Principles of Spine Trauma

An undiagnosed or suboptimally managed spine injury can result in a neurologic deficit and
permanently impair a patient's function and quality of life, and in some cases may lead to death. Archeological
records from over 45,000 years ago are noted to forewarn that paralysis is incurable and this remains true today,
but that does not that nothing can be done for patients who sustain severe neurologic deficits. Patients with
spinal cord injury today regain mobility, improve their quality of life, and achieve prolonged survival. Fractures
and dislocations of the spine are serious injuries that most commonly occur in young people. Nearly 43% of
patients with spinal cord injuries sustain multiple injuries.it is estimated that each year 50 people in 1 million
sustain a spinal cord injury. With the development of regional trauma centers and increased training of
paramedics and emergency medical technicians, the chances of survival after serious spinal cord injury have
increased. Overall, 85% of patients with a spinal cord injury who survive the first 24 hours are still alive 10
years later compared with 98% of patients of similar age and sex without spinal cord injury.
TERMINOLOGY OF SPINAL CORD INJURY
Neural tissue injuries are divided into two broad etiology based categories: primary injury refers to
physical tissue disruption caused by mechanical forces, and secondary injury refers to additional neural tissue
damage resulting from the biologic response initiated by the physical tissue disruption. The extent of structural
damage to neural tissue is indicated by other descriptive terms. Concussion refers to physiologic disruption
without anatomic injury. Contusion refers to physical neural tissue disruption leading to hemorrhage and
swelling (the most common type of spinal cord injury), or laceration, which describes loss of structural
continuity of the neural tissue (rare in blunt trauma). The clinical response to injury is typically described in
temporal terms: acute refers to the first few hours after injury; subacute typically refers to several hours to days
following injury, and chronic refers to intervals of weeks to months after the injury. The functional
consequences of spinal cord injury are usually described by terms that refer to the severity and pattern of
neurologic dysfunction. Complete spinal cord injury, incomplete injury, or transient spinal cord dysfunction
describe different grades of severity of neurologic injury.
EVALUATION OF SPINAL INJURY
History
A detailed history of the mechanism of injury is important, but frequently is unobtainable at the initial
examination. The most common causes of severe spinal trauma are motor vehicle accidents, falls, diving
accidents, and gunshot wounds. Spinal injury should be suspected in any patient with a head injury or severe
facial or scalp lacerations. In any patient with recent trauma, complaints of neck pain or spinal pain should be
considered indicative of a spinal injury until proved otherwise. Other risk factors associated with spinal injury,
include an inability to assess neck pain because of a secondary distracting injury, abnormal neurological
findings, a history of transient neurological symptoms, physical signs of spinal trauma (e.g., ecchymosis and
abrasions), unreliable examination, significant head or face trauma, or an inconsolable child. If the cervical
spine is not already rigidly immobilized in a patient with any of these risk factors, immobilization should be
applied before the physical examination is continued.
Stable and unstable injuries
Spinal injuries carry a double threat: damage to the vertebral column and damage to the neural tissues.
While the full extent of the damage may be apparent from the moment of injury, there is always the fear
that movement may cause or aggravate the neural lesion; hence the importance of establishing whether
the injury is stable or unstable and treating it as unstable until proven otherwise.
A stable injury is one in which the vertebral components will not be displaced by normal movements;

in a stable injury, if the neural elements are undamaged there is little

risk of them becoming damaged.
An unstable injury is one in which there is a significant risk of
displacement and consequent damage or further damage to the
neural tissues. In assessing spinal stability, three structural elements
must be considered: the posterior osseoligamentous complex (or
posterior column) consisting of the pedicles, facet joints, posterior bony
arch, interspinous and supraspinous ligaments; the middle column
comprising the posterior half of the vertebral body, the posterior part of
the intervertebral disc and the posterior longitudinal ligament; and the
anterior column composed of the anterior half of the vertebral body, the
anterior part of the intervertebral disc and the anterior longitudinal
ligament (Denis, 1983)(Fig.1). All fractures involving the middle
column and at least one other column should be regarded as unstable.
Mechanism of injury

Fig.1.Structural elements of the spine The

vertical lines show Denis classification of the
structural elements of the spine.

There are three basic mechanisms of injury: traction (avulsion), direct injury and indirect injury.
Traction injury. In the lumbar spine resisted muscle effort may avulse transverse processes; in the
cervical spine the seventh spinous process can be avulsed (clayshovellers fracture).
Direct injury. Penetrating injuries to the spine, particularly from firearms and knives, are becoming
increasingly common.
Indirect injury. This is the most common cause of significant spinal damage; it occurs most typically in
a fall from a height when the spinal column collapses in its vertical axis, or else during violent free movements
of the neck or trunk. A variety of forces may be applied to the spine (often simultaneously): axial compression,
flexion, lateral compression, flexion-rotation, shear, flexion-distraction and extension.
Spinal injuries may damage both bone and soft tissue (ligaments, facet joint capsule and intervertebral
disc).The bone injury will usually heal; however, if the bone structures heal in an abnormal position the healed
soft tissues may not always protect against progressive deformity.
Early management
The essential principle is that if there is the slightest possibility of a spinal injury in a trauma patient, the
spine must be immobilized until the patient has been resuscitated and other life-threatening injuries have been
identified and treated. Immobilization is abandoned only when spinal injury has been excluded by clinical and
radiological assessment.
Cervical spine.The head and neck are supported in the neutral position. A backboard, sandbags, a forehead tape
and a semirigid collar are applied.
Thoracolumbar spine. The patient should be moved without flexion or rotation of the thoracolumbar spine.
A scoop stretcher and spinal board are very useful; however in the paralysed patient, there is a high risk of
pressure sores adequate padding is essential. If the back is to be examined, or if the patient is to be placed onto
a scoop stretcher or spinal board, the logrolling technique should be used.

Physical Examination
A general physical examination is done with the
patient supine. The patients mental status and the level of
consciousness should be determined quickly, including
pupillary size and reaction. Epidural or subdural
hematoma, a depressed skull fracture, or other intracranial
pathological conditions may cause progressive deterioration in
neurological function. The Glasgow Coma Scale is useful in
determining the level of consciousness.
The patient may be supporting his or her head with
their hands a warning to the examiner to be equally careful!
The head and face are thoroughly inspected for bruises or
grazes which could indicate indirect
trauma to the cervical spine. The neck is inspected for
deformity, bruising or penetrating injury (Fig.2). The bones
and soft tissues of the neck are gently palpated for tenderness
and areas of bogginess, or increased space
between the spinous processes, suggesting instability due to posterior column failure.The spinous processes
should be palpated from the upper cervical to the lumbosacral region. A painful spinous process may indicate a
spinal injury. Palpable defects in the interspinous ligaments may indicate disruption of the supporting
ligamentous complex. The back of the neck must also be examined but throughout the entire examination the
cervical spine must not be moved because of the risk of injuring the cord in an unstable injury.The back is
inspected for deformity, penetrating injury, haematoma or bruising. The bone and soft-tissue structures are
palpated, again with particular reference to the interspinous spaces. A haematoma, a gap or a step are signs of
instability.
Fig.2
a.Severe facial bruising always
suspect a hyperextension injury of
the neck.
b.Bruising over the lower back
should raise the suspicion of a
lumbar vertebral fracture.

General Examination shock

Three types of shock may be encountered in patients with spinal injury:
Hypovolaemic shock is suggested by tachycardia, peripheral shutdown and, in later stages, hypotension.
Neurogenic shock reflects loss of the sympathetic pathways in the spinal cord; the peripheral vessels dilate
causing hypotension but the heart, deprived of its sympathetic innervation, does not respond by increasing its
rate. The combination of paralysis, warm and well-perfused peripheral areas, bradycardia and hypotension with
a low diastolic blood pressure suggests neurogenic shock.
Spinal shock occurs when the spinal cord fails temporarily following injury. Even parts of the cord without
structural damage may not function. Below the level of the injury, the muscles are flaccid, the reflexes absent
and sensation is lost. This rarely lasts for more than 48 hours and during this period it is difficult to tell whether
the neurological lesion is complete or incomplete. A positive bulbocavernosus reflex or return of the anal wink
reflex indicates the end of spinal shock. If no motor or sensory function below the level of injury can be

documented when spinal shock ends, a complete spinal cord injury is present, and the prognosis is poor for
recovery of distal motor or sensory function.
Neurological Evaluation
A full neurological examination is carried out in every case; this may have to be repeated several times
during the first few days. Each dermatome, myotome and reflex is tested.Use of the American Spinal Injury
Association (ASIA) form is helpful in organizing this evaluation. A detailed initial neurological examination,
including sensory, motor, and reflex function, is important in determining prognosis and treatment .
The presence of an incomplete or complete spinal cord injury must be determined and documented by
meticulous neurological examination.
Sensory examination is performed with light touch, then pinpricks (using a sterile needle), beginning at
the head and neck and progressing distally, to examine specific dermatome distributions (see Fig. 3).

