12, Spinal Disorder

SPINE DISORDERS
dr. Jainal Arifin, M.Kes., Sp.OT (K) Spine

Learning Objectives
• Able to diagnose and referred patients with:
• Spine deformity
• Spondylitis
• Spondylodiscitis
• Teratoma sacrocoxigeal
• Able to explain:
• Spondylolisthesis
• Spondylolysis
SPINE DEFORMITY
Spine Deformity
• Adult deformity
• Adult idiopathic dan degenerative scoliosis
• Fixed sagital imbalance
• Spondylolysis
• Child deformity
• Pediatric cervical disorders
• Idiopathic scoliosis
• Sagittal plane deformities
• Neuromuscular spinal deformities
• Congenital scoliosis
• Spondylitis
Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011
ADULT DEFORMITY
• Adult idiopathic dan degenerative scoliosis
• Fixed sagital imbalance
• Spondylolysis
Adult Idiopathic and Degenerative
Scoliosis
Definition
• De novo scoliosis begins at age 40 in patients with no
preexisting deformity. The deformity occurs in conjunction
with multilevel asymmetric disc degeneration. The discs
degenerate more on one side than the other, resulting in a
lumbar deformity
• Adult idiopathic scoliosis presumably had some degree of

deformity as a teenager.
Etiology
• A primary muscle disorder
• An elastic fiber system defect (abnormal fibrillin
metabolism)
• Disorganized skeletal growth
Epidemiology
• Stirling et al studied almost 16,000 patients aged 6-14
years in England and found the point prevalence of
idiopathic scoliosis (Cobb angle >10°) to be 0.5% (76 of
15,799 patients).
• The prevalence of scoliosis was highest (1.2%) in patients
aged 12-14 years.
• Most patients with idiopathic scoliosis are female
Clinical Manifestation
• Usually one sees a double lumbar curve pattern in which
one curve, most commonly left-sided, is from T12 to L3
and the second curve is right-sided from L3 to the
sacrum.
• At L3–L4 there is usually a rotatory subluxation with
lateral listhesis, which forms the transitional segment
between the two curves.
Physical Examination
• Baseline assessment of posture and body contour.
• Shoulder unleveling and protruding scapulae are
common.
• The presence or absence of hamstring tightness should
be investigated, and screening should be performed for
ataxia and/or poor balance or proprioception (ie, Romberg
test).
Radiology
Treatment
Nonoperative management include:
• analgesics,
• orthotics,
• physical therapy,
• manual manipulation,
• activity modification,
• behavioral therapy, and
• injections

Indications for surgical treatment
• Progressive deformity
• Progressive pain
• Spinal claudication symptoms
• Neurologic deficit
Fixed Sagital Imbalance
Definition
• A condition that occurs as a result of the loss of the
normal lumbar lordosis or an increase in thoracic
kyphosis, or both, resulting in the forward displacement of
the head relative to the sacrum and pelvis.
Etiology
• Etiology:
• Prior placement of Harrington distraction instrumentation for the
treatment of scoliosis
• Degenerative sagittal imbalance
• Post-traumatic patient
• Patient with ankylosing spondylitis
• Consequences:
• Difficulties with forward gaze
• Compensatory hip and knee flexion contractures
• Loss of physiologic endurance as a result of increased energy
expenditure

Clinical History
• Duration of symptoms
• Type and location of pain
• Symptoms of spinal stenosis
• Fatigue and limited endurance that result in a diminished
capability to perform daily activities
• Prior spinal surgery (levels decompressed or fused and
complications sustained during or after surgery)
• Medical comorbidities (diabetes, cardiac disease, and
osteoporosis)

Physical Exam
• Standing balance
• Unable to stand erect
• Had to flex their knees to stand erect
• Gait
• Signs of cervical or thoracic myelopathy

Treatment
• Patient is minimally to mildly symptomatic  surgery may
be unnecessary
• Nonoperative management options:

• Physical therapy
• Anti-inflammatory medications
• Lifestyle modifications.

Spondylolysis
Definition
• A defect in the pars interarticularis of the posterior
vertebral arch and is a common cause of back pain and
disability
• Most commonly caused by repeated and increased

stress
• May lead to instability of the spinal column

Asian Spine J 2014;8(6):856-863 •http://dx.doi.org/10.4184/asj.2014.8.6.856
Br J Sports Med 2000;34:415–422
Anatomy
• Region between superior and
inferior articulating facet of the
vertebra
• Weakest area in the neural arch
• Susceptible to stress fracture

