<p> Spine</p><p>Cervical DDD . Vertebral artery – MC when - natural lordosis – each segment 2-3 degrees use of high-speed burr - MC C56, then C67, C45 . 1/100 cases - neurologic o C5,6,7 MC affected b/c associated complications motion segm w/ most motion . pseudarthrosis o watershed area of blood supply to SC  10% for 1-level here fusions, 44% for 3- - Inverted radial reflex = C6 level level fusions - Risks: lifting, cigarettes, driving  not always painful - Discogenic neck pain  tx w/ PSF w/ wiring o Axial pain - Radiculopathy Cervical anatomy o From osteophyte - C3-6 bifid spinous processes o Soft disc (HNP) - C7 vertebra prominens - Myelopathy - carotid tubercle – lat process of C6 - False-positive MRI - cricoid cart C6 o Under age 40: 14% - thyroid cart C45 o After 40: 28% - uncinate processes projections off post-lat - Affect lower numbered root – ALWAYS surf of sup end plates - 75 % of pt improve w/ conserve tx o joints of Luschka - articulation w/ - RA convex inf-lat surf of caudal vert o RF for cervical involvement: RF+, ext - vert A passes ant to TP’s of C7 before periph jt involvement, male gender, enterins spine at C6 foramen steroid use - art supply of ant 2/3 cerv spinal cord – Ant o surg for post antlanto-dens of < 14 Spinal A. mm, cord diameter < 6 mm in flexion, - Average Sagittal diam of spin canal averages cerv-med angle of < 135 deg, 13 mm 23 mm at C1, dec 15 mm @ C7 or less SAC - C3-8 nerve roots exist ant to facet jt C2 nerve root exist post to C1-2 facet o sup migration of odontoid alone not o indication for surg jt - Surgery - AA jt 50% of overall cerv rotation o Persistent radiculopathy 6 wks Cervical myelopathy o Progressive significant weakness - Congenital stenosis Myelopathy o - Spondylosis ACDF most common o o Anterior bars Avoid laminectemy o o Kyphosis o Possible for keyhole foraminotomy - OPLL (MC in Asians) (posterior approach) - Sx . Unilateral radiculopathy o Gait deterioration o Plating should be used for 2 or 3- . Most significant complication level fusions . Broad-based shuffling gait o Smith-Robinson intervals o UE weakness/clumsiness - Complications – anterior approach o Myelopathy hand (loss of intrinsics, o Recurrent laryngeal N. ulnar drift of fingers) . 1% occurrence o UMN signs . Laryngoscopy if no o Will eventually progress (surg will resolution after 6 wks keep pt where they are) Spine</p><p>- XX - AAI increases w/ duration o Sagittal diameter canal: < 13 mm is o Is reducible, then becomes fixed, stenosis (nl is 17 mm) then SMO o Pavlov’s (Torg’s) ratio: o Myelopathy worsens, may lead to canal/vertebral body death . < 0.8 is stenosis (but too - Ranawat sensitive) o I: neck pain, nl neuro exam - MRI o II: UMN signs, dysesthesias, nl o Stenosis, cord flattening strength o Compressive ratio (AP diameter vs. o III: objective weakness transverse side-side diameter) AP . A: Ambulatory, B: non- should be more than 40% of ambulatory transverse - SMO - Surgery - anterior o McRae’s line – across foramen o anterior approach to address magnum – if across then basilar compression invagination o plate may prevent fusion of strut graft - If > 4 mm motion @ C1-2 o for 3-level corpectemies, need o Any elective surgery: collar to OR, posterior plating as well awake intubation or spinal o halo not definitive for lower cervical - Surgical indications spine o SAC < 14 mm (distance behind dens - Surgery – posterior to front of post arch): operate o If lordotic, then decompression o Ranawat IIIA: operate posteriorly is advantageous (if o Basilar invagination kyphotic, then not good enough) . Ranawat line < 14 mm (line o Laminoplasty: avoid kyphosis, perp to line through arch of preserve motion, good for multi-level C1 – distance to pedicle (usu disease 17 mm)) o Laminectemy and plating – get pt o Subaxial subluxation back into lordosis and keep them . Canal < 14 mm there . instability - Cervical surgery outcome o Controversy: o 80% pain relief . Ranawat II, IIIB (probably o 90% neuro improvement operate) o prognosis correlates to severity of . 