1
Fifth stage
Surgery-Ortho
Lec-10
.د
مثنى
1/1/2014
Pyogenic Spinal Infection
Acute pyogenic infection of the spine is uncommon ,
diagnosis and treatment are often unnecessarily delayed.
The elderly, chronically ill and immuno-deficient patients are at greatest risk.
It might follow surgery in renal system.
Tuberculosis of spine:
The spine is the most commonest site of skeletal tuberculosis and the most dangerous
It is blood – born infection settled in the vertebral bodies , bone destruction and
caseation follow with spread of the infection to the adjacent disc space and adjacent
vertebrae.
As the vertebral bodies collapse , a sharp angulation or (kyphos) develops. Caseation
and cold abscess formation may extend to the neighboring vertebrae or escape into
paravertebral soft tissue .
There is risk of spinal cord damage due to pressure by the abscess or displaced bone
or ischemia from spinal artery thrombosis.
Clinically there is long history of ill health and back ache ; the deformity is some time
the dominant feature or the patient presented with cold abscess pointing in the groin ;
or with parasthesia and weakness of the legs .
The characteristic feature in late cases is an angular thoracic kyphosis .
Pott`s paraplegia is the most dangerous complication of spinal tuberculosis .
Imaging:
X- ray , the entire spine should be x- rayed to detect any infection in other vertebrae .
Earliest sign is local osteoporosis of two adjacent vertebrae and narrowing of
intervertebral disc space ; then there will be bone destruction and collapse of the
adjacent vertebral bodies lead to angular deformity.
Para spinal soft tissue shadow may be due to para vertebral abscess . CT and MRI is
very helpful
Investigation : Mantoux test is +ve ; ESR is high
2
Differential diagnosis:
1 - pyogenic infection .
2- malignant disease .
Treatment:
the aim of treatment is:
1- to eradicate the disease .
2- to prevent or correct the deformity .
3-to prevent or treat the major complication , mainly paraplegia .
The way of treatment will be by anti T.B chemotherapy and surgical drainage of the
pus collection ; surgical curration of the diseased bone ; anterior spinal fusion and
bone grafting sometimes used
Intervertebral disc prolapse
The spine is a non-homogeneous complex-shape consist of 24 vertebrae, separated by
intervertebral discs with numerous muscles and ligaments attached to them.
Intervertebral discs act as a kind of cushion to soften the impacts caused by the
movement of body.
The intervertebral discs make up about one fourth of entire length of the vertebral
column.
The discs absorb the stress and strain transmitted to the vertebral column.
The intervertebral disc is a structure composed of the gelatenus nucleous pulposus at
the center surrounded by annulus fibrosus .
The spine is a non-homogeneous complex-shape consist of 24 vertebrae, separated by
intervertebral discs with numerous muscles and ligaments attached to them.
Intervertebral discs act as a kind of cushion to soften the impacts caused by the
movement of body.
The intervertebral discs make up about one fourth of entire length of the vertebral
column.
The discs absorb the stress and strain transmitted to the vertebral column.
The intervertebral disc is a structure composed of the gelatenus nucleous pulposus at
the center surrounded by annulus fibrosus .
Clinical features:
Acute disc prolapse may occur at any age, but is uncommon in the very young and the
very old. The patient is usually a fit adult aged 20–45 years.
3
Typically, while lifting or stooping he has severe back pain and is unable to straighten
up. Either then or a day or two later pain is felt in the buttock and lower limb (sciatica).
Both backache and sciatica are made worse by coughing or straining. Later there may
be parasthesia or numbness in the leg or foot, and occasionally muscle weakness.
Cauda equina compression is rare but may cause urinary retention and perineal
numbness.
on examination: The patient usually stands with a slight list to one side(‘sciatic
scoliosis’).
All back movements are restricted, and during forward flexion the list may increase.
There is often tenderness in the midline of the low back, and paravertebral muscle
spasm.
Straight leg raising is restricted and painful on the affected side.
Neurological examination may show muscle weakness(and, later, wasting), diminished
reflexes and sensory loss corresponding to the affected level.
Imaging:
1- X-rays : are helpful, not to show an abnormal disc space but to exclude bone
disease. After several attacks the disc space may be narrowed and small osteophytes
appear.
2- CT and MRI : These are now the preferred methods of spinal imaging.
Treatment:
symptomatic treatment include: Heat , analgesics, and exercises strengthen muscles,
but there are only three ways of treating the prolapse itself –
rest,
reduction or
removal, followed by
rehabilitation.
Rest: With an acute attack the patient should be kept in bed, with hips and knees
slightly flexed. A nonsteroidal anti- inflammatory drug is useful in most of patients.
Reduction: Continuous bed rest and traction for 2weeks may reduce the herniation. If
the symptoms and signs do not improve during that period, an epidural injection of
corticosteroid and local anaesthetic may help.
Removal: The indications for operative removal of a prolapse are:
(1) a cauda equina compression syndrome , this is an emergency.