Epidemiology
• Male : female = 2 : 1
• Eskimo >> Whites >> African Americans
• Defect bilateral  greater chance of progression to

listhesis
• Most common location of spondylitic defect  L5

Br J Sports Med 2000;34:415–422
Patophysiology
• Genetic predisposition
• Spondylolysis occurs in 15–70% of first-degree relatives

of individuals with the disorder
• Risk factor for spondylolysis: activities that involve

hyperextension of lumbar spine, persistent lordosis,
repetitive load

Br J Sports Med 2000;34:415–422
• Low back pain (onset associated with history of trauma or
inciting event)
• Rarely radiating to the buttocks or posterior thigh
• Worsen with activity or on hyperextension of the spine
• Exacerbate pain: weight bearing, lifting
• Antalgic gait, increased lumbar lordosis, hamstring tightness
• Focal tenderness in acute, mild discomfort in chronic cases
• Single-leg hyperextension test  to differentiate unilateral
(asymmetrical low back pain) from bilateral spondylolysis

Br J Sports Med 2000;34:415–422
Radiologic Findings
• Plain radiograph AP (Ferguson view), lateral, oblique
• Right and left oblique views
• Oblique views  sensitive in diagnosing spondylolisis
• Lateral views (standing position)  degree of olisthesis in
spondylolisthesis

Br J Sports Med 2000;34:415–422
Treatment

Treatment
• Mainly focuses on pain relief, core muscle strengthening,
and restoration of full lumbar range of motion
• Surgical intervention is indicated for patients with

persistent pain, progressive spondylolisthesis, or
neurologic symptoms who fail conservative management

Br J Sports Med 2000;34:415–422
Spondylolisthesis
Definition
• Spondylos, meaning “vertebrae,” and
olisthesis, meaning “to slip”
• Forward translation of one vertebra on

another in the sagittal plane of of the
spine
• Most common location of

spondylolisthesis  L5–S1

Eur Radiol . 2014 February ; 24(2): 441–448. doi:10.1007/s00330-013-3041-5
Rev Bras Ortopv.49(1); Jan-Feb 2014PMC4511775
Etiology
• Due to the body’s center of gravity being anterior to the
lumbosacral joint, slippage occurs as the lumbar spine
rotates around the sacral dome
• The age of the patient when these defects occur and the
individual’s sagittal alignment of the spine determine to
what degree the deformity progresses

Classification

• Low back pain (often radiates to
buttocks and posterior thigh if L5
root is involved)
• Hamstring tightness (associated
with fixed flexion at the hip and
knees)
• Increased popliteal angle on
straight-leg raise
• Focal neurologic deficit or
radiculopathy
• Phalen-Dickson sign
• Constant loading of the pars defects may hinder bony
healing resulting in a fibrous union that may be a persistent
source of pain
• Local expansion of fibrocartilaginous scar tissue within the

area of the pars defect may cause nerve root compression
• Tension on the nerve root also increases with progression

of olisthesis, increasing further the likelihood of radicular
symptoms with disease progression

• Higher grade subluxations traction of the cauda equina over
the sacrum  signs and symptoms of cauda equina
compression (perineal paresthesia, decreased sphincter tone,
and urinary retention)
Low grade High grade

Radiologic Findings
• Plain radiograph AP, lateral,
oblique
• Follow-up is recommended
at least annually until
skeletal maturity and more
frequently during peak
height velocity before
puberty
Treatment

Treatment
• Conservative therapy is still recommended as the initial
modality
• The importance of radiographic and neurologic follow-up

should be stressed  higher risk for slip progression
owing to facet hypoplasia
• Documentation of slip percentage, angle, sacral

