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Principle of the
spine disorders
Dr. Rendra Leonas,SpOT, FiCS, (k) spine, M.Humkes
Depart. Orthopaedic Rs. Moh Hoesin Palembang

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Outline of Presentation
1

Anatomy and Physical examination

Diagnosis

Treatment

Conclusion

Introduction : Incidence

Treatment difficult
multiplicity of factors involved.
Pain generators elusive
Diagnostic imaging frequently inconclusive.

Introduction :
Anatomy of the spine

Lumbosaral
Lumbosaral
Protection
Protection
Support
Support
Mobility
Mobility

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Anatomy and Physiology

33 bones comprise the spine

Function
Skeletal support structure
Major portion of axial skeleton
Protective container for
spinal cord

Vertebral Body
Major weight-bearing
component
Anterior to other
vertebrae components

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Anatomy and Physiology

Characteristic of the
Vertebrae
Cervical
C-1 & C-2 no
vertebral body
Support head
Allow for turning of
head
Vertebral body size
increase inferiorly they
become

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Anatomy and Physiology

Characteristic of
theVertebrae
Lumbar spine has
strongest and
largest
weight bearing of the
body
Sacral & Coccyx
vertebrae are fused
No vertebral body

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Anatomy and Physiology

Components of
Vertebrae
Spinal Canal
Opening in the
vertebrae that the spinal
cord passes through

Pedicles
Thick, bony structures
that connect the
vertebral body to the
spinous and transverse
processes

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Anatomy and Physiology

Components of Vertebrae
Laminae

Posterior bones of vertebrae that make up foramen

Spinous Process
Posterior prominence on vertebrae

Intervertebral Disks
Cartilagenous pad between vertebrae
Serves as shock absorber

Transverse Process
Bilateral projections from vertebrae
Muscle attachment and articulation location with ribs

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Intervertebral Disc

nucleus
pulposus
annulus
fibrosus
hyaline cartilage
end plates

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Facet Joints
Act to limit shear and torsion
motions between vertebrae
Orientation of facet changes
along length of spine
Cervical : couple lateral
bending and torsional motion
Thoracic : coronal plane
orientation of joint surfaces
Lumbar : sagital plane
orientation of joint surfaces
Facets carry 10-20% of
compressive load in upright
standing, >50% of anterior shear
load in forward fexion

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SPINAL CORD
Only 2% of human CNS, but innervate almost all

areas of the body

Caudal two-third of the CNS, From for.magnum to
IV disc L1 L2
43-45cm length + 25cm fillum terminale with
mean caliber of 10 mm, 30 gr weight
Protected by vertebral canal with 2 enlarged zones
(cervical & lumbar) and narrowing at the level of
thoracic spine

SPINAL CORD

31 medullary segments 31 spinal nerve

roots : 8C, 12T, 5L, 5S, 1Co

Radix dorsalis & ventralis enlargement :
spinal ganglion fuse n.spinalis out
intervertebral foramina ventral ramus &
dorsal ramus
Unequal growth of spinal cord and
vertebral canal direction & length of
spinal nerve roots vary according to level
of emergence

SPINAL CORD BLOOD SUPPLY

1 anterior and 2
posterior spinal
arteries
Ant. spinal artery
Gray Matter
Post .spinal artery
White Matter
Venous drainage
ant & post spinal
veins

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Anatomy and Physiology

SPINAL NERVES
31 pairs of spinal nerves :

8 cervical
12 thoracic
5 lumbar
5 saccral
1 coccygeal

Each has both motor and sensory fibers

Motor fibers = anterior or ventral root
Sensory fibers = posterior or dorsal root
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SPINAL NERVES
C1 : exits between

atlas & occipital bone

C2-C7 : exit above
corresponding C vert.
C8 : exit between
vert. C7 and Th1
Thoracic, lumbar,
sacral nerves exit
below the
corresponding vert.