Motor examination should be systematic,

beginning with the upper extremities. During
motor examination, it is important to differentiate
between complete and incomplete spinal cord
injuries and pure nerve root lesions. Key muscle
groups and their corresponding nerve root levels
that should be evaluated in a patient with spinal
cord injury. After examination of the extremities
and trunk, the presence or absence of sacral motor
sparing should be determined by voluntary rectal
sphincter or toe flexor contractions. If voluntary
contraction of the sacrally innervated muscles is
present with sacral sensation, the prognosis for
recovery of motor function is good. The presence
of an anal reflex without sacral sensation is
consistent with a complete injury.Quadriplegia is
indicated by flaccid paralysis of the extremities.
Spinal Cord Syndromes
Spinal cord syndromes result from incomplete traumatic lesions. By definition, an incomplete spinal
cord injury is one in which some motor or sensory function is spared distal to the cord injury.
A complete spinal cord injury is manifested by total motor and sensory loss distal to the injury. When
the bulbocavernosus reflex is positive, and no sacral sensation or motor function has returned, the paralysis is
permanent and complete in most patients.
An incomplete spinal cord syndrome may be a Brown-Squard syndrome, central cord syndrome,
anterior cord syndrome, posterior cord syndrome, or rarely monoparesis of the upper extremity. (see Fig. 5)
Central cord syndrome is the most common. It consists of destruction of the central area of the spinal
cord, including gray and white matter. Generally, patients
have a quadriparesis involving the upper extremities to a
greater degree than the lower. Sensory sparing varies, but
usually sacral pinprick sensation is preserved.
Brown-Squard syndrome is an injury to either half
of the spinal cord.It is characterized by motor weakness on
the side of the lesion and the contralateral loss of pain and
temperature sensation.Prognosis for recovery is good, with
significant neurological improvement often occurring.
Anterior cord syndrome usually is caused by a
hyperflexion injury in which bone or disc fragments
compress the anterior spinal artery and cord. It is
characterized by complete motor loss and loss of pain and
temperature discrimination below the level of injury. The
posterior columns are spared to varying degrees (see Fig.
35-9D), resulting in preservation of deep touch, position
sense, and vibratory sensation. Prognosis for significant
recovery in this injury is poor.
Posterior cord syndrome involves the dorsal
columns of the spinal cord and produces loss of
proprioception vibrating sense, while preserving other
sensory and motor functions. This syndrome is rare and
usually is caused by an extension injury.

Conus medullaris syndrome, or injury of the sacral cord (conus) and lumbar nerve roots within the
spinal canal,usually results in arefl exic bladder, bowel, and lower extremities. Most of these injuries occur
between T11 and L2.
Cauda equina syndrome, or injury between the conus and the lumbosacral nerve roots within the spinal
canal, also results in arefl exic bladder, bowel, and lower limbs.
Imaging
X-ray examination of the spine
is mandatory for all accident victims
complaining of pain or stiffness in
the neck or back or peripheral
paraesthesiae, all patients with head
injuries or severe facial injuries
(cervical spine), patients with rib
fractures or severe seat-belt bruising
(thoracic spine), and those with severe
pelvic
or
abdominal
injuries
(thoracolumbar
spine).
This
is
performed during the secondary survey.
Accident victims who are unconscious
should have spine x-rays as part of the
routine work-up.(TRAUMA SERIES:
lateral view of the cervical spine and
anteroposterior views of the chest and
pelvis.). Pain is often poorly localized;
views should include several segments above and below the painful area.
In addition to anteroposterior and lateral views, open-mouth views are needed for the upper two cervical
vertebrae and oblique views may be needed for the cervical as well as the thoracolumbar region. Lateral flexion
and extension views can be made to determine the stability of the cervical spine, but these are not routinely
recommended in the initial examination.
CT is ideal for showing structural damage to
individual
vertebrae and displacement of bone
fragments into the vertebral canal. In fact, screening
CT is employed routinely in many centres; the
drawback is its high level of radiation exposure.
MRI is the method of choice for displaying
the intervertebral discs, ligamentum flavum and
neural structures, and is indicated for all patients with
neurological signs and those who are considered for
surgery. CT myelography, with the intrathecal
introduction of contrast agent, provides information
on the dimensions of the spinal canal, impingement
by fracture fragments or intervertebral disc, and root
avulsion. This investigation has been largely replaced
by MRI.
Three-dimensional reconstruction of CT
images defines certain complex fracture patterns.
Spiral CT allows high resolution sagittal
reconstruction and when available, is useful for
displaying fractures of the odontoid process.

Principles of treatment
The objectives of treatment are:
to preserve neurological function;
to minimize a perceived threat of neurological compression;
to stabilize the spine;
to rehabilitate the patient.
The indications for urgent surgical stabilization are: (a) an unstable fracture with progressive
neurological deficit and (b) controversially an unstable fracture in a patient with multiple injuries.
Patients with no neurological injury
Stable injuries. If the spinal injury is stable, the patient is treated by supporting the spine in a position that will
cause no further strain; a firm collar or lumbar brace will usually suffice, but the patient may need to rest in
bed until pain and muscle spasm subside. A progressive neurological deficit may occasionally develop, which
could be an indication for decompression and fusion.
Unstable injuries. If the spinal injury is unstable, it should be held secure until the tissues heal and the spine
becomes stable. Alternatively (particularly in the thoracolumbar spine) internal fixation can be carried out.
Patients with a neurological injury
Once spinal shock has recovered, the full extent of the neurological injury is assessed. Caring for patients with
neurological injury requires the infrastructure of an experienced multidisciplinary team;
If the spinal injury is stable (which is rare), the patient can be treated conservatively and rehabilitated as soon as
possible.
With the usual unstable injury, conservative treatment can be still be used; this is highly demanding and is best
carried out in a special unit. After a few weeks the injury stabilizes spontaneously and the patient can be got
out of bed for intensive rehabilitation. This approach is applicable to almost all injuries. Early operative stabilization is preferred by many; it facilitates nursing by inexperienced carers and reduces the risk of spinal deformity.
Fracture of the cervical spine
C1(Atlas) ring fracture
Sudden severe load on the top of the head may cause a bursting
force which fractures the ring of the atlas(Jeffersons fracture)(Fig.7).
There is no encroachment on the neural canal and, usually, no neurological
damage.
The fracture is seen on the open-mouth view (Fig.6) (if the lateral masses
are spread away from the odontoid peg) and the lateral view. A CT scan is
particularly helpful in defining the fracture. If it is undisplaced, the
injuryis stable and the patient wears a semi-rigid collar or halo-vest until
the fracture unites. If there is sideways spreading of the lateral masses, this
injury is unstable and should be treated by a halo-vest for several weeks. If
there is persisting instability on x-ray, a posterior C1/2 fixation and fusion
is needed. A hyperextension injury can fracture either the anterior or
posterior arch of the atlas. These injuries are usually relatively stable and
are managed with a halo-vest or semi-rigid collar until union occurs.

Fig.6 Open-mouth view: note the

C1 lateral masses overhang over
the lateral edges of the C2(unstable
lesion)

C2 pars interarticularis fractures

(Hangmans Fractures)
The term hangmans fracture
(bilateral fractures of the pars
interarticularis of C2) originally referred
to neck injuries incurred during the
hanging of criminals(Fig.8). The most
common cause of hangmans fracture
now is a motor vehicle accident with
hyperextension of the head on the neck. In civilian injuries, the mechanism is more complex, with varying
degrees of extension, compression and flexion. This is one cause of death in motor vehicle accidents when the
forehead strikes the dashboard. Neurological damage, however, is unusual because the fracture of the posterior
arch tends to decompress the spinal cord. Nevertheless the fracture is
potentially unstable.
Levine classified these fractures into three types (Fig. 8).
Type I fractures are minimally displaced Because ligamentous injury
is minimal, these fractures are stable and usually heal with 12 weeks
of immobilization in a rigid cervical orthosis. Type II fractures have
more than 3 mm of anterior translation and significant angulation.
Treatment consists of application of halo ring. Immobilization in a
halo vest does not achieve or maintain reduction, and halo traction
with slight extension may be necessary for 3 to 6 weeks to maintain
anatomical reduction. The patient can be mobilized in a halo vest for
the rest of the 3-month period.
Type III injuries combine a bipedicular fracture with posterior facet
injuries. They usually have severe angulation and translation. Type
III injuries are the only type of hangmans fracture that commonly require surgical stabilization. These fractures
frequently are associated with neurological deficits. Open reduction and internal fi xation usually are required
because of inability to obtain or maintain reduction of the C2-3. After posterior cervical fusion at the C2-3 level,
halo vest immobilization for 3 months is necessary.
C2 Odontoid process fracture
Odontoid fractures are uncommon. They usually occur as flexion injuries in young adults after highvelocity
accidents or severe falls. However, they also occur in elderly, osteoporotic people as a result of low-energy
trauma in which the neck is forced into hyperextension, e.g. a fall onto the face or forehead.
Odontoid fractures have been classified by Anderson and DAlonzo (1974) as follows(Fig.9):
Type I An avulsion fracture of the tip of the odontoid process due to traction by the alar ligaments.
The fracture is stable (above the transverse ligament) and unites without difficulty.
Type II A fracture at the junction of the odontoid process and the body of the axis. This is the most
common (and potentially the most dangerous) type.The fracture is unstable and prone to non-union.
Type III A fracture through the body of the axis. The fracture is stable and almost always unites with
immobilization.
Clinical features.The history is usually that of a severe neck strain followed by pain and stiffness due to muscle
spasm.The diagnosis is confirmed by high quality x-ray examination; it is important to rule out an associated
occipito-cervical injury which commands immediate attention. In some cases the clinical features are mild and
continue to be overlooked for weeks on end.Neurological symptoms occur in a significant numberof cases.
Imaging.Plain x-rays usually show the fracture, although the extent of the injury is not always. Tomography is
helpful but MRI has the advantage that it may reveal rupture of the transverse ligament; this can cause
instability in the absence of a fracture.

