The Spine

Trauma, Infection, Degenerative

Ahmad Fauzi
Divisi Orthopaedi & Traumatologi
Ilmu Bedah FK UNILA

TRAUMA

ASIA Impairment Scale

ASIA Motor Score & Level

6 point scale
0 = total paralysis
1 = palpable or visible contraction
2 = active movement, full ROM with gravity eliminated
3 = active movement, full ROM against gravity
4 = active movement, full ROM against moderate resistance
5 = (normal) active movement, full ROM against full resistance

Key muscles:
C5 - Elbow flexors (biceps, brachialis)
C6 - Wrist extensors (ECRL, ECRB)
C7 - Elbow extensors (triceps)
C8 - Finger flexors to the middle finger (FDP)
T1 - Small finger abductors (AbDM)
L2 - Hip flexors (iliopsoas)
L3 - Knee extensors (quadriceps)
L4 - Ankle dorsiflexors (tibialis anterior)
L5 - Long toe extensors (EHL)
S1 - Ankle plantarflexors (gastrocnemius, soleus)

Other muscles also evaluated but their grades are not used in determining motor score or motor
level [diaphragm (fluoro), deltoids, abdominals (Beevor's sign), medial hamstrings, hip
adductors - graded as absent, weak or normal; anal sphincter - Yes/No].
For myotomes not testable, the motor level is presumed to be the same as the sensory level.
Motor level (L or R), defined by the lowest key muscle that has a grade of at least 3, provided
the key muscles above are normal.

ASIA Impairment Scale

A

Complete

No motor or sensory function is preserved in the sacral

segments S4-S5

Incomplete

Sensory but not motor function is preserved below the

neurological level and includes sacral segments S4-S5

Incomplete

Motor function is preserved below the neurological

level, and more than half of the key muscles below the
neurological level have a muscle grade of less than 3

Incomplete

Motor function is preserved below the neurological

level, and at least half of the key muscles below the
neurological level have a muscle grade of 3 or more

Normal

Motor and sensory function is normal

Key muscles: L2 = iliopsoas; L3 = quadriceps; L4 = Tib ant; L5 = EHL; S1 = gastrosoleus

POSTERIOR

MIDDLE

ANTERIOR

3 Columns
(Denis
Classification)

Compression
Fracture

Burst Fracture

Flexion-distraction
Injury (Chance)

Flexion-distraction (Chance) injuries

Fracture Dislocation

Four Major Spinal Injuries (Denis)

Type of Fracture

Stability

Neural Injury

Compression

Stable

Nil

Burst fracture

Unstable

Nil to severe *

Flexion-distraction

Unstable

Nil to severe *

Fracture dislocation

Unstable

Severe

Aims of Treatment

Restore alignment and stability to spinal column

Improve neurological status
Facilitate mobility and rehabilitation

Surgical vs. Non-surgical treatment

CONSERVATIVE TREATMENT
Used only for minor and stable fractures

Bed rest
X Postural reduction (lumbar spine)
Ambulatory treatment
Spinal jacket (TLSO)
Free ambulation to pain tolerance

SURGICAL TREATMENT
SPINAL STABILISATION
BONY RECONSTRUCTION
SPINAL INSTRUMENTATION

SPINAL DECOMPRESSION
Direct : Removal of bony fragments
Indirect : Re-alignment of the spine

SPINAL STABILISATION
Earlier mobilisation for rehab
Promote rapid soft tissue healing

Absolute Indication For Surgery

Worsening neurological status

Burst Fracture

Corpectomy, Reconstruction by Kaneda

Instrumentation, Mesh Cage

Burst Fracture

Posterior Reduction, Instrumentation and

Fusion

Fracture Dislocation

Fracture Dislocation

INFECTION

Spondilitis Tuberculosis

Epidemiology
One of the most common problem in the developing

countries
Indonesia is in the 3rd place for the most TB contributing
country after India & China
Almost of all the patient is in the range of productive age
(15 54 years old)
Vertebrae is the 2nd common place for infected organ by
Mycobacterium Tuberculosis ( 50% )
15% of all extra pulmonary TB cases
Male > female & Children > adults
The most common site ; thoraco-lumbar , thoracal,
lumbar, and cervical

Pathogenesis
Secondary infection focus from the other part of organ

via blood transmission (hematogen)

Small tubercel (superior or inferior-anterior site of
vertebrae body) activate Chaperonin 10 high
stimulator of bone resorption destruction of anterior
part of vertebrae body khypose respiratory problem
& paraplegia
Granulomatous reaction blocking bone formation
relatively avascular sequester
Reach the soft tissue paravertebrae abscess
following the fascia of psoas muscle psoas abscess
( cold abscess )
Narrowing of adjacent disc (being avascular)