SPINAL NERVES

Segmental control of upper limb movements

SPINAL NERVES

Segmental control of lower limbs movements

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OVERVIEW

LOOK
inspection

FEEL
palpation

MOVE
active & passive
movements
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EXAMINATION : STANDING
Look :
bruise
hematom
wound : gun shoot wound
stab wound
Deformity

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EXAMINATION :STANDING
Feel :
Tenderness: may be bony, intervertebral or

paravertebral
Bony prominence or steps
spinous processes
using C7 &/or L4-5
as landmarks

facet joints
approx. 2cm lateral to spinous processes

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EXAMINATION : STANDING

Feel :
assess alignment, mobility &
tenderness of:
transverse processes of vertebrae
lateral to spinous processes

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EXAMINATION :STANDING
Feel :
Tenderness: may be bony, intervertebral or

paravertebral
Bony prominence or steps
spinous processes
using C7 &/or L4-5
as landmarks

facet joints
approx. 2cm lateral to spinous processes

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EXAMINATION : STANDING

Feel :
assess alignment, mobility &
tenderness of:
transverse processes of vertebrae
lateral to spinous processes

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Signs of nerve root compression

Standard full neurological examination of
both lower limbs :
tone, power (MRC grading)
sensation (light touch, pinprick &
proprioceptive if indicated)
reflexes (physiologic and patologic)
an anatomical distribution [dermatome(s) or
myotome(s)]
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Neurological Examination

Objectives :
Determine if defect is present
Localize the level of the deficit

Include :
Sensory
Motor
Reflex
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Neurological Examination

Sensory examination
Explain, eyes closed
Examine : touch, 2 point discrimination,
proprioceptive.
Sensory dermatomes, compare each
opposite

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Sensory Dermatome

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Muscle Power Grading

0 - complete paralysis
1 - flicker of contraction possible
2 - movement is possible when gravity is
excluded
3 - movement is possible against gravity
4 - movement is possible against gravity + some
resistance
5 - normal power

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Neurological Examination

Motor examination
Muscle grading
Compare each side

Cervical :
Scapular

C4

Deltoid & Biceps

C5

Wrist extension & supination

C6

Wrist flexion & Pronation

C7

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Neurological Examination

Motor examination
Lumbo-sacral
Hip flexor
Hip extensor

L 1,2,3
S1

Knee flexor
Knee extensor

L 4,5, S1,2
L 2,3,4

Ankle flexor
Ankle extensor

S1
L5

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Reflexes

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Biceps

Brachioradialis

Triceps

Hoffman

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PROVOCATIVE TESTS
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COMMENTS

TEST
SLR : sitting & supine

Must produce radicular symptom in the distribution of the

provoked root, for sciatic nerve , that means pain distal to knee

Lasgue's sign

SLR radiculopathy aggravated by ankle dorsoflexion

Contralateral SLR

Well-leg SLR puts tension on involved root from opposite direction

Kernig's test

The neck is flexed chin to chest. The hip is flexed to 90, and then
the leg is the extended similar to SLR; radiculopathy is reproduced

Bowstring sign

SLR radiculopathy aggravated by applying pressure over popliteal

fossa.

Femoral stretch test

Prone patient; examiner stretch femoral nerve roots to test L2-L4

irritation

Nafziger's test

Compression of neck vein for 10 s with patient lying supine ;

coughing then reproduces radiculopathy

Milgram's test

Patient raises both legs off the examining table and hold this
position for 30 s; radiculopathy maybe reproduced

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Trauma (fractures)
Infections
Iatrogenic causes
Degenerative
chances
Neoplasma
Congenital

Occupational risks :
Repetitive forward
bending bending and
twisting
Frequents lifting on
the job
whole body fibration
(WBV) ; energy
delivered to the body