Treatment
Type I fractures. Isolated
fractures of the odontoid tip are
uncommon. They need no
more than immobilization in a
rigid collar until discomfort
subsides. Type II fractures
These are often unstable and
prone to non-union, especially
if displaced more than 5
mm.Undisplaced fractures can be held by fitting a halo-vest or in elderly patients a rigid collar. Displaced
fractures should be reduced by traction and can then be held by operative posterior C1/2 fusion; Anterior screw
fixation(Fig.10) is suitable for Type II
fractures that run from anteriorsuperior to posterior-inferior, provided
the fracture is not comminuted, that
the transverse ligament is not ruptured,
that the fracture is fully reduced and
the bone solid enough to hold a screw.
If full operative facilities are not
available, immobilization can be
applied by using a halo-vest with
repeated x-ray monitoring to check for
stability.
Type III fractures If undisplaced, these
are treated in a halo-vest for 812
weeks. If displaced, attempts should
be made at reducing the fracture by
halo traction, the neck is then
immobilized in a halo-vest for 812
weeks.
Lower cervical spine
Fractures of the cervical spine from C3 to C7 tend to produce characteristic fracture patterns, depending
on the mechanism of injury: flexion, axial compression, flexionrotation or hyperextension
Posterior ligament injury
Sudden flexion of the mid-cervical spine can result in damage to the posterior ligament complex (the
interspinous ligament, facet capsule and supraspinous ligament). The upper vertebra tilts forward on the one
below, opening up the interspinous space posteriorly The patient complains of pain and there may be localized
tenderness posteriorly. X-ray may reveal a slightly increased gap between the adjacent spines.A flexion view
would, of course, show the widened interspinous space more clearly, but flexion should not be permitted in the
early post-injury period. This is why the diagnosis is often made only some weeks after the injury, when the
patient goes on complaining of pain. The assessment of stability is essential in these cases. If the angulation of
the vertebral body with its neighbor exceeds 11 degrees, if there is anterior translation of one vertebral body
upon the other of more than 3.5 mm or if the facets are fractured or displaced, then the injury is unstable and it
should be treated as a subluxation or dislocation(Fig.11). If it is certain that the injury is stable, a semi-rigid
collar for 6 weeks is adequate; if the injury is unstable then posterior fixation and fusion is advisable.

Wedge compression fracture

A pure flexion injury results in a wedge compression fracture of the vertebral body (Fig. 12). The middle
and posterior elements remain intact and the injury is stable. All that is needed is a comfortable collar for 612
weeks. A note of warning: The x-ray should be carefully examined to exclude damage to the middle column
and posterior displacement of the vertebral body fragment, i.e. features of a burst fracture (see below)
which is potentially dangerous. If there is the least doubt, an axial CT or MRI should be obtained.
Burst and compression-flexion (teardrop) fractures
These severe injuries are due to axial compression of the cervical spine,
usually in diving or athletic accidents
(Fig. 13). If the vertebral body is crushed in neutral position of the neck
the result is a burst fracture. With combined axial compression and
flexion, an antero-inferior fragment of the vertebral body is sheared off,
producing the eponymous tear-drop(Fig.14) on the lateral x-ray. In both
types of fracture there is a risk of posterior displacement of the vertebral
body fragment and spinal cord injury. Plain x-rays show either a crushed
vertebral body (burst fracture) or a flexion deformity with a triangular
fragment separated from the antero-inferior edge of the fractured vertebra
(the innocent-looking teardrop). The x-ray images should be carefully
examined for evidence of middle column damage and posterior
displacement (even very slight displacement) of the main body fragment.
Traction must be applied immediately and CT or MRI should be performed
to look for retro-pulsion of bone fragments into the spinal canal.
TREATMENT
If there is no neurological deficit, the patient can be treated surgically or
by confinement to bed and traction
for 24 weeks, followed by a further period of immobilization in a halovest for 68 weeks. (The halo-vest is unsuitable for initial treatment
because it does not provide axial traction). If there is any deterioration of
neurological status while the fracture is believed to be unstable, and the
MRI shows that there is a threat of cord compression, then urgent anterior
decompression is considered anterior corpectomy, bone grafting and
plate fixation(Fig.15), and sometimes also posterior stabilization(Fig.16).
Fracture-dislocations
Bilateral facet joint dislocations are caused by severe flexion or
flexionrotation injuries. The inferior articular facets of one vertebra ride
forward over the superior facets of the vertebra below. One or both of the
articular masses may be fractured or there may be a pure dislocation
jumped facets. The posterior ligaments are ruptured and the spine is unstable; often there is cord damage.
The lateral x-ray shows forward displacement of a vertebra on the one below of greater than half the
vertebras antero-posterior width. The displacement must be reduced as a matter of urgency. Skull traction is
used, starting with 5 kg and increasing it step-wise by similar amounts up to about 30kg. The entire procedure
should be done without anaesthesia (or under mild sedation only) and neurological examination should be
repeated after each incremental step. If neurological symptoms or signs develop, or increase, further attempts at
closed reduction should be stopped.
When x-rays show that the dislocation has been reduced, traction is diminished to about 5 kg and then
maintained for 6 weeks. During this time MRI can be performed to rule out the presence of an associated
disc disruption. At the end of that period the patient should still wear a collar for another 6 weeks; however, it
may be more convenient to immobilize the neck in a halo-vest for 12 weeks(Fig.17).

Another alternative is to
carry out a posterior fusion as soon as
reduction has been achieved; the
patient is then allowed up in a
cervical brace which is worn for 68
weeks. Posterior open reduction and
fusion is also indicated if closed
reduction fails.(fig.16)
The need for pre-reduction
MRI is for the ability to diagnose an
extruded disc fragment which may
further compromise any neurological
lesion but can be dealt with by
anterior decompression(fig.15). This
is particularly applicable to elderly
patients in whom immediate closed
reduction may be hazardous and long
periods on their backs can lead to
pressure sores.
Unilateral facet dislocation This is a flexionrotation injury in which only
one apophyseal joint is dislocated. There may be an associated fracture of the facet.
On the lateral x-ray the vertebral body appears to be partially displaced (less than
one-half of its width); on the anteroposterior x-ray the alignment of the spinous
processes is distorted. Cord damage is unusual and the injury is stable. Management
is the same as for bilateral dislocation.
As a general rule, if closed reduction fails, open reduction and posterior fixation are
advisable. After reduction, if the patient is neurologically intact the neck is
immobilized in a halo-vest for 68 weeks. Patients left with an unreduced unilateral
facet dislocation may develop neck pain and nerve root symptoms longterm if poorly
managed.