Infection pathways

Clinical appearance

Back pain ( chronic, local or

radicular )
Back stiffness
Systemic symptoms ( fever,
malaise, night sweat, loss of
body weight )
back color
Bone alignment
Mass or gibbus
Tenderness
Bone structural & muscle spasm
Neurological deficit
Limited range of movement

Laboratory findings

Leukocyte >>>
SER is prolonged
CRP (C-reactive protein )
ELISA (false negative >>)
PCR (polymerase chain reaction)
Tuberculin test (Mantoux)

Immunology test
Intradermal tuberculin
test ( Mantoux )
67,5 87,5 % positive

Biopsy
Identifikasi basil
tuberkel diagnosis
yang definitif
Pewarnaan dengan
basil tahan asam,
fluorokrome dan
Ziehl-Nielsen atau
kultur

Plain radiographs
Affected vertebrae (segment

& number)
Bone destruction rate
Khypose angle
Anterior part destruction
Paravertebrae abscess
(fusiform shadow)
Narrowing of adjacent discs

CT-SCAN & MRI

CT-SCAN :
Calcification of soft tissue
abscess
Posterior element

Osteolytic lesion
MRI :
Central necrosis (abscess)
Inhomogen appearance

Histo - pathology
Gambaran granuloma

dan kaseosa, yang terdiri

dari suatu zona pusat
granular dan nekrosis
kaseosa yang asidofilik
yang dikelilingi oleh selsel epitheloid dan sel-sel
raksasa Langhans.
Sekumpulan limfosit juga
tampak di tepi luar dari
granuloma.

Treatment
The aim : eradicate the infection, stabilize the

vertebrae & to correct the khypose

The combination of chemotherapy or surgical
therapy
INH (5-15mg/KgBW/day) orally
Rifampicin (10-15mg/KgBW/day) orally
Pirazinamid (25-35/KgBW/day) orally
Ethambutol (15-20mg/KgBW/day) orally
Streptomycin (15-30mg/KgBW/day) IV

Surgical therapy
The indications :
Significant neurological deficit
Cervical segment abscess
Posterior lesion with abscess or sinus
Vertebrae instability / progressive khypose
Failed of chemotherapy treatment in 3 6
months
Recurrence infection

Degenerative

Low Back Pain

Definisi
Nyeri pada punggung bawah

Etiologi
Spinal

Degeneratif
Infeksi
Trauma
Kelainan bawaan

Non spinal

Viserogenik
Vaskulogenik
Neurogenik
Psikogenik

Biomekanik

Anamnesis

Onset nyeri
Lokasi
Kualitas
Kuantitas
Yang memperberat
Yang memperingan

 Pemeriksaan fisik
Pemeriksaan refleks
Lasegue tes
SLR tes

Pemeriksaan penunjang

Radiologis
Cek darah lengkap
EMG
Urinalisa

Viscerogenik
Karakteristik :

Mekanisme nyeri punggung bawah akibat adanya lesi

pada traktus genitourinarius dan organ-organ
intra peritoneal maupun retro-peritoneal
mengiritasi peritoneum posterior
Nyeri tidak dipengaruhi oleh aktifitas dan
berkurang dengan istirahat

pelvis
yang
tidak

Vaskulogenik
Abnormalitas dari aorta descendens dan arteri
iliaka, misalnya sumbatan vaskuler atau
aneurisma

Degenerasi Discus

Pengurangan kondroitin sulfat

dan air
Penurunan turgor dan gaya
pegas
Stiffness

Hernia Nucleus Pulposus

Jepitan saraf pada canalis

spinalis, dan atau foramen

intervertebralis
Nyeri dijalarkan ke dada
belakang, punggung dan
kaki
Nyeri terus menerus
Bertambah berat pada :

Robekan anulus fibrosus

Herniasi nucleus pulposus

batuk, menguap,
cekukan, atau posisi
badan membungkuk ke
depan, berdiri lama

Nyeri berkurang bila

berbaring

Kompresi saraf pada foramen

Spondilosis dan spondilolisthesis

Terapi
1. Konservatif
Moderate bed rest
Spinal manipulation
Physical therapy
Medication
NSAIDs
Muscle relaxants
Rarely narcotics

2. Operatif

Indikasi Operatif

Low back pain for at least 2 years

Incapacitating
Neurological deficits
Resistant to physical therapy and medication
Positive MRI findings (degenerative changes) at
L4-5 and/or L5-S1

TERIMA KASIH