Virtual Osteopathic Orthopedic

Board Review Course

Spine

Concepts & Patterns

April 25, 2020

Timothy R. Borman DO, FAOAO Clinical Spinal Instability

• The Loss of the Ability of the Spine Under Physiologic Loads to

• Maintain its Pattern of Displacement so that there is:

• No Initial or Additional Neurological Deficit

• No Major Deformity

• No Incapacitating Pain Basic Elements of a Systematic Analysis of the Problem of Clinical Instability in the Spine

• Anatomic Considerations

• Biomechanical Factors

• Clinical Considerations

• Treatment Considerations

• Recommended Evaluation System

• Recommended Management Recognizing and/or Suspecting Occult Cervical Spinal Instability

• History of a Flexion Injury

• Widening of the Interspinous Space

• Subluxation of Facet Joint

• Compression Fracture of Subjacent Vertebra

• Fixed Loss of Cervical Lordosis Clinical & Radiologic Findings of Cervical Spinal Instability

• AtlantoDens Interval Greater than

• 4mm in Children

• 5mm in Adults

• Widened Interspinous Space

• Narrowed or Widened Disc Space

• Acute Kyphotic Angulation

• Wide Facet Joints Clinical Examples of Spinal Instability

• Anterior Elements Destroyed/Unable to Function

• Posterior Elements Destroyed/Unable to Function

• Spinal Cord/Cauda Equina Damage

• Nerve Root Damage

• Dangerous Loading Anticipated Imaging Findings of Spinal Instability

• Lateral X-ray/CT/ MRI Vertebral Body Displacement

• Cervical > 4 mm Thoracic > 2.5 mm Lumbar > 4.5 degrees

• Resting Relative Lateral X-ray/CT/MRI Angulation:

• Cervical >11 degrees Thoracic > 5 degrees Lumbar > 22 degrees

• Relative Lateral Flexion Extension X-rays Translation

• Cervical > 11 degrees as Compared to Adjacent Uninjured Level Spinal Fractures Imaging in High Energy Injuries

• Fully Image Spinal Fractures with: •X-rays •CT Scan and/orMRI Scan • X-ray and/or CT Image the Entire Spine • To Screen for Concomitant Spinal Fractures Low Energy Spinal Fractures & Imaging

• Low Energy Fractures in the Setting of Normal Activities of Daily Living are Pathologic

• Identify the Underlying Cause, ie. Osteoporosis, Multiple Myeloma, Metastatic Disease, etc

• Image Fracture with CT, as well as Plain X-rays

• Consider MRI/Bone Scan for Determining Age of Fx and extent of Underlying Disease

• Fracture(s) may be Acute and/or Subacute and/or Chronic

• Chronic/SubAcute Vertebral Fractures May or May Not be the Pain Generator Spinal Cord Injuries Complete vs InComplete

• Classification Based Upon Ability to Convey Messages

• To and/or From the Brain

• To Parts of Body Below the Level of the Spinal Injury

• Complete Loss-No Messages Crossing the Injured Cord Level

• Incomplete Loss-Some Motor or Sensory Function Present at Least in the Sacral Segments (S4-S5) Spinal Cord Injuries-Complete vs Incomplete

• Spinal Shock

• Occurs within 24 hours due to Edema to Cord Surrounding the Injury

• Lasts for 24 to 48 Hours After Cord Injury

• Loss of Bulbocavernosus Reflex Confirms Presence of Spinal Shock

• Cannot Determine Incomplete Spinal Cord Injury during Spinal Shock Phase

• Spinal Shock Resolution

• Return of Bulbocavernosus Reflex

• Presence of Incomplete Spinal Cord Injury Now Becomes Possible by Physical Exam Incomplete Spinal Cord Injury Syndromes

• Central Cord Syndrome

• Anterior Cord Syndrome

• Brown Sequard Syndrome

• Posterior Cord Syndrome

• Conus Medullaris/Cauda Equina Syndromes

• May Have Mixed Features of Each Syndrome

• Nerve Root Injury With or Without Cord Injury • Central Spinal Cord Syndrome

• Hyper Extension Cervical Spine Injury in Older Patients

• “The Pincer Mechanism of Injury”