Double injuries
With high-energy trauma the cervical spine may be injured at more than one level. Discovery of the
most obvious lesion is no reason to drop ones guard.
Avulsion injury of the spinous process
Fracture of the C7 spinous process may occur with severe
voluntary contraction of the muscles at the back of the neck; it is known
as the clay-shovellers fracture.(Fig.18) The injury is painful but
harmless. No treatmentis required; as soon as symptoms permit, neck
exercises are encouraged.
Cervical disc herniation
Acute post-traumatic disc herniation may cause severe pain
radiating to one or both upper limbs, and neurological symptoms and
signs ranging from mild paraesthesia to weakness, loss of a reflex and
blunted
sensation. Rarely a patient presents with full-blown paresis. The diagnosis is confirmed by MRI or
CTmyelography. Sudden paresis will need immediate surgical decompression. With lesser symptoms and signs,
one can afford to wait a few days for improvement; if this does not occur, then anterior discectomy and
interbody fusion will be needed.(Fig.15)
Neurapraxia of the cervical cord
Accidents causing sudden, severe axial loading with the neck in hyperflexion or hyperextension are
occasionally followed by transient pain, paraesthesia and weakness in the arms or legs, all in the absence of any
x-ray or MRI abnormality. Symptoms may last for as little as a few minutes or as long as two or three days.
The condition has been called neurapraxia of the cervical cord and is ascribed to pinching of the cord by the
bony edges of the mobile spinal canal and/or local compression by infolding of the posterior longitudinal
ligament or the ligamentum flavum. Congenital narrowing of the spinal canal may be a predisposing factor.
Treatment consists of reassurance (after full neurological investigation) and graded exercises to improve
strength in the neck muscles.
Sprained neck (WHIPLASH INJURY)
Soft-tissue sprains of the neck are so common after motor vehicle accidents that they now constitute a
veritable epidemic. There is usually a history of a lowvelocity rear-end collision in which the occupants
body is forced against the car seat while his or her head flips backwards and then recoils in flexion. This
mechanism has generated the imaginative term whiplash injury. Women are affected more often than men,
perhaps because their neck muscles are more gracile.
Clinical features Often the victim is unaware of any abnormality immediately after the collision. Pain and
stiffness of the neck usually appear within the next 1248 hours, or occasionally only several days later. Pain
sometimes radiates to the shoulders or interscapular area and may be accompanied by other, more ill-defined,
symptoms such as headache, dizziness, blurring of vision, paraesthesia in the arms. Neck muscles are tender
and movement often restricted. X-ray examination may show straightening out of the normal cervical lordosis, a
sign of muscle spasm;in other respects the appearances are usually normal
Treatment Collars are more likely to hinder than help recovery. Simple pain-relieving measures, including
analgesic medication, may be needed during the first few weeks.
Thoracolumbar injuries
Most injuries of the thoracolumbar spine occur in the transitional area T11 to L2 between the
somewhat rigid upper and middle thoracic column and the flexible lumbar spine. The upper three-quarters of
the thoracic segments are also protected to some extent by the rib-cage and fractures in this region tend to be

mechanically stable. However, the spinal canal in that area is relatively narrow so cord damage is not
uncommon and when it does occur it is usually complete .The spinal cord actually ends at L1 and below that
level it is the lower nerve roots that are at risk.
Pathogenesis
Pathogenetic mechanisms fall into three main groups:
low-energy insufficiency fractures arising from comparatively mild compressive stress in osteoporotic bone;
minor fractures of the vertebral processes due to compressive, tensile or tortional strains;
highenergy fractures or fracture-dislocations due to major injuries sustained in motor vehicle collisions, falls or
diving from heights, sporting events, horse-riding and collapsed buildings.
Examination
Patients complaining of back pain following an injury or showing signs of bruising and tenderness over
the spine, as well as those suffering head or neck injuries, chest injuries, pelvic fractures or multiple injuries
elsewhere, should undergo a careful examination of the spine and a full neurological examination, including
rectal examination to assess sphincter tone.
Imaging
X-rays The anteroposterior x-ray may show loss of height or splaying of the vertebral body with a crush
fracture. Widening of the distance between the pedicles at one level, or an increased distance between two
adjacent spinous processes, is associated with posterior column damage. The lateral view is examined for
alignment, bone outline, structural integrity, disc space defects and soft-tissue shadow abnormalities.
CT and MRI Rapid screening CT scans are now routine in many accident units. Not only are they more reliable
than x-rays in showing bone injuries throughout the spine, and indispensable if axial views are necessary, but
they also eliminate the delay, discomfort and anxiety so often associated with multiple attempts at getting the
right views with plain x-rays. In some cases MRI also may be needed to evaluate neurological or other softtissue injuries.
Treatment
Treatment depends on: (a) the type of anatomical disruption; (b) whether the injury is stable or unstable;
(c) whether there is neurological involvement or not; and (d) the presence or absence of concomitant
injuries.
MINOR INJURIES
Fractures of the transverse processes
The transverse processes can be avulsed with sudden muscular activity. Isolated injuries need no more
than symptomatic treatment. More ominous than usual is a fracture of the transverse process of L5; this should
alert one to the possibility of a vertical shear injury of the pelvis.
Fracture of the pars interarticularis
A stress fracture of the pars interarticularis should be suspected if a gymnast or athlete or weight-lifter
complains of the sudden onset of back pain during the course of strenuous activity. The injury is often
ascribed to a disc prolapse, whereas in fact it may be a stress fracture of the pars interarticularis (traumatic
spondylolysis). This is best seen in the oblique x-rays.Bilateral fractures occasionally lead to spondylolisthesis.
The fracture usually heals spontaneously, provided the patient is prepared to forego his (more often her)
athletic passion for several months.
MAJOR INJURIES
Flexioncompression injury
This is by far the most common vertebral fracture and is due to severe spinal flexion(Fig 19a), though in
osteoporotic individuals fracture may occur with minimal trauma. The posterior ligaments usually remain intact,

although if anterior collapse is marked they may be damaged by distraction. Pain may be quite severe but the
fracture is usually stable. Neurological injury is extremely rare. Patients with minimal wedging and a stable
fracture pattern are kept in bed for a week or two until pain subsides and are then mobilized; no support is
needed. Those with moderate wedging (loss of 2040 per cent of anterior vertebral height) and a stable injury
can be allowed up after a week, wearing a thoracolumbar brace(Fig.19c) or a body cast applied with the back in
extension. At 3 months, flexionextension x-rays are obtained with the patient out of the orthosis; if there
is no instability, the brace is gradually discarded. If the deformity increases and neurological signs appear, or
if the patient cannot tolerate the orthosis, surgical stabilization is indicated(Fig.19b).

If loss of anterior vertebral height is greater than 40 per cent, it is likely that the posterior ligaments
have been damaged by distraction and will be unable to resist further collapse and deformity. If the patient is
neurologically intact, surgical correction and internal fixation is the preferred treatment. If nerve loss is
incomplete there is the potential for further recovery; any increase in kyphotic deformity or MRI signs of
impending cord neurological compression would be an indication for operative decompression and stabilization.
If there is complete paraplegia with no improvement after 48 hours, conservative management is adequate; the
patient can be rested in bed for 56 weeks, then gradually mobilized in a brace. With severe bony injury,
however, increasing kyphosis may occur and internal fixation should be considered.
Axial compression or burst injury
Severe axial compression may explode the vertebral body, causing failure of both the anterior and the
middle columns. The posterior part of the vertebral body is shattered and fragments of bone and disc may be
displaced into the spinal canal. The injury is usually unstable. Posterior displacement of bone into the spinal
canal (retropulsion) is difficult to see on the plain lateral radiograph; a CT is essential.
If there is minimal anterior wedging and the fracture is stable with no neurological damage, the patient
is kept in bed until the acute symptoms settle and is then mobilized in a thoracolumbar brace or body cast which
is worn for about 12 weeks.
However, any new symptoms such as tingling, weakness or alteration of bladder or bowel function must
be reported immediately and should call for further imaging by MRI; anterior decompression and stabilization
may then be needed if there are signs of present or impending neurological compromise

Fracture-dislocation
Segmental displacement may
occur with various combinations of
flexion, compression, rotation and
shear.All three columns are disrupted
and the spine is grossly unstable.
These are the most dangerous injuries
and are often associated with
neurological
damage
to
the
lowermost part of the cord or the
cauda equina. The injury most
commonly
occurs
at
the
thoracolumbar junction. X-rays may
show fractures through the vertebral
body, pedicles, articular processes
and laminae(Fig.20); there may be
varying degrees of subluxation or
even bilateral facet dislocation. CT is
helpful in demonstrating the degree
of spinal canal occlusion. In
neurologically intact patients, most
fracture-dislocations will benefit from early surgery. In fracture-dislocation with paraplegia, there is no
convincing evidence that surgery will facilitate nursing, shorten the hospital stay, help the patients
rehabilitation or reduce the chance of painful deformity. In fracture-dislocation with a partial neurological
deficit, there is also no evidence that surgical stabilization and decompression provides a better neurological
outcome than conservative treatment.
In fracture-dislocation without neurological surgical stabilization will prevent future neurological
complications and allow earlier rehabilitation.
Cord transection
Motor paralysis, sensory loss and visceral paralysis occur below the level of the cord lesion; as with cord
concussion, the motor paralysis is at first flaccid. This is a temporary condition known as cord shock, but the
injury is anatomical and irreparable. After a time the cord below the level of transaction recovers from the
shock and acts as an independent structure; that is, it manifests reflex activity. Within 48 hours the primitive
anal wink and bulbocavernosus reflexes return. Within 4 weeks of injury tendon reflexes return and the flaccid
paralysis becomes spastic, with increased tone, increased tendon reflexes and clonus; flexor spasms and
contractures may develop with inadequate management.