(2) Neurological deterioration while under conservative treatment.
4
(3) persistent disabling pain and signs of sciatic tension after 2–3 weeks of conservative
treatment.
The two operations most widely performed are laminotomy and microdiscectomy.
Spondylolysis
It is defect in the neural arch ( paras interarticularis) of the 5th or 4th lumber vertebra,
it predispose to spondylolisthesis.
It might follow injuries ( fibrous non union of fracture or stress fracture) or congenital.
X-ray in oblique view would shows the defect.
Most of cases need no treatment, belt, analgesia for short time and physiotherapy may
used some times.
Spondylolisthesis
forward displacement of one vertebra over other vertebra
‘Spondylolisthesis’ means forward translation of one segment of the spine upon
another.
The shift is nearly always between L4 and L5, or between L5 and the sacrum, ( fig. . ).
Normal discs, laminae and facets constitute a locking mechanism that prevents each
vertebra from moving forwards on the one below. Forward shift (or slip) occurs only
when this mechanism has failed.
Classification: six types:
Dysplastic (20 per cent) The superior sacral facets are congenitally defective.
Lytic or isthmic (50 per cent) In this, the commonest variety, there are defects in the
pars inter articularis (spondylolysis), or repeated breaking and healing may lead to
elongation of the pars.
Degenerative (25 per cent) Degenerative changes in the facet joints and the discs.
Post-traumatic (Unusual fractures).
Pathological Bone destruction (e.g. due to tuberculosis or neoplasm) may lead to
vertebral slipping.
Postoperative (iatropathic) occasionally, excessive operative removal of bone in
decompression operations.
5
Clinical features
Backache is the usual presenting symptom; it is often intermittent, coming on after
exercise or strain. Sciatica may occur in one or both legs.
On examination the buttocks look flat, the sacrum appears to extend to the waist and
transverse loin creases are seen. A ‘step’ can often be felt when the fingers are run
down the spine.
In children the condition is painless but the mother may notice protruded abdomen
.In old age intermittent claudication may occur due to associated spinal stenosis.
Imaging:
X-ray: 1- lateral view show the forward shift of the upper part of the spinal column on
the stable vertebra below.
2- oblique views which is the best view to see the gap in the pars interarticularis
(decapitated Scotty dog) sign.
In doubtful cases, CT may be helpful.
Treatment:
Conservative treatment, analgesic antiinflammatory drugs, avoiding lifting weights,
using lumber built.
Operative treatment is indicated:
(1) if the symptoms are disabling.
(2) if the slip is more than 50 per cent and progressing.
(3) if neurological compression is significant.
Surgical treatment carried out by reduction, internal fixation and spinal fusion
Spinal stenosis:
The term spinal stenosis is used to describe abnormal narrowing of the central canal, the
lateral recesses or the intervertebral foramina to the point where the neural elements are
compromised. When this occurs the patient develops neurological symptoms and signs in
the lower limbs called neural claudication.
The causes of spinal stenosis are:
1- congenital.
2- chronic disc protrusion.
3- osteoarthritis of the facet joints.
4- spondylolisthesis.
5- Paget disease.
6
Clinical features
The patient, usually aged over 50, complains of aching, heaviness, numbness and
parasthesia in the thighs and legs; it comes on after standing upright or walking for 5–
10 minutes, and is consistently relieved by sitting, squatting or leaning against a wall to
flex the spine (hence the term ‘spinal claudication’).
The patient may prefer walking uphill, which flexes the spine (and maximizes the spinal
canal capacity), to downhill, which extends it.
Imaging
X-rays will usually show features of disc degeneration and proliferative osteoarthritis or
degenerative spondylolisthesis. Measurement of the spinal canal can be carried out on
plain films, but more reliable information is obtained from myelography, CT and MRI. The
MRI and CT is the reliable and safe imaging nowadays.
Treatment:
Conservative measures, including instruction in spinal posture, reduce weight may suffice.
Most patients are prepared to put up with their symptoms and simply avoid uncomfortable
postures. If discomfort is marked and activities such as standing and walking are severely
restricted, operative decompression is almost always successful (laminactomy).
Spondylosis
Spondylosis is osteoarthritis of spine, it is very common.
It result from degenerative changes, previous injuries and spinal diseases. There is
scleroses of facet joints, reduction of joint space and osteophytes formation which
might compress the spinal canal and nerve roots.
Spondylosis may cause chronic backache after activities or early morning, spinal
stenosis or radiculopathy.
X-ray shows osteoarthritis changes in posterior facets joints and reduction in
intervertebral disc space.
The treatment depend on the severity of the symptoms and disability, in the mild cases
treatment is unnecessary, analgesia, belt and physiotherapy may be used in moderate
symptoms, rarely surgery used in treatment of severe cases.
Coccydynia
Coccydynia is chronic painful condition in the region of the coccyx, the pain persist for
many weeks or months , after local injury.
There is local tenderness, other causes of pain in this region should be excluded.
It is self limiting condition, analgesia and local steroid injection may used .