• Anterior Spinal Canal Disc Osteophyte Impingement Coupled with

• Posterior Spinal Canal Impingement

• Motor Loss Greater in Upper Extremities than Lower Extremities

• Sacral Sparing Anterior Spinal Cord Syndrome

• Cervical Spine Level

• Anterior 2/3 of Cord Injures

• Loss of Motor Function & Sensation Below Injured Level

• Retains Only Crude Deep Touch & Proprioception Sensation Distal to Cord Injury Brown Sequard Spinal Cord Syndrome

• Hemi Section Cord Injury

• Ipsilateral Loss of Motor Function

• Contralateral Loss of:

• Pain

• Temperature

• Light Touch Sensation Posterior Spinal Cord Syndrome

• Causes

• Penetrating Cord Injury

• Occlusion Posterior Spinal Artery

• Ipsilateral Loss of Proprioception, Vibration, Touch • Conus Medullaris/Cauda Equina Syndromes

• Surgical Emergency as Prompt Decompression Can Reverse Deficits

• Loss of Sensation

• Lower Extremities-May be Unilateral

• Perianal & Perineal Sensation

• Loss of Motor Strength

• Lower Extremities-May be Unilateral

• Loss of Rectal Sphincter Strength

• Loss of Urinary Muscle Function-Incontinence and/or Retention Spinal Pain Patterns & Generators

• Neck & Back Axial Pain Complaints

• Radicular Pain

• Referred Pain

• Axial and Extremity Pain Spinal Pain Patterns & Generators

• Neck & Back Pain Complaints

• Very Common Reason for Provider Evaluation

• Oftentimes Associated with Recent New Activity, Prolonged Postures and/or Unaccustomed Extended Exertion

• Usually Mild to Moderate Symptoms

• Quite Commonly Pain is Temporary in Duration Spinal Pain Patterns & Generators

• Neck & Back Pain Complaints

• Specific Pain Generator Difficult to Identify with Confidence

• May Reflect Underlying Visceral Disease: GB, CV, GU, Pulmonary

• May Represent Beginning Symptoms of Serious Medical Condition with “Red Flags”

• May be Initial Presentation of:

• Degenerative Disc Disease

• Facet Degenerative Joint Disease

• Inflammatory Spondylarthropathy Spinal Pain Patterns & Generators

• Cervical Spine Conditions Can Cause Pain Referral into the Upper Arm, to the Elbow Without any Nerve Root Involvement

• Cervical Radiculopathy Almost Always Involves Signs/Symptoms into the Upper Extremity Beyond the Elbow

• Lumbar Spine Conditions Can Cause Pain Referral into the Thigh, to the Knee Without any Nerve Root Involvement

• Lumbar Radiculopathy Almost Always Involves Signs/Symptoms into the Lower Extremity Beyond the Knee

• Referred Pain from the Cervical Spine and/or Lumbar Spine can be combined with true Radicular Pain Presenting a Mixed Pain Pattern Shoulder/Neck and Hip/Lumbar Pain Patterns

• Shoulder Conditions Often Radiate to the Neck and Upper Extremity

• Shoulder & Cervical Spine Conditions Can CoExist & Their Symptoms can Overlap One Another Simultaneously

• Hip & Sacroiliac Conditions Often Radiate to the Low Back and Lower Extremity

• Hip & LumboSacral Spine Conditions Can CoExist & Their Symptoms can Overlap One Another Simultaneously Shoulder & Neck Diagnostic Evaluation

• Neck and/or Shoulder Complaints

• Take History & Perform Physical Exam

• Cervical Spine & Shoulder

• Consider Imaging of Both Cervical Spine & Shoulder Joint

• Consider Radiologist Assistance of Arthrogram Documented Local Anesthesia Injection into the GlenoHumeral Joint

• Patient Must Keep Detailed Pain Diary Before and After the Injection Hip & Spine Diagnostic Evaluation