8 mm C1-2 w/ cord myelopathy #1, cord compression, compression age . progressive instability . pain Rheumatoid C-spine - Surgical treatment - 25-80% involvement in RA o C1-2 instability - synovial jt ant and post to dens . PSF, wiring, Halo o pannus w/ ligamentous laxity . Magerl (transarticular) screws o cord compression . Odontoidectemy transorally – - C1-2 instability MC rarely needed (if fusion, then - Basilar invagination (superior migration of pannus will resorb) odontoid) o Basilar invagination: fuse to - Subaxial instability occiput - Mixed patterns o Subaxial instability: PSF Spine</p><p>. continue drip 48h if started @ Spinal Cord Injury 3-8h - MVA – 50% o skeletal traction, reduce - GSW increasing – may be 50% . incomplete cord injury - Complete . in an awake/alert pt, cooperate o No distal function w/ exam o BCR intact or 48h after injury o MRI for suspected HNP o C6 quad – threshold after which . Facet jump w/ disc narrowing you gain a lot of function (warning sign) - Incomplete . For neurologic worsening o Anterior cord . NOT for complete injury . May mimic complete . Before operative reduction . Loss of motor o GSW: usu non-op except for cauda . Worst prognosis when severe equina or through colon o Central cord - Incomplete SCI . MC o Decompress when neuro plateaus, . UE worse than LE, some sometimes emergently with preserved motor compressive lesion . Late: LMN in UE, UMN in o With decompression, root return 1-2 LE levels of root return . Good prognosis: ambulatory, - Complete SCI bladder control, clumsy hands o Stabilize to facilitate rehab (e.g. no o Brown-Sequard halo) . Usually penetrating trauma o Decompress for root return . Ipsilateral paralysis, (controversial) contralateral loss of pain/temp (2 levels below) Cervical Spine Trauma . Best prognosis, 99% - Up to 25% SCI occur after initial traum ambulatory episode during management/transport - Complications - Motorcyclists higher inc of thor spinal o Neurogenic shock injuries . Hypotension, bradycardia - AS or DISH . Swan-ganz monitoring, o nondispl fx common careful w/ fluids o high rate of delayed dx . Pressors o unstable o Skin problems (rotorest bed) - XX not req in pt w/o neck pain, awake o Urosepsis – aseptic technique w/ - 2-6% neck pain have sign C-spine injury foley, prevent bladder from getting - MRI has lack of correlation b/w clin sign inj full (controversy) o Autonomic dysreflexia - Reasons for missing it: multisystem trauma, . HA, agitation, HTN head injury, LOC, EtOH intox . Should check foley and - Adequate XX mandatory to top of T1 (if not, disimpact pt then CT) - Treatments - Occipital condyle fx o Steroids for all x pregnancy, under 13 o 11% mort rate from ass inj . Initiate w/in 8 hr o ass C-spine inj at additional level is . 30 mg/kg over 1st hr, 5.4 31% mg/kg next 23h - Occ-cervical dislocation Spine</p><p> o Powers ratio = basion to post arch/ant . from axial compression and arch to opisthion hyperextension . ratio > 1, then ant dissociation . Less than 2 mm displacement o use of traction = 10% rate of neuro – tx w/ collar deterioration . Usu neuro intact - Atlas fx . Usu heal despite displacement o Jefferson fx – bilateral fx of ant/post o Type II - hypertext, axial load, then arches rebound flexion o Only 50% are isolated fx o Type IIa – worse with traction o Open-mouth XX: . flexion-distraction inj . 