inclination, wedging, and pelvic tilt is recommended as
part of proper documentation of progression of the
deformity.
CHILD DEFORMITY
• Pediatric cervical disorders
• Idiopathic scoliosis
• Sagittal plane deformities
• Neuromuscular spinal deformities
• Congenital scoliosis
Pediatric Cervical Disorders
Torticollis
Cervical Anomalies
Torticollis
Definition
• Torticollis is a clinical diagnosis based on head tilt in
association with a rotatory deviation of the cranium.
Type of torticollis
• Congenital muscular torticollis in the newborn period.
• Its cause is unknown, but it has been hypothesized to
arise from compression of the soft tissues of the neck
during delivery, resulting in a compartment syndrome
Causes of torticollis
• Congenital anomalies of the craniocervical junction or upper cervical spine
• Ocular or auditory dysfunction
• Tumors involving the posterior fossa, brainstem, or spinal cord
• Osseous tumors (osteoid osteoma, aneurysmal bone cyst)
• Infection
• Inflammatory disorders (e.g. juvenile rheumatoid arthritis)
• Fracture
• Rotatory subluxation of the atlantoaxial joints
• Sandifer’s syndrome (gastroesophageal reflux and torticollis)
• Normal cervical alignmentand motion,
• History of recent upper respiratory infection ( syndrome),
• Normal neurologic examination, and spasm in the
sternocleidomastoid muscle on the side opposite the head
tilt the “cock robin” deformity.
Treatment
• Soft cervical collar and activity restriction.
• Traction via a head halter
• If reduction  immobilization is continued for at least 6
weeks with a Minerva cast or halo cast.
• Surgery is indicated for failure of reduction following
traction treatment,
Cervical Anomalies
Definition
• Association with spinal deformity, spinal instability, and
spinal cord and brainstem compression resulting in
myelopathy
Located of Cervical Anomalies
OCCIPUT–C2 REGION
1. Congenital anomalies associated with neural
compression
a. Basilar impression
b. Congenital cervical stenosis
c. Arnold-Chiari malformation
2. Anomalies associated with cervical instability at
occiput–C1
a. Occipitalization of C1 (skeletal dysplasia)
b. Skeletal dysplasia (e.g. Kniest’s dysplasia)
c. Down’s syndrome
3. Anomalies associated with C1–C2 instability
a. Odontoid anomalies (aplasia, hypoplasia, os odontoideum)
b. Skeletal dysplasia (e.g. mucopolysaccharidosis)
c. Down syndrome
SUBAXIAL CERVICAL REGION
1. Anomalies associated with deformity and instability
Klippel-Feil anomaly
2. Miscellaneous disorders
a. Postlaminectomy kyphosis
b. Neurofibromatosis
c. Skeletal dysplasia (e.g. Larsen’s syndrome)
Basilar Impression
• Basilar impression  downward displacement of the base
of the skull in the area of the foramen magnum.
• Identified by the protrusion of the tip of the odontoid
through the foramen magnum.
Clinical Problems
• Patients present with a short neck, painful cervical motion,
and asymmetry of the skull and face, nuchal pain, vertigo,
long tract signs with associated cerebellar ataxia, and
lower cranial nerve involvement resulting in dysarthria and
dysphagia.
Treatment
• Decompression  anterior transoral odontoid resection or
posterior suboccipital craniectomy and C1 laminectomy
• Stabilization
Idiopathic Scoliosis
Idiopathic Scoliosis
• The most common type of scoliosis
• Characterized by lateral bending and fixed rotation of the
spine in the absence of any known cause
• The criterion for diagnosis  a coronal plane spinal
curvature of 10° or more as measured by the Cobb
method
• Curves less than 10° are referred to as spinal asymmetry
Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Classification of Idiopathic Scoliosis
• Classified as:
• Infantile (birth–3 years)
• Juvenile (3–10 years)
• Adolescent (after 10 years)
• Alternative classification:
• Early-onset scoliosis (0–5 years)
• Late-onset scoliosis (after 5 years)

Etiology of Idiopathic Scoliosis
• Genetic factors:
• A genetic basis has been confirmed and genetic testing for
adolescent idiopathic scoliosis is currently available
• Central nervous system (CNS) factors:
• CNS asymmetry, vestibular dysfunction
• Collagen, muscle, and platelet defects
• Growth and hormonal factors:
• Asymmetric spinal growth patterns, melatonin
• Biomechanical factors

Infantile Idiopathic Scoliosis
• Common in Europe but rare in the United States (,1% of
cases in United States)
• Male predominance
• Left thoracic curve pattern is most common
• Association with plagiocephaly, developmental delay,
congenital heart disease, and developmental hip
dysplasia
• Types:
• Resolving type (85%)
• Progressive type (15%)

Treatment of Infantile Idiopathic Scoliosis
Resolving curves
• Observed with serial physical examinations and
radiographic monitoring
• Sleeping in the prone position is recommended because
supine positioning has been associated with infantile
curves by some investigators.
Progressive curves
• Treated with serial casting followed by orthotic treatment
with a Milwaukee brace
• Curves that continue to progress despite orthotic
treatment require surgery.
Juvenile Idiopathic Scoliosis
• Less common than adolescent idiopathic scoliosis
• Increasing female predominance
• Most common curve patterns are right thoracic and
double major curve types
• Approximately 70% of curves progress and require some
forms of treatment (bracing or surgery)
• MRI of the entire spine to visualize from the craniocervical
junction to the sacrum is appropriate

Treatment of Juvenile Idiopathic Scoliosis
• Orthotic treatment is initiated for curves in the 25° to 50°
range
• Surgical treatment is considered when curve magnitude
exceeds 50° to 60°.

Adolescent Idiopathic Scoliosis
• The most common type of scoliosis in children
• 0.3% patients develop curves requiring treatment
• A female predominance is noted, which increases
substantially for larger curves requiring treatment
• Thoracic curve patterns are generally convex to the right
(atypical curve patterns are an indication for MRI)
• Not typically associated with severe pain

King-Moe Classification
Treatment of Adolescent Idiopathic Scoliosis
• Observation, orthoses, and operation (the three O’s).
• Exercise programs, electrical stimulation, special diets,
chiropractic adjustment, acupuncture, or other
nontraditional treatment methods are effective in
preventing curve progression or correcting established
curves  NO EVIDENCE

Sagittal Plane Deformities
Types of SPD
Included:
• Scheuermann’s kyphosis
• Postural round back
• Congenital kyphosis
• Congenital lordosis