• Hip and/or Low Back Complaints

• Take History & Perform Physical Exam

• Lumbar Spine & Hip

• Consider Imaging of Both Lumbar Spine, Pelvis & Hip Joint

• Consider Radiologist Assistance of Arthrogram Documented Local Anesthesia Injection into the Hip and/or Sacroiliac Joint

• Patient Must Keep Detailed Pain Diary before and after the injection Spinal Pain “Red Flags”

• Chronic, Recurrent, Acute Infections, and/or IV Drug Use

• Fevers/Chills/Night Pain Predominance

• Immunosuppression Therapy

• Diabetes mellitus and/or Renal Insufficiency

• History or Suspicion of Malignancy

• Osteoporosis with or without Trauma

• Recent Spinal Surgery and/or Spinal Injections

• Recent Trauma History

• Physical Abuse Victim Non Specific or Atypical Spinal Pain Presentation

• Pay Attention to Your Intuition

• Take Comprehensive History

• Perform Spinal & Extremity Exam

• Patient Dressed Down to Gown & Shorts

• Ancillary Studies Screening

• Technetium Bone Scan

• ESR, CRP

• Nonspecific Studies but Quite Sensitive NonSpecific or Atypical Spinal Pain Evaluation Ancillary Studies

• Abnormal Technetium Bone Scan Reflects Increased Isotope Uptake Due to:

• Increased Boney Blood Flow and/or Increased Osteoblastic Activity

• Positive with Infection, Tumor, Occult Fracture

• X-ray, CT, and/or MRI Image Any Area of the Abnormal Boney Uptake

• ESR Elevated due to Inflammation:

• Positive with Infection, Tumor, Inflammatory Arthritis Radiculopathy

• Neck Pain with Upper Extremity Pain Does Not Establish the Diagnosis of Cervical Radiculopathy

• Low Back Pain with Lower Extremity Pain Does Not Establish the Diagnosis of Lumbar Radiculopathy

• Radiculopathy requires valid objective findings of specific concordant nerve root dysfunction such as:

• Radicular Pain Pattern/Distribution

• Radicular Pattern of Diminished Sensation

• Myotomal Pattern of Muscle Weakness/Atrophy/DTR Loss or Asymmetry Spinal X-rays Under Physiologic Load

• Cervical Spine X-rays Should Include:

• Standing or Sitting Lateral Views in Flexion & Extension

• Lumbar Spine X-rays Should Include:

• Standing AP View

• Standing Lateral Views in Flexion & Extension

• Scoliosis X-rays Need to Include Standing ThoracoLumbar Long Film AP & Lateral Views MRI Considerations

• If you order a Musculosketal MRI

• Always Be Sure to Have Performed X-rays of the Area of Concern or Order the Appropriate X-rays

• MR Imaging is Not a Substitute for X-rays nor CT Scans

• When Supine MRI is Compared to Standing Lateral X-rays, Instability is Frequently Identified on X-ray even Without Lateral Flexion/Extension Views Radicular Pain

• Radicular Pain without objective findings of radiculopathy into the Extremity can be just as debilitating as Radiculopathy

• Provocative Physical Exam Maneuvers such as Spurling’s Maneuver in the Neck or Straight Leg Raising in the Low Back may help identify a precise pain radiation pattern consistent with a specific nerve root dermatome.

• Be specific and record the provocative pain pattern elicited. Radicular Pain Evaluation

• Spurling’s Maneuver

• Provoking radicular pain following a specific dermatome distal to the elbow is a positive finding

• Pain Limited to Neck or Shoulder Upon Pain Provocation is not a specific positive finding.