Spinal Deformities
Introduction
A thorough understanding of spinal anatomy is crucial for a comprehensive evaluation of a patient with
spinal disorders. The primary roles of the spine are maintaining stability, protecting the neural elements, and
allowing range of motion. Specifically adapted anatomic features facilitate these functions. The vertebra is the
structural building block of the spine, with specific morphologic and functional roles based on the vertebras
position in the spinal column.The intervertebral disks, ligaments, and muscles add stability and control. The
spinal cord travels within, and is protected by, the spine. Paired nerve roots exit at each spinal level.
Anatomy and Biomechanics
The axial skeleton is composed of 33 vertebrae, including
7 vertebrae in the neck, 12 vertebrae in the thoracic region, 5
vertebrae in the lumbar region, 5 fused vertebrae in the sacrum,
and the coccyx that typically includes 4 vertebral bodies,
sometimes partially or totally fused together (Fig. 21).
Intervertebral discs separate the vertebrae except between the first
and second cervical vertebrae (C1 and C2, respectively) and
between the
sacrum and the coccyx. The body of a vertebra is shaped like a
short cylinder and is composed primarily of
cancellous, well-vascularized bone covered by a thin layer of
cortical bone. With increasing weight-bearing loads, the vertebral
body becomes progressively taller and wider from above
downward. The posterior arch includes right and left pedicles that
project posteriorly from the posterolateral surface of the vertebral
body, and right and left laminae that project posteromedially to
fuse with the spinous process (Fig.22). The arch and body enclose
and protect the spinal cord and cauda equina and form the
vertebral foramen, through which the nerve roots pass. The
spinous process projecting posteriorly and the two transverse
processes that extend laterally from the pedicle-lamina junction
provide outrigger insertion sites for the multiple muscles and
ligaments that move and stabilize the trunk. The facet joints provide motion between two vertebrae. The
superior articular process and facet joint extend from the pedicle of the vertebra below (caudal) to articulate
with the inferior articular process and facet joint that extends from the lamina of the vertebra above.

The vertebral canal extends from the foramen magnum to the sacrum and encloses the spinal cord and
its nerve roots. The duramater is separated from the bones by an epidural space that contains fat and an
extensive plexus of epidural veins. The dural sac continues inferiorly to approximately the middle of the S2
vertebra. Inferior to the conus, the dural sac contains the cauda equina (lumbosacral nerve roots) and the filum
terminale, a cord of tissue that travels inferiorly from the conus to merge with the periosteum on the dorsum of
the coccyx . The first and second cervical vertebrae are different from the lower five cervical vertebrae (Fig 23).
The atlas (C1 vertebra) lacks a spinous process and is essentially an oval ring of bone. The lateral portions of
the C1 ring are thickened into a lateral mass that articulates with the occipital condyle superiorly and with the
lateral mass of C2 inferiorly. The axis (C2 vertebra) has a toothlike protuberance, the dens, that projects upward
from the body to provide structural support for the atlas. The dens provides a pivot point on which the head and
atlas can rotate relatively freely on the relatively flat C1-C2 articular facets.
The cervical spine is a mobile platform for the skull and is the most flexible portion of the vertebral
column. Motion of the cervical spine includes flexion and extension, right and left lateral bending, and right and
left rotation. In young adults, normal neck motion is 70 flexion, 70 extension, 50 lateral bending, and 90
rotation to each side. The degree of motion between two vertebrae is determined primarily by the orientation
of the facets; therefore, different vertebral segments contribute differing amounts to each plane of motion.
The total arc of flexionextension, however, is greater in the lower cervical vertebral segments, with peak motion
occurring at the C5-C6 level. Motion of the spine is often coupled. For example, lateral bending of the neck is
accompanied by rotation, and rotation of the cervical spine is coupled with lateral bending and flexionextension.
Thoracic vertebrae have costal facets at the upper and lower edges of the junction of the body with the
arch on each side. Primary motion in the thoracic spine is lateral bending and rotation, with lateral bending
being greater in the lower thoracic segments and rotation being greater in the upper thoracic spine.
Because of the increased axial loads and the lack of surrounding rib support, the horizontal diameter of a lumbar
vertebra is greater than its height. Lumbar vertebrae are larger and thicker anteriorly. The superior articular
facet of a lumbar vertebra faces mostly medially, and the inferior facet is directed laterally. Flexion-extension is
the primary arc of motion in the lumbar spine, with greater movement occurring in the lower lumbar segments.
The vertebral bodies of the lumbar spine support an average of 80% of the axial load experienced by the spinal
column; the facet joints support the other 20%.
Intervertebral Discs
The intervertebral discs
contribute approximately 20%
of the length of the cervical
and thoracic spine and
approximately 33% of the
length of the lumbar region. In
the cervical and lumbar
regions, the discs are thicker
anteriorly Thoracic discs have
uniform
height.
The
intervertebral disc includes the
annulus fibrosus and the
nucleus pulposus (Fig.23). The central nucleus pulposus is composed of water, type II collagen, and
proteoglycan aggregates. This composite structure provides good resistance to repeated loading in both
compression and tension. The load at the L3-L4 disc ranges from 30 kg while the individual is lying supine to
more than 300 kg when the person is lifting a 20-kg weight with the spine flexed and the knees straight.
Curves of the spine
The vertebral column has four distinct curvescervical lordosis, lumbar lordosis, thoracic kyphosis, and
sacral kyphosis (Fig.21). In stance, the sagittal vertical axis passes through the odontoid, posterior to the
cervical verte-brae, through the C7-T1 intervertebral disk, anterior to the thoracic vertebrae, through the T12-

L1 interver-tebral disk, posterior to the lumbar vertebrae, through the L5-S1 intervertebral disk, and anterior to
the sacrum.
The primary curves are those of the kyphotic thoracic and sacral regions. These form during the fetal
period.The secondary curves are those of the lordotic cervical and lumbar regions. These are initiated during the
late fetal period but do not become significant until after birth when the spinal column begins to bear the weight
of the body and head. Primary curves are caused by the wedge-shaped nature of involved vertebrae, whereas
secondary curves are caused by differences in the anterior and posterior dimensions of the intervertebral disks.
The cervical lordotic curve normally ranges from 25 to 50 degrees with an apex at C4. The thoracic
spine anatomically refers to the named vertebral levels from T1 to T12. This region is usually kyphotic, with its
apex around T7. The caudal aspect of the kyphosis typically decreases in sagittal angulation until the relatively
neutral thoracolumbar junction, which has a relatively straight inflection point. Normal thoracic kyphosis
usually ranges from 20 to 50 degrees in adults. The normal lumbar lordosis is between 40 and 70 degrees
with an apex located at the L3-4 interspace.The
lumbosacral junction is an inflection point for the
lordotic segment of the lumbar spine to the
kyphotic sacrum. Local kyphosis is measured by
the angle created between a line along the inferior
aspect of L5 and a line along the superior border of
S1. One of the most critical relationships in the
human spine that sets parameters for sagittal
balance is the lumbosacral pelvis. Recent studies
report that sagittal plane balance is mediated by the
following independent factors: sacral slope, pelvic
tilt, pelvic incidence, and lumbar lordosis (Fig. 24).
Sacral slope is the angle between the superior
border of S1 and a line parallel to the horizon. The
pelvic tilt is the angle between a line perpendicular
to the horizon and a line joining the middle of the
superior sacral endplate. Pelvic incidence (PI), or
pelvisacral angle, is defined as the angle between a
line perpendicular to the sacral plate at its midpoint
and a line connecting the same point to the center
of the bicoxofemoral axis. This number is fixed
and some believe it is the angle on which all other
spinal curves are based.

SCOLIOSIS
Scoliosis is an apparent lateral
(sideways) curvature of the spine. Apparent
because, although lateral curvature does occur,
the commonest form of scoliosis is actually a
triplanar deformity with lateral, anteroposterior
and rotational components. Two broad types of
deformity are defined: postural and structural.
Postural Scoliosis
In postural scoliosis the deformity is
secondary or compensatory to some condition
outside the spine,such as a short leg, or pelvic
tilt due to contracture of the hip. When the
patient sits (thereby cancelling leg length
asymmetry) the curve disappears. Local muscle

spasm associated with a prolapsed lumbar disc may cause a skew back; although sometimes called sciatic
scoliosis this, too, is a spurious deformity.(Fig.31)
Structural scoliosis
In structural scoliosis there is a non-correctable deformity of the affected spinal segment, an essential
component of which is vertebral rotation. The spinous processes swing round towards the concavity of the
curve and the transverse processes on the convexity rotate posteriorly. Primary curves presents characteristic
modifications: cuneiform vertebrae at the center of curvature, while outheredge vertebraes are rhomboid and
reseambles to normal aspect (neutral vertebrae). In the thoracic region the ribs on the convex side stand out
prominently, producing the rib hump, which is a characteristic part of the overall deformity(gibbus) determining
the characteristic ovalar-oblique thoracic cage. Secondary (compensatory) curves nearly always develop to
counterbalance the primary deformity; they are usually less marked and more easily correctable, but with time
they, too, become fixed.
Once fully established, the deformity is liable to increase throughout the growth period. Thereafter,
further deterioration is slight, though curves greater than 50 degrees may go on increasing by 1 degree per year.
With very severe curves, chest deformity is marked and cardiopulmonary function is usually affected.
Classification
Aetiology
Most cases have no obvious cause (idiopathic scoliosis). This group constitutes about 80 per cent of all
cases of scoliosis. The deformity is often familial and the population incidence of serious curves (over 30
degrees and therefore needing treatment) is three per 1000; trivial curves are very much more common.
Other varieties are congenital or osteopathic (due to bony anomalies)(fig.32), neuropathic, myopathic
(associated with some muscle dystrophies poliomyelitis, syringomyelia, Friedreich heredoataxia), scoliosis in
neurofibromatosis Recklinghausen, posttraumatic scoliosis, skeletal genetic disorders (Morquio disease, Marfan
disease, osteogenesis imperfecta), scoliosis in vertebral tumors .