Etiology of SPD
a. Myelomeningocele
b. Idiopathic scoliosis
c. Achondroplasia
d. Postlaminectomy kyphosis
e. Postirradiation kyphosis
f. Tuberculosis
g. Trauma
h. Spondylolisthesis

Scheuermann's Kyphosis
• A developmental condition
that occurs in adolescents
• Characterized by increased
thoracic kyphosis
accompanied by lumbar
hyperlordosis

• Boys >> girls
• Pain: aching in nature, does not wake the patient from
sleep, and does not radiate
• Exacerbated pain: vigorous activity and prolonged sitting

• The severity of the back pain is variable, with some patients
denying significant symptoms and instead presenting for
evaluation of poor posture
• Neurologic symptoms are highly unusual
• Non surgical treatment: exercises and anti-inflammatory
medications

Postural Roundback
• The kyphosis is less severe (<60°)
• Patient is able to actively correct the thoracic kyphosis and
may appear more athletically active
• Parents may also have some round-back deformity
• Focal wedging and endplate changes are absent on the
lateral radiograph.
Congenital Kyphosis
• Type I: defect of vertebral body formation (hemivertebra) 
more common, more serious  lead to a sharp angular
kyphosis that may cause paraplegia
• Type II: defect of vertebral body segmentation (block vertebra
or bar)
• Type III: mixed or combined lesion. Type 1 defects are more
common and more serious

Congenital Kyphosis
Congenital Kyphosis
• Does not respond to nonoperative treatment
• Posterior in situ fusion should be considered for a young
child (1–5 years old) with a kyphosis measuring <50°
• Kyphosis >50° and older children require an anterior and
posterior fusion

Congenital Kyphosis
• Symptomatic neural compression at the apex of the
kyphosis requires decompression
• In select deformities, circumferential decompression and
fusion may be achieved through a singlestage posterior
surgical approach
• Extensive preoperative evaluation is required, including
cardiopulmonary assessment, evaluation of the
genitourinary system, detailed neurologic examination,
MRI of the neural axis, and a CT scan to define osseous
abnormalities

Congenital Lordosis
• A rare disorder caused by failure of posterior
segmentation, typically spanning multiple segments, with
persistent anterior growth
• Progressive thoracic lordosis causes diminution of the
spine-sternal distance and restriction of pulmonary
function
Congenital Lordosis
• Diagnosed early in life  surgical treatment consists of
anterior spinal fusion to eliminate anterior growth potential
• Patients presenting later in life  require more complex
surgery
• Moderate deformities may be treated with wide posterior
release followed by segmental instrumentation and fusion
• Severe deformities require anterior and posterior spinal
surgery
• Preoperative pulmonary function tests are necessary.
• Associated pulmonary hypertension increases mortality
and may be a contraindication to surgery

Neuromuscular Spinal Deformities
• Neuromuscular disease cause spinal deformities
• Spinal muscle imbalance acting in concert with gravity in a
growing child  alteration of vertebral loading patterns
creates secondary changes in the vertebrae and soft
tissues around the spine, according to the Heuter-
Volkmann principle (increased loading across an
epiphyseal growth plate inhibits growth and decreased
pressure tends to accelerate growth)
• Deformities that may develop including scoliosis (most
common), hyperkyphosis, hyperlordosis, and complex
multiplanar deformities

• Evaluation requires assessment of the underlying
neuromuscular disease in combination with the spinal
deformity
• Multidisciplinary evaluation is required for problems
associated with the underlying neuromuscular disease
• Develops at an earlier age than
• More likely to progress in severity due to the early age of
onset of neuromuscular disease

• Tend to be longer and involve more vertebrae
• Frequently accompanied by pelvic obliquity, which may
compromise sitting ability and
• upper extremity function
• Do not respond well to orthotic treatment
• Spinal surgery is frequently required

• Diagnosis is based on clinical examination and confirmed
with long cassette radiographs
• Upright radiographs are obtained in patients who are able
to stand
• Patients who are able to sit without hand support are
assessed in the sitting position
• Patients who are unable to sit are evaluated with
recumbent anteroposterior (AP) and lateral radiographs

• The examiner should assess curve magnitude, curve
progression, spinal balance, pelvic obliquity (if present),
and curve flexibility
• Spinal MRI is required if intraspinal disease is suspected
• After a child is diagnosed with neuromuscular disease, the
patient should have yearly examinations to assess for
development of spinal deformity
• Treatment options: observation, orthotic management,
and surgical treatment with spinal instrumentation and
fusion

Congenital Scoliosis
Definition
• A lateral curvature of the spine  vertebral anomalies that
produce a frontal plane growth asymmetry.
• The anomalies are present at birth, but the curvature may
take years to become clinically evident.
• Homeobox genes of the Hox class are thought to be
responsible for the congenital spinal malformations
• Anomalies form during weeks 4 to 6 of the embryonic
period
• Main categories:
• Defects of segmentation
• Defects of formation