7 mm spread = transverse . severe angulation, minimal ligament injury translation  w/ XX mag – 8.1 cm . surg for type II w/ severe ang o 2 types of transv lig injury o Type III – associated w/ C2-3 facet . midsubstance ruptures (type I) dislocation, type I pars fx  least likely to heal . all: open red, fusion  PSF C1-2 o up to 5mm of displacement can occur . type II – avulsion fx w/o disruption of post lig, or C23 disc  higher rates of healing - Facet dislocation 25% displacement usu unilateral  Halo o 50% displacement usu bilateral o usual tx: Halo o - Odontoid fx o SCI worsens w/ increasing o Type II displacement . RF for nonunion: o Skeletal tx, closed reduction comminution, disp > 6 mm, o Tx: PSF after reduction (b/c risk of post displ, delay dx, age > loss of reduction) 50yo - Vertebral body fx . Surg treatment: Elderly, 5-mm o Ext immob for 6-12 wks displacement, irreducible o Burst fx, decompression best through . For elderly: collar vs. surgery ant approach w/ corpectemy (no halo – poorly tolerated) o Facet dislocations . PSF (magerl or wiring) or . 25% subluxation – unilateral anterior screw osteosynthesis . 50% - bilateral (one screw) . 26% will fail attempted closed  No anterior screw for red, higher fail rates w/ nonunion or for non- unilateral facet disloc anatomic reduction  red ant using Caspar (obliquity or anterior pins displacement of dens) . unilateral facet fx most freq . Nonoperative tx: young, non- missed C-spine inj on XX displaced o High-risk SCI o Type III : Halo . Esp Tear-drop Fx (small chip - Hangman’s fx back posteroinferior corner of o Bilateral fx pars of C2 body) o Mechanism: hyperextension then . Disruption of posterior cortex flexion – higher neuro injury o Nondisplaced hangman’s (type I) – stable Spine</p><p>. Post ligamentous injury – dx . Anterior to temp fossa, post to by widening of interspinous supraorbital N. distance o Pin loosening 35%  Highly unstable o Infx 20%  Tx: ASF/strut/plate or o Discomfort 18% ASF/strut w/ PSF o Dural puncture 1% . Stable – heal in brace/halo - Pediatric . Surgery if SCI: early rehab o Before age 2 – Minerva cast o Multiple pins (6-8) Ankylosing spondylitis o Low torque (4-5#) - High risk C-spine injury - High risk delayed neuro deficit (should be Thoracolumbar trauma admitted)  Precarious blood supply to thor SC - Epidural hematoma  Facets oriented in coronal plane – red amount of Tx w/ laminectemy o ext of thor spine - Requires more aggressive stabilization  Nl apex of kyphosis is T6-8 (front/back) - Dx w/ CT scan  Chance – flexion/distractive mechanism - Marginal syndesmophytes o High chance of visceral injury o Ossification anterior discs and ALL  T2-T12 Usually stable o Non-marginal syndesmophytes o (just ALL) – DISH o But high risk for neuro injury - DISH  T11-L1 o 3 consecutive levels of nonmarginal o Isolated conus injury syndes w/o DDD o Mixed neuro pattern  L2 down: cauda equina, better prognosis Pseudosubluxation  2 out of 3 columns disrupted = unstable - Horizontal facets C2-3  Any translation - Usu under 4 yo o Unstable - Minimal hx of trauma o Tx: fusion - No compensatory lordosis below  Complete SCI: stabilize for rehab - Reverses on extension  Incomplete SCI (even if neuro deficit was transient) Halo o Stabilize to protect recovery - Ideal orthosis upper C-spine o Decompress early - Fixes skull relative to torso  Compression fx o Allows intercalated paradoxical - neuro intact, less than 30 deg kyphosis, less motion in subaxial region than 50% vert body height o Unreliable for immobilization lower o tx w/ hyperextension orthosis C-spine (facet jump) - fx above T6, use cerv extension on TLSO - Total 4 pins, 8# torque, go back 24h later to  Burst fx – surgery for any of these: tighten - With widening of interpedicular distance, - Complications translation, tender, grey-turner sign = post lig o Anterior pin in temporalis fossa injury . Weak bone o Tx: operation . Increase in loosening, infx o Canal compromise > 50% o Recommend site o Kyphosis > 20 deg o Compression > 50% Spine</p><p> o Even in neuro intact pt o load-bearing axis more post o Decompression: o compression fx less common than . Anterior, posterolateral burst  Anterior for late with o greater flexion moment req, so post neuro deficits column inj MC  Indirect (by restoring o lordosis affects mechanics of healing alignment) = 50% o treatment usu nonop clearance o single leg spica for fx of L4 and L5 to  NOT just laminectemy control pelvis, LS junction o Stabilization o 8-12 wk brace . Avoid distraction L3 down o beware of laminar fx in cases that . With only 4 pedicle screws – 50% need post decompression breakage and kyphosis (need one o unlikely to progress kyphosis level above, 2 below) o surgery for progressive or severe neuro . Posterior is more stable – do in deficit, deformity unstable injuries without neuro . surgery is difficult deficits - TL Junction Trauma . Anterior for neuro decompression o Sagittal alignment of spine changes . w/ complete inj – PSF to imp from kyphosis to lordosis, evenly rehab distributes stress on ant and mid o Burst and laminar fx columns . 34% dural tear o discs taller in thor spine – dec ant . + neuro deficit, then 74% dural column stiffness tear o 3-column inj inc risk of posttraumatic  indication to go posteriorly kyphosis to remove entrapped nerve o Tx: root . hyperextension body casting  Chance vs. TLSO x 3 mo o Distractive, flexion . incomplete inj – ant o Rotated around lap belt decompression/stab o Abdominal visceral injury o stable burst fx o If pure bony, then cast or brace . initial kyphotic improvement o If soft tissue, unreliable pt, non-anatomic in surg pt is lost over time reduction . residual kyphosis is not . Surgery w/ compression implant reliable predictor of chronic (4 ped screws ok) pain o Pediatric bony chance . degree of remodeling similar . Tx: cast immobilization for 6 wks, in pt tx surg or nonsurg then TLSO - Sacrum trauma o if fulcrum by vert body, then ant o vertical fx MC column fails in comp, mid/post fails . post SI plating/screws in tension o lower sacral roots (S2-4) missed b/c o if fulcrum ant to VB, all three only L5 and S1 can be evaluated columns fail in tension o Zone 2 fx w/ 28% neural inj o PSF, short-segm post compression . screws should not be loaded in constructs compression - Low lumbar burst fx o unilateral sacral root inj have nl o 4% of all spine fx bowel/bladder Spine</p><p>. 90% bulge/degeneration Lumbar Degenerative Disorders  Lumbar discs . 100 billion annual cost o TNF-alpha key in sensitizing . 90% resolution in 1st month nerve root to pain . RF: men, obesity, smoking, lifting, vibration, . local acc of sodium ion sitting, job dissatisfaction channels – pathway . R/O Red flags . IL-1B, IL-6, PGE2, phosph-  Tumor, infx A2 found in nerve root and  Trauma DRG  Cauda equina sx (urinary retention) o sensory fibers most vulnerable to . No imaging in 1st month compression (affected 1st and . Lumbar disc dz recover last) - Degeneration o Posterolateral o Decrease in nutritional transport . MC o Low pH . Lower numbered root o Decreased H20 o Far lateral (foraminal) HNP o Decreased proteoglycans . Maybe 10% o Decreased type II collagen . Upper numbered root  Type II collagen in NP and AF replaced o Tension sign – most predictive by type I collagen finding  Chondroitin sulfate replaced by keratin . SLR sulfate  Sitting/supine  inc dissociation b/w collage and PG in  Reproduce disc pain/parasthesias  Disc innervated by sinuvertebral N. @ 30-70 deg  nerve endings in AF – substance P,  Reproduce leg pain calcitonin gene-related peptide,  L5/S1 vasoactive intestinal peptide radiculopathy  L45 MC  X-leg SLR  Recurrent torsional strains (tearing outer . Femoral nerve stretch test fibers of annulus)  L3 or L4 root nd  Lumbar spondylosis o Pt w/ 2 episode of sciatica o Disc dessication, collapse . 