Phychosocial factors

 History
Physical examination
Laboratory finding
Imaging :
- Plain x-ray
CT
MRI

Pain
Numbnes
Claudicatio
Paralysis
Paresthesia
Deformity

 Based on :
Etiology

Congenital
Infection
Neoplasm
Trauma
Degenerative
Others

Demands

Age
Job
Socioeconomic condition
etc

 Conservative :

Medication
Physical therapy
External supports

Operative

Simple operative, single or in combination :

Disectomy
Facetectomy, etc

Complex :

Decompression
Fusion, etc

Spinal trauma

Introduction
50 % associated with other injuries
suspect if mutiple trauma or head injuries
more common traffic accident, falls, sport inj
principle management accord ATLS and
using collar and long spine board

transf patient inline traction and log rolling

Clinical evaluation

Secondary survey from head to toe

History of trauma and neurologic status at
the time accident
Palpation any tenderness and bruising or
gap between two spinous proc
Neurologic evaluation incl rectal
examination, perianal sensation, bulbous
reflex

INTRODUCTION
The cervical column is
extremely vulnerable to
injury

Function:
Movement - flexion,
extension, lateral bending
and rotation
Attached at the cephalic
aspect - the skull and its
contents

INTRODUCTION
Injury - when loads
exceed the ability of the
supporting structures to
dissipate energy

Mainly hyperextension:
older patients with
spondylolytic disease
younger patients with
congenitally narrowed
spinal canals

INTRODUCTION
Jefferson & Meyer identified
C2 and C5 as the two most
common areas of cervical
spine injury

Produce neurological damage

in approximately 40% of
patients

10% of traumatic cord injuries

have no obvious radiographic
evidence of vertebral injury

SPINAL TRAUMA
Definition: injury has occurred
to any of the following
structures:
Bony elements
Soft tissues
Neurological structures

Two concerns of spinal

trauma:
Instability of the vertebral
column
Actual or potential
neurological injury

SPINAL INSTABILITY
Definition: Loss of normal
relationship between anatomic
structures with a resulting
alteration of natural function:
Spine can no longer carry
normal loads
Permanent deformity may
occur resulting in severe
pain
Potential for catastrophic
neurological injury

MECHANISM OF INJURY
Understanding details of the
injury aids in diagnosis

Spinal trauma patients may

have injury to other anatomic
structures, impeding
neurologic evaluation

If possible, question witnesses

for additional details

CLASSIFICATION OF
FRACTURES

Stable and Unstable

Stable

Spine can withstand

physical loads
No significant
displacement or deformity
to bone or soft tissue

Unstable
Spine may not be able to
carry normal loads
Most likely have significant
deformity and pain
Potential for catastrophic
neurologic injury

DENIS CLASSIFICATION
METHOD
Used to grade thoracolumbar
and cervical fractures

Based on 3-column theory of

the spine:
Anterior = ALL and anterior 2/3
of vertebral body/disc
Middle = posterior 1/3 of
vertebral body/disc and PLL
Posterior = pedicles, lamina,
facets, post. Ligaments

Middle column is key to

stability

Magerl Classification
Thoracolumbar fractures
Three types of fractures

based on mechanism of
failure:
Type A = compressive
loads
Type B = distraction forces
Type C = multidirectional
forces with translation

Subtypes delineate
stability

AO CLASSIFICATION

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Occipito-Atlantal
dislocation
Rare
Fatal brainstem
compression
All ligaments
Disrupted

Atlanto-occipital
Fracture

CERVICAL TRAUMA
Craniovertebral Junction Fractures

There are reports of

patients surviving
Need to fix ligamentous
healing in halo vest
unpredictable
Traction contraindicated
Good cervico-occipital
fusion posteriorly
Avoid smoking and
NSAIDs

CERVICAL TRAUMA
Craniovertebral Junction Fractures

C1 fractures:
1. Posterior arch fracture
2. Lateral mass fracture
3. Burst fracture (Jefferson
fracture)

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Jeffersons fracture:
53% have associated
cervical injuries
especially at C2
Sometimes without
neurological deficit