• Role of brace treatment for congenital scoliosis is limited
• Orthoses will not halt the progression of a rigid congenital
structural abnormality
• A brace may control a compensatory curvature or a long
flexible curvature in which the rigid congenital deformity
comprises a small section of the entire spinal deformity
• Total contact braces may restrict chest wall development
and should not be used
• A Milwaukee brace (cervicothoracolubosacral orthosis,
CTLSO) is preferable

SPONDYLITIS
Definition
• A chronic inflammatory disease characterized by variable
symptomatic course and progressive involvement of the
sacroiliac and axial skeletal joints
• Prototype of spondyloarthropathies
• Characterized by axial skeletal arthritis, absence of
rheumatoid factor in serum, lack of rheumatoid nodules,
and a presence of HLA-B27

Reumatologia 2015; 53, 1: 3–8 DOI: 10.5114/reum.2015.50550
Clin Rheumatol. 2015 June ; 34(6): 1009–1018. doi:10.1007/s10067-015-2949-3
Clin Rheumatol (2016) 35:1769–1776 DOI 10.1007/s10067-016-3231-z
Epidemiology
• Male : female = 3 : 1
• Women  less symptomatic, less severe disease,
present more often cervical spine disease with minimal
lumbar spine symptoms
• Rarely occurs in individual >50 years

Pathogenesis
• Unkonwn
• Genetic predisposition

Clinical Manifestations
• Back pain  greatest in the morning, increased by
periods of inactivity , improves with exercise
• Slowly progressive stiffness
• Difficulty of sleeping
• Fatigue
• Flattening of the lumbar spine
• Loss of the normal lordosis

• Lumbosacral spine disease  most often
• Thoracic spine disease  decreased motion at the
costovertebral joints, reduced chest expansion, and
impaired pulmonary functions
• Cervical spine disease  less frequent, primary
symptoms are neck stiffness and pain, cause the head to
protrude forward

• Peripheral joint arthritis (hip, kness, elbows, shoulders,
and ankles) occurs in 30% patients within th first 10-years
of disease
• Extra-articular manifestations  fever, weight loss, iritis,

inflammation of the anterior uveal tract of the eye, may
present cardio and/or pulmonary involvement

Physical Examinations
• Musculosceletal examination  discover limitation of
motion of the axial skeleton
• Percussion over sacroiliac joints  pain
• Measurement of spinal motion  Schober test, lateral
bending of the lumbosacral spine, occiput to wall, chest
expansion
• Paraspinous muscles may be tender on palpation and in
spasm  limitation of back motion
• Finger-to-floor measurement

Laboratorium Finding
• Not spesific
• Mild anemia in 15% patients
• Increased of erythrocyte sedimentation rate in 80% of
patients with active disease
• Patients with normal sedimentation rate  elevated CRP
• HLA positive in 90% patients

Radiographic Evaluation
•

DIAGNOSIS

Pyogenic Spondylitis
Definiton
• A neurological and life threatening condition
• It encompasses a broad range of clinical entities,
including pyogenic spondylodiscitis, septic discitis,
vertebral osteomyelitis, and epidural abscess
International Orthopaedics (SICOT) (2012) 36:397–

404
Epidemiology
• The spine is a common site of infection and accounts for
2–7% of all cases of musculoskeletal infections
• Approximately 95% of pyogenic spinal infections involve
the vertebral body and/or the intervertebral disc, with only
5% involving the posterior elements of the spine
• Incidence: 0,2–2 cases per 100,000 per annum
• The incidence is rising, possibly related to the improved
life expectancy of patients with chronic debilitating
diseases

404
Epidemiology
• Affecting predominantly people in their fifth decade of life
and the age-adjusted incidence increases with every
decade thereafter
• Males : females = 2 : 1

404
Predisposing factors
• Diabetes mellitus
• Protein malnutrition  decreased number of T cells with
impaired cytokines productions
• Substance abuse
• HIV infection  defective neutrophils, decreased cell count
and leucocyte dysfunction
• Malignancy
• Long-term steroid use  disarms both humoral and cellular
response to infectious agents
• Chronic renal failure
• Liver cirrhosis
• Septicaemia
404
Pathophysiology
• Commonly arises from haematogenous spread of bacteria
• The arterial route of spread is more common than the
venous route, usually from skin, respiratory tract,
genitourinary tract, gastrointestinal tract or the oral cavity,
giving rise to bacteraemia
• The cellular bone marrow and the sluggish but
voluminous blood supply to the spine make it particularly
vulnerable to bacterial inoculation and infection

404
Pathophysiology
• The usual involvement of adjacent segments of
contiguous vertebrae can be explained by the arterial
supply of the axial skeleton
• The same segmental artery supplies an intervening disc
as well as the lower portion of the upper vertebra and the
upper portion of the adjacent lower vertebra
• Thus, pyogenic spondylitis typically involves two adjacent
vertebrae and the intervening disc