90% improve, but 50% will o Progressive facet arthrosis have recurrence o Disc bulging, osteophytosis . future episodes 100% for three prior episodes o Abnormal kinematics, leads to 90% improve w/o surgery, most further degeneration o better 4-6 wks, some after 12 wks  Abnormal MRI . surg results deteriorate after o Age 20-39 ASx pt 12 wks . 21% HNP . operative vs. nonoperative . 50% bulge/deterioration about equal @ 4 yrs Age 40-59 o . nonoperative tx best usually . 22% HNP o Surg indications . 50% bulge /deterioration . Cauda equina Age 60-79 o . Progressive weakness . 36% HNP . Persistent, disabling pain . 21% stenosis o Results Spine</p><p>. 90% relief of leg pain - Lateral recess stenosis . neuro recovery independent of o b/w sac and medial wall pedicle surg or not o L5 nerve root  if no pain, then no surg o Overhang of sup art facet, facet . 15-30% persistent back pain capsule, disc . neuro recovery - Foraminal stenosis  50% motor/sensory o Lateral to medial pedicle “exit zone”  25% reflex o Facet enlargement of overriding, . complications: uncinate spur, disc  dural tear (tx is for o L4 (exiting nerve root) watertight), o foraminal height ranges 20-23 mm  recurrent HNP (3- . < 15 mm, post disc height < 4 11%), mm ass w/ nerve root  discitis compression in 80% pt o (occur 3-6 wks . foraminal area dec 20% after surgery, during extension, inc 12% back pain) inflexion o test: MRI w/  nerve root gadolinium compression least in  vascular catastrophe flexion, highest in ext . Extension to painful side Lumbar spinal stenosis worsens sx (Kemp sign) - Combo of degenerative and developmental o narrowing - Clinical - absolute stenosis < 10mm, 10-13 mm relative o Back pain, stiffness (loss of lordosis) stenosis o Pain on lumbar extension - decrease to < 100 mm2 is more reliable o Leg pain (buttock or hip) measure of lumbar stenosis . Usu prox to distal o claudication occur in 90% of pt w/ . Worse w/ walking cross-x canal area < 90% . Neurogenic claudication in - nerve compression in animal studies only 50% o rapid onset (0.05 s) causes more o Neuro nl > 50% damage than insidious onset pressure o MRI or CT myelo (previously (20s) operated spine) - Soft tissue contributes 40% narrowing . Thecal sac < 100 mm2 - Men > women . Facet, capsule, lig flav - Congenital compressing root in lat recess o Short pedicles, medially placed facets or foramen o Trefoil canal - Surgery o Achondroplasia o bladder sx preop is neg prog indicator - Acquired o Persistent pain o Spondylotic change o Progressive weakness (rare) - Spondylolisthesis o Laminectemy, partial facetectemy - Post-surgical o Fusion - Combined . Degenerative - Central compression (L4-5) spondylolisthesis or scoliosis o Inferior facet and ligamentum flavum . Instability (multiple o Root compression L5 operations) Spine</p><p> o XX nl for 3 wks Thoracic disc disease o Maybe endplate destruction - 1% all clinically relevant discs o Tc/Ga scan - high false + on MRI . Sensitivity 90% - thoracic facets vertical – which allow lateral . Accuracy 85% bending/rotation, limit flex/ex . Indium wbc is NOT helpful - blood supply tenuous from T4-T9 . gallium can follow tx response - cord:canal ratio higher in thoracic spine than o MRI c-spine . Sensitivity 96%, spec 95%, accuracy 94% - Most T8-T12 . imaging modality of choice - Location o Management o Central, posterolateral, lateral . Need Needle biopsy (+ 50% of time) or - Clinical bld cx o Back pain . NOT broad spectrum antibx o Radiculopathy (abd wall) . Appropriate IV antibx for 12 wks o Myelopathy  Monitor healing w/ ESR o Check sensory pinprick . Surgery only for