CERVICAL TRAUMA
Craniovertebral Junction Fractures

C1 fractures:
Most can be treated with
immobilization in a rigid
cervical orthosis or a halo
vest
Isolated posterior arch
fractures - stable injuries can be treated in a cervical
collar for 8 to 12 weeks

CERVICAL TRAUMA
Craniovertebral Junction Fractures

C1 fractures:
If loss of reduction occurs
at C2 fracture
stabilisation later when the
C1 ring has healed
If lateral mass displaced >
7mm halo traction until
reduction is achieved

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Rotatory subluxation
C1-2:
Often missed until later
Torticollis
Wink sign on open mouth
view
CT helpful

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Fielding and Hawkins:

A, Type Isimple rotary
displacement without
anterior shift; odontoid
acts as pivot

B, Type IIrotary
displacement with anterior
displacement of 3 to 5
mm; lateral articular
process acts as pivot
C, Type IIIrotary
displacement with anterior
displacement of more than
5 mm
D, Type IVrotary
displacement with
posterior displacement.

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Rotatory subluxation of
C1-2:
Acute
Reduce closed with halo
traction
Then apply halo vest

Chronic
Open reduction posteriorly

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Occipital condyle
fractures:
Rare
Lower cranial nerve
palsies, eg. Hypoglossal
Treat in a halo-vest
If instability seen in
dynamic x-rays then C0C2 fusion

Anderson and Montesano

CERVICAL TRAUMA
Fractures of Odontoid
Process:

Type 1 fractures at tip

Type 2 fractures at waist
Type 3 fractures at base
Types 2 and 3 are not
stable

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Dens fractures:

Type 2 commonest
36% non-union rate
68% healing in halo-vest
98% healing with C1-2 fusion

Type 3 90% union rate

Degree of initial
displacement important:
> 5mm higher non-union

Anderson and D'Alonzo

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Magerl and Seemann:

98% fusion rate compared
to 86% using wires and
autograft
4.1% vertebral artery injury

Transarticular Screw Fixation

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Etter et al:
92.3% fusion rate
17% major complication
rate

Anterior Screw Fixation

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Hangmans fracture
Involves C2
Sudden
hyperextension of
head and neck forces
vertebrae against
spinal cord
Complete neurological
loss can occur

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Hangmans fracture:
Type I fractures are
minimally displaced - caused
by hyperextension and axial
loading with failure of the
neural arch in tension
Because ligamentous injury
is minimal - stable - heal with
12 weeks of immobilization in
a rigid cervical orthosis

Levine and Edwards

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Hangmans fracture:
Type II fractures have more
than 3 mm of anterior
translation and significant
angulation
The C2-3 disc may be
disrupted
Treatment - application of
skull traction through tongs
or a halo ring with slight
extension of the neck over a
rolled-up towel

Levine and Edwards

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Hangmans fracture:
Type IIA fractures are a
variant of type II fractures
-severe angulation between
C2 and C3 with minimal
translation
A more horizontal than
vertical fracture line through
the C2 arch
Treatment is application of
a halo vest with slight
compression

Levine and Edwards

CERVICAL TRAUMA
Craniovertebral Junction Fractures

Hangmans fracture:
Type III injuries combine a
bipedicular fracture with
posterior facet injuries
Severe angulation and
translation of the neural
arch fracture and an
associated unilateral or
bilateral facet dislocation at
C2-3
Commonly require surgical
stabilization

Levine and Edwards

Imaging

Depend on clinical finding (pain and

deformity)

After patient hemodynamic stabile

X ray ap and lateral view in the cervical
must incl C1-C7 (swimmers position or
open mouth) , thoracolumbar junction

Ct scan or MRI can be obtained

Case 1

Male, 34 y.o
MVA
Incomplete spinal
cord injury + Mild HI

Case 2

Male, 80 y.o
MVA
No neck pain
No deficit neurologic
Mild HI

 Swimmer view

 Axial CT Scan

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