404
Pathophysiology
• In children, the bacterial inoculation is through the
persisting vascular channels in the disc space and
pyogenic discitis may occur after bacteraemia
• In adults, the disc is avascular, the bacteria invade the
end-arterial arcades in the subchondral region adjacent to
the intervertebral disc. The infection then spreads by
direct extension through the end-plates to the
intervertebral disc

404
Pathophysiology
• In the lumbar spine, the Batson’s paravertebral venous
plexus may act as a potential route of infection,
particularly in cases of sepsis originating from the pelvic
organs
• In the cervical spine, the pre-vertebral pharyngeal venous
plexus may act as a route for the spread of bacteria in
cases of infections around the head and neck regions

404
Etiology
• Common organisms: Staphylococcus aureus and
streptococcus species
• Escherichia coli and proteus may be present in patients
with urinary tract infections
• In intravenous drug abusers, Gram negative bacilli are
frequently isolated
• In immune-compromised patients, organisms of low
virulence such as coagulase negative staphylococcus and
streptococcus viridians may also cause the infections

404
Etiology
• Anaerobic organisms can be inoculated directly into
patients with penetrating spine trauma and are common in
patients with diabetes mellitus
• Salmonella osteomyelitis may be the culprit particularly in
children with sickle cell anaemia
• In one-third of cases the infective organisms are never
identified

404
Clinical Presentation
• Back or neck pain (>90% of cases)
• Fever is typically not present (<20% of patients)
• Other symptoms include nausea, vomiting, anorexia,
weight loss, lethargy, and confusion
• Difficulty in swallowing is also another symptom, which
may be caused by cervical pyogenic spondylitis with
retropharyngeal abscess
• Limb weakness, numbness and sphincter dysfunction can
be caused by spinal cord or cauda equina compression

404
Lab Test
• Erythrocyte sedimentation rate (ESR) is a sensitive
laboratory indicator of pyogenic infection
• The average ESR in patients with pyogenic spondylitis
ranges from 43–87 mm per hour
• Elevation in ESR correlates with the presence of
inflammatory response but it is not specific for infection
• ESR normalises in an irregular and slow fashion even
after successful treatment of an infection
• ESR provides additional data regarding the possible
presence of infection and some information on response
to treatment

404
Lab Test
• C-reactive protein (CRP) is an acute phase protein
synthesised by hepatocytes
• Elevated in 90% or more of patients with spinal infection
• More specific than ESR
• CRP normalises postoperatively or after appropriate
treatment of an infectious process faster than the ESR
• Therefore an elevation in CRP and/or ESR should not be
taken as pathognomonic for an infection
• However, ESR and CRP serve as good screening and
surveillance tests in the diagnosis and treatment of spinal
infections
404
Lab Test
• The white blood cell (WBC) count may not be elevated in
patients with a spinal infection
• The WBC is not particularly useful in making a diagnosis
of spinal infection, but should be part of an infection/fever
workup as it may provide some general guidance
concerning a response to treatment

404
Lab Test
• Given the variability in the source of infection, blood
cultures, urinalysis, and urine for culture should be
obtained in patients suspected of having a spinal infection
• About 25–59% of positive blood cultures identify the
causative microorganism
• Sputum culture should be obtained to look for subclinical
chest infection

404
Imaging Studies
• Plain radiographs should be taken for all patients
suspected of having spinal infections.
• These will reveal the degree of bony destruction and
evaluate any corresponding coronal or sagittal
mal-alignment resulting from the disease process
• The earliest signs are blurring of the end-plates and
decrease in disc space, which happen two to eight weeks
after the onset of the infection
• Gold standard  MRI

404
404
404
Biopsy
• The definitive diagnosis of pyogenic spondylitis can only
be made on microscopic or bacteriological examination
and culture of the infected tissues
• In the absence of a positive blood culture, the
recommended algorithm of management in a stable
patient is to withhold antibiotics until a fluoroscopic or CT-
guided percutaneous biopsy is done

404
Biopsy
• A negative result may be due to insufficient tissue or
administration of antibiotics
• If the initial biopsy is negative and withholding antibiotics
is considered safe clinically, a further biopsy can be
attempted
If a fluoroscopic or CT-guided percutaneous biopsy fails to
identify the organism, an open biopsy should be
performed

404
Non-surgical Treatment
• The choice of antibiotic is adjusted according to the
subsequent bacterial culture results
• Empirical antibiotics comprising penicillin or first
generation cephalosporin are used to cover the common
infective organisms
• For immune-compromised patients and intravenous drug
abusers  broader spectrum antibiotics with better gram
negative bacteria coverage, is added
• For patients sensitive to beta-lactam antibiotics 
clindamycin, vancomycin, quinolones, tetracycline and
cotrimoxazole