• Straight Leg Raising

• Provoking radicular pain following a specific dermatome distal to the knee is a positive finding

• Provoking low back or thigh pain is not a specific positive finding. Diagnostic Spinal Injections

• Diagnostic Local Anesthetic Injection under the direction of a well trained Spinal Injection Specialist of a Specific Spinal Nerve Root May Help Identify the Radicular Pain Generator

• The Resolution of Pain for the Expected Local Anesthetic Duration is Most Important

• Inject only (1) specific nerve root per Week Diagnostic Spinal Injections

• Indicated for the Purpose of Identifying a Specific Pain Generator Such as:

• Specific Nerve Root

• Sacroiliac Joint

• Facet Joint

• Limit Diagnostic Injection to one (1) Region per Week

• Patient Needs to Keep Detailed Pain Diary Before and Following Injection

• The Resolution of Pain for the Expected Local Anesthetic Duration is the Important Data

• Therapeutic Effect of Spinal Injections has only Fair Efficacy per Scientific Analysis Myelopathy-Spinal Cord Injury or Disease

• Onset Varied: Obvious & Acute versus Subtle & Insidious

• Axial Pain Most Common Presenting Complaint, Acute or Chronic

• Presentation May be Delayed When Pain not a Major Symptom

• Other Symptoms: Gait Dysfunction, Frequent Falls, Lower Extremity Weakness, Sensory Change

• Balance & Gait Abnormality:

• + Romberg Trouble Tandem Walking Trouble Climbing to/from Exam Table

• Bowel/Bladder Dysfunction: Irritable Bladder Urinary Retention

• Lower Extremity Findings: Weakness, Hyperreflexia, Ankle Clonus, Sensory Changes

• Concurrent Lumbar Pathology not Uncommon

• May Combine with Radiculopathy especially in Cervical Spine, “Numb, Clumsy Hand Syndrome” Myelopathy-Spinal Cord Injury and/or Disease Causes

• Infection

• Primary Spinal Cord

• Acute and/or Chronic Spinal Canal and/or Vertebral Body

• Trauma

• Herniated Disc

• Degenerative Disc Disease

• Tumors

• Upper Motor Neuron Disease, ie Multiple Sclerosis Surgery for Myelopathy Due to Spinal Cord Compression

• High Index of Suspicion Hastens Prompt Diagnosis

• No Improvement can be Expected with Nonoperative Treatment

• Earlier Surgical Decompression/Stabilization Best Results

• Anterior Surgical Decompression & Fusion

• May Prevent Worsening

• May Lead to Some Degree of Improved Neurological Outcome Lower Extremity Claudication

• Spinal Neurogenic Claudication-Lumbar Spinal Stenosis

• Symptoms Worsen with Lower Extremity Exertion

• Symptoms Improve with Flexed Lumbar Posture “Shopping Cart Sign”

• Vascular Claudication-Vascular Insufficiency

• No Pedal Pulses-Order Abdominal & Lower Extremity Vascular Ultrasound

• Symptoms Worsen with Lower Extremity Exertion

• Neurogenic and Vascular Claudication May Be Present Concurrently

• Treatment Priority “The Rule of the Artery is Supreme” Optimizing Spinal Surgery Decision Making

• Patient’s Comprehensive Pain & Functional History is Valuable

• Concordant Data: Does the Clinical Summary Make Sense?

• History Physical Imaging Studies Clinical Course

• Diagnostic Injections Electrodiagnostic Studies

• Understand the Patient’s Expectations

• Surgeon’s Intuition is Valuable Optimizing Spinal Surgery Decision Making

• Have Specific Reasons for the Surgery You Recommend

• Tailor the Surgery to the Patient’s Unique Clinical Presentation

• Value Your Cognitive Analysis

• If the Clinical Presentation Does Not Make Sense to You, Reach Out to a Respected Colleague.

• Share Realistic Surgical Recovery Time & Results with Your Patients Spinal Surgery Considerations

• Neither Discectomy Nor Spinal Decompression Rarely Relieves Axial Neck nor Back Pain. These Operations are Best Suited for Treating Neural Symptomatology

• Successful Spinal Fusion Surgery May Improve Function, However, May Not Abolish Neck nor Back Pain

• Radiologic Evidence of Spinal Fusion Healing Is Necessary

• “ There is Nothing So Humbling As Postoperative Follow-up.”