervertebral disc may be displaced into spinal canal.

May be stable but usually unstable

Neurologic defisit (+) unstable ]]

Fracture-DislocationSegemental

displacementAll three column

distrupted, posterior ligament torn, posterior facet joint fracture, and spinal column dislocated.

Completely unstable

ManagementEarly management

Rescucitation (Airway & cervical control, Breathing, Circulation)Immobilization (Rigid Collar Neck, Long Spine Board) Neurologic AssesmentInj. Methylprednisolone 30 mg/kgBB bolus, and 5,4 mg/kgBB/hour for 23 hours.

Definitive Management1. Cervical Spine

-Cervical collar- Halo ring- Fixation

2. Thoracolumbal

- Bed rest- Brace- Decompression and stabilization

Subaxial Cervical Spine Injury Classification System

(SLIC)

Components Points

Morphology No abnormality Compression Burst Distraction Rotation/translation

01

+1 = 234

Disco-ligamentous complex (DLC) Intact Indeterminate Disrupted

012

Neurological Status Intact Root injury Complete cord injury Incomplete cord injury Continuous cord compression in setting of neurological deficit

0123

+1

Subaxial Cervical Spine Injury Classification System (SLIC)

Subaxial Cervical Spine Injury Classification System

(SLIC)

Fracture dislocation C7-T1 with decompression and posterior stabilization

Nama : Rudi FebriantoLahir : Sumbawa, 18 Februari 1975Status : Menikah ( 1 istri, 3 Anak)Pendidikan :

SD 3 MataramSMP 1 MataramSMA 1 MataramPendidikan dokter FK UI 1993 – 1999Pendidikan orthopedi & traumatologi FK UI 2003 – 2008

Ketua SMF Orthopedi & Traumatologi RSUP NTB/FK UNRAM

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