o UMN (UE vs. LE)  Tissue for dx o Thoracic MRI  Significant destruction/deformity - Treatment  Epidural/paraspinal abscess o Surgery  Failed abx tx . Progressive neuro  ANY neuro deficit . Myelopathy o Risk is greater Cspine > . Radiculopathy? (maybe Tspine > Lspine SNRB) o Increased in RA, DM, o Approach elderly . Transthoracic – central HNP o Operate even if seen late . Costotransversectemy –  Always anterior posterolateral o Ant . Transpedicular – lateral debridement/decompressio . NOT laminectemy n o Auto strut graft same time Infection (modified Hong Kong o Hematogenous seeding of VB procedure) o S. aureus MC o Post fixation usu RF for paralysis: DM, RA, steroids, inc age, o unnecessary Staph, cephalad level of infx o Avoid laminectemy if ant CT-guided bx best results o column is infected Deposits of bacteria in endplate – then erosion o o auto BG safe through – disc destruction o TB In child, vascularity extends through cart growth o - Increased incidence: AIDS, IVDA plate into NP - Kyphosis - in adults, BV reach only annulus - Skip Lesions o Occurs in elderly, immunocompromised - Sinus formation o Preceding infx (50% of time) - Paraplegia . URI, UTI, skin - Tx . w/ partial treatment o Disc is involved on MRI! (if not – then tumor) Spine</p><p> o Ambulant chemotherapy (= results w/ - pt w/ complete neuro def are at higher risk surgery) for infx o Surgery (usu b/c deformity, kyphosis) Metastatic Spine Dz . Modified Hong Kong - Spine most common skeletal metastasis . 9 mo chemotherapy - Skeleton 3rd MC (lung/liver) . like for pyogenic infx - Start in body (90%), then spread to - MC granulomatous dz of spine pedicle - 10% w/ TB will dev MS infx - XX nl until 30-40% VB destroyed o 50% will have spinal involvement - Loss of pedicle (cortical bone) is early XX - peridiskal type sign o disc resistant to infx until very late - Warning signs (unlike pyogenic) o Age > 50 - central type o History of CA o mistake for tumors – isolated to one o Recent wt. loss vertebra o Pain at rest - anterior type - Dx o multiple VB along ALL o XX o multiple levels o MRI: test of choice - infx takes longer perior of time, more . Marrow replacement deformity observed at time of ppt (distinguishes b/w - thoracic spine MC location for spinal TB osteoporosis), ST mass - ESR nl in 25% of pt . Disc spared on every cut (dist - MRI w/ gad study of choice b/w infx) - PCR better for fast identification - Tx - early debridement led to faster, better neuro o Systemic chemo, hormonal, steroids recovery o Radiation: MC local tx o Epidural abscess o Surgery - S. aureus in > 60% pt . Tissue for dx (needle bx) - MRI w/ gad imaging mod of choice . Failure of RT - early dx prevents devastating outcomes . Increasing pain/neuro def o Candida MC fungal pathogens . Radioresistant tumor o PO Infx . For Instability - Discitis  Translational . Incidence 1% open, less w/ less invasive deformity proc  Ant/post column . Hx: 2-4 wks involvement  Severe unremitting LBP  Sign collapse  Low grade fever, WBC  > 50% VB destruction . MRI w/ gado . Anterior surgery usu . Needs needle bx (tx even if negative)  Decompression/stabili . IV antibx zation . Rarely surgery (usu autofusion)  Site of pathology - use of microscope increases infx from 0.7%  One-stage to 1.4% reconstruction - overall postoperative infx risk higher in . Posterolateral trauma pt  Only for multilevel disease, skip lesions Spine</p><p> Results as good o ave age 56 yo . Ant/Post both for o Midline mass  Circumferential lesion . large ST mass  Translation o Physaliferous cells  Dz in TL junction o single, large dose of radiation . Avoid laminectemy!! o Sacrum, clivus, but can occ in spine . Bone graft for survival > 6 mo o Slow growth, so aggressive surgical tx Primary spine tumors . Better to