404
• Optimal duration of antibiotic therapy is not well defined,
with several studies recommending six to eight weeks of
intravenous therapy and others recommending only four
weeks
• Antibiotic therapy for less than four weeks may result in
an unacceptably high recurrence rate

404
Surgical Treatment
• Only 10–20% of patients require open surgery
• Surgical treatment is absolutely indicated in patients with
spinal cord or cauda equina compression with progressive
neurological deficits
• Relative indications for surgery:
• Uncertain diagnosis for which open surgery can obtain tissues for
bacteriological and histological confirmation
• Failed conservative treatment with lack of clinical improvement
after two to three weeks of antibiotic treatment
• Significant progressive spinal deformity with biomechanical
instability

404
Non-Pyogenic Spondylitis
Definiton
• Non Pyogenic infections may be caused by fungi, certain
bacteria, and spirochetes. The most common Non-
pyogenic spine infection in the world is tuberculosis.

Epidemiology
• The incidence of TB spondylitis varies considerably
throughout the world and is usually proportional to
the quality of public health services available.
• It is extremely common in underdeveloped countries
where malnutrition and overcrowding are major
problems

Epidemiology
• In affluent countries, the incidence has decreased
dramatically in the past 30 years and it now is uncommon
• Bone and joint involvement develops in approximately

10% of patients with tuberculosis, and half of these
affected patients have tuberculosis of the spine.
• A neurologic deficit will develop in 10% to 47% of those

with TB spondylitis.

Etiology
• Spinal tuberculosis may occur from hematogenous spread
from well-established foci outside the spine.
• The pulmonary and genitourinary systems are the most
frequent sources, but spinal tuberculosis may also arise
from other skeletal lesions.
• The primary focus of infection may be quiescent.
• Spinal involvement may develop from visceral lesions by
direct extension.

Etiology
• Infection is most commonly caused by Mycobacterium
tuberculosis, but any species of Mycobacterium may be
responsible.

Pathophysiology
• The pathogenesis of the early stages of spinal
tuberculosis is similar to that of pyogenic infections of the
spine and may result from hematogenous spread or from
direct extension of disease.

• The clinical presentation of TB spondylitis is variable and
depends on many factors.
• In the classic presentation, the patient complains of spine
pain and exhibits manifestations of chronic illness such as
• weight loss,
• malaise, and
• intermittent fever.

• The physical findings include local tenderness, muscle
spasm, and restricted motion. The patient may also have
a spinal deformity and neurologic deficit
• The location of the pain corresponds to the site of the

disease, which is most frequent in the thoracic region,
less common in the lumbar region, and rare in the cervical
spine and sacrum

• Patients may present with an abscess in any one of many
locations including the groin and buttocks.

Diagnostic Evaluation
• The tuberculin purified protein derivative (PPD) skin test is
usually positive and indicates either past or present
exposure to Mycobacterium.
• Cultures of early morning urine samples may be helpful in
cases of renal involvement, and sputum specimens and
gastric washings may be positive with active pulmonary
disease.
• These laboratory findings are helpful in the diagnosis, but
an absolute diagnosis can be made only by biopsy of the
spine lesion

Imaging Studies
• The earliest finding may be bone rarefaction, regardless
of type.
• With peridiscal involvement, disc space narrowing is
followed by bone destruction, similar to pyogenic
infections.
• With anterior multilevel spine involvement, the anterior
aspect of several adjacent vertebrae may be eroded in a
scalloped fashion.
• Central body involvement resembles a tumor, with central
rarefaction and bone destruction followed by collapse

Imaging Studies
• CT is useful to delineate soft tissue changes around the
spine and in the canal but is not capable of differentiating
an abscess from granulation tissue.

Imaging Studies

Imaging Studies
• MRI is the imaging modality of choice because it
demonstrates both bony and soft tissue involvement.
• The MRI findings in TB spondylitis may be
indistinguishable from pyogenic infections, but there are
some differences that are characteristic of tuberculosis
and reflect the different pathologic types described earlier

Imaging Studies
Abscess in the left psoas muscle in association with L3 and L4 tuberculous vertebral osteomyelitis. The periphery of the abscess
enhances after administration of gadolinium, suggesting that the mass is an abscess rather than granulation tissue. The psoas abscess
was found to be a sterile loculation of pus. A, Axial image. B, Coronal image.

Management
• The goals of management are to eradicate the infection
and to prevent or treat neurologic deficits and spinal
deformity.

• Drug therapy is usually started preoperatively but may be
started after operation if a biopsy is necessary.
• The first line of drugs currently in use include isoniazid

(INH), rifampin (RMP), pyrazinamide (PZA), streptomycin
(STM), and ethambutol (EMB).