Primary curvature
Thoracic scoliosis (Th6-Th12) ussualy with right side convexity and lombar compensatory curvature.
Progression is more severe with early-onset
Thoraco-lumbar scoliosis(Th11-L3) - right side convexity, sever prognosis
Lumbar scoliosis(Th6-L2) left side convexity, with better outcome than the first two
Cervico-Thoracic scoliosis left side convexity with thoracic and thoraco-lumbar compensatory
curvature. Develops ussualy in individuals with poliomyelitis and neurofibromatosis
Double primary curve scoliosis(Th6-Th11 and Th11-L4) one thoracic dextroconvex curvature and a
lumbar one with left side convexity, balanced, fearly good prognosis.

Degree of curvature
I.<300
II.<500
III<900
IV>900

Mobility
I - mobile
II- partial mobile
III- fixed.
Age
- early-onset (infantile) idiopathic scoliosis- This variety, which presents in children aged 3 or under.
Boys predominate and most curves are thoracic with convexity to the left. Although 90 per cent of infantile
curves resolve spontaneously, progressive curves can become very severe; those in which the rib-vertebra angle
at the apex of the curve differs on the two sides by more than 20 degrees are likely to deteriorate Because this
also influences the development of the lungs, there is a high incidence of cardiopulmonary dysfunction.From
about the age of 4 years onwards curve progression slows down or ceases and the child may not need further
treatment. If the deformity continues to deteriorate, surgical correction may be required.
- early-onset (juvenile) idiopathic scoliosis - Presenting in children aged 412, this type is
uncommon. There are 3 subgroups: I: 4-7 years-severe, similar to infantile scoliosis; II: 8-10 years
intermediate; III: 11-12 years-the characteristics of this group are similar to those of the adolescent group, but
the prognosis is worse and surgical correction may be necessary before puberty. However, if the child is very
young, a brace may hold the curve stationary until the age of 10 years, when fusion is more likely to succeed.
-adolescent scoliosis (late-onset) most frecvent of all, onsets after puberty, and the evolution is shortuntil the growing is cesed (17-18 years in girls, 19-20years in boys). This is the commonest type, occurring in
90 per cent of cases, mostly in girls. Progression is not inevitable; indeed, most curves less than 20 degrees
either resolve spontaneously or remain unchanged. However, once a curve starts to progress, it usually goes on
doing so throughout the remaining growth period (and, to a much lesser degree, beyond that).
-adult scoliosis(late-onset) in most cases represents the evolution of a puberty onset scoliosis, primary
onset after puberty being exceptional. It develops in individuals with idiopatic/neuropatic curvatures>500 (with
a rate of 1-20 per year), hypotonic paravertebral musculature, pregnancy.
Reliable predictors of progression are: (1) a very
young age; (2) marked curvature; (3) an incomplete Risser
sign at presentation.In prepubertal children, rapid progression
is liable to occur during the growth spurt.
Clinical features
Deformity is usually the presenting symptom: an
obvious skew back or a rib hump in thoracic curves, and
asymmetrical prominence of one hip in thoracolumbar curves.
Balanced curves sometimes pass unnoticed until an adult
presents with backache.
Pain is a rare complaint and should alert the clinician
to the possibility of a neural tumour and the need for MRI.
Scoliosis in children is a painless deformity. Scoliosis with
pain suggests a spinal tumour until proved otherwise.
There may be a family history of scoliosis or a record
of some abnormality during pregnancy or childbirth; the early
developmental milestones should be noted.

The trunk should be completely exposed and the patient

examined from in front, from the back and from the side. Skin
pigmentation and congenital anomalies such as sacral dimples or
hair tufts are sought. The spine may be obviously deviated from the
midline, or this may become apparent only when the patient bends
forward (the Adams test)(Fig.25). The level and direction of the
major curve convexity are noted (e.g. right thoracic means a curve
in the thoracic spine and convex to the right). The hip (pelvis) sticks
out on the concave side and the scapula on the convex. The breasts
and shoulders also may be asymmetrical.With thoracic scoliosis,
rotation causes the rib angles to protrude, thus producing an
asymmetrical rib hump on the convex side of the curve.
In balanced deformities the occiput is over the midline; in
unbalanced (or decompensated) curves it is not. This can be
determined more accurately by dropping a plumbline from the
prominent spinous process of C7 and noting whether it falls along
the gluteal cleft.(Fig.32). In associated kyphosis, where the head is
projected forward, the plumb wire is difficult to apply on the
occiput, the most posterior aspect of the spine is used than as
referance.In this manner the maximal deviations of the spine can be
measured, as well as the gibbus hight with the spine flexed.It is also
important the measurement of the length of the inferior limbs, the
hight and weight of the patient.
The diagnostic feature of fixed (as distinct from postural or
mobile) scoliosis is that forward bending makes the curve more obvious. Spinal mobility should be assessed and
the effect of lateral bending on the curve noted; is there some flexibility in the curve and can it be passively
corrected? Side-on posture should also be observed. There may appear to be excessive kyphosis or lordosis.
Neurological examination is important. Any abnormality suggesting a spinal cord lesion calls for CT and/or
MRI.
Leg length is measured. If one
side is short, the pelvis is
levelled by standing the patient
on wooden blocks and the spine
is
re-examined.
General
examination includes a search
for the possible cause and an
assessment of cardiopulmonary
function (which is reduced in
severe curves).
Imaging
PLAIN X-RAYS
Full-length
postero-anterior
(PA) and lateral x-rays of the
spine and iliac crests must be
taken with the patient erect.
Structural
curves
show
vertebral rotation: in the PA
x-ray, vertebrae towards the
apex of the curve appear to be
asymmetrical and the spinous
processes are deviated towards

the concavity. Remember that PA in relation to the patient is not PA in relation to the rotated vertebrae! The
upper and lower ends of the curve are identified as the levels where vertebrae start to angle away from the
curve. The degree of curvature is measured by drawing lines on the x-ray at the upper border of the uppermost
vertebra and the lower border of the lowermost vertebra of the curve; the angle subtended by these lines is the
angle of curvature (Cobbs angle).(Fig.26). The site of the curve apex should be noted. Right thoracic curves
are the commonest, the great majority in girls in adolescent idiopathic scoliosis. Left thoracic curves are so
unusual that if seen they should be further investigated by MRI to exclude spinal tumours. The primary
structural curve is usually balanced by compensatory curves above and below, or by a second primary curve
also with vertebral rotation (some-times there are multiple primary curves). Lateral bending views are taken to
assess the degree of curve correctability. The rotation of vertebral bodies can be measured using the Moe-Nash
method- measuring, in millimeters, the distance between the vertebral pedicul and the lateral edge of the
vertebral body-in the most rotated vertebrae(fig.34).

SKELETAL MATURITY RISSERS SIGN

This is assessed in several ways (this is important because the curve often progresses most during the period of
rapid skeletal growth and maturation). The iliac apophyses start ossifying shortly after puberty; ossification
extends medially and, once the iliac crests are completely ossified, further progression of the scoliosis is
minimal (Rissers sign)(fig.27).

The Risser-Cotrel skeletal maturation test marks the onset and progressive fusion, in 5 stages, of secondary
ossification nucleus of the iliac crest.The ossification process begins at the anterior-superior iliac spine at the
age of 12-14 years. When ossification is complete (around 17 years) skeletal growth and maturation ends, as the
progression of scoliosis. In most cases of idiopathic scoliosis skeletal age is lower than the chronological age.
This stage of development usually coincides with fusion of the vertebral ring apophyses. Skeletal age may
also be estimated from x-rays of the wrist and hand.
SPECIAL IMAGING
CT and MRI may be necessary to define a vertebral abnormality or cord compression. Special investigations
Pulmonary function tests are performed in all cases of severe chest deformity. A marked reduction in vital
capacity is associated with diminished life expectancy and carries obvious risks for surgery. Patients with
muscular dystrophies or connective tissue disorders require full biochemical and neuromuscular investigation of
the underlying condition.
Prognosis and treatment
Prognosis is the key to treatment: the aim is to prevent severe deformity. Generally speaking, the
younger the child and the higher the curve the worse is the prognosis. Management differs for the different
types of scoliosis, which are considered later.
The natural evolution of scoliosis is toward aggravation of deviation and symptoms. The relationship
between the progression of scoliosis and the skeletal growth and maturation is marked by two aspects.
Prepubertary period is characterized by slow progression, but after the onset of puberty the progression of
scoliosis is accelerated 2 to 8 times, and it ceases when the skeletal growth and maturation is complete around
17 years in girls and 19 years in boys (see Risser-Cotrel test).
Prognostic is determined by a series of factors:

-onset age progression of scoliosis in faster in early onset types, in general 1-20 per mounths. After
skeletal maturation in complete it is considered that scoliosis in stabilizated, exception are congenital and
neuropathic scoliosis.
-location of primary curve thoracic and thoraco-lumbar scoliosis have a more sever prognosis.
-degree of curvature type I scoliosis (<300) are less sever than the more marked deformations (>300).
Treatment
The aims of treatment are: (1) to prevent a mild deformity from becoming severe; (2) to correct an
existing deformity that is unacceptable to the patient. At 49-monthly intervals the patient is examined,
photographed and x-rayed so that curves can be measured and checked for progression.
NON-OPERATIVE TREATMENT
If the patient is approaching skeletal maturity and the deformity is acceptable (which usually means it is
less than 30 degrees and well balanced), treatment is probably unnecessary unless sequential x-rays show
definite progression.
Exercises are often prescribed; they have no effect on the curve but they do maintain muscle tone and may
inspire confidence in a favourable outcome.
Correction can be achieved using seriate plaster apparatus , during a 3-6 mounths intervals, (Abbott, Risser,
Cotrel), equipped with an internal metalic frames that applies pressure on the convexity as well as achieving the
elongation and rotation correction of the spine. This results are then maintained with bracing.
Bracing has been used for many years in the treatment of progressive scoliotic curves between 20 and 30
degrees(fig.28). The Milwaukee brace is principally a thoracic support consisting of a pelvic corset connected
by adjustable steel supports to a cervical ring carrying occipital and chin pads; its purpose is to reduce the

lumbar lordosis and encourage active stre-tching and straightening of the thoracic spine. The Boston brace is a
snug-fitting underarm brace that provides lumbar or low thoracolumbar support. Corrective pads may be added
to these devices to apply pressure at a particular site. A well-made brace can be worn 23 hours out of 24 and
does not preclude full daily activities, including sport and exercises.It has long been recognized that bracing will
not improve the curve at best it will merely stop it from getting worse.
OPERATIVE TREATMENT
Surgery is indicated: (1) for curves of more than 30 degrees that are cosmetically unacceptable,
especially in pre-pubertal children who are liable to develop marked progression during the growth spurt; (2) for
milder deformity that is deteriorating rapidly. Balanced, double primary curves require operation only if they
are greater than 40 degrees and progressing.

The objectives are: (1) to halt progression of the deformity; (2) to straighten the curve (including the
rotational component) by some form of instrumentation; (3) to arthrodese the entire primary curve by bone
grafting.
Surgical options include: Harrington system In the original system a rod was applied posteriorly along
the concave side of the curve;
attached to the rod were
movable hooks that were
engaged in the uppermost
and lowermost vertebrae so
as to distract the curve. If the
curve is flexible, it will
passively correct and bone
grafts are then applied to
obtain fusion over the length
of the curve. A major
drawback of the original
distraction instrumentation is
that it does not correct the
rotational deformity at the
apex of the curve and thus
the rib prominence remains
virtually unchanged.

Rod and sublaminar wiring (Luque) This is a modification of the Harrington system. Wires are passed under the
vertebral laminae at multiple levels and fixed to the rod on the concave side of the curve, thus providing a more
controlled and secure fixation. By bending the rod and arranging the mechanism so that the wires pull
backwards rather than merely sideways, the rotational component of the deformity can also be substantially
improved. However, the sublaminar wires are dangerously close to the dura and the risk of neurological damage
is increased. (fig.36).
Cotrel-Dubousset system This mechanism
combines a pedicle screw box foundation at
the caudal end of the deformity, with
multiple hooks which can be placed at
various levels to produce either distraction or
compression.It has been claimed that this
system can correct the rotational deformity.
It is also sufficiently rigid to make
postoperative bracing unnecessary.
Anterior instrumentation (Dwyer; Zielke;
Kaneda) Rigid curves and thoracolumbar
curves associated with lumbar lordosis can
be corrected by approaching the spine from
the front, removing the discs throughout the
curve and then applying a compression
device (either a braided cable or a rod linking
transverse vertebral body screws) along the
convex side of the curve. Bone grafts are
added to achieve fusion. In some cases

combined anterior and posterior instrumentation is necessary Advantages of this system are: (1) that it provides
strong fixation with fewer vertebral segments having to be fused; (2) that overall shortening of the deformed
section (by disc excision and vertebral compression) lessens the risk of cord injury due to spinal distraction. In
some centres, transthoracic scoliosis surgery is now performed endoscopically through several ports, in order to
reduce the morbidity associated with open thoracic surgery and rib resection.
Complications of surgery
Neurological compromise With modern techniques the incidence of permanent paralysis has been reduced to
less than 1 per cent. From the patients point of view this is small comfort. Every effort should be made to
provide adequate safeguards.
Spinal decompensation Overcorrection may produce an unbalanced spine. This should be avoided by careful
preoperative planning and selection of the appropriate levels of fusion.
Pseudarthrosis Incomplete fusion occurs in about 2-18% of cases and may require further operation and
grafting.
Implant failure Hooks may cut out and rods may break. If this is associated with a symptomatic
pseudarthrosis, revision fusion/fixation will be needed.
KYPHOSIS
Rather confusingly, the term kyphosis is used to describe both the normal (gentle rounding of the
thoracic spine) and the abnormal (excessive thoracic curvature or straightening out of the cervical or lumbar
lordotic curves). Excessive thoracic curvature might be better described as hyperkyphosis. Kyphos, or gibbus,
is a sharp posterior angulation due to localized collapse or wedging of one or more vertebrae. This may be the
result of a congenital defect, a fracture (sometimes pathological) or spinal tuberculosis.
Postural Kyphosis
Postural kyphosis is usually associated with other postural defects
such as flat feet. It is voluntarily correctable. If treatment is needed, this
consists of posture training and exercises. Compensatory kyphosis is
secondary to some other deformity, usually increased lumbosacral
lordosis. This deformity, too, is correctable.
Structural kyphosis
Structural kyphosis is fixed and associated with changes in the
shape of the vertebrae. In children this may be due to congenital vertebral
defects; it is also seen in skeletal dysplasias such as achondroplasia and in
osteogenesis imperfecta. Older children may develop severe deformity
secondary to tuberculous spondylitis.
In adolescence the commonest cause is Scheuermanns disease
(see later). In adults kyphosis could be due to an old childhood disorder;
tuberculous spondylitis, ankylosing spondylitis or spinal trauma. In
elderly people, osteoporosis may result in vertebral compression and an
increase in a previously mild, asymptomatic deformity.
Congenital kyphosis
Vertebral anomalies leading to kyphosis may be due to failure of
formation (type I), failure of segmentation (type II) or a combination of these:
Type I (failure of formation) This is the commonest (and the worst) type. If the anterior part of the
vertebral body fails to develop, progressive kyphosis and posterior displacement of the hemivertebra may lead
to cord compression. In children younger than 6 years with curves of less than 40 degrees, posterior spinal
fusion alone may prevent further progression. Older children or more severe curves may need combined

anterior and posterior fusion, and those with neurological complications will require cord decompression as
well as fusion.
Type II (failure of segmentation) Type II usually takes the form of an anterior intervertebral bar; as the
posterior elements continue to grow, that segment of the spine gradually becomes kyphotic. The risk of
neurological compression is much less, but if the curve is progressive a posterior fusion will be needed.

Adolescent kyphosis (juvenile osteochondrosis; Scheuermanns disease)

Scheuermann, in 1920, described a condition that he called juvenile dorsal kyphosis, distinguishing it
from the more common postural (correctable) kyphosis.
The characteristic feature was a fixed round-back deformity associated with wedging of several thoracic
vertebrae. The term vertebral osteochondritis was adopted because the primary defect appeared to be in the
ossification of the ring epiphyses that define the peripheral rims on the upper and lower surfaces of each
vertebral body. The true nature of the disorder is still not known; the cartilaginous end-plates may be weaker
than normal (perhaps due to a collagen defect) and are then damaged by pressure of the adjacent intervertebral
discs during strenuous activity.
The normal curve of the thoracic spine ensures that the anterior edges of the vertebrae are subjected to
the greatest stress and this is where the damage is greatest. Similar changes may occur in the lumbar spine, but
here wedging is unusual.
Clinical features
The condition starts at puberty and affects boys more often than girls. The parents notice that the child,
an otherwise fit teenager, is becoming increasingly round-shouldered. The patient may complain of
backacheand fatigue; this sometimes increases after the end of growth and may become severe. A smooth
thoracic kyphosis is seen; it may produce a marked hump. Below it is a compensatory lumbar lordosis. The
deformity cannot be corrected by changes in posture. Movements are normal but tight hamstrings often limit
straight leg raising. A mild scoliosis is not uncommon. Rare complications are spastic paresis of the lower limbs
and with severe deformity of the thorax cardiopulmonary dysfunction.
In later life patients with thoracic kyphosis may develop lumbar backache. In some cases, however,
lumbar Scheuermanns disease itself may cause pain (see later).