take everything out - After age 40, think metastatic and risk bowel/bladder - Posterior elements . surg w/ wide margins only tx o Benign - Multiple myeloma o Osteoid osteoma / osteoblastoma o solitary plasmacytoma often o ABC (ant or post) – rarely ant alone progresses to MM o Tx: excisional bx, intralesional o MC primary malignancy of bone and - Anterior column spine o Malignant - Spinal Cord tumors o Ewing’s o MC malign in epidural space is LA o Osteosarcoma . spread from VB or o Lymphoma paraspinous nodes o Myeloma o intramedullary tumors o Could be hemangioma (10%), GCT, . astrocytoma, ependymomas EG - Osteosarcoma - Osteoid Osteoma o VB including sacrum o 70% painful juvenile scoliotic deform o Tx: neo-adjuvant tx, then reassess ass w/ osteoid ostteomas around apex o Aggressive tx at resection of concavity of curve o Prognosis bleak o most sens study is bone scan . poorer than appendicular OSA - Osteoblastoma o Same goes for chondrosarcoma o more readily detected on XX b/c of - Impending collapse larger size (> 2 cm) o thoracic spine – 50% of VB o local recurrences in 10-15% of pt involvement or 25% VB w/ costvert . 50% I pt w/ high-grade involvement - GCT o lumbar spine – 40% VB or 25% w/ o 5-10% of all GCT pedicle or post body involvement o sacrum MC - radiation tx delayed 6 wks after spinal o recurrence 80% in grade III reconstruction involving arthrodesis to permit . metastasis 10% early phases of BG revascularization - ABC o can involve multiple adjacent spinal Spondylolysis segm - acquired condition - Hemangiomas - MC in males, 6% of population o 11% of pop - L5 MC - primary lesion is stress fx of pars o low-dose radiation effective interarticularis that is unhealed o embolization effective - standing XX make deformity worse vert cement augm procedures ok o - instability = < 3mm translation - Chordoma Spine</p><p>- CT myelograms can miss foraminal stenosis . L5-S1 spondy’s don’t move b/c compression is lateral to root sleeve/dye on flex/ext - SPECT more spec and sens than technetium . L45 more unstable – more scans need surgery - Type I – dysplastic o Nerve root compression o LS junction . L5-S1 spondylolisthesis = L5 o L5 trapezoidal N. root o S1 rounded/domed . Foraminal stenosis - Type II – isthmic . Stump of pars, stress fx build- o pars defect, elongated pars, acute pars up, disc, pedicle can compress fx . Cauda equina rare - Type III – degenerative  May see postop from o incompetence of arthritic facet jt high grade slips - Type IV – trauma o Tx - Degenerative spondy . Nonoperative o more prevalent in women, African- . Flexion exercise program Amer (more painful in extension) o L45 MC . Surgery o + correlation b/w sagittally oriented  Wait 6 mo facet jt and spondy  For leg pain (some for o bilateral facet angles > 45 deg at L45 back pain) lead to 25x chance of spondy  Posterolateral IT o L51 more coronal facets fusion (no . more resistance to translation decompression alone) o L5 nerve root MC affected o To L4 for > o bladder dysfx in 3% pt 50% slip (o/w L5-S1) o decompression w/o fusion, lead to ALIF 25% need reoperation o . best for o even w/ pseudarthrosis, pt have better grade I outcome than w/ decompression alone Interbody - Adult isthmic spondylolisthesis o fusion (TLIF) o Fatigue fx pars interarticularis is good option (spondylolysis) . pt do o rarely progress beyond grade II better o progression MC in adolescence o +/- increase in adulthood is uncommon o instrumentation injections not studied o o +/- reduction o L5 MC (82%) . Decompression o 5-6% of nl population has it  Results worse in pt . 2x MC in men decompressed/fused . gymnasts, football linemen vs. fused alone . 75% present by age 6  Indications . 75% w/ slip o Leg pain below . MC cause of back pain in knee children under 10 o Neuro deficit . 