• A number of second-line agents that occasionally are
used in special circumstances include ethionamide,
cycloserine, kanamycin, capreomycin, prothionamide, and
para-aminosalicylic (PAS).
“Multiple drugs are used because of the potential for

resistance to a single agent”

Surgical Treatment
• An operation may be performed to drain abscesses, to
débride sequestered bone and disc, to decompress the
spinal cord, or to stabilize the spine for the prevention or
correction of deformity.
• Abscess drainage is indicated only if the patient is septic

from the abscess or has a neurologic deficit from an
epidural abscess or when the abscess is extremely
extensive

Surgical Treatment
• Débridement, decompression, and fusion in the thoracic
spine may be performed through a transthoracic
approach, through a costotransversectomy, or by an
extrapleural anterolateral approach.

Complications of surgical treatment
Early
• Wound sepsis,
• Pleural effusion,
• Pulmonary embolism,
• Csf fistula into the pleural cavity,
• Ileus,
• Progressive neurologic deficit,
• Damage to the ureter,
• Loss of graft
• Fixation or graft fracture,

• Atelectasis,
• Pneumonia,
• Air leak,
• Horner syndrome, and
• Injury to one of the great vessels.

Late complications
• Graft resorption,
• Graft fracture,
• Nonunion, and
• Progressive kyphosis

Prognosis
• The prognosis depends on the age and general health of
the patient, the severity and duration of the neurologic
deficit, and the treatment selected.

SPONDYLODISCITIS
Definition
• A destructive lesion of the disc and its surrounding
vertebral bodies
• Complication of ankylosing spondylitis

J Antimicrob Chemother 2010; 65 Suppl 3: iii11–24
Epidemiology
• Is the main manifestation of haematogenous osteomyelitis
in patients aged over 50 years and represents 3–5% of all

cases of osteomyelitis
• Vertebral osteomyelitis has a male preponderance, with a
male to female ratio of 1.5–2:1.

Etiology
• Caused by localized inflammation or minor trauma
• Genitourinary tract (17%),
• Skin and soft tissue (11%),
• Intravascular devices (5%),
• Gastrointestinal tract (5%),
• Respiratory tract (2%) and the oral cavity (2%).
• Endocarditis was reported in 12%

Clinical features
• Symptoms – non spesific
• Clinical manifestation: new onset of localized pain in the
spine which is improved with bed rest
• Back or neck pain is very common
• Neurological deficits, including leg weakness, paralysis,
sensory deficit, radiculopathy and sphincter loss.
• Spinal deformities, predominantly kyphosis and gibbus
formation, are commoner in tuberculous spondylitis.

Treatment
Medical management
• Eradicate the infection, restore and preserve the structure
and function of the spine, and alleviate pain.
• Conservative management consists of antimicrobial
therapy and non-pharmacological treatments such as
physiotherapy and immobilization.
• Immobilization is advocated when pain is significant or
there is a risk of spinal instability.

TERATOMA
SACROCOXIGEAL
Definition
• Teratomas are neoplasms which contain derivatives of
more than one of the three primary germ cell layers of the
embryo
• Tumors that develop at the base of the spine by the
tailbone (coccyx) known as the sacrococcygeal region
• The most common congenital tumour in the neonate
• Female : male = 4:1
Postgrad Med J 2000;76:754-759 doi:10.1136/pmj.76.902.754

Type and Size
• Type I - Primarily external or has a minimal presacral
component
• Type II - Predominantly external but has a significant
intrapelvic component
• Type III - Predominantly intrapelvic with abdominal
extension, with a small external component
• Type IV - Entirely within the pelvis and abdomen
• Range 1 to 30 cm, average 8 cm
Postgrad Med J 2000;76:754-759 doi:10.1136/pmj.76.902.754

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SPINE DISORDERS

dr. Jainal Arifin, M.Kes., Sp.OT (K) Spine

• Adult idiopathic scoliosis presumably had some degree of

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

• Nonoperative management options:

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

• Most commonly caused by repeated and increased

• May lead to instability of the spinal column

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

• Weakest area in the neural arch

• Susceptible to stress fracture

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

• Eskimo >> Whites >> African Americans

• Defect bilateral  greater chance of progression to

• Most common location of spondylitic defect  L5

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

• Spondylolysis occurs in 15–70% of first-degree relatives

• Risk factor for spondylolysis: activities that involve

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Asian Spine J 2014;8(6):856-863 •http://dx.doi.org/10.4184/asj.2014.8.6.856

• Surgical intervention is indicated for patients with

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

• Forward translation of one vertebra on

• Most common location of

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

• Local expansion of fibrocartilaginous scar tissue within the

• Tension on the nerve root also increases with progression

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Low grade High grade

Asian Spine J 2014;8(6):856-863 •http://dx.doi.org/10.4184/asj.2014.8.6.856

• The importance of radiographic and neurologic follow-up

• Documentation of slip percentage, angle, sacral

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Devlin VJ. Spine Secrets Plus 2 nd Ed. 2012

Herkowitz HN. Rothman-Simeone The Spine 6 th Ed. 2011