Imaging
X-ray In lateral radiographs of the spine the vertebral endplates of several adjacent vertebrae (usually T610)
appear irregular or fragmented. The changes are more marked anteriorly and one or more vertebral bodies may
become wedge shaped. There may also be small radiolucent defects in the subchondral bone (Schmorls nodes),
which are thought to be due to central (axial) disc protrusions.
The angle of deformity is measured in the same way as for scoliosis, except that here the lateral x-ray is
used and the lines mark the uppermost and lowermost affected vertebrae. Wedging of more than 5 degrees in
three adjacent vertebrae and an overall kyphosis angle of more than 40 degrees are abnormal.
Mild scoliosis is not uncommon.
Differential diagnosis
Postural kyphosis Postural round back is common in adolescence. It is painless, and the patient can correct
the deformity voluntarily. The curve is a long one and other postural defects are common. The x-ray appearance
is normal.
Discitis, osteomyelitis and tuberculous spondylitis If the changes are restricted to one intervertebral level, they
can be mistaken for an infective lesion. However, infection causes more severe pain, may be associated with
systemic symptoms and signs and produces more marked x-ray changes, including signs of bone erosion and
paravertebral soft-tissue swelling.
Spondyloepiphyseal dysplasia In mild cases this can produce changes at multiple levels resembling those of
Scheuermanns disease. Look for the characteristic defects in other joints.
Outcome
The condition is often quite painful during adolescence, but (except in the most severe cases) symptoms
subside after a few years.
TREATMENT
Curves of 40 degrees or less require only back-strengthening exercises and postural training. More
severe curvature in a child who still has some years of growth ahead responds well to a period of 1224 months
in a brace that holds the lumbar spine flat and the thoracic spine in extension (decreased kyphosis).
Check the position by x-ray to ensure that the brace is effective.
The older adolescent or young adult with a rigid curve of more than 60 degrees may need operative

correction and fusion using a hook-rod system (modified Harrington or Cotrel-Dubousset).

Patients with severe kyphotic deformities (kyphosis of greater than 75 degrees) require a combined
anterior and posterior approach. In these procedures, the spine is approached anteriorly, and the shortened
ligaments, fibrous tissue, and cartilaginous remnants are removed. Autogenous bone graft is then positioned to
support the anterior column. Vertebrectomy is unnecessary unless there are problems of spinal cord
compression. Once the discectomy is completed, the spine becomes much more flexible. The posterior
procedure must encompass the entire length of the affected vertebrae and at least one normal vertebra above and
one below. The posterior fusion is always slightly longer than the anterior fusion. Autogenous bone graft is
recommended as graft material. If possible, internal fixation is used posteriorly. Only compression-type
instrumentation is used; distraction should never be used. Traction also should not be used in patients with type
I deformities because it is associated with a high incidence of paraplegia.(Fig.39)

Kyphosis in the elderly

Degeneration of intervertebral discs probably produces the gradually increasing stoop characteristic of
the aged. The disc spaces become narrowed and the vertebrae slightly wedged. There is little pain unless
osteoarthritis of the facet joints is also present.
Osteoporotic kyphosis
Postmenopausal osteoporosis may result in one or more compression fractures of the thoracic spine.
Patients are usually in their 60s or 70s and may complain of pain. Kyphosis is seldom marked.
Often the main complaint is of lumbosacral pain, which results from the compensatory lumbar lordosis
in an ageing, osteoarthritic spine.

Treatment is directed at the underlying condition and may include hormone and bone mineral
replacement therapy.
Senile osteoporosis affects both men and women. Patients are usually over 75 years of age, often
incapacitated by some other illness, and lacking exercise. They complain of back pain, and spinal deformity
may be marked. X-rays reveal multiple vertebral fractures. It is important to exclude other conditions such as
metastatic disease or myelomatosis.
Treatment Treatment is symptomatic. Bed rest and spinal bracing merely aggravate the osteoporosis. More
recently, fresh compression fractures are being treated by the transpedicular injection of methacrylate or bone
graft substitute paste in order to stop further deformity and control pain (vertebroplasty) or to correct the
wedge deformity and maintain correction (kyphoplasty).(Fig.40)

SPONDYLOLISTHESIS
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.
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
Various classifications have been suggested. Basically there are six types of spondylolisthesis(Fig.41):
Dysplastic (20 per cent) The superior sacral facets are congenitally defective; slow but inexorable forward slip
leads to severe displacement. Associated anomalies (usually spina bifida occulta) are common.
Lytic or isthmic (50 per cent) In this, the commonest variety, there are defects in the pars interarticularis
(spondylolysis), or repeated breaking and healing may lead to elongation of the pars. The defect (which occurs
in about 5 per cent of people) is usually present by the age of 7, but the slip may appear only some years later. It
is difficult to exclude a genetic factor because spondylolisthesis often runs in families, and is more common in
certain races. An acquired factor probably supervenes to produce what is essentially an ununited stress fracture.
The condition is more common than usual in those whose spines are subjected to extraordinary stresses (e.g.
competitive gymnasts and weight-lifters).

Degenerative (25 per cent) Degenerative changes in the facet joints and the discs permit forward slip
(nearly always at L4/5 and mainly in women of middle age) despite intact laminae. Many of these patients have
generalized osteoarthritis and pyrophosphate crystal arthropathy.
Post-traumatic Unusual fractures may result in destabilization of the lumbar spine.
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 results in progressive spondylolisthesis.

Pathology
In the common lytic type of spondylolisthesis the pars interarticularis on both sides is disrupted, as in an
ununited fracture (spondylolysis), leaving the posterior neural arch separated from the vertebral body anteriorly;
the gap is occupied by fibrous tissue. With stress, the vertebral body and superior facets in front of the gap may
subluxate or dislocate forwards, carrying the superimposed vertebral column with it (spondylolisthesis); the
isolated segment of neural arch maintains its normal relationship to the sacral facets. When there is no gap, the
pars interarticularis is elongated or the facets are defective. The degree of slip is measured by the amount of
overlap of adjacent vertebral bodies and is usually expressed as a percentage(Fig.42). With forward slipping
there may be pressure on the dura mater and cauda equina, or on the emerging nerve roots; these roots may also
be compressed in the narrowed intervertebral foramina. Disc prolapse is liable to occur.

Clinical features Spondylolysis, and even a wellmarked spondylolisthesis, may be discovered

incidentally during routine x-ray examination. In
children the condition is usually painless but the
mother may notice the unduly protruding abdomen
and peculiar stance. In adolescents and adults
backache is the usual presenting symptom; it is often
intermittent, coming on after exercise or strain.
Sciatica may occur in one or both legs. Patients aged
over 50 are usually women with degenerative
spondylolisthesis. They always have backache, some
have sciatica and some present because of
claudication due to spinal stenosis. On examination
the buttocks look curiously flat, the sacrum appears to
extend to the waist and transverse loin creases are
seen. The lumbar spine is on a plane in front of the
sacrum and looks too short. Sometimes there is a
scoliosis. A step can often be felt when the
fingers are run down the spine. Movements are
usually normal in the younger patients but there may
be hamstring tightness; in the degenerative group
the spine is often stiff.

X-RAYS
Lateral views (Fig.43) show the forward shift of the upper part of the spinal column on the stable
vertebra below; elongation of the arch or defective facets may be seen. The gap in the pars interarticularis is
best seen in the oblique views. In doubtful cases, reversed gantry CT may be helpful. Measurement of the
spinal canal can be carried out on plain films, but more reliable information is obtained from myelography, CT
and MRI.
Prognosis
Dysplastic spondylolisthesis appears at an early age, often goes on to a severe slip and carries a significant risk
of neurological complications. ent displacement does not progress after adulthood, but may predispose the
patient to later back problems. It is not a contraindication to strenuous work unless severe pain supervenes .
With slips of more than 25 per cent there is an increased risk of backache in later life.
Degenerative spondylolisthesis is rare before the age of 50, progresses slowly and seldom exceeds 30 per cent.
Treatment
Conservative treatment, similar to that for other types of back pain, is suitable for most patients. Operative
treatment is indicated: (1) if the symptoms are disabling and interfere significantly with work and recreational
activities; (2) if the slip is more than 50 per cent and progressing; (3) if neurological compression is significant.
For children, posterior intertransverse fusion in situ is almost always successful; if neurological signs appear,
decompression can be carried out later. For adults, either posterior or anterior fusion is suitable(Fig.43).
However, in the degenerative group, where neurological symptoms predominate, decompression without
fusion may suffice. Note on post-traumatic spondylolisthesis The patient found to have spondylolysis or

spondylolisthesis after recent back injury (usually hyperextension) may have fractured the pars, or merely
strained the fibrous tissue of a pre-existing lesion. If doubt exists (and it usually does) a plaster jacket should be
worn for 3 months; the recent fracture may join spontaneously. If union does not occur the assumption is that
spondylolisthesis was
present before injury and treatment is along the lines already indicated

Fig.44. L4-L5 /spondylolisthesis: decompression, reduction,

intervertebral fusion with metallic cages and posterior
instrumentation using transpedicular screws

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