80% pars defects evident on Older pt plain lateral XX o Spine</p><p> Foraminotomy, not - Tx: just Gill o Nonoperative (consider other sources - Dysplastic spondy of pain) o often high-grade slips o combined ant-post surg lower infx o MC slip seen in children than staged procedures o trapezoid L5, def of post arch, o Surgery only for: incompetent L51 disc . Curve progression o L5 nerve root MC affected . Intractable curve pain o highest risk for progression (concavity) – not LBP o crouched gait . Cosmesis o in situ fusion w/ decompression best . PSF w/ instrumentation o reduction leads to 8-30% neuro  Smaller, flexible deficits thoracic curves (< 60 . inc implant failure deg) . creates ant column defect o 40% correction o decreased nonunion rates when ALIF on side- combo w/ post open reduction bending, then no benefit w/ Adult Deformity anterior - Thoracic curves > 60 deg greatest risk for  selective thoracic progression fusion - degen scol higher rate of progression  very flexible TL or (3.3deg/year) lumbar curves, but - RF for progression: curve > 30 deg, apical o nonunion rotation > 33%, > 6mm listhesis, poor seating rates higher in of L5 on S1 lumbar spine - scoliosis pt more back pain than control  young, middle-aged - 10 deg inc in curve over 40 deg results in adults 10% dec in curve flexibility . ASF w/ instrumentation - 10-year inc in age dec flex of 5%, and LS  Flexible TL / lumbar fractional curve by 10% curves - thoracoplasty – 27% decline in pulm fx by 3  Save distal fusion mo postop levels - Degenerative  Young adults o Lumbar, lower magnitude  Cannot reverse o Rotation, lateral listhesis kyphosis o More likely to have stenosis . ASF/PSF w/ instrum (concavity) than old idiopathic  Large (> 70 deg) - Natural hx curves, rigid o Pain controversial (no stat  Lumbar component of relationship) a double major curve o Progression o b/c of risk of . Below 30 deg rare nonunion . Above 50 deg – 30 deg in 30  Long fusion to sacrum yrs o If L5 is tilted o Resp failure rare o If pain at o Life expectancy or pregnancy concavity at L5 unaffected  Advantages Spine</p><p> o Increased o Cosmetic deformity (MC reason for correction in surgery) rigid curves o ASF/PSF w/ compression implant o Decreased for > 55 deg pseudo . If can correct to < 55 deg, then . in fixed LS fractional curve post alone is ok  end plate osteotomy at . o/w fusion mass is under L4 or L5 can make end tension vert horiz, reduce . thoracoscopic an option curve, avoid fusion to - Post-traumatic sacrum o Unrecognized post disruption . Complications o Pain, deformity, neuro involvement  15-20% in lumbar, TL o Most of time, Surgery: curves . Ant decompression for neuro  decreased w/ ASF/PSF deficits  observe if Asx . ASF/PSF for > 55 deg  delayed paraplegia can deformity occur hours after proc . Pedicle-subtraction osteotomy  from ischemia of SC corrects about 30 deg from postop hypovolemia, tension Ankylosing Spondylitis of spinal BV on - spondylodiskitis (Andersson lesions) concavity, destructive lesions at TL junction atherosclerosis - AAI in 2-20% of pt compared to 16-25% in - Outcome RA o 70% reduction in pain, 30% reduction - cervical deformity best corrected w/ of deformity osteotomy b/w C7-T1, widest area of cerv canal Adult kyphosis - thoracic kyphosis best tx w/ extension - Causes osteotomy @ or below L2 o Osteoporosis - mean correction of 34.5 deg per osteotomy o Scheuermann’s level o Post-traumatic - Osteoporosis o Nonoperative tx at all costs o Surg indications: . Intractable back pain . Neuro def . burst fx, prog deformity . need 3-4 levels above and below apex (extended segm fixation) . ant column reconstruction - Scheuermann’s o Severe back pain rare o (> 66 deg) more likely to have pain o PFT’s increased</p>